Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
How do you decide when to place a drain after a subdural hematoma evacuation?
Drain use following chronic subdural hematoma drainage has long been controversial. The risk of brain injury while placing subdural drains has been well described and should be carefully considered when making the decision to do so. On the other hand, studies have demonstrated that subdural drains r...
What is you approach to management of a traumatic pseudoaneurysm for a patient who has a concurrent traumatic ICH?
If the aneurysm is ruptured, then I treat acutes similar to a ruptured sacular aneurysm. If it is unruptured, then I get a short interval follow-up CTA in 3 days. If enlarging, then treat. If stable, then I will manage conservatively with serial imaging follow-up.
How do you approach treatment and management of angiogram negative non-aneurysmal subarachnoid hemorrhage?
We repeat the catheter-based angiogram 7-10 days after the initial angiogram negative angiogram. MRI of the brain, including the spine, if SAH is predominantly in the posterior fossa.
What is your approach to clearing the cervical spine in intubated patients more than 24 hours after their initial injury?
I think the answer to this depends upon the suspicion of injury. This then goes back to what was the incident that caused concern for clearing the cervical spine. Many times, we rely upon the CT scan of the cervical spine, and we look for fractures, dislocations, or soft tissue swelling. If the conc...
What is your approach to a reherniated lumbar disc that was initially treated with a minimally invasive hemilaminectomy and discectomy?
I am a firm believer that you can always do more for someone and you cannot undo anything you do. Barring any instability on imaging, I routinely perform a redo microdiscectomy. There are some case series to suggest a spinal fusion may provide a more definitive and sustained amount of relief in some...
How does the TOBAS SRS registry change your approach to small AVMs in deep eloquent areas with prior rupture?
I emphasize that SRS is a reasonable attempt to reduce risk with about a 50–65% chance of cure at three years and a roughly 1 in 6 chance of a serious complication, including a 1 in 20 risk of another hemorrhage during follow‑up, and a 5-10% risk of brain injury from radiation-induced changes Micros...
Under what circumstances would you start steroids for a patient with a new brain tumor prior to biopsy or resection?
In my opinion, for all brain tumors regardless of type, steroids should be initiated if it is felt that perilesional edema is the predominant cause of presenting symptoms or the amount of perilesional edema is large enough to cause midline or trans-tentorial shift, even if asymptomatic. Otherwise, f...
When would you consider a posterior approach for patients with a cervical radiculopathy and foraminal stenosis without central stenosis?
I consider it mainly in older patients >70 years old with unilateral radiculopathy and an already-present disc space collapse at the index level.
When do you order an MRA to better evaluate results from a CTA?
MRA is better for aneurysms that have been coiled (too much artifact on CTA). CTA is better for aneurysms that have been clipped (too much artifact on MRA). MRA usually focuses on the Circle of Willis. The rare distal MCA/ACA/PCA aneurysms may be missed. In contrast to CTA, MRA does not require cont...
How do you choose between titanium and cobalt-chromium rods in a patient undergoing multilevel posterior spinal fusion?
I very much favor titanium due to its increased ductility (with improved MRI compatibility as an extra). It is critical to remember that the instrumentation is there solely to stabilize until fusion occurs, NOT to substitute for fusion-related stability. If you are a strong advocate of anterior colu...