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Postoperative ketorolac administration and pseudoarthrosis following multilevel posterior cervical decompression and fusion

Spine. 2026;51(15):1101–1107

Objective
To determine whether ketorolac administered within 48 hours of multilevel posterior cervical decompression and fusion increases the risk of pseudoarthrosis.

Methods
Retrospective TriNetX database study covering 2002–2024. Propensity matching produced two cohorts of 1,376 patients treated with ketorolac or acetaminophen alone.

Main results
Pseudoarthrosis rates were similar at one year (6.3% in both groups) and four years (8.1% versus 8.4%). There were also no significant differences in reoperation, hardware complications, infection, bleeding or thromboembolic events. Ketorolac was associated with a modest reduction in later opioid prescriptions (RR 0.909; 95% CI 0.834–0.980).

Interpretation
Short-term postoperative ketorolac was not associated with impaired fusion in this matched cohort. This supports its cautious inclusion in multimodal analgesia after posterior cervical fusion.

Limitations
Retrospective database study dependent on diagnostic and medication coding. Dose, duration, adherence, imaging confirmation of fusion and over-the-counter NSAID exposure could not be fully assessed.

Clinical takeaway
A limited postoperative ketorolac regimen does not appear to produce a clinically meaningful increase in pseudoarthrosis following multilevel posterior cervical fusion.

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Surgical revascularization versus nonsurgical management in children with symptomatic moyamoya arteriopathy: a North American multicenter cohort study

Journal of Neurosurgery: Pediatrics. 2026;38(2):205–214.

Objective
To compare recurrent ischemic events after surgical revascularization or conservative treatment in children with symptomatic moyamoya arteriopathy.

Methods
Retrospective comparison of 49 children treated at two North American institutions: 24 received nonsurgical management and 25 underwent predominantly indirect revascularization. Median age was 6 years.

Main results
Ipsilateral ischemic event–free survival at 12, 24 and 60 months was 52.8%, 52.8% and 31.7% with nonsurgical management, compared with 87.7%, 83.0% and 83.0% after surgery. Surgical revascularization was associated with a substantially longer time to recurrence (HR 0.15; 95% CI 0.04–0.51).

Interpretation
The findings strongly favor revascularization for children with symptomatic disease. Nevertheless, treatment strategy was closely linked to the institution, making residual confounding likely.

Limitations
Small retrospective cohort, center-dependent treatment allocation and differences in patient selection. The observed association involving race should not be interpreted as causal.

Clinical takeaway
In symptomatic pediatric moyamoya, timely referral for surgical revascularization appears preferable to observation alone.

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

Journal of Neurosurgery. 2026;145(2):347–361

Objective
To evaluate the safety and oncological value of maximum resection in a large contemporary series of insular gliomas.

Methods
Single-center retrospective study of 502 resections performed in 394 patients between 1997 and 2022. The series included newly diagnosed and recurrent low- and high-grade gliomas treated using a transcortical approach with cortical and subcortical mapping.

Main results
Among newly diagnosed grade 2 gliomas, persistent motor or language deficits occurred in fewer than 4% of patients. Transient motor and language deficits occurred in 9.5% and 20%, respectively. A residual tumor volume below 2.7 cm³ was associated with longer overall survival in grade 2 glioma. In newly diagnosed IDH-wildtype glioblastoma, resection of more than 88.6% of the contrast-enhancing tumor was associated with improved progression-free and overall survival. Permanent limb weakness was independently associated with worse survival (HR 2.06; 95% CI 1.14–3.74).

Interpretation
Extensive insular glioma resection can be achieved with relatively low permanent morbidity when modern mapping techniques are used. Functional preservation remains essential because permanent deficits may eliminate the survival benefit of aggressive resection.

Limitations
Retrospective, single-center experience spanning 25 years, during which imaging, molecular classification and adjuvant treatments changed considerably.

Clinical takeaway
The goal should be maximum safe—not simply maximum—resection, guided by functional boundaries and postoperative residual volume.

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Factors associated with overall survival and 90-day mortality following resection of melanoma brain metastases

Operative Neurosurgery. 2026;31(2):270–284

Objective

To identify factors associated with early postoperative mortality and overall survival after surgical resection of melanoma brain metastases.

Methods

This retrospective single-center study included 103 patients who underwent resection as their initial treatment for melanoma brain metastases between 2009 and 2018. The primary outcomes were overall survival, 90-day mortality and development of leptomeningeal disease.

Main results

Nineteen patients (18%) died within 90 days of surgery. Elevated lactate dehydrogenase at diagnosis was independently associated with greater early mortality (OR 7.17).

Factors associated with lower 90-day mortality included:

  • Postoperative Karnofsky Performance Status ≥80: OR 0.13.
  • Brain metastasis already present at the diagnosis of stage IV disease: OR 0.11.

Better overall survival was associated with:

  • Preoperative Karnofsky score ≥80: HR 0.46.
  • Adjuvant stereotactic radiosurgery: HR 0.55.
  • Surgical reduction of total intracranial tumor burden by ≥95.6%: HR 0.47.
  • Synchronous diagnosis of brain metastasis and stage IV melanoma: HR 0.59.

No evaluated factor was significantly associated with subsequent leptomeningeal disease. PubMed abstract

Interpretation

Functional status remains central to surgical selection. The study also suggests that the value of surgery may depend not only on removing the symptomatic lesion but on achieving a major reduction in the patient’s total intracranial tumor burden.

The association between adjuvant stereotactic radiosurgery and longer survival supports a combined local-treatment strategy rather than surgery alone. Elevated LDH may help identify patients at particularly high risk of early postoperative death.

Limitations

The study was retrospective, conducted at a single tertiary cancer center and included patients treated between 2009 and 2018. Systemic melanoma therapy has evolved substantially since that period. The survival associations cannot establish that extensive resection or adjuvant radiosurgery directly caused better survival because healthier patients may have been more likely to receive these treatments.

Clinical takeaway

Surgery for melanoma brain metastases should be considered within a multimodal treatment strategy. Patients with good functional status are the most likely to benefit, while elevated LDH identifies a group with substantial early mortality risk. When safely achievable, a reduction of at least approximately 95% of total intracranial tumor burden may provide greater benefit than limited resection of the dominant lesion alone.

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Resection versus fenestration for Rathke’s cleft cysts

J Neurosurg 145:92–102, 2026

In patients undergoing transsphenoidal surgery for a symptomatic Rathke’s cleft cyst, does cyst-wall resection reduce recurrence sufficiently to justify its potentially greater endocrine morbidity, or is simple fenestration the preferable strategy?

Objective

To compare the long-term clinical and radiological outcomes of cyst-wall resection and fenestration in patients undergoing transsphenoidal surgery for Rathke’s cleft cysts.

Methods

This retrospective, single-center study included 278 patients treated between 2000 and 2023:

  • 122 underwent cyst-wall resection.
  • 156 underwent fenestration and drainage.
  • Mean follow-up was 68 months.
  • A propensity-matched cohort of 242 patients was used for the principal comparison.

The authors analyzed headache, visual and endocrine outcomes, postoperative complications and cyst recurrence.

Main results

Fenestration and resection achieved similar improvement in visual and endocrine symptoms. However, headache resolution was significantly better after fenestration:

  • Gross-total resection: 43%
  • Subtotal resection: 34%
  • Fenestration: 59%

New growth-hormone deficiency was less frequent after fenestration:

  • Gross-total resection: 10%
  • Subtotal resection: 16%
  • Fenestration: 3.2%

The overall recurrence rate was 24%:

  • Gross-total resection: 18%
  • Subtotal resection: 39%
  • Fenestration: 25%

Recurrence-free survival was comparable between fenestration and gross-total resection. Subtotal resection showed the least favorable results.

A residual cyst on postoperative MRI was the strongest independent predictor of recurrence (HR 4.01; 95% CI 2.41–6.65).

Interpretation

The findings question the need for routine aggressive cyst-wall removal. Fenestration provided equivalent visual and endocrine improvement, better headache relief and fewer new hormonal deficits without increasing recurrence compared with gross-total resection.

Attempting cyst-wall resection without achieving complete removal may offer little benefit: subtotal resection combines greater pituitary manipulation with a relatively high recurrence rate.

Limitations

The study was retrospective and conducted at a single institution. Treatment selection was not randomized, surgical practice evolved during the 23-year study period, and follow-up was longer in the fenestration group.

Clinical takeaway

Wide fenestration appears to offer the best balance between decompression, symptom relief, endocrine preservation and recurrence control. Aggressive cyst-wall removal should not be pursued when the wall is firmly adherent to the pituitary gland or stalk.

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Resection and permanent intracranial brachytherapy using modular, biocompatible cesium-131 implants for recurrent aggressive meningiomas: 5-year results from a prospective phase 2 trial

J Neurosurg 145:206–213, 2026

This prospective single-center phase 2 trial evaluates maximal safe resection combined with intraoperative Cs-131 collagen tile brachytherapy (R+CTBT) for 29 recurrent, aggressive meningiomas, reporting improved local control rates at long-term follow-up compared with each tumor’s prior same-site treatment. Outcomes include Kaplan–Meier local control at 36–60 months, hazard ratios from Cox models, and detailed adverse-event reporting.

The report describes patient selection, implant technique, dosimetry metrics, statistical methods, and safety considerations, highlighting a lower symptomatic radiation necrosis rate with Cs-131 tiles and acceptable surgical complications, while noting single-center design and limited sample size as study limitations.

Objective Evaluate whether maximal safe resection plus Cs-131 collagen tile brachytherapy (R+CTBT) improves control of recurrent aggressive meningiomas versus the patient’s prior same-site treatment.

Design Prospective, nonrandomized, single-center phase 2 trial enrolling patients with recurrent aggressive meningiomas (June 2013–Jan 2018), with follow-up through August 2020.

Procedure After maximal safe resection and intraoperative pathologic confirmation, Cs-131 seeds were embedded into collagen squares (“tiles”) and placed in the resection bed; postoperative CT was used for radiation planning and MRI for extent of resection assessment.

Population 29 tumors in 27 patients (median age 66); tumors at time of R+CTBT were predominantly WHO grade 2 (90%), with 3% grade 1 and 7% grade 3.

Efficacy Local control at 48 and 60 months was 73% and 48% after R+CTBT versus 21% and 17% after prior same-site treatment (HR 0.145, p < 0.001).

Outcomes detail Local progression (≤ 1.5 cm from operative bed) occurred in 8/29 (28%) implant sites over a median radiographic follow-up of 34.8 months.

Complications Surgery-related complications requiring intervention occurred in 4/29 (14%) (1 early infection; 3 delayed wound breakdown/infection).

Radiation injury Symptomatic radiation brain injury/radiation necrosis occurred in 4/29 (14%), and all cases resolved with medical therapy.

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Outcomes after cervical disc replacement compared with anterior cervical discectomy and fusion at medium- to long-term follow-up

Neurosurg Focus 61(1):E5, 2026

This retrospective propensity score–matched analysis of 18,916 adults compares long-term functional and surgical outcomes after cervical disc replacement (CDR) versus anterior cervical discectomy and fusion (ACDF) using a large federated EHR network. Results across 6 months to 5 years show consistently lower risks after CDR for anterior reoperation, posterior revision, adjacent segment disease, new-onset cervical pain, ADL dependence, and surgical site infections.

The study emphasizes durable biomechanical advantages of motion-preserving CDR, with sustained reductions in opioid use and functional impairment at 5 years, while acknowledging limitations of EHR-based retrospective study design, potential selection bias, and absence of granular radiographic and patient-reported outcome data.

Objective Compare long-term functional and clinical outcomes of cervical disc replacement (CDR) versus anterior cervical discectomy and fusion (ACDF) for degenerative cervical disc disease, focusing on whether motion preservation reduces adjacent segment disease and reoperation.

Methods Queried TriNetX EHR network for adults (≥18) undergoing CDR or ACDF for degenerative indications; performed 1:1 propensity score matching and assessed outcomes from 6 months to 5 years, including Kaplan–Meier analyses for reoperation/adjacent segment disease.

Cohort After matching, 9458 patients were included in each group (mean age 48 years).

Reoperation & pain Across follow-up time points, CDR was associated with lower risk of anterior reoperation (RR 0.62, 95% CI 0.52–0.74) and new-onset cervical pain (RR 0.64, 95% CI 0.55–0.73) versus ACDF.

Infection At 1-, 2-, and 5-year follow-ups, CDR showed lower surgical site infection risk (RR 0.62, 95% CI 0.48–0.78).

Sagittal alignment No difference between groups in coding for acquired cervical kyphosis/lordosis after 2 years (p > 0.05).

Opioids (5-year) At 5 years, CDR was associated with lower opioid use (RR 0.66, 95% CI 0.54–0.82).

Conclusion & caution Results suggest superior long-term outcomes with CDR versus ACDF, but interpretation should be cautious due to limitations of retrospective EHR-based analyses; CDR is presented as a viable alternative for degenerative cervical pathologies.

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Idiopathic normal pressure hydrocephalus: validation of the DESH score in the Capital Region of Denmark

Acta Neurochirurgica (2026) 168:155

This study validates the DESH radiological scoring system as a predictor of shunt surgery response in 127 patients with idiopathic normal pressure hydrocephalus (iNPH) at a Danish neurosurgical center, showing a significant positive association at a mean 7.4-month follow-up. The analysis adjusted for age, sex, and imaging modality, with blinded radiologic assessment and multivariate logistic regression demonstrating increased odds of a positive outcome per DESH point.

The paper also examines whether CT versus MRI confounds DESH grading, finding no evidence of modality-driven bias in this cohort but noting that formal equivalence requires paired within-patient imaging. Limitations include selection bias from preselected tested patients and lack of paired imaging, while strengths are external validation, cohort size, and blinded scoring.

Objective External validation of the DESH score as a prognostic marker for shunt response in idiopathic normal pressure hydrocephalus (iNPH), and assessment of whether CT vs MRI confounds DESH grading/outcome association.

Cohort Retrospective study of 127 shunt-operated iNPH patients (2013–2020) with preoperative CT and/or MRI and ≥2 months follow-up; mean follow-up 7.4 months.

Predictors assessed Radiologic markers (Evans’ index, callosal angle, Sylvian fissure dilation, tight high convexity, focal sulci) and their combined DESH score were compared against shunt response.

Primary finding Higher DESH score was significantly associated with objective shunt response after adjustment for age, sex, and modality (OR 1.35, p=0.036).

Modality impact No significant difference in DESH score assessments between CT and MRI, and including/excluding modality did not meaningfully change regression coefficients.

Outcome rate 81.9% of patients had a positive response to shunt surgery in this cohort.

Interpretation CT may be a practical alternative for DESH-based initial evaluation when MRI is impractical, but formal equivalence of CT vs MRI DESH scoring requires paired-imaging studies.

Key limitation Cohort was preselected based on prior diagnostic testing (e.g., infusion/tap testing), increasing pretest probability and limiting generalizability (potential selection bias).

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Surgical skill is not a virtue

J Neurosurg 145:281–283, 2026

This commentary examines the emotional and ethical burden neurosurgeons carry when surgical complications occur, using cerebral aneurysm surgery as a focal example to quantify lifetime risks and consequences. It contrasts the high technical demands and inevitable failures of neurosurgery with the personal toll of complications, including burnout, substance abuse, family strain, and elevated suicide rates.

The author argues for reframing surgical identity: technical skill is not a moral virtue. Emphasizing cultivated courage, relational commitment to patients, and character formation in training, the piece calls for open discussion of virtue ethics in surgical education to foster resilience and align clinical performance with the patient’s broader good.

Career complication burden A cerebrovascular neurosurgeon performing ~900 aneurysm surgeries can expect to cause roughly 27–60 strokes (3%–8% risk) and about 9 deaths (~1% mortality) over a career, excluding complications from other operations

Rupture vs treatment tradeoff Aneurysm rupture is catastrophic (30%–50% mortality; >30% long-term disability among survivors) yet rupture is rare, while preemptive surgery carries complication costs that patients and surgeons both bear

Hidden surgeon suffering Surgical successes are quickly forgotten, but complications can become lifelong, intrusive burdens that follow surgeons beyond work and create persistent regret

Downstream harms The cumulative burden is associated with high levels of physician burnout, family dysfunction/divorce, substance abuse, and elevated physician suicide rates; denial/avoidance can worsen relationships and invite legal risk

Skill-virtue confusion Training and professional culture can lead surgeons to treat technical skill as a moral virtue, so inevitable complications are experienced as failures of character rather than limits of medicine or circumstance

Key distinction Surgical skill is not a virtue; virtues are character dispositions aimed at human good, while skill is “technical goodness,” and medicine must be more than technique when technical answers fail

Relational triumph after technical failure A surgeon can fail technically yet “triumph relationally” by sustaining courage, honesty about what happened, and commitment to accompany patients and families through outcomes

Cultivating virtues for resilience Courage and character should be intentionally modeled and habituated in surgical training; separating skill failure from character failure supports resilience and continued service after complications

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Diabetes as a significant risk factor for postoperative dysphagia following cervical spine surgery

J Neurosurg Spine 45:19–29, 2026

This clinical study evaluates whether preoperative diabetes increases the risk and severity of postoperative dysphagia after cervical spine surgery, using prospectively collected multi-institutional registry data and validated EAT-10 scores at baseline and 1, 3, and 12 months. Multivariable mixed-effects logistic regression identified diabetes as an independent predictor of dysphagia at 1 and 3 months, with higher incidence and worse PROMs in diabetic patients.

The cohort of 2001 patients (20% with diabetes) demonstrated significantly greater new postoperative dysphagia and higher EAT-10 score changes among diabetics, particularly after anterior procedures; however, diabetes did not independently predict dysphagia at 12 months. The authors discuss clinical implications, limitations (lack of HbA1c and neuropathy data), and recommend surgeons counsel patients about elevated short-term dysphagia risk.

Objective Relationship between preoperative diabetes and incidence of postoperative dysphagia after cervical spine surgery, assessed using EAT-10 at baseline and 1, 3, and 12 months post-op

Cohort 2001 cervical spine surgery patients; 400 (20%) had diabetes; baseline dysphagia rates were not significantly different (18% diabetes vs 14% no diabetes)

Higher dysphagia rates Patients with diabetes had higher postoperative dysphagia incidence at 1 month (66% vs 54%), 3 months (39% vs 26%), and 12 months (33% vs 24%)

Independent prediction (all patients) After adjusting for baseline dysphagia and other factors, diabetes independently predicted postoperative dysphagia at 1 month (OR 1.46) and 3 months (OR 1.63), but not at 12 months (OR 1.21)

New dysphagia (no baseline dysphagia) Among patients without baseline dysphagia, diabetes was associated with higher new dysphagia at 1 month (62% vs 50%), 3 months (34% vs 21%), and 12 months (27% vs 18%)

Independent prediction (new dysphagia) In those without baseline dysphagia, diabetes independently predicted new dysphagia at 1 month (OR 1.49) and 3 months (OR 1.81), but not at 12 months (OR 1.31)

Symptom severity change Mean EAT-10 change from baseline to 12 months was worse with preoperative diabetes (2.440 ± 5.013 vs 1.688 ± 4.139) among those without baseline dysphagia

Conclusion Diabetes is a significant risk factor for postoperative dysphagia after cervical spine surgery, with strongest independent effect at early time points (1 and 3 months)

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Reevaluating routine imaging: clinical utility of postoperative CT after stereotactic brain biopsy

J Neurosurg 145:190–205, 2026

This study evaluates the clinical value of routine postoperative CT after stereotactic brain biopsy (SBB) by analyzing 753 procedures over 28 years to identify predictors of hemorrhage, frequency of radiographic bleeding, and consequences for patient management. The authors compare imaging findings with symptoms, interventions, and hematoma expansion to assess whether a selective, symptom-driven imaging strategy is safe.

Key results show that 42% of initial postoperative CTs detected blood—mostly small, clinically silent biopsy-site or tract bleeds—while only 5% of CTs altered management. Predictors of postoperative hemorrhage included intraoperative blood through the biopsy needle, lower platelet counts, preoperative intralesional hemorrhage, and early neurological symptoms, supporting selective rather than routine imaging

Objective Identify predictors of post–stereotactic brain biopsy (SBB) hemorrhage and assess whether selective, symptom-driven postoperative CT can safely replace routine CT.

Methods Retrospective review of 753 SBBs (1993–2021) with postoperative CT within 48 hours; recorded any hemorrhage, new/worsening neurological symptoms within 30 days (early vs delayed), and “clinically significant hemorrhage” (CT blood prompting a management change attributable to hemorrhage).

Hemorrhage frequency/location Blood appeared on first postoperative CT in 316/753 (42%) cases, predominantly at the biopsy site and/or along the trajectory (97% of bleeds); most were clinically silent at the time of the first CT.

Key predictors of blood on CT Independent associations included early postoperative symptoms (OR 3.82), intraoperative blood through the biopsy needle (OR 2.88), preoperative intralesional hemorrhage (OR 31.4), and platelet count >100–150 × 10⁹/L (OR 1.7); platelet count ≤100 × 10⁹/L showed ~4× higher risk but was not statistically significant.

Symptoms & interventions New/worsening neurological symptoms occurred in 161/753 (21%); altered mental status post-SBB correlated with blood on CT (69% vs 31%); 4 cases required intervention (2 hemorrhage evacuations, 2 ventriculostomies).

Predictive value of initial CT Positive predictive value for detecting a new/expanding hemorrhage was 17%, while negative predictive value for ruling out subsequent new hemorrhage was 98%; no new bleeding occurred beyond 48 hours postoperatively.

Management impact Postoperative CT altered management in 5% of cases, mainly in symptomatic patients rather than neurologically stable ones.

Conclusion/recommendation Routine postoperative CT after SBB may be unnecessary for all patients; selective imaging is recommended for bleeding diathesis, intraoperative bleeding, existing intralesional hemorrhage, and/or new or worsening neurological symptoms, potentially reducing cost and radiation without compromising safety.

 

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Focused ultrasound thalamotomy for essential tremor in octogenarians

J Neurosurg 145:27–35, 2026

This multicenter retrospective cohort study evaluates unilateral MR-guided high-intensity focused ultrasound (MRgHIFU) thalamotomy targeting the ventral intermediate nucleus (VIM) for medically refractory essential tremor in patients aged 80 years and older. Results from 129 patients show marked reductions in tremor and disability scores, high patient-reported relief, and generally mild, transient adverse events.

Age-stratified analyses found comparable tremor benefit across 80–84 and ≥85 year groups, modest gait changes, and low rates of serious complications, supporting MRgHIFU as a noninvasive therapeutic option for elderly patients ineligible for deep brain stimulation.

Objective Evaluate safety and efficacy of unilateral MRgHIFU thalamotomy targeting the VIM for medication-refractory essential tremor in patients aged ≥ 80 years.

Design Retrospective, multicenter cohort of consecutive patients treated between 2016 and 2023 at five academic centers, with assessments at baseline, immediately posttreatment, and 3 months.

Primary outcome Tremor severity measured by TETRAS; primary endpoint was change from baseline to follow-up.

Efficacy In 129 patients (mean age 84), mean TETRAS improved by 9.2 points at 3 months (p < 0.001), with significant improvement also seen on CRST and mean patient-reported tremor relief of 81%.

Gait effects DGI gait scores improved modestly overall but were not significant in the ≥ 85 years subgroup.

Safety Adverse events were generally mild/transient; nonsurgical adverse events occurred in 1.6% of patients.

Age-stratified results Treatment response and adverse event profiles did not significantly differ between ages 80–84 and ≥ 85 years.

Conclusion Unilateral MRgHIFU VIM thalamotomy provides a low-complication, noninvasive option that significantly improves tremor and disability in adults aged ≥ 80 years, supporting consideration for those ineligible for invasive procedures like DBS.

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Intraoperative Ultrasound in Chiari 1 Decompression: Clarity or Confusion?

Neurosurgery 99:19–29, 2026

This systematic review evaluates intraoperative ultrasound (iUS) use in guiding the extent of posterior fossa decompression (PFD versus PFD+) for Chiari malformation type 1, analyzing nine studies (844 patients) for iUS criteria, conversion rates, and positive predictive values. It finds substantial heterogeneity in acquisition, qualitative versus quantitative criteria, and outcome reporting, limiting iUS’s reliability for intraoperative decision making.

The authors propose a standardized reporting framework emphasizing defined CSF space measurements, dynamic metrics (e.g., CSF flow velocity, tonsillar excursion), triplicate measurements with dual raters, and ≥12-month validated outcomes to enable reproducible research and clearer assessment of iUS utility.

Clinical dilemma Bone-only posterior fossa decompression (PFD) is less invasive, while dural opening/expansion (PFD+) may be more effective but has higher complication risk; intraoperative ultrasound (iUS) is used to help decide whether PFD alone is sufficient, but its role/criteria are not defined.

Evidence base 9 studies (1 prospective, 8 retrospective) totaling 844 patients (pediatric and adult) were included; risk of bias was low in 1 study, moderate in 3, and high in 5.

How iUS was applied iUS was used after bony decompression and before dural opening; none of the studies used iUS after opening the dura.

Decision criteria heterogeneity 8 studies used qualitative criteria (e.g., “enough space,” tonsillar pulsation, piston-like motion, bidirectional flow), and 1 study used a quantitative CSF flow-velocity threshold.

Conversion surgery outcomes “Conversion” (later revision from PFD to PFD+ due to persistent/worsening symptoms) occurred in 35/844 patients (5% overall), with study-level conversion rates from 0% to 16%.

Predictive value variability Positive predictive value (PPV) for iUS-guided PFD success ranged from 0.857 to 1.000 across studies, varying with criteria and study design.

Main conclusion Current evidence does not support iUS as a robust intraoperative test for deciding extent of decompression because of heterogeneous application and lack of standardized assessment criteria; sensitivity/specificity cannot be determined with available data structure.

Proposed path forward A standardized reporting framework is proposed, emphasizing defined acquisition parameters, quantitative/operationalized criteria, validated outcome measures, and ≥12-month follow-up to enable comparability and future pooled analyses.

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Predictive Values of Lumbar Infusion Testing in Idiopathic Normal Pressure Hydrocephalus Diagnosis

Neurosurgery 99:50–59, 2026

This study evaluates lumbar infusion testing (LIT) as an adjunctive diagnostic tool for idiopathic normal-pressure hydrocephalus (iNPH) in a cohort of 165 patients, defining an optimal Rout threshold (≈12 mm Hg·mL−1·min−1) with good sensitivity and specificity. It reports LIT’s role in multidisciplinary decision-making, its safety, and its contribution to selecting patients for ventriculoperitoneal shunting and improving postshunt outcomes.

The authors detail standardized clinical, radiological, and hydrodynamic assessments, show outcome rates after shunting across pretest probability groups, and propose a diagnostic algorithm positioning LIT as a reproducible, low-morbidity adjunct when clinical and imaging data remain inconclusive.

Goal Evaluate lumbar infusion testing (LIT) performance to support shunt decision-making in suspected idiopathic normal-pressure hydrocephalus (iNPH), given no single reliable diagnostic test exists.

Cohort 201 referred; 165 had interpretable LIT results (mean age 79), assessed with combined clinical, radiological, and hydrodynamic workup.

Symptom profile In the 165-patient LIT cohort, gait disturbance was present in 98.8%, cognitive impairment in 86.6%, and urinary disturbances in 58.8%.

Key metric CSF outflow resistance (Rout) differed significantly across diagnostic probability groups, and the optimal cutoff was ~12 mm Hg/mL/min (AUC 0.8441), yielding 78.1% sensitivity and 74.3% specificity for shunt-response prediction.

Clinical utility (borderline cases) In patients initially classified as possible iNPH who were shunted based on LIT findings, 75.6% improved clinically.

Outcomes (high-probability cases) In the probable iNPH group, 87.1% of shunted patients showed improvement.

Safety No complications (e.g., intracranial hypotension syndrome or infection) were observed after LIT in this cohort.

Conclusion LIT is not definitive for iNPH diagnosis but is a safe, reproducible adjunct that helps in diagnostic uncertainty, supports earlier decision-making, and can help avoid unnecessary surgery when combined with clinical and radiological assessment.

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Resectability of White Matter Tracts in Patients With Language-Critical Gliomas

Neurosurgery 99:140–148, 2026

This study evaluates how resections of language-associated white matter tracts (WMTs) predict persistent postoperative language deficits (PLDs) in 68 glioma patients using tractography, intraoperative mapping, and outcome assessments. Results show WMT resection strongly predicts PLDs with high negative predictive value but modest positive predictive value, and temporal/parietal segments carry the greatest risk.

Anatomic clustering localized high-risk resections to the temporoparietal junction and middle temporal lobe, while frontal operculum and orbitofrontal tracts were often resectable without lasting deficits. Anatomically stratifying tracts (parietal/temporal) improved positive predictive value, supporting tractography-informed surgical planning alongside intraoperative mapping.

Goal Identify predictors of permanent postoperative language deficits (PLDs) in language-eloquent glioma surgery by analyzing which language-associated white matter tract (WMT) segments are resected.

Cohort & approach Retrospective analysis of consecutive adults undergoing awake craniotomy with intraoperative language mapping; WMT tractography reconstructed 6 language-related tracts and parcellated by anatomic location; outcomes based on formal language testing pre-op vs 1–3 months post-op (with clinical follow-up to 6 months for persistence).

Overall predictive signal Any WMT resection strongly increased odds of PLDs (odds ratio 16.0, P = .0115) with high NPV 97.4% but low PPV 29.6%.

Anatomic vulnerability Resections associated with PLDs clustered in the temporoparietal junction (TPJ) and middle temporal lobe (MTL), while resections without PLDs were more diffuse and concentrated in frontal/anterior regions.

Resectability by region Frontal tract segments showed near-complete resectability (PPV = 0 across reported frontal segments), whereas parietal/temporal segments had higher PPVs (eg, parietal AF 0.4, temporal AF 1, temporal IFOF 0.5, temporal ILF 0.5).

Stratified model Focusing only on parietal and temporal tract segment resections improved prediction of PLDs (odds ratio 29.4, P < .001) and increased PPV to 50% (NPV 96.7%).

Resection volume The volume of tract resected did not differ by functional outcome (U = 84.0, P = .70), suggesting location/segment matters more than amount.

Clinical implication WMT resections in orbitofrontal, anterior temporal, and frontal operculum regions were often tolerated, while parietal/temporal WMT injuries substantially increased PLD risk.

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Speech mapping in awake high-grade glioma resection: subcortical tract proximity as a predictor of language outcomes

J Neurosurg 145:179–189, 2026

This clinical study evaluates intraoperative predictors of postoperative language decline in awake resections of language-eloquent high-grade gliomas using diffusion tractography, 5-ALA, and subcortical stimulation with standardized language testing. It reports rates of transient and permanent deficits, correlates specific white matter tracts (IFOF, ILF, AF/SLF) with domain-specific impairments, and presents stimulation thresholds predictive of decline.

The paper emphasizes that preoperative deficits and positive stimulation of multiple tracts increase risk of lasting language impairment, while most single-tract-related declines tend to recover by three months; proposed SCS amplitude cutoffs are offered as practical guidance to balance maximal resection and language preservation.

Objective Identify intraoperative predictors of postoperative language decline and predictors of temporal language recovery after awake resection of language-eloquent high-grade glioma (HGG).

Methods Single-center cohort (Jan 2017–Nov 2024) undergoing awake craniotomy with diffusion tractography, 5-ALA, subcortical stimulation (SCS), and intraoperative language testing; language outcomes assessed at 48 hours, 2 weeks, and 3 months.

Outcomes New or worsened postoperative language deficit occurred in 53.1% (69/130) and was permanent (>3 months) in 9.2% (12/130).

Key intraoperative predictor (domain-specific) Clinical deterioration during awake testing predicted short-term decline in semantic processing (IFOF) (RR 3.47), reading (ILF) (RR 21.4), and auditory naming/repetition (AF/SLF) (RR 6.98).

Permanent-deficit risk factors Higher risk of persistent language decline was associated with preoperative speech deficit (RR 2.65), intraoperative ILF-related reading deterioration (RR 8.92), and positive SCS of multiple language tracts.

Tract sensitivity & recovery Posterior ILF–related reading function showed the greatest sensitivity to decline and the lowest propensity for recovery; all observed reading deficits were linked to tumors near the posterior ILF.

SCS threshold cutoffs ROC/Youden-derived SCS amplitudes predictive of postoperative deficits were reported per tract: IFOF 5.5 mA (48h/2w), 4.5 mA (3m); ILF (reading) 7.0 mA (48h/2w), 4.5 mA (3m); AF/SLF 5.5 mA (48h/2w), 2.5 mA (3m).

Multiple-tract involvement At 3 months, deficits occurred in 7.4% (5/68) with single-tract positive SCS versus 75.0% (9/12) with two tracts; both patients with all three tracts stimulated had persistent deficits beyond 3 months.

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Multiple-level (≥ 3) cervical artificial disc replacement: illustrative case and systematic review of the literature

Neurosurg Focus 61(1):E8, 2026

This systematic review and illustrative case evaluate outcomes of multilevel (≥3 levels) cervical artificial disc replacement (C-ADR), synthesizing data from five studies and one clinical example to assess pain relief, functional recovery, range-of-motion preservation, complications, and reoperation rates. The review reports consistent, durable improvements in VAS and NDI scores, preserved segmental and global cervical motion, low revision rates, and primarily transient complications across 3- and 4-level cohorts.

The article compares multilevel C-ADR with anterior cervical discectomy and fusion (ACDF), emphasizing motion-preserving biomechanical advantages that may reduce adjacent segment degeneration. Limitations include sparse, mostly retrospective data, heterogeneous reporting, and limited long-term follow-up, prompting a call for larger prospective trials and extended surveillance for implant longevity and ASD risk.

Objective Characterize outcomes and complications after multilevel (≥ 3 levels) cervical artificial disc replacement (C-ADR), including an illustrative 3-level case for technical discussion.

Methods Systematic review conducted per PRISMA guidelines, querying PubMed and MEDLINE (August 2025) for primary peer-reviewed studies reporting ≥ 3-level C-ADR outcomes, including range of motion (ROM) preservation and complications.

Clinical outcomes Across 5 studies of 3- and 4-level C-ADR, patients had substantial, durable improvements in pain, disability, and quality of life (e.g., neck/arm VAS decreases > 50%) with benefits reported up to 7 years.

Motion preservation Multilevel C-ADR preserved segmental and global cervical ROM, contrasting with near-complete loss of motion reported after multilevel fusion comparators.

Adjacent segment disease No cases of symptomatic adjacent segment degeneration requiring reoperation were reported in the reviewed multilevel C-ADR studies.

Complications/reoperation Complication rates were low and mostly transient; reoperation was required in only 0%–2% of cases across included studies.

Illustrative case A 50-year-old man with progressive cervical myeloradiculopathy underwent 3-level C-ADR (C4–5, C5–6, C6–7) with uncomplicated recovery, immediate symptom relief, and return to unrestricted activity by 6 weeks with preserved motion at 6 months.

Conclusions/limitations 3- and 4-level C-ADR appears safe and effective for appropriately selected patients with durable pain relief and low revision rates, but evidence remains limited (only five stratified studies; largely retrospective) and devices are not FDA-approved for ≥ 3 levels.

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Corticosteroid Use Before Stereotactic Brain Biopsy for Suspected Lymphoma

Neurosurgery 99:30–39, 2026

This retrospective cohort study evaluates whether preoperative corticosteroid therapy (CST) affects the diagnostic yield of stereotactic brain biopsy (SBB) in 104 patients with pathologically confirmed primary central nervous system lymphoma (PCNSL). The analysis stratifies patients by steroid timing, duration, and cumulative dexamethasone-equivalent dose, reporting diagnostic rates, radiographic features, and complications.

Results show a 92.3% overall diagnostic yield that remained high regardless of CST exposure, dose, or timing, with comparable postoperative complication rates. The authors conclude short-course CST for symptom control appears safe before SBB, while emphasizing multidisciplinary coordination and need for prospective standardized protocols.

Clinical question Whether preoperative corticosteroid therapy (CST) (timing, dose, duration) reduces stereotactic brain biopsy (SBB) diagnostic yield in suspected primary CNS lymphoma (PCNSL), and whether it affects postoperative complications

Cohort & design Retrospective review of 725 SBBs (2014–2025) identifying 104 pathologically confirmed PCNSL cases; CST-naive vs CST-exposed with stratification by last-dose timing, cumulative dexamethasone-equivalent dose, and duration

Overall yield Initial SBB diagnostic yield for PCNSL was 92.3% (96/104), with 8 nondiagnostic initial biopsies

CST vs no CST yield Diagnostic yield was 95.3% with CST (41/43) vs 90.2% without CST (55/61), not significant (P = .46)

Timing of last CST dose Yield remained high across intervals: ≤48 h 96.4%, 48–72 h 91.7%, >72 h 100% (P = .66)

Cumulative dose & duration Yield did not differ by cumulative dexamethasone dose (≤20 mg 95.5%, 21–40 mg 100%, >40 mg 100%, P = 1.0) or by duration (≤5 days 94.6% vs >5 days 100%, P = 1.0)

Complications Postoperative complications occurred in 4.8% of PCNSL cases, with no significant difference between CST-exposed and CST-naive patients (P = .84)

Nondiagnostic biopsies & next steps Only 2/8 initially nondiagnostic cases had prebiopsy CST; all 8 were ultimately confirmed PCNSL via repeat SBB, CSF cytology, or postmortem, supporting repeat/alternative diagnostic approaches when initial biopsy is nondiagnostic

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The suprabulbar approach for jugular fossa schwannomas: case series and technical nuances

J Neurosurg 145:120–131, 2026

This clinical article details a cadaveric and retrospective clinical study of the suprabulbar approach for resection of jugular fossa schwannomas, describing anatomical measurements, stepwise surgical technique, perioperative protocols, and outcomes in 22 patients treated between 1994 and 2024. The authors report a 77% gross-total resection rate, low morbidity, no mortality, and favorable cranial nerve preservation with mean follow-up of 31.4 months.

The paper emphasizes anatomical rationale from bilateral cadaver dissections to define the presigmoid infralabyrinthine window, operative nuances (mastoidectomy, presigmoid dura management, endoscopic assistance), and the approach’s versatility to combine intradural access with neck dissection for large dumbbell tumors while minimizing cranial nerve and venous complications.

Problem Jugular fossa schwannomas are rare lower cranial nerve tumors whose complex anatomy makes surgery difficult and morbidity-prone, especially for swallowing/voice deficits.

Approach The suprabulbar approach uses a presigmoid infralabyrinthine/retrofacial window created via mastoidectomy to access the jugular fossa while preserving the labyrinth and facial nerve, and enabling jugular bulb decompression.

Anatomic basis Cadaveric measurements characterized the surgical corridor (means: sigmoid sinus width 13.5 ± 3.9 mm; jugular bulb width 10.9 ± 1.4 mm; sigmoid-to-retrofacial space 12.8 ± 3 mm; labyrinth-to–jugular bulb dome 10.6 ± 2.6 mm; jugular foramen diameter 8.1 ± 1.2 mm).

Clinical series 22 patients (1994–2024) underwent resection; tumors were predominantly dumbbell-shaped type D (91%), mean max diameter 2.9 ± 1.1 cm, with frequent presenting dysphagia (64%) and hearing loss (41%).

Technique extensions Intradural tumor can be followed via presigmoid dural opening, distal tumor can be removed endoscopically, and caudal extracranial extension can be addressed with single-stage upper neck dissection when needed.

Resection outcomes Gross-total resection was achieved in 77% (17/22); subtotal resection occurred in 5 cases (including one due to intraoperative arrhythmias).

Safety profile No deaths or permanent neurological deficits; transient postoperative cranial nerve deficits occurred in 14% and resolved during follow-up; one perioperative complication was a suspected CSF leak treated with spinal drainage.

Follow-up/recurrence Mean follow-up was 31.4 months; 64% improved in preoperative neurological deficits; confirmed recurrence occurred in 14% (3/22), all successfully reoperated.

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Use of pelvic incidence to predict proximal junctional failure in long-segment spinal fusion

J Neurosurg Spine 45:44–54, 2026

This clinical study evaluates how pelvic incidence (PI) affects spinopelvic correction and proximal junctional failure (PJF) after long-segment thoracolumbar fusion with pelvic fixation in 204 adult spinal deformity patients. Patients were stratified by PI (<55° vs >55°) and analyzed for radiographic outcomes, complications, and PROMs using frequentist and Bayesian models.

Key findings show lower PI independently predicts higher PJF risk (21% vs 9%), with lower thoracic UIV and revision surgery as additional predictors; lower PI patients more often met age-adjusted alignment goals but experienced greater overcorrection relative to individualized morphology.

Objective Evaluate how pelvic incidence (PI) affects spinopelvic correction and complication rates (especially proximal junctional pathology) after long-segment fusion for adult spinal deformity.

Cohort Retrospective analysis of 204 patients undergoing open posterior long-segment thoracolumbar fusion with pelvic fixation (≥ 6 levels) with ≥ 1-year follow-up; grouped by PI cutoff 55° into lower PI (n=108) vs higher PI (n=96).

Primary finding (PJF rates) Lower PI patients had higher proximal junctional failure (PJF) at 1 year than higher PI patients (21% vs 9%, p=0.019).

UIV subgroup With an upper thoracic UIV (T2–5), PJF was 15% in lower PI vs 0% in higher PI (p=0.014).

Independent predictors Multivariate analysis: lower PI (OR 4.3, p=0.006), lower thoracic UIV (T10–12) (OR 6.5, p=0.005), and revision surgery (OR 23.8, p=0.001) independently predicted PJF.

Model confirmation Bayesian mixed-effects modeling also identified lower PI (OR 6.25, posterior probability 0.996) and lower thoracic UIV (OR 7.03, posterior probability 0.997) as significant predictors of PJF.

PJK vs PJF Proximal junctional kyphosis (PJK) rates were similar between PI groups at 1 year (38% vs 41%, p=0.697), despite the PJF difference.

Planning implication Preoperative PI morphology may guide individualized surgical planning to reduce risk of junctional pathology, since lower PI carried higher PJF risk after long-segment fusion.

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