Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
Under what circumstances would you consider awake mapping for DBS placement?
DBS outcomes data now clearly support the notion that asleep image-guided DBS electrode placement outcomes for Parkinson's Disease are at least equivalent to awake surgery, with or without microelectrode recording. The real question at this point is under what conditions an awake DBS surgery is ever...
Under what circumstances would you consider utilizing deep brain stimulation for treatment of obesity?
Probably not indicated for obesity, given the new GLP therapies that have emerged in the past few years. I am not a proponent of the idea of "food addiction" either, which may be the rationale for nucleus accumbens DBS. Dr. Casey Halpern at U Penn may be a better person to ask about that.
Under what circumstances would you utilize a radial approach versus a femoral approach for vascular access during an angiogram?
The choice of radial vs femoral access for neuro-interventional procedures is typically based on provider preference and experience but is influenced by several important considerations: The first consideration is local site-specific disease and anatomy, i.e., peripheral vascular disease, presence ...
Under what circumstances would you treat intractable drug-resistant epilepsy with focused ultrasound rather than other surgical approaches?
Essentially, the only condition of intractable epilepsy that might be considered treatable with high-intensity focused ultrasound would be intractable seizures associated with a hypothalamic hamartoma.
How do you decide between an ALIF vs. a TLIF for L5-S1 spondylolisthesis?
ALiF if robust likelihood of fusion and restoration of optimal lordosis.
Under what circumstances do you consider an enbloc resection versus biopsy for a lower lumbar spinal column tumor?
Typically, a biopsy is performed prior to en bloc resection rather than “either or.” A biopsy is necessary if there is a differential diagnosis based on imaging, and if the diagnosis will affect management: radiation and chemotherapy alone vs. intralesional resection/debulking and adjuvant therapy v...
Under what circumstances would you consider a selective dorsal rhizotomy for treatment of lower extremity spasticity?
There are two basic categories to indicate a patient for SDR. The first category is ambulatory patients for whom we are looking to improve the quality of gait. These are generally patients around 3-8 years of age, GMFCS II-III, who have good ability to comply with PT instructions, good selective mot...
How do you determine when to change an EVD in a trauma patient that may not need a shunt?
The keyword here is “change”. I don’t routinely change an EVD based on time. I believe the actuarial data suggest that the major risk of infection is during insertion/replacement, showing up days later due to progression rather than subsequent inoculation. This obviates any indications for routine, ...
When placing a shunt at birth for hydrocephalus secondary to IVH, how do you decide between a programmable and non-programmable shunt?
In infants, I exclusively use programmable shunts. My feeling is that shunt requirements change as the child grows and the fontanelle ultimately closes. Over the first year of life, I titrate the resistance of the shunt to the maximal setting tolerated by the child. I use developmental milestones, p...
How do you determine timing for surveillance imaging for an asymptomatic patient who was incidentally found to have a meningioma?
Timing for surveillance imaging of an incidental, asymptomatic meningioma is a risk-stratified decision that balances tumor biology, radiographic features, patient factors, and anatomic context. Start with baseline risk characterization. The most important determinants are tumor size, location, imag...