BACKGROUND AND IMPORTANCE:With the wide availability of MRI for brain and cervical spine complaints, adult patients are diagnosed with Chiari I malformation (CMI) frequently. Although there are few reports of spontaneous resolution of CMI in adults, it is important to consider when choosing conservative vs surgical management in minimally symptomatic and asymptomatic patients. CLINICAL PRESENTATION:A woman presented at age 55 with a 2-year history of left-sided headaches and left facial numbness. MRI brain demonstrated cerebellar tonsillar ectopia 12 mm below the foramen magnum. Owing to atypical symptoms, surgical management was not recommended. She presented 10 years later with dizziness and gait disturbance. MRI cervical spine showed resolution of cerebellar tonsillar ectopia and no syringomyelia. CONCLUSION:We identified 7 cases of spontaneous regression of adult CMI in the literature. Unlike the previous cases, this patient never had definitive symptoms attributable to CMI. This case illustrates radiographic resolution of cerebellar tonsillar ectopia and strengthens the argument for conservative management in patients with radiographic cerebellar tonsillar ectopia and atypical symptoms.
BACKGROUND AND OBJECTIVES:Spinal epidural teratoma (SET) is a rare spinal tumor, particularly in the pediatric population. Because of its rarity and potential for extensive growth into both intraspinal and extraspinal compartments, surgical strategies are not well-standardized. This study aims to describe a successful 2-stage surgical approach for an extensive infantile SET and review the existing literature. METHODS:A 1-month-old male infant presented with a large SET extending from T4 to L2 and into the posterior mediastinum. A two-stage surgical approach was performed to achieve gross total resection (GTR). The intraspinal tumor was removed using a split-spinous process laminotomy from T7 to L3. This technique used the natural flexibility of the infant's vertebral arches to create an "open-door" access without detaching the paravertebral muscles. The second surgery was performed 1 month later for the remnant tumor located inside the posterior mediastinal space. The intrathoracic tumor was removed using a thoracoscope with only three 5-mm ports and a small incision for specimen extraction. RESULTS:Histopathology confirmed a mature teratoma. Postoperative MRI demonstrated GTR. The patient remained neurologically intact and was discharged without respiratory or surgical complications. At the 16-month follow-up, there was no evidence of recurrence or spinal deformity. A literature review identified only 10 previous cases of pediatric SET, highlighting a male predominance and a high frequency of multilevel extension. Paraparesis was common in most cases, whereas 2 infants presented with dyspnea because of mediastinal compression. Histologically, all except 1 case were mature teratomas, and all cases treated with GTR remained recurrence-free. CONCLUSION:GTR is the gold standard for pediatric SET because of its histologically mature nature. A staged approach with "open-door" split-spinous process laminotomy and thoracoscopic surgery was an effective strategy. Reducing surgical stress is essential in fragile infants with extensive SETs.
BACKGROUND AND OBJECTIVES:The thalamus, a neural processor and integrator for forebrain activities, is an uncommon site for metastatic lesions. Stereotactic radiosurgery (SRS) has become a noninvasive treatment for brain metastases. This study assesses the efficacy, safety, and outcomes of SRS in patients with thalamic metastases, focusing on local control, overall survival (OS), progression-free survival, neurological outcomes, and treatment response factors. METHODS:We retrospectively reviewed cases of thalamic brain metastases treated with SRS at our institute between 2002 and 2024. A total of 49 lesions from 47 patients were included. Statistical analyses were performed logistic regression, the χ2 test, the t-test, and the Mann-Whitney U test. Survival outcomes were assessed using Kaplan-Meier analysis, and model performance was evaluated using receiver operating characteristic analysis. A literature review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines supplemented the analysis. RESULTS:The median OS was 18 months (95% CI, 9.4-26.6). The median age at diagnosis was 60 years; 61.7% were female. Primary tumor histology included non-small cell lung cancer (46.8%), breast cancer (14.9%), and small cell lung cancer (10.6%), among others. The median size of metastases was 1.0 cm with a mean volume of 2 cm3. The median prescribed dose was 22 Gy. Higher maximum radiation doses were associated with lower tumor recurrence (P = .042). Cumulative 6-, 9-, 12-, and 24-month local control rates were 100%, 90%, 82.5%, and 78%. OS rates were 78.7%, 70.8%, 68.2%, and 40.4%, respectively. CONCLUSION:Our results showed sufficient local control after treatment. SRS demonstrates efficacy and safety in managing thalamic metastases, with high local control rates over time, supporting its role as an effective treatment option.
BACKGROUND AND OBJECTIVES:Neurosurgery remains one of the most competitive residency specialties in the United States. For applicants, particularly international medical graduates (IMGs), preresidency fellowships (PRFs) have emerged to strengthen applications through research, clinical exposure, and mentorship. However, data on the effectiveness of PRFs in improving residency match outcomes remain limited. This study aims to assess the utility of neurosurgery PRFs in enhancing applicant preparedness, clinical competency, and match success. METHODS:A cross-sectional survey was distributed to current and former neurosurgery PRF participants in the United States between October 2024 and March 2025. Data collected included demographics, match outcomes, and perceptions of PRF utility. Likert scales and composite rankings were used to evaluate experiences and factors contributing to successful or unsuccessful match outcomes. RESULTS:Of 58 publicly identifiable fellows, 33 responded (57% response rate), most of whom (61%) were non-US IMGs. Among those who participated in the match (n = 30), 57% successfully matched into neurosurgery. PRFs were rated as extremely or very useful by 68% of respondents, with the most valued factors for success being PRF experience, letters of recommendation, and research productivity. Respondents who did not match cited low board scores and lack of neurosurgery mentorship as primary barriers. Most participants (88%) reported that they would recommend PRFs to future applicants. CONCLUSION:PRFs serve as valuable preparatory programs that improve match outcomes, especially for IMGs. They enhance clinical exposure, academic productivity, and access to mentorship. Further standardization and expansion of PRFs could increase accessibility and support equity in neurosurgical training pathways.
BACKGROUND AND OBJECTIVES:To determine whether preoperative frailty [5-item/11-item modified frailty index (mFI-5/mFI-11)] independently predicts length of stay (LOS) and early facial nerve function after vestibular schwannoma (VS) resection when adjusting for tumor and operative factors at a single center with standardized postoperative care. METHODS:This was a single-center, institutional review board-approved, retrospective review of consecutive adults undergoing microsurgical VS resection from 2014 to 2025. Candidate predictors included mFI-5, mFI-11, age, temporal muscle thickness, tumor size, surgical approach, preoperative nonauditory cranial nerve deficits, immediate postoperative facial nerve function, and ventriculoperitoneal shunt requirement. Primary outcomes were LOS (days) and House-Brackmann (HB) grade at discharge, modeled with negative binomial and cumulative odds ordinal logistic regression, respectively (two-sided α = 0.05). RESULTS:Among 192 patients, larger tumor size was independently associated with longer LOS (adjusted incidence rate ratio [IRR] 1.16 per cm, 95% CI, 1.03-1.31) and worse early facial nerve outcomes. The translabyrinthine approach was associated with shorter LOS than retrosigmoid (IRR 0.72, 95% CI, 0.53-0.96) and ventriculoperitoneal shunt prolonged hospitalization (IRR 2.51, 95% CI, 1.63-3.86). Discharge HB grade was most strongly associated with preoperative HB grade. In contrast, mFI-5 and mFI-11 were not independently associated with LOS or discharge HB (mFI-5 LOS IRR 1.14, 95% CI, 0.99-1.32, P = .07; mFI-11 IRR 1.08, 95% CI, 0.98-1.20, P = .13). Higher mFI-5 was associated with nonhome discharge univariably (P = .017). Substituting individual comorbidities for frailty indices did not materially alter findings. CONCLUSION:In VS microsurgery, tumor size rather than frailty was the dominant correlate of early postoperative outcomes after adjustment. Because frailer patients are often selected out before elective surgery, the null adjusted association does not prove frailty is clinically irrelevant but reflects its limited incremental value among already-fit patients. Counseling should prioritize tumor characteristics and surgical approach. These hypothesis-generating findings warrant prospective multicenter confirmation.
BACKGROUND AND OBJECTIVES:Subcortical glioblastomas present surgical challenges owing to their proximity to critical anatomy. In this study, we assessed the utility of laser interstitial thermal therapy (LITT) in the management of subcortical glioblastomas. METHODS:Clinical outcomes were evaluated in 80 consecutive patients with subcortical glioblastoma (isocitrate dehydrogenase wild-type, H3K27 nonmutant) treated surgically between 2017 and 2025. During this time period, LITT was increasingly incorporated into stereotactic needle biopsy (SNB) and surgical resection (SR) workflows, enabling comparisons between SNB vs SNB + LITT and between SR only vs planned subtotal resection (STR) + LITT. RESULTS:Among 46 treatments involving SNB, 24 underwent SNB only and 22 SNB + LITT. Lesion size was similar between these groups (1.72 ± 0.38 vs 1.92 ± 0.36 cm, P = .07), with comparable procedural morbidity (4.2% vs 4.5%, P = 1.0). In newly diagnosed glioblastoma, SNB + LITT was associated with improved overall survival compared with SNB alone (median 375 vs 162 days, P = .0012). Thirty-four patients underwent resections (18 SR, 16 STR + LITT). Lesion size was comparable between these cohorts (3.77 ± 0.68 vs 3.74 ± 0.83 cm, P = .9) as was the extent of cytoreduction (77.8% vs 93.8%, P = .34), but STR + LITT was associated with fewer permanent postoperative deficits (0% vs 27.8%, P = .047). Survival did not differ between STR + LITT and SR (median 368 vs 289 days, P = .43). Across all patients, postoperative motor deficits were associated with worse survival (112 vs 254 days, P < .001). CONCLUSION:Our results support incorporating LITT as a staged procedure into planned STR or in conjunction with SNB in the management of subcortical glioblastoma. Postoperative motor deficit is associated with poor survival outcomes.
BACKGROUND AND OBJECTIVES:External ventricular drain (EVD) placement is a routine neurosurgical procedure for cerebrospinal fluid (CSF) diversion. Despite standardized procedures, a considerable risk of infection remains. While CSF EVD-related infections (EVD-RI) are common and have been extensively studied, surgical site infections (SSI) as a distinct subset are, at least when compared with CSF EVD-RI, relatively rare and remain poorly understood in the context of EVD placement. Hence, the aim of this study was to determine the incidence and risk factors of SSI after EVD placement. METHODS:All consecutive adult patients undergoing EVD placement at a single neurosurgical center between January 2014 and April 2022 were included in this study. SSIs were defined according to the Centers for Disease Control and Prevention criteria for SSIs and were subsequently classified and managed in accordance with the institutional neurosurgical SSI guidelines. Patient-related and procedure-related factors were assessed for their role as independent predictors or confounders using a purposeful variable selection procedure, as proposed by Hosmer and Lemeshow. RESULTS:A total of 384 patients (418 EVDs; 34 bilateral) were included in this study. The incidence of SSI was 2.9% per patient and 2.6% per catheter. Factors associated with a significantly higher risk of SSI after EVD placement included concurrent CSF EVD-RI (odds ratio [OR] = 40.50, 95% CI: 7.17-399.29; P < .001), obesity (OR = 21.40, 95% CI: 2.08-200.81, P = .006) and arteriovenous malformation (OR = 50.27, 95% CI: 3.06-1124.25, P = .007) as an indication for EVD placement, whereas angiography was associated with a significantly lower risk (OR = 0.073, 95% CI: 0.010-0.45, P = .005). CONCLUSION:Postoperative SSI after EVD placement is a relatively rare, potentially preventable, and clinically and economically relevant complication. Both patient- and procedure-related factors influence SSI risk, with obesity and concurrent CSF EVD-RI emerging as strong predictors, highlighting the importance of meticulous perioperative management and vigilant postoperative surveillance, particularly in these risk groups.
BACKGROUND AND OBJECTIVES:Preserving the quality and integrity of resected tumor tissue is essential to ensure the reliability of downstream analyses. The effects of ultrasonic aspirators (UAs) on cellular viability, tissue morphology, and molecular quality remain poorly characterized. This study directly compares tissue quality after collection by conventional sharp dissection (SD) vs UA. METHODS:Paired tumor specimens were collected intraoperatively from 28 patients undergoing surgical resection of intracranial tumors. Samples collected by SD and UA were obtained from immediately adjacent regions. Cellular viability was assessed by automated cell counting. Tissue architecture was evaluated on hematoxylin and eosin-stained sections. Adherent monolayer cultures were established from paired specimens. RNA concentration and functional integrity were assessed by spectrophotometry and quantitative polymerase chain reaction of 4 housekeeping genes (GAPDH, TBP, HPRT1, and PGK1). RESULTS:Cellular viability was higher in SD compared with UA specimens (80.25% ± 9.70% vs 72.33% ± 9.52%; P = .0364). Higher UA power settings inversely correlated with cell viability (P = .0490). Histopathological examination confirmed diagnostic adequacy of both methods. Cell culture establishment was successful for all specimens. RNA concentration was significantly greater in SD vs UA specimens (median 88.8 vs 14.2 ng/µL; P = .0420). Despite differences in RNA yield, housekeeping gene amplification was comparable across methods (all P > .05). CONCLUSION:SD preserves cellular viability, RNA concentration, and tissue architecture more effectively than ultrasonic aspiration. However, both methods yielded tissue suitable for histopathological diagnosis and in vitro culture. These findings support a dual-collection strategy.
BACKGROUND AND OBJECTIVES:Skull base surgery requires precise 3-dimensional (3D) anatomic understanding and advanced drilling techniques within a confined operative space. Although cadaveric dissection remains the gold standard for training, its availability is limited. This study aimed to evaluate the educational utility of a commercially available full-skull 3D model for skull base surgery training. METHODS:A full-skull 3D model reproducing the cranial base and brain was used in a hands-on training session involving 8 neurosurgeons, including 2 residents and 6 board-certified surgeons. Multiple skull base approaches were practiced. In addition, a patient-specific tumor model generated from clinical imaging data was incorporated to simulate pathological anatomy. Participants completed a questionnaire using a 5-point Likert scale to assess bone hardness, anatomic accuracy, realism, drilling sensation, safety and usability, and overall satisfaction. RESULTS:Overall satisfaction with the model was high across all evaluation categories. Anatomic accuracy, realism, and usability received high mean scores. Overlay visualization of individual responses demonstrated consistent trends without reliance on inferential statistics. Qualitative feedback indicated that the model was particularly useful for understanding spatial orientation and approach selection, whereas limitations were noted regarding tactile realism, including uniform bone hardness and dural texture. CONCLUSION:The full-skull 3D model demonstrated substantial educational value as a supplementary training tool for skull base surgery. By enabling repeated practice, approach comparison, and patient-specific simulation, this model may complement cadaver-based training, particularly for early-stage neurosurgeons. Further studies with larger cohorts are warranted to establish its role within structured skull base education programs.
BACKGROUND AND IMPORTANCE:Dysplastic and polylobulated aneurysms of the posterior inferior cerebellar artery (PICA) present significant technical challenges because of their irregular geometry and proximity to the lower cranial nerves and brainstem perforators. When endovascular options carry elevated risks, microsurgical clip reconstruction remains a definitive treatment to restore the vascular architecture. CLINICAL PRESENTATION:A 46-year-old woman presented for the elective surgical management of an unruptured, polylobulated left PICA aneurysm. She had a history of subarachnoid hemorrhage secondary to a ruptured anterior communicating artery aneurysm, which was successfully clipped alongside an unruptured right middle cerebral artery aneurysm in November 2024. Interdisciplinary case discussion considered endovascular treatment, including flow-diverting stents; however, the patient was unwilling to take dual antiplatelet therapy (aspirin and clopidogrel), and digital subtraction angiography demonstrated complex polylobulated morphology with multiple small perforators arising from the aneurysm base, making endovascular therapy high-risk. Microsurgical intervention was chosen because the surgical approach allowed for direct visualization and safe control of the aneurysm and surrounding neurovascular structures. A left medial suboccipital craniotomy with a subtonsillar approach was used. Stepwise reconstruction was performed using 2 straight mini clips (Aesculap No. 710 and 720) under continuous intraoperative neuromonitoring, including somatosensory evoked potentials, motor evoked potentials, and cranial nerve IX-XII electromyography. Multimodal verification, including microvascular Doppler, aneurysm puncture, and indocyanine green videoangiography, confirmed complete aneurysm obliteration and preservation of the parent vessel and perforators. The patient was discharged on postoperative day 4 without neurological deficits. Follow-up at 3 months confirmed favorable clinical and radiological outcome. CONCLUSION:For complex PICA aneurysms, a systematic approach incorporating subtonsillar exposure and multimodal intraoperative verification helps ensure complete exclusion while protecting the local neurovascular circulation.
BACKGROUND AND OBJECTIVES: Posterior clinoid process meningiomas (PCPMs) are extremely rare tumors arising from the central skull base and are surgically challenging because of their proximity to critical neurovascular structures. Although endoscopic endonasal approaches have been reported for small lesions, an optimal strategy for medium-to-large PCPMs remains controversial. To evaluate the surgical technique and clinical outcomes of the minimal anterior and posterior combined (MAPC) transpetrosal approach for medium-to-large PCPMs. METHODS: We retrospectively reviewed 5 consecutive patients with PCPMs who underwent microsurgical resection by the MAPC transpetrosal approach between 2018 and 2024. This approach involves limited petrous bone drilling combined with wide opening of Meckel's cave to mobilize the trigeminal nerve, providing a posterolateral corridor between the trigeminal and trochlear nerves. Surgical outcomes, extent of resection, complications, and follow-up results were analyzed. RESULTS: The mean patient age was 54.6 years, and the mean tumor diameter was 33.7 mm. Gross-total resection was achieved in 2 patients (40%) and subtotal resection in 3 (60%). Transient cranial nerve deficits, mainly involving oculomotor nerves, occurred postoperatively but improved within 3 months. No surgery-related mortality, cerebrospinal fluid leakage, visual deterioration, or vascular complications occurred. Adjuvant stereotactic radiosurgery or radiotherapy was performed for residual tumors in 2 patients. During a mean follow-up of 55 months, no tumor recurrence was observed. CONCLUSION: The MAPC transpetrosal approach provides a safe and effective surgical corridor for medium-to-large PCPMs and enables maximal safe resection with acceptable morbidity.
BACKGROUND AND OBJECTIVES:Posterior fixation of the cervical spine (PFC) is commonly performed with rod-connected screws inserted in the vertebras. Because of the many sensitive structures located adjacent to the vertebras, computer-assisted navigation is often used with PFCs. We assessed safety and efficacy of free-hand placed PFCs. METHODS:We retrospectively identified all the patients in our institution between Januray 2006 and December 2016 who underwent a primary PFC for any indication. The postoperative images and medical records were evaluated for possible clinical failures, which was considered as a reoperation to cervical spine within 1 year after primary surgery for any reason, or a new screw-related adverse event including nerve root injury, spinal cord injury, or vertebral artery injury. RESULTS:In total, 332 patients and 1476 screws were included in the study. The evaluated screws were primarily pedicle and lateral mass screws. The rate of screw malposition was 12% (171/1476). The overall rate of clinical failure was 16% (52/332) and was significantly higher in patients with screw malposition than in those without malposition (24% vs 12%, P = .03). The rate of screw insertion-related clinical failure was 6.0% (20/332). The C7 pedicle seemed to be more prone to screw malposition than other locations (26/86, 30%). CONCLUSION:Clinical failure after posterior cervical spine fixation occurs significantly more frequently in patients with screw malposition compared with those without malposition. The overall rate of screw insertion-related clinical failure was 6.0%. These findings suggest that improving screw placement accuracy may reduce the risk of complications.
BACKGROUND AND OBJECTIVES:Cervical spondyloptosis, defined as Grade V spondylolisthesis with complete vertebral body displacement, represents the most severe form of spinal trauma with fewer than 100 cases reported in literature. Despite increasing case reports, optimal surgical management remains controversial, with significant heterogeneity regarding reduction techniques and stabilization approaches. METHODS:We present 2 distinct patients with traumatic C7-T1 cervical spondyloptosis treated at our institution between 2021 and 2023, with differences in neurological presentation and fracture morphology that influenced management decisions. Comprehensive literature review analyzed predictive factors for reduction success and surgical approach selection. RESULTS:Both patients achieved successful anatomic reduction and stabilization. However, neurological outcomes were variable and correlated with initial injury severity. Patient 2 (American Spinal Injury Association C) progressed to near-complete recovery (4+/5 grip strength only) by the 6-month follow-up, while the Patient 1 (American Spinal Injury Association A) showed no motor recovery at the 4-week follow-up and was subsequently lost to long-term care. No hardware failure or loss of reduction occurred. Literature analysis revealed that facet joint morphology is the primary predictor of closed reduction success, with locked facets necessitating open reduction in 67% of cases. CONCLUSION:Cervical spondyloptosis requires individualized surgical planning based on 2 critical decision points: reduction success (predicted primarily by facet joint integrity) and stabilization strategy selection. Single-approach techniques are sufficient when complete closed reduction is achieved, while combined approaches provide optimal stability for complex cases, particularly at the cervicothoracic junction. While successful anatomic reduction can be achieved, neurological recovery remains highly variable and primarily dependent on initial injury severity.
BACKGROUND AND OBJECTIVES:Cerebrospinal fluid (CSF) leakage remains a common and clinically significant complication following skull base surgery, particularly with the translabyrinthine approach for cerebellopontine (CP) angle tumor resection. We aimed to evaluate the safety and efficacy of Foamagen in CP angle tumor resection performed through the translabyrinthine approach. METHODS:Patients undergoing CP angle tumor resection using the translabyrinthine approach were categorized into 2 groups based on the dural closure material: the intervention group received Foamagen, whereas the control group received the standard sealant DuraSeal (Integra LifeSciences). Outcomes included CSF leakage (wound leak or rhinorrhea), surgical site infection, need for lumbar drainage, and reoperation at discharge and at 3-month follow-up. RESULTS:Among 40 patients, 18 were assigned to the Foamagen group and 22 to the DuraSeal group. Baseline characteristics were comparable between the groups. At discharge, the incidence of CSF leakage was low and similar in both groups [5.6% (95% CI: 0.1%-27.3%) vs 4.5% (95% CI: 0.1%-22.8%); risk difference +1.0% (95% CI: -12.7% to +14.7%), P = 1.000]. No significant differences were observed in postoperative infection (5.6% vs 4.5%, P = 1.000), lumbar drain placement (11.1% vs 4.5%, P = .579), or reoperation rates (0% vs 4.5%, P = .369). At the 3-month follow-up, no CSF leakage or abnormal dural thickening was identified in either group. CONCLUSION:In this small exploratory cohort, Foamagen demonstrated outcomes comparable with those of the standard sealant DuraSeal. Foamagen may therefore serve as a safe and effective alternative for preventing CSF leakage following CP angle tumor resection. However, the study was substantially underpowered to establish noninferiority, and larger prospective studies are warranted to confirm this observation.
Combat and sport require individuals to be ready for successful completion of the task at hand. Cognitive readiness and attention may be impaired for many reasons, including concussion or subconcussive injury, insufficient sleep, fatigue, or any other disruption or deviation of baseline physiology. While rapid readiness screening may identify individuals who are not "ready" for a given task, it is also important to find interventions which can rapidly return an individual to a state of readiness. Although general health practices such as nutrition, physical conditioning, and adequate rest support overall performance, targeted interventions-focused on oculo-vestibular, verbal-cognitive function, and motor control-may accelerate return to readiness. Additional modalities such as structured sleep optimization protocols, controlled stimulant use, and specific supplements may also contribute to rapid restoration. This paper describes an evidence-based framework for developing guidelines that identify, evaluate, and implement rapid readiness restoration strategies across diverse preclinical settings, including military far-forward environments, sports sidelines, and garrison or training contexts.
BACKGROUND AND OBJECTIVES:Dorsal root entry zone (DREZ) lesioning is an established treatment of refractory deafferentation pain after brachial plexus avulsion. Exposure often requires multilevel cervical or cervicothoracic laminectomy, which may predispose to postoperative kyphosis. We evaluated whether concurrent posterior instrumented fusion preserves sagittal alignment and reduces delayed deformity after DREZ lesioning. METHODS:We retrospectively reviewed patients undergoing cervical or cervicothoracic DREZ lesioning at a single institution from 2013 to 2025. Patients were grouped by concurrent posterior fusion vs nonfusion DREZ. Radiographic outcomes included C2-C7 Cobb angle, cervical sagittal vertical axis (CSVA), T1 slope, C2 slope, and T1 slope minus cervical lordosis. Nonfusion patients with paired standing radiographs underwent exploratory comparison. Clinical outcomes included pain relief, complications, and reoperation. RESULTS:Twenty-three patients were included: 8 fusion and 15 nonfusion. In the fusion cohort, median follow-up was 16.0 (IQR: 10.9-21.4). Paired standing radiographs were available in 7 of 8 fusion patients and 3 of 15 nonfusion patients. In the fusion cohort, mean C2-C7 Cobb improved from 2.5° ± 23.1° to 18.3° ± 20.8°, whereas CSVA remained stable. All fusion patients maintained postoperative CSVA ≤40 mm, and 7 of 8 maintained T1 slope minus cervical lordosis ≤20°. No fusion patient developed new or progressive postoperative kyphosis. Durable pain relief occurred in 5 of 8 fusion patients and 10 of 15 nonfusion patients. In the nonfusion cohort, postoperative kyphosis was documented in 8 of 15 patients, new or progressive kyphosis/deformity in 5 of 12 evaluable patients, and reoperation for deformity, instability, or radiographic failure in 5 of 15. CONCLUSION:Concurrent posterior fusion during cervicothoracic DREZ lesioning was associated with preserved sagittal alignment and absence of new progressive postoperative kyphosis. Fusion should be considered when DREZ requires extensive multilevel exposure, particularly across the cervicothoracic junction.
BACKGROUND AND OBJECTIVES:Postoperative C5 palsy (CP) is a recognized complication after cervical decompressive surgery for degenerative cervical myelopathy. Although cervical sagittal alignment has been implicated in its pathogenesis, the relative impact of static alignment parameters vs postoperative alignment changes remains unclear. This study aimed to evaluate the association between cervical sagittal alignment and postoperative CP, with emphasis on the magnitude of alignment correction. METHODS:A systematic review and meta-analysis was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. PubMed, Web of Science, Scopus, and Embase were searched from inception to January 2025. Retrospective cohort studies comparing degenerative cervical myelopathy patients with and without postoperative CP and reporting cervical sagittal parameters were included. Outcomes included preoperative values, postoperative values, and magnitude of change (Δ) in C2-C7 lordosis, C2-C7 sagittal vertical axis (SVA), C4-C5 segmental lordosis, T1 slope, T1 slope-cervical lordosis mismatch, and Ishihara index. Standardized mean differences (SMDs) with 95% CIs were pooled. RESULTS:Thirty-seven studies comprising 4948 patients were included, with an overall CP incidence of 10.83%. Static preoperative parameters, including C2-C7 lordosis, C2-C7 SVA, T1 slope, and T1 slope-cervical lordosis mismatch, were not significantly associated with CP. By contrast, patients who developed CP demonstrated significantly greater postoperative increases in C2-C7 lordosis (SMD = 1.04), C2-C7 SVA (SMD = 1.38), C4-C5 segmental lordosis (SMD = 0.44), and Ishihara index (SMD = 1.79). Subgroup analyses showed significant associations in anterior procedures and laminectomy, but not in laminoplasty. CONCLUSION:Postoperative CP is primarily driven by the magnitude of sagittal alignment correction rather than baseline alignment. These findings support a stretch-mediated mechanism related to postoperative spinal cord and nerve root biomechanics and highlight the importance of balanced sagittal correction to reduce the risk of CP.
BACKGROUND AND OBJECTIVES:Intrasacral meningoceles (IM) are a type of spinal meningeal cyst that can develop within the sacral spinal canal and cause sacral radiculopathy symptoms. The research on IM is sparse, comprised largely of case reviews lacking standardization with validated measures. However, a disease-specific health-related quality-of-life scale has been published for Tarlov cysts to measure symptoms before and after surgical treatment. The purpose of this study was to validate the Tarlov Cyst Quality-of-Life (TCQoL) survey as a disease-specific health-related quality-of-life measure for patients surgically treated for symptomatic IM. METHODS:Patients surgically treated for IM between 2016 and 2024 were included. Patients completed preoperative surveys within 2 weeks of surgery and postoperative surveys 6 months after surgery. Surveys included the Short-Form 36, the Oswestry Disability Index, a visual analog scale for pain, and the TCQoL scale. Psychometric analyses including construct validity, internal consistency, sensitivity to clinical change, and discriminative validity were performed to validate the TCQoL. RESULTS:Our cohort included 81 patients. Discriminative validity was demonstrated by significant improvement in each of the 11 items and the overall scale score from preoperative to postoperative (P < .001 for all comparisons). Cronbach alpha was 0.84 for the scale, suggesting good internal consistency. Concurrent validity was established by correlating scale scores of the TCQoL with the Oswestry Disability Index r(79) = 0.68 (0.54, 0.79), P < .001 and all 8 of the Short-Form 36 subscale scores with correlations ranging from -0.19 (-0.45, -0.03) for mental health to -0.59 (-0.70, -0.40) for physical function. The minimum clinically important difference was 0.6. CONCLUSION:We validated the TCQoL for patients surgically treated for IM. This scale can be used as a disease-specific health-related quality-of-life measure that is sensitive to measure clinical change in this population.
BACKGROUND AND OBJECTIVES:Physician compensation models increasingly rely on productivity metrics, with current procedural terminology (CPT) codes and relative value unit (RVU) assignments standardizing procedure complexity and informing reimbursement. Pediatric neurosurgery receives lower RVU assignments than adult counterparts, with many procedures lacking assigned codes despite yearly evaluations. Understanding current coding knowledge, patterns, and interest in change among pediatric neurosurgeons is essential for accurate CPT and RVU alignment with procedure complexity. METHODS:The Pediatric Coding and Reimbursement Committee developed a 24-question survey using Modified Delphi methodology to assess coding habits, knowledge, training, resources, and perceptions within pediatric neurosurgery. The American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Pediatric Section distributed the survey to members in Spring 2024, collecting 119 responses. RESULTS:Response rate for the survey was 21.6%. Overall, 94.2% of the respondents were full-time attendings and the remainder were fellows (3.3%) and residents (2.5%). Although 55.6% code independently or with billing departments, others rely solely on billing assistance. Self-reported coding knowledge was poor, with only 15.7% feeling confident coding without billing support. Notably, 59.3% have never performed formal coding training postresidency, and 30.6% do not know how to find formal training. In addition, 41.6% were unfamiliar with American Association of Neurological Surgeons coding resources. However, 68.6% considered coding "very" important for training incorporation, and 90.2% believed a Pediatric Neurosurgery Coding Manual would be beneficial. Clinical scenarios with unclear coding guidance showed significant practice variability. CONCLUSION:The pediatric coding landscape features predominantly large academic practices with RVU-based compensation, yet individual surgeons report disparities between coding importance and abilities. Despite expressing poor coding knowledge and limited awareness of formal training resources, pediatric neurosurgeons demonstrate high interest in coding education while simultaneously expressing poor coding knowledge and lack of awareness of formal training or online resources. These findings highlight significant opportunities for coding education and standardization within existing CPT architecture, enabling better protection of the field's financial viability through improved reimbursement understanding.
This narrative review elaborates on the development of neurovascular surgery in Nigeria, highlighting the growth over the years. It also elucidates the severe shortage of specialists, the financial burden to patients who may require neurovascular services, and the limited diagnostic and therapeutic equipment. It highlights the critical need for specialized training programs, workforce expansion, infrastructural improvements, sustainable financing, and financial reforms. The authors reviewed the literature narratively and examined, in broad strokes, the historical background of neurovascular surgery in Nigeria, the current practices, outcomes, and training and gave recommendations. Search keywords used include neurovascular surgery in Nigeria, history of neurosurgery in Nigeria, endovascular facilities in Nigeria, and advances in neuroimaging in Nigeria in various combinations using Boolean operators. Searches were conducted in a nonsystematic manner through Public/Publisher MEDLINE, SCOPUS, and African Journal Online. The field of neurovascular surgery experienced significant growth, driven by the contributions of Dr E. L. Odeku in the 1960s and 1970s. However, this progress was hindered by economic and political instability between the 1980s and 2001s. Since the resurgence era began in 2002, substantial advancements have been made. However, the challenges being faced are numerous, and development is quite slow. A multidisciplinary approach is crucial to improving neurovascular care in Nigeria and other low- and middle-income countries, and addressing these deficiencies is essential for optimizing patient outcomes and advancing neurovascular care. This study highlights the state of neurovascular surgery in Nigeria, elucidates the challenges of this practice, and offers recommendations for improvement.
