Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
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...
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 ...
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...
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...