Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
How do you determine if the occipital condyle needs to be drilled during a far lateral approach for an intradural lesion?
The determination to drill the occipital condyle depends on the location and size of the lesion; for example, for very large lesions that have already displaced the brainstem quite a bit more posteriorly or contralaterally, condylar drilling is not needed. This can generally be determined on an axia...
How do you determine which patients should receive an endoscopic strip craniectomy?
In my view, the candidate for endoscopic strip craniotomy should ideally be less than four months of age at the time of surgery, and the family must commit faithfully to a molding helmet for up to a year.
Do you wait to treat small asymptomatic brain metastases until they reach a certain size?
I typically treat all lesions on MRI that are found to be concerning for brain metastases. This is after a discussion with our neuroradiologist colleagues. If there is uncertainty that a small lesion may not be a brain metastasis, then I will elect to follow with a surveillance MRI and treat in the ...
Does CEA still have a role instead of stenting for surgical management of asymptomatic carotid artery disease?
In most patients with asymptomatic high-grade stenosis, stenting is preferable to endarterectomy based on the results of CREST-2. In a small percentage of such patients, stenting may not be technically feasible. Also, some patients may not want to take the medications usually prescribed after stenti...
Has MR spectroscopy ever led you to forego a planned stereotactic biopsy in a patient with a suspected intracranial neoplasm?
I have never had spectroscopy allow me to forego a stereotactic biopsy when I suspected active/progressive neoplasm; however, if I suspected necrosis more than recurrence or tumor and spectroscopy was in accordance with that, then I have been able to save people a biopsy in that situation.
Do you incorporate MR Spectroscopy into preoperative planning for brain biopsies for suspected new brain tumors?
Yes, when possible.
How do you determine which type of re-vascularization technique is appropriate to treat a patient with Moya Moya disease?
There are 2 types: indirect and direct. The direct bypass involves suturing a branch of the STA to a cortical branch of the MCA. This is by far the best method to treat ADULT cases. In children, the INDIRECT method, which is easier and does not involve direct suturing of arteries together, is usuall...
How would you approach patients with clinical symptoms of cervical myelopathy without myelopathic signs and mild to moderate spinal canal compression?
If a patient has clinical symptoms of cervical myelopathy without myelopathic signs and mild to moderate spinal cord compression, I usually discuss with the patient the pros and cons of a surgical procedure to give the spinal cord more room. My decision-making also depends upon things like the patie...
How would you manage an enlarging brain metastasis that has progressed in size three months after radiosurgery?
Before making a decision, I would want to know the tumor histology, SRS dose delivered, and whether the current site of progression is truly within the prior radiation field (using new MRI fused to the SRS plan in treatment planning software). If the lesion is within the high-dose region and the pat...
How do you determine the timeline for healing after craniotomy prior to starting chemotherapy and radiation?
I typically wait at least 10-14 days post-op, always after neurosurgery has re-evaluated the craniotomy site for appropriate healing and has already removed staples or sutures.