Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
How has the EMBOLISE trial changed your practice regarding concurrent subdural hematoma evacuation and MMA embolization?
We prefer concurrent with Borvo/SEPS and embo in the angio suite; however, if the patient presents after hours, we do Borvo/SEPS upon presentation and embo the next day. Basically, two procedures under local and sedation, either together or part-based on convenience.
In the case of concomitant tethered cord and Chiari malformation with syringomyelia, how do you determine priority of treatment?
I am an old-fashioned physician in addressing this interesting question. The answer depends on the clinical symptoms and the degree of disability the patient is experiencing. This means performing a careful clinical assessment of what is the major problem the patient is having and how surgery would ...
Under what circumstances do you consider duraplasty for Chiari 1 decompression?
I always place a duraplasty for Chiari 1 to increase the space around the tonsils and attempt to resume normal biphasic flow of CSF anteriorly and posteriorly.
What is the best approach in a patient with a single brain metastasis in the setting of progressing systemic disease?
There is no single "best approach" for a single brain metastasis, even in the setting of progressing systemic disease. First, ask if it is obvious that a single lesion is a brain metastasis. The patient needs to be made aware that the diagnostic error rate can be as high as 15%. If unsure, then tiss...
What criteria do you use to select elderly patients for focused ultrasound thalamotomy?
Elderly patients are perfectly suitable for MRgFUS treatment and are considered if their tremor is resistant to appropriate medical therapy, including propranolol and/or primidone. It should be equal to or greater than 2 on the FTM scale for tremor, and interfere substantially with daily activities ...
Under what circumstances would you use onyx rather than coils to treat a ruptured aneurysm?
Onyx is rarely used for the typical ruptured saccular aneurysm, given the range of excellent endovascular alternatives: coils, flow diverters, and intrasaccular flow disruptors such as the WEB device. Its current role is as a liquid embolic for vessel sacrifice in complex fusiform or dissecting aneu...
When do you consider treatment with temporal bone windows to decrease intracranial pressure for patients with Idiopathic Intracranial Hypertension?
I would consider this an outdated operation. There are several better ways of treating this.
For patients with hydrocephalus secondary to leptomeningeal disease, how do you determine what type of shunt device to place?
For my small part, please ask neuro-oncology if they plan to use intrathecal chemo (and need a hybrid with Ommaya).
When do you consider EVD in pediatric severe TBI when initial imaging is unremarkable?
The guidelines state that intracranial pressure monitoring is indicated for severe TBI when GCS is 12 or less, regardless of what the head imaging looks like. Either a bolt or an EVD can be used for measuring intracranial pressure. In cases where our index of suspicion for elevated intracranial pres...
What is your approach to the management of a patient with traumatic unilateral perched facets?
I like to have a go at awake closed reduction under fluoro, with flexion, contralateral lateral bending, and rotation toward the side of the injury. That is purely an option, however. Since this deformity is reducible from either front or back, the ORIF approach is the dealer’s choice, although the ...