Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
What is your approach to treating babies with IVH secondary to prematurity and a full but soft fontanelle?
The fontanel in a baby can be very deceiving. Studies in trauma have shown that even experts have trouble discerning intracranial pressure based on the fontanel fullness, so in itself it should not be a deciding factor. In this day and age, most hospitals are using the ELVIS protocol to help determi...
What factors do you consider for surgical timing for management of a large pituitary mass with suprasellar extension?
There are several factors to consider for management of a large pituitary mass with suprasellar extension. The number one consideration is the presence of visual symptoms, their severity, and their duration. Tumors that are slow-growing may cause fairly substantial optic nerve/chiasm compression, bu...
What activity restrictions do you counsel patients on after radiosurgery for arteriovenous malformations, given the continued risk of hemorrhage until nidus obliteration?
Prior to radiosurgery for an arteriovenous malformation, I counsel patients that the risk of hemorrhage is not immediately eliminated by treatment and may persist until the nidus is completely obliterated, which can take several years. Therefore, posttreatment follow-up and clinical surveillance rem...
Do you recommend additional spinal MRI’s for an asymptomatic Chiari I malformation?
Age does not matter; the severity of the Chiari does. Although subjective, I would image the spine if I thought the foramen magnum was crowded enough to potentially cause a syrinx. I am not a big believer in "a high incidence" of tethered cord in the Chiari I population, so this concern would play i...
Under what circumstances would you consider decompressing the cystic part of a cystic brain mass prior to resecting the nodule?
When the tumor nodule is near the surface, heading straight for the tumor may be reasonable. If the tumor is more hidden, sometimes we try to leave the cyst intact to make sure the navigation is still very accurate until we at least see the tumor a bit. There are other times when the best access to ...
How often do you monitor pituitary adenomas once established as non-functioning?
That depends on the size and location (close to the chiasma?). Without pathology, which may help determine aggressiveness (mitotic rate, Ki67), it is impossible to predict the growth rate. For macros, I repeat an MRI in 6 months, and, if no change, I double the interval. For micros, there is recent ...
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 ...
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.
Under what circumstances do you consider a biopsy for a patient with a new brain lesion who is undergoing active systemic cancer treatment?
Indications for biopsy would be rare: First - if the brain lesion is dural-based and slow-growing, and the patient has excellent systemic control. Second - if the brain lesions are progressing despite standard radiation therapy. Third - if control of CNS disease is being done using CNS-penetrating t...
How do you determine when to use a standalone cage during an extension of an anterior cervical fusion?
Standalone cage for extension of ACDF is a good option to limit the invasiveness of surgery, in the right conditions. Solid prior fusion, good bone quality, absence of significant segmental instability, and single-level disease are all factors that would make it a reasonable, favorable option.