Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
How do you approach a patient with a solitary brain metastasis from small cell lung cancer s/p resection with otherwise limited thoracic disease?
This is rather an uncommon situation but can happen if a patient presents with a synchronous solitary brain metastasis (with or w/o symptom) and undergoes craniotomy and resection only to find out that it is small cell lung cancer. Additional information is needed on the volume of intra-thoracic dis...
Would you consider bevacizumab for a patient with SCLC who has asymptomatic brain metastasis progression after CNS radiation while on maintenance immunotherapy?
I am assuming SCLC is small cell. I wouldn't do it now that we have agents such as tarlatamab, which has better CNS penetrance. Adding bevacizumab to atezo does have a rationale and theoretical benefit. The CeLEBrATE study, which was recently published, showed synergy between chemo, atezo, and bev, ...
How would you manage a recurrent meningioma of the cervical spine after resection alone?
I had a case like this 2 years ago. Treating with 5 fractions felt so "en vogue" and I therefore phoned some CNS-focused friends who may be considered spine SBRT leaders, and they all recommended standard fractionation, supporting my inclination.My case was a subtotally resected Gr 1 tumor with blan...
Under what circumstances would you consider irradiation for brain metastases with active or recent bleeding?
Melanoma and renal cell cancer brain metastases are prone to bleed. When metastases bleed, usually they cause acute symptoms depending on the location within the brain (seizures, sudden onset headaches, acute motor dysfunctions, etc.). These patients are commonly seen in the Emergency Department, at...
What is your preferred site for central venous access in patients with concern for raised intracranial pressures?
Subclavian is our preferred central venous access for raised ICP, but we also utilize femoral lines for patients at high risk of pneumothorax or who need more emergent access. We have historically avoided IJ lines because of concern for impeding venous drainage by blocking the IJ. I do not think thi...
What is your approach to managing post-operative dysphagia following C-spine surgery?
Dysphagia is relatively common after anterior C-spine surgery. (recently estimated at 10%, Shimizu et al., PMID 40461647). While I have less rigorous personal data, anecdotally, I agree with the conclusions of the authors that postoperative pain is a significant predictor. While I typically defer in...
Is there any evidence that radiotherapy can worsen balance, dizziness, or vertigo in patients treated for vestibular schwannoma due to transient edema?
While the answer from Dr. @Dr. First Last addresses a much broader category of patients treated with SRS, we have looked specifically at post radiation side effects after treatment of vestibular schwannomas treated with either SRS (12.5 Gy), hypofractionated SRS (hSRT with 5 fractions of 5 Gy), or c...
How do you decide between using an intracranial pressure monitor (bolt) versus an extraventricular drain (EVD) for intracranial pressure monitoring in cases of diffuse cerebral injury?
I think the decision about whether to place an external ventricular drain (EVD) or an intraparenchymal ICP monitor (IPM) rests on many factors, including:1) Need for CSF drainage - if the patient has hydrocephalus or CSF drainage is anticipated to be useful in controlling ICP, then an EVD is prefera...
For how long do you treat an early spinal hardware infection secondary to MSSA after operative washout and retention of hardware?
This infection is a key research interest of mine and one I'm deeply passionate about. I typically treat with a 12-week induction regimen, preferably using antibiofilm-active agents—an approach adapted from the DATIPO trial for prosthetic joint infections (PJI). I generally do not recommend routine ...
How do you manage an unresectable high-grade glioma of the distal cord/cauda equina?
Doses may vary by institution. Our typically practice is to cover the gross disease to 54 to 50.4 Gy in 1.8’s for conus/cauda and then approximately two vertebral bodies above and below to 50.4-45 Gy (for instance if the superior extent is in true cord, then it’s typically prescribed to 45 Gy with p...