Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
For a patient with large volume glioblastoma, what do you do if they are found to have a subdural infection in the middle of chemoRT requiring repeat surgery?
In this scenario, the patient will likely stop the daily treatments for a variable period of time that I would estimate to be measured in weeks while recuperating from surgery and receiving IV antibiotics. When cleared for radiation, I would start by doing a new Simulation using an updated MRI to ac...
Do you routinely obtain a biopsy of a presumed meningioma prior to SRS to confirm grade 1?
There is an emerging and growing body of data using various AI tools and radiomics analysis, as well as the incorporation of advanced imaging, that aim to improve the ability to predict the grade of meningioma. Most of this work remains "limited institution" in terms of applicability. In the current...
For large AVMs that cannot meet the V12 dose constraint, how low are you willing to go in terms of single fraction dosing?
We usually use a “volume staging” approach by treating part of the AVM to 18-20 Gy in one fraction (meeting the V12 dose constraint), and return to treat the remaining nidus about 2 years later. Generally, most or all of the treated nidus has occluded by then. There will, of course, be some dose ove...
What is your approach to counseling families who's loved one has a progressive malignant brain tumor but is not a surgical candidate?
Thank you for the question. There are two scenarios for answering this question. If I were involved in taking care of the patient during initial treatment up to this point and know the patient and family well. My approach to counseling in this scenario begins with understanding their experience and ...
How do you decide which patients would benefit from ECAP-closed loop spinal cord stimulation?
The EVOKE trial enrolled patients with chronic, intractable back and leg pain refractory to conservative therapy - including both persistent spinal pain syndrome (PSPS) type 1 and 2, with the following eligibility criteria: Overall, back, and leg pain VAS ≥60 mm Oswestry Disability Index 41–80 Stab...
For which patients would you consider offering a spinal cord stimulator for management of autonomic dysfunction?
The use of SCS for its effects on the autonomic nervous system is one of the more interesting applications of neurostimulation. We’ve known for years that SCS has a potent sympatholytic effect, and it has been used for peripheral and cardiac ischemia extensively. This use has been more prevalent in ...
How do you approach management of a patient with a VNS device that is having impedance challenges?
We always take an X-ray to ensure that there is no obvious disconnect or breakage of the lead. If not, we prepare to replace the electrode, including consent and surgical prep. If we can resolve the impedance issue by checking or tightening the connection to the IPG, then we will do so and close. If...
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...