Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
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 ...
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.
What patient factor led to performing a direct bypass rather than an indirect bypass for treatment of moyamoya?
The honest answer is that the evidence for selecting a direct or indirect bypass is limited and imperfect. There are no large randomized controlled trials and most data comes from retrospective cohort studies and meta-analyses. The key factors favoring direct bypass for moyamoya are age, cerebrovasc...
What is your treatment strategy for pregnant patients with newly discovered prolactinomas?
There are a few factors in this decision, with lots of subtle variations. Some factors to consider are: 1) how big is the tumor (microadenoma versus macroadenoma), and 2) are there any symptoms other than elevated prolactin (e.g., visual field defect)? Assuming there are no major compressive symptom...
For patients who have 4 levels of ventral cervical compression, how do you determine whether to do an anterior or posterior approach?
If most of the pathology is anterior, then I go anterior. Most of the time, this is the case. If it’s posterior, then I go posterior. Rarely would I need to do both.
In patients with medically-refractory left temporal epilepsy, and left dominant language and memory, how should you approach surgical intervention?
Dominant temporal lobe epilepsies are often not candidates for hippocampal ablation or anterior temporal lobectomy because the risk for memory decline is deemed to be too high. Although having left temporal lobe epilepsy does not rule out the possibility of a resective/ablative surgery, in your part...
Under what circumstances would you place an EVD for Hunt Hess 1 or 2 patients with subarachnoid hemorrhage secondary to a ruptured cerebral aneurysm?
I would place an EVD for a ruptured aneurysm in patients who are clinically doing very well (Hunt Hess 1 or 2) if they have imaging evidence of ventriculomegaly.