Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
How do you distinguish between episodes of vascular steal and seizures in patients with an AVM?
Distinguishing between vascular steal and seizures in patients with AVMs can be challenging, but certain patterns may help. Vascular steal occurs when blood is shunted through the AVM nidus, bypassing the surrounding tissue and causing regional or global oligemia. The shunting can result in transien...
How do you decide between MRgFUS thalamotomy, LITT, and stereotactic radiosurgery for an older patient with medication-refractory essential tremor who is not a DBS candidate?
MRgFUS and stereotactic radiosurgery (typically using the Gamma Knife) are non-invasive methods to perform a thalamotomy for older patients with functionally disabling medication-refractory essential tremor. There is substantial clinical evidence supporting both of these methods in the literature. T...
How do you determine which targeting modality to utilize for DBS placement?
Target selection requires multidisciplinary evaluation involving movement disorder specialists, neurosurgeons, neuropsychologists, and psychiatrists to assess motor, cognitive, and behavioral status comprehensively. The team must identify surgical goals, weigh individual patient factors, and arrive ...
How would you advise a younger patient with residual/recurrent optic nerve meningioma, proceeding with radiotherapy, about the risks of malignant transformation or induction of other brain malignancies because of radiation?
The risk of malignant transformation of an optic nerve sheath meningioma (ONSM) after RT appears to be remarkably low, much lower than the risk of blindness from an untreated, progressive ONSM. In a younger patient, I would lean toward RT for patients with imaging progression or early visual loss, ...
How do you determine timing between stage 1 anterior fusion and stage 2 posterior fusion for deformity correction?
Typically, I split it over two days if I'm doing a> 1-level interbody fusion. If it's a 1-level, I'll typically try to do both stages on the same day unless there is a compelling reason not to. For me, the determination is all about minimizing time-under-anesthesia for the patient.
What type of drain do you place after burr holes for subdural?
I am on the more aggressive side with my drainage. I place a 7-French Blake drain from hole to hole in a 2-hole procedure and set it to grenade suction. The placement of the drain is facilitated by using the 8 French red rubber irrigation catheter to guide it. The end of the Blake drain is sutured i...
Under what circumstances would you perform bilateral focused ultrasound thalamotomy for severe bilateral essential tremor?
This is an evolving area of movement disorder surgery. In my opinion, HIFU is best used for unilateral tremor control in patients who have medical co-morbidities, cognitive issues (dementia), living situations (assisted care), or a geographic location that makes follow-up difficult or effectively pr...
How would you empirically manage a large sellar/suprasellar mass with encasement of the right cavernous and terminal internal carotid arteries?
Knowing the histology of the mass would really help in creating more accurate treatment recommendations. A biopsy of a sellar mass is usually accomplished by an endonasal-endoscopic transsphenoidal approach utilizing the expertise of an ENT surgeon and a skull-base neurosurgeon. However, in this cas...
How do concerning TCD trends affect your management of a clinically stable patient with aneurysmal subarachnoid hemorrhage?
I have been relying on TCD to manage clinically stable SAH patients for years. There are several management interventions that I might make in a patient who is showing significant vasospasm on TCD but otherwise seems clinically stable. These interventions include keeping a patient in ICU for frequen...
Which chronic trigeminal pain patients have you found responded best to peripheral nerve stimulation implants?
Trigeminal neuropathic pain (TNP), i.e., traumatic or unintentional surgical injury to the trigeminal system, is the main indication for neurostimulation. This should be a peripheral procedure targeted at the relevant nerve distribution, e.g., supraorbital or infraorbital. Use a multicontact electro...