Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
How do you approach decision making in terms to adjuvant chemotherapy after CSI in adult medulloblastoma?
Medulloblastoma is a chemotherapy sensitive disease. The NCCN guidelines have options for CSI alone or followed by chemotherapy for standard risk disease (M0, residual disease <1.5cm2, classic or desmoplastic histology) and recommend post-CSI chemotherapy for high risk disease. Unfortunately, 25% of...
How do you manage asymptomatic radiation necrosis in a glioblastoma?
If a patient is not symptomatic from radiation necrosis, the only thing that would make me consider initiation of dexamethasone (Consideration of Avastin reserved for symptoms refractory to steroids) would be significant midline shift that is progressing, but this is usually going to lead to symptom...
How do you manage TTFields for a patient with glioblastoma in the setting of disease progression?
Continuation of Tumor Treating Field (TTF) therapy at progression is an individualized decision for each patient.In the EF-14 trial upon which TTF was approved for newly diagnosed GBM after chemoradiotherapy, TTF was able to be continued until second progression. In this study, 18% more patients wer...
Do you discourage patients from skydiving/roller coasters with a Chiari malformation?
No, I don't.
What workup do you recommend for patients with low back pain and imaging concerning for spina bifida occulta?
In cases of suspected spina bifida occulta, imaging of the entire spine and Neurosurgery referral are usually recommended. MRI is generally considered the imaging modality of choice, which can also detect other coexisting abnormalities such as tethered cord, while CT can be helpful in better imaging...
When would you recommend standard of care over hypofractionated treatment in an elderly patient diagnosed with Glioblastoma?
Treatment of patients with newly diagnosed GBM who are >70 years of age is controversial and treatment decisions should be individualized. Some patients who are GREATER THAN 70 years of age are candidates for standard 6-week RT+TMZ and some patients who are LESS THAN 70 years of age may require modi...
How do you discuss curative vs palliative treatment intent for patients with favorable risk 1p/19q co-deleted oligodendrogliomas?
Although my name is on a publication calling low-grade oligodendroglioma an "incurable disease", this is not a term that I use with patients — even in the case of glioblastoma. We do not have a published 20-year follow-up of RTOG 9802 to see if there is a plateau in PFS. Are we only delaying inevita...
Would you recommend upfront radiosurgery for trigeminal neuralgia caused by AVM abutment at the entry root zone?
Radiosurgery (SRS) at high doses to the dorsal nerve root entry zone is an effective treatment modality for primary or idiopathic trigeminal neuralgia (TN), but is significantly less efficacious when utilized for secondary trigeminal neuralgia, as caused by tumors, plaques, AVMs, etc. There are case...
What is the role of kyphoplasty or vertebroplasty in patients with osteoporotic spinal fractures?
Vertebroplasty and kyphoplasty can be grouped together as vertebral augmentation. They have a single indication: To reduce pain arising from a documented vertebral fracture. Kyphoplasty has an inflatable balloon and in theory, can improve vertebral height prior to introduction of the cement. I am no...
How would you manage a recurrent anaplastic supratentorial ependymoma in an adult?
There is no well-defined standard-of-care approach for previously irradiated, now recurrent ependymoma, in any setting, whether it is adult or pediatric, cranial or spinal, and supra vs. infratentorial. Unfortunately, the natural history at this stage is characterized by multiple relapses, each with...