Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
How would you empirically manage a large sellar/suprasellar mass with encasement of the right cavernous and terminal internal carotid arteries?
Knowing the histology of the mass would really help in creating more accurate treatment recommendations. A biopsy of a sellar mass is usually accomplished by an endonasal-endoscopic transsphenoidal approach utilizing the expertise of an ENT surgeon and a skull-base neurosurgeon. However, in this cas...
How do you determine when to change an EVD in a trauma patient that may not need a shunt?
The keyword here is “change”. I don’t routinely change an EVD based on time. I believe the actuarial data suggest that the major risk of infection is during insertion/replacement, showing up days later due to progression rather than subsequent inoculation. This obviates any indications for routine, ...
When placing a shunt at birth for hydrocephalus secondary to IVH, how do you decide between a programmable and non-programmable shunt?
In infants, I exclusively use programmable shunts. My feeling is that shunt requirements change as the child grows and the fontanelle ultimately closes. Over the first year of life, I titrate the resistance of the shunt to the maximal setting tolerated by the child. I use developmental milestones, p...
How do you determine timing for surveillance imaging for an asymptomatic patient who was incidentally found to have a meningioma?
Timing for surveillance imaging of an incidental, asymptomatic meningioma is a risk-stratified decision that balances tumor biology, radiographic features, patient factors, and anatomic context. Start with baseline risk characterization. The most important determinants are tumor size, location, imag...
What is your approach to a completely resected WHO grade II meningioma?
Any attempt toward a definitive answer to this question will at best be too cursory and at worst will jar Pandora’s box, but let’s give it a shot. How to optimally approach patients following gross total resection (GTR) of a WHO grade 2 meningioma remains sufficiently uncertain that 2 randomized tri...
Can SRS be used to treat an atypical meningioma?
I agree with @Dr. First Last, and approach patients with atypical meningioma in the same fashion, preferring IMRT to SRS. Indeed most publications have used fractionated external beam therapy, but several centers have published results with SRS. I encourage anyone to have a close look at these. The ...
Among patients with secured subarachnoid hemorrhage who are receiving daily TCDs, what is the appropriate frequency of post operative neurological assessments?
I think a textbook might state something like "every 1-2 hours in the acute setting." However, in my opinion, the frequency of neurological examinations should be tailored to the individual patient and involves considerable clinical judgement. Factors that might influence this decision include a) se...
How do you decide what type of spinal cord stimulator to utilize for pain control?
If by “type” we mean percutaneous vs. paddle, they each have pros and cons. Perc leads are less invasive and can have a greater craniocaudal span. Paddles can be more power efficient, have more programming options in a mediolateral dimension, but are more invasive to place. I generally favor paddles...
Do you recommend a prolonged duration of antibiotics and/or suppression for patients without pre-existing hardware who have placement of new hardware after decompression/washout of a Staphylococcus aureus epidural abscess?
If the hardware is placed in the setting of active infection, then I usually chronically suppress the patient indefinitely after treating for the acute infection.
Under what circumstances would you consider using the robot rather than stealth for image guided screw placement?
Largely, robotics in spine surgery serves as an adjunct to spinal navigation, utilizing similar platforms but paired with a rigid arm. Robotics does allow for preoperative planning of hardware placement that can be performed on a thin-sliced CT and merged with intraoperative imaging with fluoro or C...