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Achieving Alignment and Implant-Specific Goals in Anterior Lumbar Interbody Fusion, and Predictors of Postoperative Intradiscal Lordosis

Operative Neurosurgery 31:431–444, 2026

Planning anterior lumbar interbody fusion requires distinguishing the lordosis built into an implant from the additional correction achieved at the treated segment. Hamouda and colleagues examine how baseline alignment, cage characteristics, operative level and posterior fixation contribute to this relationship. By comparing intraoperative and postoperative imaging, their study also addresses whether the correction obtained during surgery is maintained on standing. The findings support individualized alignment planning, while cautioning against interpreting implant geometry or the choice of construct as an isolated determinant of surgical success.

Objective

To identify predictors of postoperative intradiscal lordosis and its change from baseline after one- or two-level ALIF, and to evaluate the relationship between intraoperative supine alignment and early postoperative standing measurements.

Methods

This retrospective, single-center study included 204 adults treated between 2019 and 2023 at 258 levels: 80 at L4–5 and 178 at L5–S1. Ninety patients underwent stand-alone ALIF and 114 received supplementary posterior instrumentation. Patients with prior lumbar interbody fusion, surgery for trauma, tumor or infection, combined interbody approaches, or pelvic fixation were excluded.

The authors reviewed standing preoperative radiographs, intraoperative images and postoperative standing radiographs, obtained a median of two days after surgery. Measurements included intradiscal lordosis, disc height, spinopelvic alignment, implant dimensions and cage position. Separate regression models evaluated the final intradiscal angle and the change from baseline. Median overall follow-up was 12.4 months, although the principal alignment comparisons concerned the early postoperative period.

Main results

Tables 2 and 3 report a median intradiscal lordosis of 6.7° before surgery and 17.8° postoperatively, with a median individual change of 10.4°. The median gain was 8.1° after stand-alone ALIF and 11.5° with posterior instrumentation. The between-construct difference was significant at L5–S1, but not at L4–5.

Greater cage lordosis, greater baseline intradiscal lordosis, L5–S1 implantation and posterior instrumentation independently predicted a larger postoperative angle. Each additional degree of implant lordosis was associated with 0.62° greater postoperative intradiscal lordosis (95% CI 0.44–0.79). This coefficient describes the adjusted association with the final angle, not the correction gained from baseline.

The separate change model showed that greater preoperative lordosis was associated with less additional correction. Thus, achieving a larger final angle and gaining more lordosis are distinct outcomes.

Intraoperative imaging showed no significant additional increase in intradiscal lordosis after posterior instrumentation compared with the preceding post-ALIF measurement. The authors considered differences in initial correction and maintenance of alignment on standing as possible explanations for the better results in the circumferential group, rather than attributing them solely to posterior corrective maneuvers.

Interpretation — operative relevance

The most useful planning distinction is between the intended final segmental angle and the additional correction required to reach it. A cage’s stated lordosis should not be presented as the expected angular gain. A segment with relatively preserved baseline lordosis may reach a larger final angle while requiring less correction than a more collapsed disc space.

The operative description emphasizes trial selection that provides contact with both vertebral endplates without excessive distraction. This is relevant to the balance between restoring alignment and avoiding an unnecessarily aggressive increase in disc height. The study does not establish a numerical distraction limit or demonstrate that selecting the tallest or most lordotic available implant improves clinical outcomes.

Posterior fixation was associated with greater correction, particularly at L5–S1, but the intraoperative comparisons do not show that the posterior stage itself reliably adds lordosis. The decision to supplement the anterior construct therefore requires the broader stabilization and decompression assessment; the reported group difference is not, by itself, an indication for instrumentation. In the described practice, an open posterior approach was generally used when decompression was also needed, whereas percutaneous fixation was favored when stabilization alone was required.

Finally, intraoperative alignment should be interpreted in relation to postoperative standing measurements. The study supports attention to this transition, but does not provide a validated patient-specific formula for predicting standing correction from a supine image.

Limitations

The retrospective design and nonrandom selection of constructs prevent causal conclusions. Baseline alignment differed between groups, and implant selection and endplate preparation depended on surgeon judgment. The heterogeneous indications also limit the ability to isolate the influence of individual anatomical features or technical maneuvers. Patient-reported outcomes were not available, so greater radiographic correction cannot be equated with better pain relief, function or long-term clinical benefit.

There are internal numerical discrepancies between the abstract, narrative and tables. The overall descriptive values above follow the concordant entries in Tables 2 and 3; conflicting subgroup estimates have not been used to define a quantitative treatment target.

Clinical takeaway

Define the required correction before selecting the implant, distinguish angular gain from final lordosis, and consider the treated level and fixation strategy together. This study supports anatomically informed ALIF planning and assessment of achieved alignment, rather than maximizing cage dimensions or assuming that posterior instrumentation will automatically produce further correction.

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Drainage Volume, Drainage Time, and Irrigation Volume in Chronic Subdural Hematoma

Neurosurgery 99:537–544, 2026

Postoperative drainage is an important component of chronic subdural hematoma surgery, yet the interpretation of drainage volume and duration remains clinically relevant to the prevention of recurrence. This analysis of the FINISH trial examines their association with reoperation, alongside the volume of intraoperative irrigation. Its findings invite a critical appraisal of the assumption that greater drainage necessarily reflects more effective evacuation, while emphasizing the distinction between observational associations and evidence sufficient to establish a standardized drainage protocol.

Objective

To examine whether drainage and irrigation measurements relate to recurrence requiring reoperation.

Methods

This post hoc analysis used 546 patients from the multicenter FINISH irrigation trial. Logistic regression assessed drainage volume, duration and irrigation volume against outcomes.

Main results

Reoperation occurred in 84 patients (15.4%). Median drainage was 70 mL over 48 hours. Each additional 100 mL was associated with higher reoperation odds (OR 1.15, 95% CI 1.02–1.31). Reoperation rates were 18.2% with drainage under 48 hours and 12.1% at 48 hours or longer. Irrigation volume was not associated with reoperation.

Interpretation — operative relevance

The practical decision is how to interpret the postoperative drain within the evacuation strategy. The study does not justify deliberately increasing or restricting output. A high output may identify a different clinical situation rather than cause recurrence.

Similarly, these comparisons do not establish that extending every drain beyond 48 hours improves outcome. The duration comparison was not randomized, even though the parent trial was. More irrigation should not be equated automatically with a better operation.

Limitations

Drainage exposures were observational. Clinical decisions and unmeasured factors may explain part of the associations. The abstract does not provide a validated output-based removal algorithm or enough procedural detail to compare drain position, suction or irrigation technique.

Clinical takeaway

Document output and elapsed drainage time together, and interpret them alongside clinical recovery. This paper is useful for reviewing a unit’s drain protocol; it does not supply a new mandatory removal threshold or irrigation dose.

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Spinal meningiomas: histopathological grading using a benchmark radiomics model with notes on disease control

Neurosurg Focus 61(3):E8, 2026

Could preoperative imaging help anticipate the biological behavior of spinal meningiomas?
This study applies radiomics—quantitative analysis of imaging features—to distinguish tumor pathology groups.
The model showed promising discrimination using open-source tools and internal validation.
Its potential role is to inform counselling, but clinical adoption requires independent testing.

Objective

To develop a preoperative radiomics classifier for spinal meningioma pathology and explore factors associated with disease control.

Methods

Investigators retrospectively reviewed institutional surgical records from 2012–2025. Manually segmented contrast-enhanced images underwent PyRadiomics feature extraction. An ensemble classifier used 10 features and nested cross-validation.

The study’s “high-grade” category combined WHO grade 2 tumors with grade 1 tumors showing atypia; this is not equivalent to conventional WHO high-grade classification.

Main results

Among 74 patients, the model achieved an area under the receiver-operating-characteristic curve of 0.879 and a mean F1 score of 0.748.

The clinical analysis included 55 patients, with median radiographic follow-up of 22.2 months and four recurrences. Subtotal resection was associated with poorer progression-free survival than gross-total resection: HR 10.62 (95% CI 1.46–77.05; P=.019). Institutional abstract

Interpretation

The imaging approach merits further investigation, but discrimination within one institution does not establish performance across scanners, imaging protocols or patient populations. An AUC of 0.879 should not be described as “87.9% diagnostic accuracy.”

The recurrence analysis is exploratory. Its wide confidence interval signals considerable uncertainty, and it does not justify pursuing complete resection at the expense of neurological function.

Limitations

The small retrospective cohort and internal validation limit generalizability. The unconventional pathology grouping complicates comparison with other grading studies. Four recurrence events provide limited support for prognostic modelling.

Publisher and PubMed retrieval failed; verification relied on the authors’ institutional abstract. Full methodological details and supplementary material could not be assessed.

Clinical takeaway

Radiomics is a promising research adjunct for preoperative assessment of spinal meningiomas. This model should not yet determine resection extent, radiation treatment or surveillance schedules without external validation and confirmation of clinical utility.

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Long-Term Outcomes of Gamma Knife Surgery for Vestibular Schwannomas: Tumor Stability Supports Reduced Surveillance After 10 Years

J Neurosurg 145:721–731, 2026

How long should imaging continue after apparently successful radiosurgery for a vestibular schwannoma? This large single-center series follows 878 patients after single-session Gamma Knife treatment, with a median clinical follow-up exceeding 12 years. Patients stable and free of salvage treatment during the first 5 years had very little subsequent true progression. Hearing preservation improved in the more recent treatment era, while delayed cystic and cranial-nerve complications remained uncommon but possible. The findings support less intensive imaging after a decade of stability, not the complete abandonment of individualized clinical follow-up.

Objective

To evaluate the long-term durability, functional outcomes and late adverse events of Gamma Knife surgery for sporadic vestibular schwannoma and determine whether routine imaging intensity can be reduced after prolonged stability.

Methods

This retrospective single-center study included 878 patients treated with single-session Gamma Knife surgery between May 1991 and January 2020. Tumors were classified from intracanalicular disease through severe brainstem compression using a modified Koos-based system. A prespecified subgroup contained 793 patients with at least 5 years of follow-up and no salvage treatment during the first 5 years.

Main results

The median clinical follow-up was 154.5 months. Overall, 7.5% required salvage treatment. Early salvage was more frequent for tumors with severe brainstem compression and fourth-ventricle deviation: 24.7% at 5 years versus 3.6% for less advanced types.

Among patients stable during the first 5 years, cumulative salvage incidence at 15 years was 2.1%, and true progression was identified in only two patients (0.3%). In patients with Gardner–Robertson class I hearing, 10-year serviceable-hearing preservation improved from 48% in the 1991–2004 era to 63% in 2005–2023. Delayed cyst-related complications occurred in 3.1%, trigeminal neuralgia in 1.6%, persistent facial palsy in 0.1% and malignant transformation in 0.2%.

Interpretation

Early anatomical severity predicts the initial need for rescue, but prolonged stability is strongly reassuring. The very low late-progression rate makes indefinite frequent MRI difficult to justify in every stable patient. Nevertheless, the presence of rare delayed effects means that surveillance should transition to a risk-adapted strategy with clear instructions for symptom-triggered reassessment.

Limitations

This was a retrospective experience from one high-volume center over almost three decades. Dose planning, imaging quality, hearing assessment and selection for radiosurgery evolved substantially. The proposal to reduce surveillance is inferred from observed event rates rather than tested prospectively, and the results apply principally to sporadic small- and medium-sized tumors suitable for single-session treatment.

Clinical takeaway

After Gamma Knife surgery, maintain closer imaging during the first years, especially for large tumors with brainstem compression. If control remains stable through 5 years and no concerning symptoms develop, progressively lengthen intervals; after 10 years, consider individualized low-intensity surveillance while preserving access for new hearing, facial, trigeminal, vestibular or hydrocephalic symptoms.

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Surgical Versus Nonoperative Treatment for Adult Spinal Deformity: A Multicenter Propensity Score–Matched Study of Two-Year Patient-Reported Outcomes

Spine 2026;51:1197–1208

Choosing between reconstruction and nonoperative care for adult spinal deformity demands a realistic estimate of benefit rather than radiographic enthusiasm alone. This multicenter analysis uses propensity matching to compare patients with similar measured baseline characteristics. At 2 years, surgery produced substantially greater improvement in disability and scoliosis-specific quality of life. Clinically meaningful benefit was achieved by a much larger proportion of surgical patients, although the cohort was relatively young and only mildly to moderately impaired at baseline. The results strengthen comparative-effectiveness evidence but do not replace individualized discussion of complications and residual confounding.

Objective

To compare 2-year patient-reported outcomes after surgical and nonoperative management of adult spinal deformity while reducing measured treatment-selection bias through propensity-score matching.

Methods

The retrospective comparison used prospectively collected data from an adult spinal-deformity registry at six centers. Of 580 eligible patients, 338 underwent surgery and 242 received nonoperative care. Propensity scores incorporated demographic variables, radiographic alignment measures and baseline Oswestry Disability Index (ODI) and Scoliosis Research Society–22 (SRS-22) scores. One-to-one matching produced 160 balanced pairs.

Main results

At 2 years, mean ODI improvement was −19.4 ± 14.2 points after surgery and −4.2 ± 12.3 with nonoperative care (p<0.001). A clinically meaningful ODI improvement of at least 15 points was achieved by 72% of surgical patients versus 29% of nonoperative patients.

The mean 2-year SRS-22 total score was 3.95 ± 0.67 after surgery and 3.46 ± 0.75 after nonoperative care (p<0.0001). The minimum clinically important difference for the SRS-22 total score was reached by 81.3% and 36.9%, respectively.

Interpretation

Among matched patients, reconstruction was associated with a large and clinically visible improvement beyond that observed with nonoperative management. Propensity matching makes the groups more comparable but cannot recreate randomization. The magnitude of benefit should therefore be presented alongside the patient’s operative risk, deformity phenotype, frailty, goals and probability of complications or revision.

Limitations

Treatment was not randomized, and unmeasured factors such as surgeon judgment, symptoms, patient preference and socioeconomic context may still influence both selection and outcome. The matched cohort had a mean age of about 45 years and mild-to-moderate baseline impairment, limiting extrapolation to older or frailer patients. Two-year follow-up does not capture late mechanical failure, revision burden or durability.

Clinical takeaway

For an appropriately selected adult with symptomatic deformity, surgery offers a substantially greater chance of meaningful 2-year improvement than continued nonoperative care. Use those probabilities in shared decision-making, but pair them with center-specific complication and revision estimates rather than presenting benefit in isolation.

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Third Ventricular Cavernous Malformations: Approach Selection for Minimally Invasive Resection and Systematic Review

Operative Neurosurgery 31:399–409, 2026

Third-ventricular cavernous malformations are rare lesions in an unforgiving anatomical corridor. This paper combines three institutional operations with a systematic review to examine how lesion position should guide the route of access. Two patients underwent endoscope-assisted supraorbital trans–lamina terminalis resection and one a port-based transsulcal exoscopic procedure. In the literature, transcallosal and transcortical transventricular craniotomies remained the most commonly reported routes. The main message is not that one minimally invasive approach is universally preferable, but that the shortest safe trajectory must be individualized around the fornices, hypothalamus, thalamus, deep veins and ventricular anatomy.

Objective

To describe minimally invasive surgical strategies for symptomatic third-ventricular cavernous malformations and synthesize the published experience to support anatomical approach selection.

Methods

The investigators reviewed a prospectively maintained institutional database and identified three symptomatic patients with imaging evidence of hemorrhage. Demographic, clinical, anatomical and surgical outcome data were analyzed. A PRISMA-based PubMed and Embase search identified the available reports of surgically treated third-ventricular cavernous malformations and the approaches used.

Main results

The institutional group included two men and one woman; all were symptomatic, none had hydrocephalus and all had signs of intralesional hemorrhage. Two lesions were removed through a supraorbital keyhole, endoscope-assisted trans–lamina terminalis route. The third was treated through a right frontal keyhole with a port-based transsulcal, exoscope-assisted route.

The review assembled 54 reported surgical cases. The most frequent routes were interhemispheric transcallosal in 26 cases (48.1%) and transcortical transventricular in 16 (29.6%). The combined experience demonstrates substantial heterogeneity in lesion origin, ventricular size and surface presentation, all of which alter the safest corridor.

Interpretation

“Minimally invasive” should describe limited tissue disruption, not merely a smaller opening. A trans–lamina terminalis route may suit an anterior or inferior lesion with favorable line of sight, whereas a transsulcal or transventricular route may better address a superior or lateral target. High-quality multiplanar and susceptibility imaging, neuronavigation and planned conversion options are more important than allegiance to a single approach.

Limitations

The institutional experience contains only three patients. The systematic review is dominated by case reports and small series, with publication bias, incomplete outcome reporting and no valid comparative groups. Some historical cases predate modern endoscopy, exoscopy, tract-informed planning and contemporary postoperative imaging.

Clinical takeaway

Select the route from the lesion’s precise relationship to the ventricular walls, foramina, fornices, hypothalamus, thalamus and deep venous structures. Use the corridor that offers direct visualization with the least neural transgression, and counsel patients that the evidence for approach superiority remains low level.

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Perioperative Management of Targeted and Immunologic Agents in Neurosurgical Oncology

Neurosurgery 99:519–529, 2026

Targeted therapy and immunotherapy have complicated the traditional decision of which antineoplastic drugs to stop before neurosurgery. This systematic review organizes the relevant agents around wound healing, bleeding and immune dysfunction. Anti-VEGF antibodies and mTOR inhibitors require particular caution because of impaired healing, while VEGF-receptor and Bruton’s tyrosine kinase inhibitors raise hemorrhagic concerns. Several immunomodulators increase infection risk, but the evidence is sparse for other widely used classes. The resulting framework is useful for multidisciplinary planning, although many intervals still rest on indirect evidence and expert consensus.

Objective

To provide a clinically actionable framework for perioperative interruption and resumption of targeted and biologic therapies in patients undergoing neurosurgical procedures.

Methods

The authors systematically reviewed pivotal trials, US Food and Drug Administration safety information, meta-analyses and society guidance. Drug classes were assessed by mechanism, pharmacokinetics and adverse effects relevant to wound healing, hemostasis and immune regulation. Recommendations were stratified by risk and combined the available evidence with expert consensus.

Main results

Anti-VEGF monoclonal antibodies carried the greatest wound-healing concern; the review recommends a preoperative interruption of at least 4 weeks and generally delaying postoperative treatment for 2–4 weeks. For mTOR inhibitors, the proposed preoperative interval was at least 1 week.

VEGF-receptor tyrosine kinase inhibitors and Bruton’s tyrosine kinase inhibitors were most concerning for bleeding and may require holds of up to 1 week, with resumption after 3–7 days once hemostasis is secure. CDK4/6 inhibitors, Janus kinase inhibitors and biologics directed at TNF, IL-6 or CD20 were linked to immunosuppression and infection risk; interruptions of 2–7 days and postoperative delays of 1–2 weeks were often proposed. Evidence remained limited for BRAF/MEK and immune-checkpoint inhibitors.

Interpretation

A single “stop all systemic therapy” rule is neither safe nor oncologically neutral. Timing should reflect the drug’s biological effect, half-life, operative magnitude, wound requirements and the consequences of delaying cancer control. The review is best used as a structured starting point for joint decisions among neurosurgery, oncology, anesthesia and pharmacy—not as a rigid calendar.

Limitations

Much of the evidence comes from non-neurosurgical populations, safety reports and expert interpretation rather than prospective perioperative trials. Recommendations within a class may not apply equally to every agent. The review cannot quantify the competing risk of oncological progression during interruption for an individual patient.

Clinical takeaway

At the preoperative visit, record the exact agent, last dose, half-life and principal surgical risk. Agree on stop and restart dates with the treating oncologist, verify wound healing and hemostasis before resumption, and document explicitly when limited evidence makes the plan individualized.

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Intractable epilepsy before and/or after awake functional mapping–based surgery for IDH-mutant grade 2 glioma: a consecutive series of 105 patients

J Neurosurg 145:623–633, 2026

Seizure control is a central component of the oncofunctional result after surgery for diffuse grade 2 glioma. This long-term series examines patients with drug-resistant epilepsy before or after awake mapping–guided resection. Just over half became completely seizure-free, whereas persistent or newly intractable epilepsy affected the remainder. Tumor location, preoperative volume and extent of resection were associated with the epileptic outcome, which in turn tracked functional status and return to work. The study argues for integrating seizure goals into surgical planning without compromising functional boundaries.

Objective

To characterize intractable epilepsy before and after awake functional mapping–based surgery for IDH-mutant grade 2 glioma and examine its relationship with tumor, surgical and quality-of-life outcomes.

Methods

The authors retrospectively selected patients operated between June 2002 and March 2024 who had intractable epilepsy before and/or after surgery and more than 1 year of follow-up. All resections were performed awake with functional mapping. Patients were divided into those with preoperative intractable epilepsy who became completely seizure-free (Engel IA), those with intractable epilepsy both before and after surgery, and those who developed it only postoperatively.

Main results

The series comprised 105 patients and 134 awake procedures, with a mean follow-up of 8.3 years. At diagnosis, 101 patients (96.2%) had seizures and 82 (78.1%) had intractable epilepsy. The mean extent of resection was 86.8%; persistent postoperative deterioration occurred in one patient.

Sixty patients (57.1%) achieved Engel IA seizure freedom. Twenty-two (21.0%) had persistent intractable epilepsy and 23 (21.9%) developed it postoperatively. Larger preoperative volume and lower extent of resection correlated with intractable epilepsy. Patients rendered seizure-free had higher postoperative Karnofsky scores and a higher return-to-work rate.

Interpretation

For grade 2 glioma, seizure control is not a secondary outcome: it is closely linked to autonomy and social reintegration. The association with resection extent supports maximizing removal within individually mapped functional limits. The anatomical signal—particularly the poorer pattern in central tumors—also indicates that epileptological success depends on the network involved, not simply on residual volume.

Limitations

This was a retrospective, highly selected single-team series restricted to patients with intractable epilepsy, not the entire grade 2 glioma population. Surgical, molecular and adjuvant-treatment practice evolved over more than two decades. Associations between resection, epilepsy and function do not prove causality, and postoperative antiseizure-medication strategies were not randomized.

Clinical takeaway

Discuss seizure freedom explicitly when planning awake surgery for IDH-mutant grade 2 glioma. Pursue the greatest functionally safe resection, document the epileptogenic network as well as eloquent function, and maintain structured long-term epileptological follow-up even in patients without preoperative pharmacoresistance.

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Artificial Intelligence Monitoring of Neurological Status From Patient Videos in the Neuroscience Intensive Care Unit

Neurosurgery 99:731–737, 2026

Intermittent neurological examinations can miss gradual or sudden change between bedside assessments, particularly where neurocritical-care expertise is limited. This proof-of-concept study applies computer-vision pose estimation to routine patient video and derives a continuous movement index. Movement increased markedly across higher Glasgow Coma Scale categories and was greater in awake or agitated than sedated patients. The method is noncontact and potentially scalable, but it measures motion rather than neurological function itself. Its clinical value will depend on prospective validation of change detection, false alarms, privacy safeguards and performance across diverse patients.

Objective

To externally compare two artificial-intelligence pose-estimation models, develop a video-derived movement index and test whether that index correlates with bedside measures of consciousness in neuroscience intensive-care patients.

Methods

The investigators retrospectively collected video from patients undergoing video EEG in a large urban neuroscience ICU between July 2024 and January 2025. ViTPose and Meta Sapiens were externally evaluated for pose estimation. The better-performing model was used to construct a computer-vision movement index, which was compared with hourly Glasgow Coma Scale and Richmond Agitation-Sedation Scale assessments.

Main results

The data set contained 998,520 video minutes from 119 patients. ViTPose outperformed Sapiens and was therefore used for the movement index.

Movement rose with increasing GCS: index values were 0.52 for GCS 3–8, 0.70 for GCS 9–13, 3.52 for GCS 14 and 10.99 for GCS 15 (p=0.01), a 21-fold difference between the lowest and highest categories. Patients who were awake or agitated (RASS >−1) had approximately 10 times more movement than asleep or sedated patients (6.59 versus 0.67; p=0.005).

Interpretation

Video pose estimation can convert continuous, otherwise unused observation into a quantitative physiological signal. Correlation with GCS and RASS establishes construct validity, not diagnostic accuracy. Sedation, restraints, weakness, seizures, nursing care and camera visibility can all alter motion independently of global neurological deterioration.

Limitations

This was a retrospective, single-center proof-of-concept study of only 119 patients selected because video EEG was available. It did not test prospective alerts, prediction of neurological events or improvement in patient outcomes. Comparisons with ordinal bedside scores were cross-sectional, and performance by diagnosis, skin tone, body habitus, occlusion or focal deficit was not established.

Clinical takeaway

AI-derived movement should be regarded as a potential adjunct to—not a replacement for—the neurological examination. Before implementation, systems need prospective event-level validation, transparent alarm thresholds, local bias testing, secure video governance and a workflow specifying who reviews and acts on alerts.

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Opioid and Neuropathic Pain Medication Use After ACDF for Degenerative Cervical Spine Disease

Spine 2026;51:1223–1232

Anterior cervical discectomy and fusion often relieves radicular or myelopathic symptoms, but medication use provides an additional real-world measure of recovery. This nationwide Finnish study links a spine registry with comprehensive outpatient prescription-purchase data. Around seven in ten preoperative users stopped repeatedly purchasing opioids or gabapentinoids after surgery, while new sustained strong-opioid use was uncommon. Nevertheless, approximately one in six patients continued repeated purchases during the first postoperative year. Preoperative medication exposure and modifiable factors such as smoking helped identify patients at risk.

Objective

To describe opioid and neuropathic-pain medication use after primary ACDF for degenerative cervical disease and identify independent predictors of repeated postoperative purchases.

Methods

The longitudinal study linked the nationwide FinSpine registry to Finland’s prescription database and included 4,366 consecutive patients operated between 2017 and 2022. Repeated postoperative use was defined as at least two purchases of the same drug class during months 2–12. New strong-opioid users had no strong-opioid purchase in the 6 months before surgery but met the repeated-purchase definition afterward. Multivariable logistic regression evaluated associated factors.

Main results

Before surgery, 41.9% purchased opioids and 41.2% gabapentinoids. During months 2–12 after ACDF, 16.5% made repeated opioid purchases and 15.6% made repeated gabapentinoid purchases. Among preoperative users, 69.5% stopped repeated opioid purchasing and 70.9% stopped repeated gabapentinoid purchasing.

Only 2.2% of previously strong-opioid-naïve patients became new repeated strong-opioid purchasers. Independent predictors of repeated postoperative purchases included pain lasting more than 1 year, smoking, greater baseline Neck Disability Index, central canal stenosis, unfavorable employment status and preoperative purchase of the same medication class.

Interpretation

Most previous users reduced sustained analgesic purchasing after ACDF, and surgery rarely initiated new repeated strong-opioid use. Yet persistent medication use in roughly one sixth of patients indicates that decompression and fusion do not address every contributor to pain, disability or pharmacological dependence. Dispensing is an objective outcome but is not synonymous with consumption or inappropriate use.

Limitations

Registry data cannot confirm whether purchased medication was taken, why it was prescribed or whether prescriptions related to cervical symptoms. Residual confounding from mental health, pain at other sites and prescriber behavior is possible. The Finnish healthcare and prescribing environment may limit international generalizability.

Clinical takeaway

Review opioid and gabapentinoid exposure before ACDF and set explicit postoperative deprescribing expectations. Patients who smoke, have symptoms exceeding 1 year, greater baseline disability or established medication use merit closer follow-up and coordinated pain management rather than automatic prescription renewal.

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Comparative Outcomes of Frontal, Bifrontal, and Pterional Craniotomies for Resection of Large Anterior Skull Base Meningiomas

Operative Neurosurgery 31:484–494, 2026

Large anterior skull-base meningiomas can be approached through unilateral frontal, bifrontal or pterional craniotomies, but anatomy and case complexity strongly influence that choice. This retrospective series compares the three exposures and uses propensity matching to reduce baseline imbalance. Bifrontal procedures had more medical and surgical complications and poorer cosmetic results after matching. Frontal procedures showed shorter progression-free survival, with subtotal resection emerging as an adverse predictor. The findings help frame approach selection but do not establish that one craniotomy is intrinsically superior for every tumor.

Objective

To compare outcomes after frontal, bifrontal and pterional craniotomy for large anterior skull-base meningiomas and identify approach-specific predictors of complications and tumor control.

Methods

The study retrospectively included 337 adults operated at one institution between 2010 and 2024, each with at least 1 year of follow-up. Eighty patients underwent bifrontal, 189 frontal and 68 pterional craniotomy. Propensity-score matching balanced groups for tumor size, grade and preoperative Karnofsky Performance Status. Complications, cosmetic outcomes and progression-free survival were then compared.

Main results

Before matching, patients selected for bifrontal surgery had larger tumors and lower functional status, whereas the frontal group had higher-grade tumors. After matching, medical complications occurred in 25.0% and surgical complications in 22.5% of the bifrontal group, both significantly more often than in the other groups. Unsatisfactory cosmetic outcomes were also more frequent after bifrontal surgery (6.25%).

Kaplan-Meier analysis showed more minor complications after bifrontal craniotomy and shorter progression-free survival in the frontal group. Olfactory-groove location predicted poorer outcomes in the pterional cohort, while subtotal resection predicted poorer outcome in the frontal cohort.

Interpretation

The bilateral exposure carries a morbidity cost even after adjustment for several markers of complexity. However, approach is inseparable from anatomy: midline extension, vascular encasement, optic involvement, surgeon experience and the probability of safe complete resection must shape the decision. A unilateral route should not be selected merely to avoid the statistical risk associated with bifrontal surgery.

Limitations

The retrospective single-center design is vulnerable to selection bias and changing surgical practice over 14 years. Matching addressed only measured variables and could not balance all anatomical features. The abstract does not provide adjusted effect sizes for every comparison, and the broad category of anterior skull-base meningioma combines distinct origins and operative challenges.

Clinical takeaway

Use the least disruptive exposure that still provides safe control of the tumor, neurovascular structures and dural attachment. Reserve a bifrontal route for anatomy that genuinely requires bilateral access, and counsel those patients about its higher observed medical, surgical and cosmetic complication burden.

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Evaluating Conscious Sedation Versus General Anesthesia for Venous Sinus Stenting for Idiopathic Intracranial Hypertension and Implications for Outpatient Management

Neurosurgery 99:700–709, 2026

Venous sinus stenting for idiopathic intracranial hypertension is commonly separated into diagnostic manometry under conscious sedation and later stenting under general anesthesia. This cohort asks whether conscious sedation and a more streamlined pathway can deliver comparable safety and efficacy. After propensity matching, outcomes did not differ significantly between conscious sedation and general anesthesia. Same-admission diagnosis and treatment were associated with more repeat stenting, although this group included every fulminant presentation. The work supports outpatient feasibility but not indiscriminate conversion to a single-session pathway.

Objective

To compare venous sinus stenting under conscious sedation and general anesthesia and to evaluate single-session diagnostic venography plus stenting versus staged procedures, with particular attention to outpatient management.

Methods

The retrospective cohort included 114 adults treated for idiopathic intracranial hypertension at one comprehensive cerebrovascular center from January 2017 through December 2024. Clinical presentation, procedural characteristics, symptom resolution and restenosis were compared between general anesthesia and conscious sedation and between same-admission and staged pathways. Propensity-score matching was used for both comparisons.

Main results

Thirty-six patients underwent general anesthesia and 78 conscious sedation. After matching, 36 patients remained in each group, with no significant difference in the measured safety or clinical outcomes. One major complication—acute visual loss caused by cerebral venous thrombosis—occurred in the conscious-sedation cohort.

Thirty-seven patients underwent same-admission venography and stenting, compared with 77 staged procedures. All 17 fulminant cases belonged to the same-admission group. Apparent differences in time to recurrent headache and visual symptoms were no longer significant after matching, but restenosis requiring repeat stenting remained more frequent after the same-admission strategy.

Interpretation

Conscious sedation appears technically feasible for venous sinus stenting in selected patients and could remove a barrier to outpatient care. The increased repeat-stenting signal after same-admission treatment may reflect the biological and clinical severity of fulminant disease, residual confounding or differences in pressure measurement and selection; it should not be attributed automatically to workflow.

Limitations

This was a retrospective single-center study with only 114 patients and one major complication, limiting safety comparisons. Anesthetic and admission strategies were chosen clinically rather than randomly. Propensity matching cannot correct unmeasured confounding, especially because every fulminant case entered the same-session group.

Clinical takeaway

Conscious sedation and staged outpatient venography followed by outpatient stenting may be reasonable in carefully selected, stable adults. Fulminant presentations still require expedited individualized treatment, and same-session stenting should not become routine until predictors of restenosis and the effect of anesthetic conditions on manometry are better defined.

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Surgical neuromodulation: prevalence of Staphylococcus aureus, decolonization, and rates of infection

J Neurosurg 145:302–310, 2026

Infection of an implanted neuromodulation system may require complete hardware removal and interruption of an effective therapy. This study examines nasal *Staphylococcus aureus* colonization and infection-prevention protocols across almost 2,000 procedures involving deep brain stimulation, spinal cord stimulation and intrathecal baclofen pumps. Methicillin-susceptible strains were substantially more frequent than MRSA and would be missed by MRSA-only screening. Introducing decolonization was associated with a marked reduction in infection after baclofen-pump procedures. The findings support screening both MSSA and MRSA before implantation while recognizing the limitations of a retrospective before-and-after comparison.

Objective

To determine the prevalence of preoperative MRSA and MSSA colonization in patients undergoing surgical neuromodulation and assess whether screening and decolonization protocols were associated with fewer surgical-site infections.

Methods

Using a prospectively maintained database, the authors retrospectively analyzed procedures performed by one surgeon at one institution between June 2013 and June 2024. The series comprised 513 spinal cord stimulator procedures, 1,050 deep brain stimulator procedures and 414 intrathecal baclofen-pump procedures.

Preoperative nasal swab results, superficial infections, deep infections requiring device removal, comorbidities and successive perioperative screening, decolonization and antibiotic protocols were reviewed. Patients were observed for at least 6 months for deep infection.

Main results

Approximately 20% of patients receiving spinal cord or deep brain stimulation and 25% receiving an intrathecal baclofen pump were colonized with *S. aureus*. MSSA was 14 times more frequent than MRSA in the spinal cord stimulation group, 9 times more frequent in the deep brain stimulation group and 3 times more frequent in the baclofen-pump group.

No deep surgical-site infections occurred in the spinal cord stimulation group. After implementation of preoperative decolonization, the infection rate associated with intrathecal baclofen pumps fell from 8% to below 2%.

Interpretation

Screening only for MRSA overlooks most *S. aureus* carriers in this population. The reduction observed after decolonization is clinically compelling, particularly for baclofen pumps, but the study cannot isolate decolonization from simultaneous changes in antibiotics, technique or perioperative care.

Limitations

This was a retrospective, single-surgeon experience spanning 11 years. The protocols changed over time rather than through random allocation, so secular improvements and differences between patient groups may explain part of the effect. The small number of deep infections limits precise comparative estimates.

Clinical takeaway

Before implanting neuromodulation hardware, screen for both MSSA and MRSA rather than MRSA alone. A structured decolonization pathway is especially reasonable for intrathecal baclofen-pump candidates, coupled with prospective surveillance of infections and protocol adherence.

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Microsurgical Management of Tentorial Dural Arteriovenous Fistula: An Analysis From CONDOR

Journal of Neurosurgery 2026;145(2):424–435

Tentorial dural arteriovenous fistulas frequently have cortical venous drainage and an aggressive natural history. This international multicenter series focuses on microsurgery, often after embolization has failed. Tailored approaches achieved angiographic success in 90% with a low rate of permanent neurological morbidity. Results were similar whether surgery was the primary or salvage strategy. The study reinforces microsurgery as a durable option when endovascular cure is incomplete or anatomically unfavorable.

Objective

To describe surgical approaches, obliteration rates, complications and longer-term durability after microsurgical treatment of tentorial dural arteriovenous fistulas.

Methods

CONDOR retrospectively collected dural fistula data from 16 international centers between 1990 and 2021. Of 161 patients with a tentorial fistula, 44 underwent microsurgery; 23 received surgery as salvage treatment after failed embolization. Success required angiographically confirmed complete obliteration or, for a high-grade lesion, elimination of cortical venous drainage.

Main results

Aggressive presentation was present in 91% of the surgical cohort: 64% presented with hemorrhage and 27% with a nonhemorrhagic neurological deficit. The retrosigmoid approach was most common (44%), followed by midline suboccipital (24%) and occipital (15%) approaches.

Surgical success was achieved in 38 of 42 assessable patients (90%). Perioperative complications occurred in 11%, while permanent neurological deficit occurred in 2%. During a mean 3-year follow-up, 2 of 38 successfully treated fistulas (5%) recurred. Primary and salvage microsurgery had similar outcomes.

Interpretation

Microsurgery provides high and durable disconnection rates for tentorial fistulas that cannot be cured safely by embolization. The range of approaches reflects anatomical heterogeneity; operative planning should target the fistulous point and cortical venous outflow rather than apply a uniform exposure.

Limitations

This retrospective registry spans three decades, with substantial evolution in angiography, embolic agents and surgical practice. Only 44 patients underwent surgery, treatment selection was nonrandom and imaging follow-up was not necessarily uniform. Outcomes from experienced referral centers may not be reproduced in lower-volume units.

Clinical takeaway

Discuss high-grade tentorial dural fistulas in a multidisciplinary cerebrovascular team. When embolization cannot provide safe definitive disconnection—or has already failed—an anatomically tailored microsurgical approach offers a high likelihood of cure with acceptable morbidity in experienced hands.

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Impact of Symptom Duration on Surgical Outcomes and Functional Recovery in Degenerative Cervical Myelopathy: Insights From a Prospective Multicenter Study

Spine  2026;51(16):1123–1129

The optimal timing of surgery for degenerative cervical myelopathy remains important because neurological decline may be slow and apparently tolerable. This large prospective multicenter cohort relates symptom duration to neurological recovery and patient-reported physical health. Surgery produced clinically meaningful neurological improvement even after prolonged symptoms. However, patients operated within two years were more likely to achieve meaningful improvement in physical quality of life. The study supports timely referral without implying that patients with longstanding disease no longer benefit.

Objective

To determine how symptom duration before surgery influences neurological, functional and patient-reported recovery after operative treatment for degenerative cervical myelopathy.

Methods

The prospective cohort included 874 patients treated at 10 institutions and followed for 2 years. Symptom duration was categorized as less than 6 months, 6 months to 2 years, 2–5 years or at least 5 years. Outcomes included the Japanese Orthopaedic Association score, SF-36, pain and neuropathic-pain scales, and JOACMEQ domains. Minimum clinically important differences were 2.5 points for JOA and 4 points for the SF-36 physical component.

Main results

Every symptom-duration group exceeded the minimum clinically important improvement in JOA score, including patients symptomatic for at least 5 years. In contrast, only patients with symptoms for less than 2 years exceeded the clinically important threshold for improvement in the SF-36 physical component.

After adjustment for relevant covariates, shorter symptom duration was associated with better recovery of extremity and bladder function and better quality-of-life outcomes on the JOACMEQ.

Interpretation

Delayed surgery does not eliminate the possibility of neurological improvement, but it may reduce the probability that recovery translates into a patient-perceived gain in physical health. The two-year point is a prognostic association rather than a rigid biological deadline.

Limitations

Patients were not randomized to early or delayed surgery, so symptom duration may correlate with access to care, disease phenotype or unmeasured severity. Recall of symptom onset can be imprecise. The cohort and instruments were predominantly Japanese, and the results do not identify ideal timing for an individual patient with mild or stable disease.

Clinical takeaway

Refer and evaluate degenerative cervical myelopathy promptly. Surgery can still be worthwhile after years of symptoms, but counseling should explain that intervention within two years is associated with a better chance of meaningful physical and quality-of-life recovery.

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Awake Craniotomy in Patients With Language Deficits: A Retrospective Cohort Study in 48 Patients

Operative Neurosurgery 31(2):p 285-292, August 2026

Preoperative aphasia is often viewed as an obstacle to reliable language mapping during awake glioma surgery. This cohort examines whether clinically relevant language impairment truly prevents meaningful intraoperative testing. Every selected patient could perform language tasks, and stimulation identified functional language boundaries in nine of ten operations. Language comprehension was generally preserved and production improved at follow-up. The findings argue against excluding patients from awake mapping solely because baseline testing is abnormal.

Objective

To evaluate the feasibility and clinical applicability of awake language mapping in patients with glioma and significant preoperative language deficits, and to describe postoperative language trajectories.

Methods

The retrospective cohort comprised 48 patients with a preoperative language score at least 1 standard deviation below the normative mean. Individual and group-level language performance was compared before and 3–6 months after surgery. The investigators reviewed the tasks used intraoperatively, whether the patient could complete them and whether direct stimulation identified functional boundaries.

Main results

All 48 patients were able to perform language tasks during awake surgery. Functional language boundaries were identified in 90% of cases. At 3–6 months, language comprehension was stable at group level, whereas language production showed significant improvement.

Individual trajectories were heterogeneous: naming improved in approximately 30%, remained stable in 63% and worsened in 7%; comprehension improved in 33%, remained stable in 52% and worsened in 14%.

Interpretation

Baseline language impairment does not automatically make awake mapping unreliable. With individualized task selection and neuropsychological preparation, mapping remains feasible and may permit function-guided resection in patients who might otherwise be denied this approach. Individual variability nevertheless requires counseling beyond group averages.

Limitations

The analysis was retrospective, involved only 48 selected patients and lacked a comparison group undergoing asleep surgery. Selection may have excluded patients with deficits too severe for attempted awake mapping. Improved scores could reflect practice effects, recovery or tumor treatment rather than mapping alone, and oncological endpoints were not the main focus.

Clinical takeaway

Do not use preoperative aphasia as an isolated contraindication to awake craniotomy. Refer suitable patients for detailed language assessment and adapt the intraoperative battery to preserved abilities; the decisive question is whether reliable patient-specific tasks can be established before surgery.

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Microsurgical Evacuation Efficacy and Functional Outcomes in Spontaneous Intracerebral Hemorrhage by Type of Antithrombotic Therapy

Neurosurgery 99:354–363, 2026

Antithrombotic treatment complicates emergency surgery for spontaneous intracerebral hemorrhage even after pharmacological reversal. This study compares hematoma burden, evacuation efficacy and functional outcome according to prior antithrombotic medication. Patients receiving these drugs presented with larger hemorrhages and had more residual blood after microsurgery. The signal was particularly concerning for antiplatelet and combined antiplatelet–anticoagulant therapy. The results emphasize that laboratory correction does not necessarily eliminate the operative consequences of disturbed hemostasis.

Objective

To determine how common categories of antithrombotic therapy affect preoperative hematoma volume, microsurgical evacuation efficacy and 12-month functional outcome in supratentorial spontaneous intracerebral hemorrhage.

Methods

The authors retrospectively studied 232 consecutive patients who underwent microsurgical evacuation between 2008 and 2022. Patients receiving antiplatelets, vitamin K antagonists, direct oral anticoagulants or combined antiplatelet–anticoagulant therapy were compared with patients taking no antithrombotic drug. Imaging, emergency reversal and modified Rankin Scale outcome at 12 months were analyzed using multivariable regression.

Main results

The cohort included 53 patients receiving antiplatelets, 29 receiving vitamin K antagonists, 13 receiving direct oral anticoagulants and 17 receiving combined therapy. Every antithrombotic category was associated with a larger absolute preoperative hematoma; the largest adjusted difference occurred with combined therapy (14.9 mL; 95% CI 0.9–29.0).

Antiplatelet therapy was associated with a 1.4-fold greater relative postoperative hematoma volume (95% CI 0.9–2.1), and combined therapy with a 2.1-fold increase (95% CI 1.1–4.0). Unfavorable 12-month outcome (mRS ≥4) occurred in 73.5% and was associated with larger preoperative and relative postoperative hematoma volumes.

Interpretation

Prior antithrombotic therapy appears to influence both the initial hemorrhage and completeness of microsurgical evacuation. The association does not prove that a different reversal regimen would improve outcome, but it identifies persistent hemostatic risk—especially with antiplatelet exposure—that should inform operative planning and postoperative imaging.

Limitations

This retrospective study spans 14 years, during which reversal protocols and perioperative practice evolved. The treatment groups were small, particularly for direct oral anticoagulants and combined therapy. Confounding by age, comorbidity, hemorrhage severity and indication for antithrombotic treatment cannot be completely excluded.

Clinical takeaway

Do not regard emergency reversal as complete normalization of surgical bleeding risk. In patients previously taking antiplatelets or combined therapy, plan meticulous hemostasis, consider early postoperative imaging and maintain a low threshold for detecting clinically important residual or recurrent hematoma.

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Maximum safe resection of insular gliomas: update on surgical outcomes from 500 cases

J Neurosurg 145:347–363, 2026

Insular gliomas remain among the most demanding intrinsic brain tumors because eloquent cortical and subcortical networks coexist with critical middle cerebral and lenticulostriate vessels. This large single-center experience evaluates whether a transcortical, mapping-guided strategy can achieve meaningful cytoreduction without unacceptable neurological morbidity. The series comprises 502 operations in 394 patients with newly diagnosed or recurrent low- and high-grade tumors. Greater extent of resection and smaller residual volumes were associated with longer survival, while persistent deficits were uncommon. The results support maximum safe resection, but also underline that oncological benefit depends on preserving neurological function.

Objective

To determine whether transcortical resection supported by cortical and subcortical mapping remains a safe and effective strategy for newly diagnosed and recurrent insular gliomas, and to examine the relationships among tumor characteristics, extent of resection, postoperative morbidity, progression-free survival and overall survival.

Methods

This retrospective single-center study analyzed 502 resections performed in 394 patients between September 1997 and December 2022. The cohort included 316 newly diagnosed tumors—165 low-grade and 151 high-grade—and 186 recurrent tumors—69 low-grade and 117 high-grade.

Tumors were classified according to the Berger-Sanai zones. Preoperative and postoperative contrast-enhancing and non–contrast-enhancing volumes were manually segmented on MRI to calculate extent of resection and residual volume. Neurological status was assessed preoperatively, immediately after surgery, at discharge, at 3 months and at least 6 months postoperatively.

The transcortical approach was adapted to hemispheric dominance and tumor anatomy. Dominant-hemisphere lesions underwent awake language and motor mapping; nondominant lesions were generally treated asleep with triple-modality motor mapping. Subcortical stimulation defined functional white-matter boundaries, while the lenticulostriate arteries marked the medial resection limit.

Progression-free and overall survival were studied using Kaplan-Meier and Cox regression analyses. Propensity-score weighting adjusted survival comparisons for factors including age, preoperative Karnofsky Performance Status and adjuvant temozolomide or radiotherapy.

Main results

Median extent of resection exceeded 80% across the analyzed molecular subtypes in both newly diagnosed and recurrent tumors. Grade 2 tumors were larger than grade 4 IDH-wildtype glioblastomas at presentation (43 versus 17.5 cm³; p<0.001), while their median residual volume was also greater (6.8 versus 0.5 cm³; p<0.001).

Among newly diagnosed grade 2 tumors, transient motor and language deficits occurred in 9.5% and 20% of cases, respectively. Persistent deficits were substantially less frequent: 0.6% for motor function and 3.3% for language. Across all 502 operations, only 3 patients (0.59%) had permanent hemiparesis below antigravity strength. Surgical and medical complications each occurred in fewer than 3% of cases, and more than 94% of patients were discharged home.

For newly diagnosed IDH-mutant grade 2 tumors, residual non–contrast-enhancing volume below 2.7 cm³ was associated with longer overall survival, while a residual volume below 4.3 cm³ was associated with longer progression-free survival. In recurrent grade 2 tumors, residual volumes below 0.8 cm³ and 1.8 cm³ were associated with improved overall and progression-free survival, respectively.

For newly diagnosed IDH-wildtype glioblastoma, resection of more than 88.6% of the contrast-enhancing component was associated with longer overall survival, and resection above 87.08% with longer progression-free survival. Median overall survival was 18.5 months when contrast-enhancing extent of resection exceeded 88.6%.

A new permanent arm or leg deficit was independently associated with worse overall survival (HR 2.06; 95% CI 1.14–3.74; p=0.017).

Interpretation

The study provides strong observational support for a transcortical, mapping-guided approach to insular glioma surgery. Meaningful cytoreduction was achievable across all Berger-Sanai zones and in both initial and repeat operations, with a low frequency of permanent neurological morbidity.

The survival analyses also refine the concept of “maximum safe resection.” Benefit was associated not only with percentage resection but with the absolute residual volume, particularly in IDH-mutant grade 2 glioma. Nevertheless, these thresholds should be interpreted as cohort-derived prognostic markers rather than mandatory surgical targets.

The association between permanent weakness and poorer survival is clinically crucial. It indicates that aggressive cytoreduction loses part of its oncological value when it produces lasting neurological injury. Functional preservation is therefore an integral component of oncological efficacy, not merely a secondary safety endpoint.

Limitations

This was a retrospective experience from a single, highly specialized center, which limits generalizability to teams with different mapping expertise or operative volumes. The 25-year inclusion period encompassed major changes in imaging, mapping, neuropathological classification and adjuvant treatment.

Molecular information was incomplete in earlier cases; survival analyses were consequently restricted to tumors that could be classified according to the 2021 WHO framework. Treatment selection was not randomized, and residual confounding remains despite propensity-score adjustment. The study does not directly compare transcortical surgery with transsylvian resection, biopsy, laser interstitial thermal therapy or IDH-inhibitor-based strategies.

The reported residual-volume and extent-of-resection cutoffs were derived retrospectively from this cohort and require external validation. Detailed neurocognitive and quality-of-life outcomes were also less comprehensive than the motor and language assessments.

Clinical takeaway

Maximum safe resection should remain the operative goal for appropriately selected adult patients with insular glioma, including selected recurrent tumors. A transcortical approach supported by individualized cortical and subcortical mapping can produce substantial cytoreduction with low permanent morbidity in experienced hands.

The surgeon should prioritize the smallest safely achievable residual volume rather than pursue a percentage target at the expense of functional pathways or lenticulostriate vessels. In practical terms, the oncological objective and the functional boundary are inseparable: avoid a permanent deficit, because neurological injury is itself associated with poorer survival.

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Evaluation of a Novel, Bedside, Ultrasonographic Neuronavigation System Versus Free-Hand Ventricular Targeting: A Double-Blinded, Prospective, Paired Comparison Study

Neurosurgery  2026;99(2):479–486

External ventricular drain placement is commonly performed using anatomical landmarks, but free-hand trajectories may miss the ventricle or traverse unintended brain structures. This prospective bench study compared conventional targeting with a portable bedside ultrasound-navigation system. Twenty-five participants of widely different experience levels performed paired procedures in realistic head models incorporating simulated brain shift. Ultrasound guidance substantially improved ventricular entry and frontal-horn targeting. These accuracy results are compelling, but clinical benefit and safety still require confirmation in patients.

Objective

To compare the accuracy of a novel bedside ultrasonographic neuronavigation system with conventional free-hand ventricular targeting across operators with different levels of neurosurgical experience.

Methods

In a prospective, double-blinded, paired-comparison experiment, 25 participants ranging from first-year medical students to attending neurosurgeons with more than 40 years of experience placed titanium wires simulating external ventricular drain stylets into three-dimensional printed head models.

The anatomically realistic models contained molded brains, simulated ventricles and brain shift. Each participant used both free-hand landmarks and ultrasound-guided navigation, allowing within-operator comparison of ventricular entry, ipsilateral frontal-horn targeting and distance from the intended target.

Main results

Ultrasound-guided trajectories entered the ventricular system in 98% of attempts, compared with 10% using the free-hand technique. The intended ipsilateral frontal horn was reached in 86% versus 8%, respectively (p<0.001).

Mean distance from the intended target was less than 0.5 mm with ultrasound guidance and nearly 8 mm with free-hand placement (p<0.001). The navigation system improved first-pass accuracy across all represented levels of operator experience.

Interpretation

Real-time portable ultrasound may reduce the dependence of ventricular catheter placement on surface landmarks, particularly when ventricular size or brain shift makes the conventional trajectory unreliable. The magnitude and consistency of the accuracy improvement justify clinical evaluation, but model performance cannot establish a reduction in hemorrhage, infection, revision or functional morbidity.

Limitations

This was a bench-model study rather than a clinical trial. Printed anatomy cannot reproduce tissue deformation, bleeding, narrow or distorted ventricles, patient movement or the time pressure of emergency care. Some investigators were associated with the device, making independent replication important. Procedure time, learning curve, complications and patient outcomes were not evaluated.

Clinical takeaway

Bedside ultrasound navigation has the potential to make ventricular access more accurate and less operator-dependent. Before routine adoption, the system requires prospective clinical comparison with free-hand placement and established navigation methods, including first-pass success, catheter grade, hemorrhage, infection, revision, workflow and cost.

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Impact of Modified Brain Injury Guideline Incorporating Neurosurgical Consultation on Resource Utilization and Follow-Up Care in Complicated Mild Traumatic Brain Injury

Neurosurgery 2026;99(2):391–400

Complicated mild traumatic brain injury often triggers admission, repeat imaging and specialist assessment despite a low probability of intervention in selected patients. The University of Utah introduced a modified Brain Injury Guideline that retained neurosurgical consultation while prioritizing appropriate resource use. This before-and-after study evaluated 977 adults with traumatic intracranial hemorrhage. Implementation increased direct emergency-department and home discharge without reducing follow-up. Fewer patients returned with radiological lesion expansion, although the observational design does not prove that the protocol caused this improvement.

Objective

To determine whether implementing a modified Brain Injury Guideline incorporating neurosurgical consultation could improve resource utilization without compromising follow-up in patients with complicated mild traumatic brain injury.

Methods

A retrospective before-and-after review included patients with mild traumatic brain injury and acute traumatic intracranial hemorrhage treated before UteBIG implementation, from January 2016 through August 2022, or afterward, from September 2022 through December 2023.

The investigators compared direct emergency-department discharge, destination after hospitalization, length of stay, provision of educational material, 3-month follow-up and emergency return with lesion expansion. The study analyzed 977 patients; 63.5% were male, mean age was 58.0 years and 57.6% had a Glasgow Coma Scale score of 15.

Main results

After implementation, direct discharge from the emergency department increased from 0.3% to 7.2% (p<0.001), and discharge home after hospitalization increased from 45.6% to 69.2% (p<0.001).

Mean length of stay decreased numerically from 8.33 to 5.17 days, but the difference was not significant (p=0.27). Receipt of educational material (78.5% versus 83.9%; p=0.06) and 3-month follow-up (67.4% versus 72.7%; p=0.13) were unchanged. Emergency-department return with lesion expansion fell from 6.0% to 2.7% (p=0.02).

Interpretation

A structured pathway that preserves neurosurgical participation may allow more selected patients with complicated mild traumatic brain injury to avoid unnecessary hospitalization or non-home discharge. The findings suggest that resource stewardship and specialist collaboration are compatible, but they should not be interpreted as evidence that every patient with a small traumatic hemorrhage can be safely discharged.

Limitations

This was a retrospective, single-center comparison across two different time periods. Changes in staffing, bed availability, discharge practice and case mix may have influenced the results. The postimplementation interval was shorter, and the study was not designed to demonstrate equivalence for rare deterioration, delayed surgery or mortality.

Clinical takeaway

Protocol-based assessment can reduce avoidable resource use in selected adults with complicated mild traumatic brain injury. Safe implementation requires explicit imaging and clinical criteria, neurosurgical availability, reliable observation and discharge instructions, and a defined route for urgent reassessment.

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