Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
In the treatment of recurrent trigeminal neuralgia, what local therapy would you recommend after failure of medical therapy?
I will recommend surgery (microvascular decompression) only when there is a surgically fixable abnormality, such as vascular compression. In that case, microvascular decompression is more effective than SRS. Otherwise, I will offer SRS, which can be offered twice targeting a root entry zone and a mo...
How would you manage the cavity of a resected anaplastic meningioma with pulmonary metastases?
Metastatic meningioma outside the CNS is rare, and its incidence has been estimated to be 0.1% with the lung being the most common site for distant metastases (Surov et al., PMID 23404622). There is no clear standard therapy for the management of metastatic meningioma. Suppose this was an anaplastic...
Is placing a VP shunt a major risk to spread medulloblastoma or other malignant brain tumors into the gut?
While most malignant primary brain tumors will NOT spread to the gut via VPS, case reports of pediatric brain tumors dominate the literature regarding this risk. Germ cell tumors are probably most commonly reported, followed by PNETs and medulloblastomas [Piatt and Garton, PMID 18431216, Kay et al.,...
Are there any therapeutic options for cauda equina syndrome secondary to dural ectasia in end-stage ankylosing spondylitis?
The cauda equina syndrome is a rare complication in patients with ankylosing spondylitis (AS). Patients with longstanding disease leading to significant ankylosis of the spine have the highest risk of developing it. The likely underlying mechanism is arachnoiditis leading to damage of the lumbosacra...
How would you manage an unresectable central meningioma in a young patient with evidence of mild compression on the optic nerve and 4th ventricle involvement?
Sometimes, unresectability is in the eye of the beholder. In a young patient, with a decent size meningioma compressing the chasm and the 4th ventricle, there are several significant risks from not pursuing a surgical approach. Our first approach would be to get an expert opinion from a renowned men...
How do you manage a large surgical cavity following resection of a melanoma brain metastasis?
I've used 30 Gy in 5 fx before for a cerebellar melanoma cavity about 4.5x3 cm. It's much less likely to cause necrosis and edema than single fx. There may be some local enhancement of IO response. Regarding immunotherapy, I don't give steroids unless symptoms occur, and try to keep it to no more th...
In a healthy patient >65 years of age with glioblastoma multiforme, what is the recommendation for temozolomide when given concurrently with adjuvant radiation therapy?
Glioblastoma (GBM) is primarily a disease of older adults. The median age of diagnosis is around 60. Many of these patients present with a host of co-morbidities that impact their performance status (PS), overlapping with GBM-related complications. There are multiple scenarios to consider when evalu...
How do you approach imaging in the treatment planning of resected high grade gliomas/glioblastoma?
We typically obtain an MRI on the same day as the planning CT (whether or not the patient had a post-operative MRI). We are biased as we operate a dedicated MRI. If this were not the case, we would probably assess on a case-by-case basis (how long has it been since the last MRI, how visible is tumor...
What risk, if any, do you quote for erectile dysfunction in a young male being treated for a lumbosacral ependymoma?
I have not been quoting a specific risk of ED in spinal ependymoma patients. ED is common with advancing age and is often multifactorial. In ependymoma, prior spine surgery, the disease itself, concurrent medication, concurrent health issues, and the psychological impact of a cancer diagnosis are, f...
How you approach treatment of a glioblastoma in the setting of prior WBRT for a metastatic non-CNS malignancy?
I think treatment to 25 Gy in 5 fractions or 40 Gy in 15 fractions to areas of enhancement and/or post-op bed can be safely delivered after whole brain (assuming the patient was treated to 30 Gy in 10 fractions). We commonly treat with SRS after whole brain RT. Just be cognizant of cumulative dose t...