Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
What is your approach to a completely resected WHO grade II meningioma?
Any attempt toward a definitive answer to this question will at best be too cursory and at worst will jar Pandora’s box, but let’s give it a shot. How to optimally approach patients following gross total resection (GTR) of a WHO grade 2 meningioma remains sufficiently uncertain that 2 randomized tri...
Can SRS be used to treat an atypical meningioma?
I agree with @Dr. First Last, and approach patients with atypical meningioma in the same fashion, preferring IMRT to SRS. Indeed most publications have used fractionated external beam therapy, but several centers have published results with SRS. I encourage anyone to have a close look at these. The ...
Among patients with secured subarachnoid hemorrhage who are receiving daily TCDs, what is the appropriate frequency of post operative neurological assessments?
I think a textbook might state something like "every 1-2 hours in the acute setting." However, in my opinion, the frequency of neurological examinations should be tailored to the individual patient and involves considerable clinical judgement. Factors that might influence this decision include a) se...
How do you decide what type of spinal cord stimulator to utilize for pain control?
If by “type” we mean percutaneous vs. paddle, they each have pros and cons. Perc leads are less invasive and can have a greater craniocaudal span. Paddles can be more power efficient, have more programming options in a mediolateral dimension, but are more invasive to place. I generally favor paddles...
Do you recommend a prolonged duration of antibiotics and/or suppression for patients without pre-existing hardware who have placement of new hardware after decompression/washout of a Staphylococcus aureus epidural abscess?
If the hardware is placed in the setting of active infection, then I usually chronically suppress the patient indefinitely after treating for the acute infection.
Under what circumstances would you consider using the robot rather than stealth for image guided screw placement?
Largely, robotics in spine surgery serves as an adjunct to spinal navigation, utilizing similar platforms but paired with a rigid arm. Robotics does allow for preoperative planning of hardware placement that can be performed on a thin-sliced CT and merged with intraoperative imaging with fluoro or C...
Under what circumstances would you consider a post-natal myelomeningocele repair rather than a fetal myelomeningocele repair?
There are certain inclusion and exclusion criteria for fetal repair of myelomeningocele. Fetal repair of myelomeningocele is generally offered only to carefully selected singleton pregnancies that meet anatomic, gestational age, maternal, and exclusion criteria based on MOMS and subsequent instituti...
Under what circumstances would you consider completing a decompressive hemicraniectomy and a frontal sinus cranialization at the same time for penetrating cranial trauma?
If craniectomy is straightforward and the patient is stable under anesthesia for less than 2 hours, we would consider cranialization at the time. Other considerations include whether assistance by a non-neurosurgeon (ophthalmologists, plastics, ENT...) is required and/or if cranialization will requi...
How do you approach treatment of a craniopharyngioma in an older adult patient?
There is a bimodal age distribution, with one peak in children between 5 and 14 years old and the second peak in adults between 50 and 75 years of age. Adamantinomatous (frequently with calcification) craniopharyngiomas are more common in children, while papillary (frequently lack calcification) cra...
What is your approach to using intra-arterial or intrathecal vasodilators in patients with vasospasm in subarachnoid hemorrhage despite usage of oral nimodipine?
Bottom line up front: The 2023 AHA/ASA focused update on aSAH recommends IA vasodilator infusion or mechanical angioplasty in clinically significant vasospasm refractory to medical therapy (Class IIa, Level B) and states that intraventricular nicardipine “may be considered” in selected patients (Cla...