Category: complications

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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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The Lumboperitoneal Shunt Study: A Systematic Review and Single-Arm Meta-Analysis of 2696 Patients

Neurosurgery 99:3–18, 2026

Scope Systematic review + single-arm random-effects meta-analysis of 49 studies including 2696 patients who underwent lumboperitoneal shunt (LPS) placement.

Search/eligibility Databases: PubMed, Embase, Web of Science (through Sept 2023); included observational studies reporting LPS complications; excluded case reports (≤4 patients), non-English, overlapping cohorts, prior non-LPS shunts; study was not prospectively registered.

Main etiologies Largest indication groups were communicating hydrocephalus (693), normal pressure hydrocephalus (631), and idiopathic intracranial hypertension (275) (1599 combined).

Revision risk Overall pooled risk of requiring shunt revision: 25% (95% CI 18%–32%; I²=93%) at median mean follow-up 19.2 months; by etiology: CH 21%, IIH 46%, NPH 10%.

Complication risks Infection: 1% (95% CI 1%–2%; I²=25%); shunt-related mortality: 0.1% (3 deaths).

Overdrainage/tonsillar herniation Overdrainage occurred in 119 patients with high heterogeneity (I²=75%); tonsillar herniation in 19 patients with significant heterogeneity (I²=50%), both reported as minimal pooled risk.

Revision causes Most common reasons for revision were obstruction (30%) and migration/slippage/fracture (20%).

Overall conclusion LPS shows acceptable revision and complication rates and appears comparable to ventriculoperitoneal shunts (VPS), but substantial heterogeneity limits confidence; supports broader integration of LPS in Western practice and calls for randomized trials.

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Adjacent segment disease treated with stand-alone lateral lumbar interbody fusion: an analysis of domino adjacent segment revisions

J Neurosurg Spine 44:884–893, 2026

This clinical study compares stand-alone lateral lumbar interbody fusion (LLIF) with circumferential LLIF plus posterior instrumentation for treating adjacent segment disease (ASD) after prior posterior lumbosacral fusion. Primary outcome focused on “domino” proximal ASD revisions, with secondary measures including cage subsidence, radiographic alignment, and perioperative metrics.

Results from 236 patients show stand-alone LLIF had significantly lower 5-year domino ASD revision rates, shorter operative times and hospital stays, and comparable alignment despite higher rates of moderate-to-severe cage subsidence. Multivariable and competing-risk analyses supported stand-alone LLIF’s protective association against subsequent adjacent-segment reoperations.

Objective Assess whether stand-alone LLIF is a durable ASD revision strategy with lower risk of subsequent “domino” adjacent-segment revision compared with circumferential LLIF (LLIF + posterior fusion extension).

Design/Methods Single-center retrospective cohort (Jan 2008–Aug 2023) of patients with prior posterior lumbosacral fusion undergoing ASD revision via stand-alone vs circumferential LLIF; primary outcome was domino ASD revision; survival analysis and multivariable Cox regression used, adjusting for alignment, stenosis severity, and fused levels.

Cohort 236 patients included (131 stand-alone; 105 circumferential); baseline demographics/treated levels similar; preop MRI showed more severe central stenosis in the circumferential group (more Schizas grade D).

Primary outcome Stand-alone LLIF had a lower 5-year incidence of domino ASD revision (13.7% vs 28.6%, p = 0.005).

Adjusted association After multivariable adjustment, stand-alone LLIF remained independently associated with fewer domino ASD revisions (HR 0.43, 95% CI 0.23–0.79; p = 0.007).

Radiographic outcomes Overall radiographic alignment was comparable between groups, but stand-alone LLIF had higher cage subsidence (Marchi grade ≥ II: 22.9% vs 9.5%, p = 0.019), and subsidence was not associated with increased revision risk.

Perioperative outcomes Stand-alone LLIF had significantly shorter operative time and hospital stay than circumferential LLIF (with lower blood loss also reported).

Conclusion Stand-alone LLIF is supported as a treatment option for ASD after prior posterior fusion, with less domino ASD revision and similar radiographic alignment, at the cost of higher subsidence rates.

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How Do Neurosurgeons Cope With Complications? Results of a Nationwide Survey

Neurosurgery 98:752–764, 2026

This study reports results of a nationwide survey assessing how neurosurgeons emotionally respond to surgical complications and which coping and defense mechanisms they use. It quantifies prevalence of patient harm, emotional impact, common adaptive and maladaptive behaviors, and associations with career effects such as limiting practice or contemplating leaving neurosurgery.

Findings show frequent use of intellectualization, humor, and affiliation alongside maladaptive behaviors that strongly predict career doubt and short-term practice changes, with junior surgeons reporting more coping strategies. The authors recommend institutional support, targeted interventions, and further longitudinal research to improve surgeon well-being and patient care.

Prevalence of serious complications Patient harm was commonly experienced: minor harm (87.3%), temporary harm (80.3%), long-term harm (79.6%), and patient death (58.4%).

Emotional impact Complications had a significant (55.6%) or profound (38.0%) immediate emotional impact, with long-term impact significant for 44.4% and profound for 12.7%.

Persistent preoccupation Respondents thought about complications weekly (41.5%) or daily (22.5%).

Common adaptive coping Frequent adaptive strategies included using errors as teaching opportunities (80.3%), speaking with a spouse/significant other (65.5%), exercise (61.9%), speaking with a mentor (51.4%), and speaking with friends (49.3%).

Common maladaptive coping Common maladaptive responses included sleep disturbances (52.8%), social withdrawal (38.0%), overeating (25.4%), procrastination (23.2%), and excessive alcohol consumption (11.3%).

Defense mechanisms used The most common defense mechanisms were intellectualization (68.3%) and humor (64.1), along with affiliation (61.2%) and altruism (53.5%).

Career/practice consequences tied to maladaptive coping Maladaptive coping was associated with higher odds of considering leaving the profession (OR 5.84) and limiting practice in the short term (OR 3.08).

Notable subgroup findings Junior neurosurgeons used more adaptive and maladaptive coping mechanisms than senior neurosurgeons, and academic neurosurgeons were more likely than private practitioners to question their clinical abilities (OR 2.68).

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Outpatient minimally invasive transforaminal lumbar interbody fusion performed at a single ambulatory surgery center: the Semmes Murphey Clinic experience

Neurosurg Focus 60(4):E5, 2026

This study reports outcomes from 179 patients undergoing single-level minimally invasive transforaminal lumbar interbody fusion (miTLIF) at a single ambulatory surgery center (ASC) between 2012–2024. It presents demographics, surgical details, complications, and validated patient-reported outcomes with 2-year follow-up showing sustained pain reduction, functional improvement, and high satisfaction.

The authors detail selection criteria, perioperative technique using tubular retractors and percutaneous pedicle screws, low complication and 90-day readmission/reoperation rates, and discuss economic and policy implications for ASC-based lumbar fusion care.

Objective Report 2-year outcomes for outpatient minimally invasive TLIF (miTLIF) performed at a single ambulatory surgery center (ASC).

Cohort 485 single-level miTLIFs were performed at the ASC (2012–2024); 179 registry-enrolled patients were analyzed (mean age 54; BMI mean 31).

Selection ASC eligibility exclusions included BMI > 50, weight > 350 lb, cardiac disease not cleared “low risk,” ASA class IIIb or above, family history of malignant hyperthermia, or inability to ambulate; Medicare primary insurance was also excluded for reimbursement reasons.

Disposition 98.3% were discharged within a few hours; 1.1% observed < 23 hours for pain control; 0.56% required hospital transfer for new-onset atrial fibrillation (treated and discharged within 23 hours).

Patient-reported outcomes Mean scores improved from baseline to 3 months and remained improved through 2 years (e.g., back pain NRS 6.98→2.40 at 3 months and 2.86 at 2 years; ODI 44.14→19.37 at 3 months and 13.87 at 2 years; EQ-5D 0.56→0.81 at 3 months and 0.82 at 2 years).

Complications Durotomy occurred in 1.7% (treated with fibrin glue, discharged within hours); superficial surgical site infection 0.56% (oral antibiotics only); postoperative hematoma 0.56%; urinary tract infection 0.56%.

Readmissions/reoperations (90-day) 2.2% readmissions and 1.1% reoperations within 90 days (including hardware failure and delayed hematoma).

Conclusion For carefully selected patients, ASC-based miTLIF showed significant, durable PROM improvement with acceptably low complications, readmissions, and reoperations.

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Clinical Significance and Utility of Early Postoperative Computed Tomography Scan Head after Brain Surgery

Neurosurgery 98:810–817, 2026

This prospective single-center study assesses the clinical value of routine early (within 6 hours) postoperative CT scans in 339 adults after intracranial surgery, correlating immediate neurological status with CT findings and resulting management changes. Results show 97.3% had only expected postoperative changes, 2.7% had hematoma without mass effect, and none required surgical intervention; only six patients had medical management altered.

The authors conclude that routine early CT provides minimal benefit for extubated, neurologically stable or expected-deficit patients and advocate selective imaging for clinical deterioration or unreliable examinations, highlighting cost, radiation, and logistical considerations particularly relevant to resource-limited settings.

Aim Evaluate whether an early postoperative head CT within 6 hours after intracranial surgery changes patient management and assess its clinical utility.

Design/setting Single-center prospective cohort of 339 intracranial surgery patients; all received CT within 6 hours and were grouped clinically as no deficit, expected deficit, or unexpected deficit.

CT classification Imaging findings were categorized as postoperative changes only, operative site hematoma without mass effect, or hematoma with mass effect (with management options: no change, medical change, or surgery).

Key findings (imaging) 97.3% (330/339) showed postoperative changes only; 2.7% (9/339) had operative site hematoma without mass effect; 0% had hematoma with mass effect.

Key findings (management impact) 98.2% (333/339) had no change in management based on early CT; 1.8% (6/339) had a change in medical management; 0% required surgical intervention.

Neurological status distribution Postoperatively, 90.9% had no fresh deficit, 7.1% had an expected deficit, and 2.1% had an unexpected deficit.

Association signal Patients with unexpected neurological deficits were more likely to have abnormal CT findings (reported OR 6.22, wide CI, P = .193, not statistically significant).

Bottom line Early postoperative CT offers minimal benefit for extubated patients with no or expected deficits; CT should be reserved for clinical deterioration or unreliable neurological examination.

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Complications associated with anterior cervical spine surgery: A systematic review of literature

Brain and Spine 6 (2026) 105897

This systematic review examines complications following anterior cervical spine surgery, quantifying incidence rates across studies and identifying major risks such as dysphagia, adjacent segment disease, recurrent laryngeal nerve palsy, infection, pseudarthrosis, esophageal perforation, hematoma, and vertebral artery injury. It synthesizes data from 116 studies (1989–2024) and assesses study quality using the Newcastle–Ottawa Scale.

The review highlights key risk factors—multilevel procedures, revision surgery, OPLL, smoking, older age, and surgeon experience—and emphasizes the importance of preoperative planning, patient selection, standardized prospective monitoring, and timely management to minimize morbidity and guide informed consent and long-term surveillance.

Aim Quantify frequency, causes, and outcomes of complications associated with anterior cervical spine surgery.

Methods Systematic review following PRISMA; searched CINAHL Plus, MEDLINE, PubMed, Scopus, and EMBASE for English-language studies (1989–2024) in adults; quality assessed with the Newcastle Ottawa Scale.

Evidence base 326 records screened; 116 studies included; study quality ranged from 3/9 to 9/9 on NOS, with frequent weaknesses in external control selection and cohort comparability.

Most common complication (dysphagia) Reported incidence varied widely (2.3%–87.5%); overall rate across all included dysphagia studies was 13%, with higher pooled incidence in prospective vs retrospective cohorts (53.7% vs 12.7%).

Other key complications (ranges) Adjacent segment disease 0.4%–32%; recurrent laryngeal nerve palsy 0.1%–9%; infection 0.39%–8.5%; pseudarthrosis 0.25%–31%; esophageal perforation 0.1%–0.45%; vertebral artery injury 0.3%–7.7%; Horner’s syndrome 0.06%–0.45%; graft failure 2.7%–35.5%; CSF leak 0%–1%; postoperative hematoma 0.21%–7%; new/worsening neurological deficits 0.37%–3.3.

Risk factors (higher complication rates) Multilevel disease, revision surgery, and ossification of the posterior longitudinal ligament (OPLL) were associated with increased complications.

Volume–outcome effect Greater surgeon experience and higher case volume were consistently associated with lower complication rates.

Prevention emphasis Reducing complications depends on thorough preoperative planning, careful patient selection, and proper surgical technique.

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The Helsinki Unruptured Intracranial Aneurysm Quality of Care study: a prospective observational study

J Neurosurg 144:507–516, 2026

This prospective single-center study evaluates the safety of unruptured intracranial aneurysm (UIA) treatments by prospectively measuring postprocedural diffusion-weighted MRI (DWI) lesions and correlating them with clinical outcomes at 3 months. Among 169 consecutive patients, 63% developed new DWI lesions, with endovascular cases showing more multiple lesions and surgical cases showing larger lesions.

Despite excellent functional outcomes by modified Rankin Scale (98% mRS 0–1) and high return-to-work rates, DWI lesions were associated with increased neurological symptoms, longer hospital stays, and worse outcomes when ≥10 mm. The authors argue that routine DWI should complement mRS to better capture ischemic burden and guide quality assessment and follow-up.

Objective Evaluate safety of unruptured intracranial aneurysm (UIA) treatment by measuring postprocedural ischemic lesions on MRI diffusion-weighted imaging (DWI) and correlating them with clinical outcomes.

Design Prospective, investigator-initiated, single-center observational cohort of consecutive UIA patients treated at Helsinki University Hospital (Dec 2022–Aug 2024) with brain MRI within 3 days and 3-month follow-up (mRS, neurological symptoms, return to work).

Cohort 169 patients: 120 (71%) endovascular and 49 (29%) surgical; aneurysm location distribution differed (most surgical cases were MCA aneurysms).

DWI incidence New DWI lesions occurred in 63% overall, with no difference between endovascular and surgical treatment (63% vs 63%).

Lesion patterns by modality Endovascular treatment more often produced high lesion counts (≥6 lesions: 14% vs 0%), while surgery more often produced larger lesions (≥10 mm: 20% vs 8%).

Symptoms association Most DWI lesions were asymptomatic (85%), but having any DWI lesion increased risk of new neurological symptoms (15% vs 2%), with 59% of symptoms transient.

mRS association Any DWI lesion was not associated with mRS outcomes, but lesions ≥10 mm were linked to poorer mRS status (mRS 0–1: 84% vs 99%) and higher risk of mRS worsening (21% vs 1%).

Return to work & conclusion 97% of previously working patients returned to work within 3 months; DWI lesions are common despite excellent mRS outcomes, and DWI may add information that mRS alone misses when assessing quality of care.

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Prevention of Ommaya Reservoir–Associated Bacterial Meningitis With Prophylactic Intraventricular Vancomycin

Neurosurgery 98:643–650, 2026

This clinical cohort study evaluates prophylactic intraventricular vancomycin (10 mg added to each intraventricular chemotherapy cycle) to prevent Ommaya reservoir–associated bacterial meningitis in patients with leptomeningeal disease. Over 501 treatments in 63 patients, infection rate was 0% versus 10.25% in a 5-year historical control, with no observed vancomycin toxicity and substantial cost savings.

The manuscript details methods, statistical analyses, safety monitoring, limitations inherent to a historical-control design, and a meta-analytic context of prior infection rates. Authors conclude prophylactic intraventricular vancomycin eliminated infections in their cohort and recommend consideration of broader adoption and prospective randomized trials.

Prophylactic intraventricular vancomycin: Adding 10 mg of intraventricular vancomycin to each cycle of planned intrathecal chemotherapy through an Ommaya reservoir (OmR) in patients with leptomeningeal disease eliminated OmR-associated bacterial meningitis infections over a 12-month period (0% infection rate in 63 patients, 501 treatments).

Historical infection rates: Prior to vancomycin prophylaxis, OmR-associated infection rates were 10.25% per patient and 1.71% per treatment in a 5-year historical control group (322 patients, 1932 treatments).

Absolute risk reduction and NNT: The absolute risk reduction for OmR-associated infection was 10.3% (P = .0028), with a number needed to treat (NNT) of 10 to prevent one infection.

No observed toxicity or resistance: No vancomycin-associated toxicity or development of antibiotic-resistant infections was observed during the study period, even with repeated dosing.

Significant cost savings: Prophylactic vancomycin cost $10 per dose, with an estimated annual savings of over $600,000 by preventing infections and associated treatments, not including potential additional savings from avoiding reservoir removal and replacement.

Robust methodology: The intervention was implemented as a global practice change, with prospective data collection for the vancomycin cohort and comparison to a well-matched historical control group, though some differences in tumor type and number of treatments existed.

Clinical and practical implications: The findings support strong consideration of prophylactic intraventricular vancomycin in OmR-based chemotherapy regimens, with the potential to significantly improve patient outcomes and reduce healthcare costs.

Need for further research: Prospective randomized trials are recommended to confirm these results and establish optimal dosing and broader applicability.

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Sarcopenia Predicts Early Adjacent Segment Disease Development After Anterior and Oblique Lumbar Interbody Fusion

Operative Neurosurgery 29:667–677, 2025

his clinical study evaluates whether sarcopenia, measured by psoas-to-vertebral body morphometrics on preoperative MRI, predicts early adjacent segment disease (ASD) within three years after anterior or oblique lumbar interbody fusion (ALIF/OLIF). Retrospective analysis of 104 patients found sarcopenia strongly associated with ASD, with sarcopenic patients showing markedly higher ASD rates and greater muscle fat infiltration.

The paper reports that psoas area, P:VBR ratios, and age remained significant predictors on multivariate analysis, while spinopelvic parameters lost significance after adjustment. The authors propose routine preoperative morphometric screening to guide surgical planning, risk counseling, and targeted perioperative optimization for high-risk patients.

• Sarcopenia: Preoperative sarcopenia, defined by reduced psoas muscle area relative to vertebral body area, is a strong independent predictor of early adjacent segment disease (ASD) within 3 years after anterior or oblique lumbar interbody fusion (ALIF/OLIF) ().

• ASD Incidence: 24% of patients developed ASD within 3 years post-ALIF/OLIF; 84.21% of sarcopenic patients developed ASD compared to 10.59% of nonsarcopenic patients.

• Morphometric Assessment: Psoas:vertebral body ratio (P:VBR) at L4 on preoperative MRI provides a simple, objective screening tool for sarcopenia and ASD risk stratification.

• Spinopelvic Parameters: Postoperative pelvic tilt (PT) and pelvic incidence-lumbar lordosis (PI-LL) mismatch were associated with ASD in univariate analysis, but not after multivariate adjustment; sarcopenia remained the strongest predictor.

• Other Risk Factors: Older age, higher preoperative disability (ODI), more instrumented/interbody levels, and prior lumbar surgery also increased ASD risk, while gender, BMI, and comorbidities did not.

• Instrumentation vs. Stand-alone Cages: Patients with stand-alone ALIF/OLIF (no posterior instrumentation) had lower rates of ASD, possibly due to less mechanical stress on adjacent segments.

• Clinical Implications: Identifying sarcopenia preoperatively can inform surgical planning, patient counseling, and may guide targeted pre- and postoperative interventions to improve outcome.

• Future Directions: Further research is needed to determine if interventions like resistance training or dietary modification can reduce ASD risk in sarcopenic patients, and to establish standardized diagnostic criteria for sarcopenia in spine surgery.

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Risk Factors for Postoperative Cerebrospinal Fluid Fistulas After Craniotomy and Craniectomy: A Systematic Review and Meta-Analysis

Acta Neurochirurgica (2025) 167:264

This systematic review and meta-analysis identified higher postoperative CSF fistula risk after infratentorial and tumor surgeries, and with primary closure. Patch grafts and watertight techniques reduce leak rates. CSF leaks are strongly linked to postoperative infections, highlighting the importance of preventive strategies in cranial neurosurgery.

Postoperative cerebrospinal fluid (CSF) fistulas are a common complication after craniotomy and craniectomy, with incidence rates ranging from 1% to 10%.

• Infratentorial surgeries have a higher CSF leak rate (7.9%) than supratentorial ones (4.6%).

• Tumor surgeries show greater risk of CSF leak than vascular procedures (odds ratio 1.82).

• Primary dural closure has a higher leak rate (12.3%) compared to patch grafts (8.5%).

• Watertight dural closure trends toward fewer leaks, but current evidence is not statistically significant.

• CSF leaks are strongly associated with postoperative infections (34.1%).

• Prevention of CSF leaks is crucial to reduce infection risk and improve surgical outcomes.

• Limitations include heterogeneous study definitions, inconsistent reporting of comorbidities, and lack of standardized data on closure techniques.

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Ventricular Entry During Glioblastoma Resection is Associated With Reduced Survival and Increased Risk of Distant Recurrence

Neurosurgery 97:601–611, 2025

Ventricular entry (VE) during glioblastoma resection is an independent risk factor for reduced overall survival and increased distant recurrence, including leptomeningeal dissemination. VE may diminish the survival benefit of gross-total resection, especially in tumors contacting the subventricular zone. Surgical strategies should weigh VE risks against maximal tumor removal.

• Ventricular entry (VE) during glioblastoma (GBM) resection is associated with significantly reduced overall survival (OS) and increased risk of distant recurrence and leptomeningeal dissemination (LMD), independent of other prognostic factors.

• Patients with VE had a median OS of 12 months versus 18 months for non-VE, and higher rates of distant recurrence (63.9% vs 39.7%).

• VE is more common in tumors contacting the subventricular zone (SVZ), and even among these, VE further reduces survival (12 vs 17 months).

• Gross-total resection (GTR) without VE provides the longest survival; GTR with VE does not significantly improve survival over less extensive resections with VE.

• VE is also associated with higher rates of postoperative hydrocephalus and need for external ventricular drains.

• Mechanistically, VE may facilitate tumor cell seeding into cerebrospinal fluid, promoting multifocal recurrences and LMD.

• Neurosurgeons should carefully weigh the risks of VE against the benefits of maximal tumor resection in surgical planning.

• Further prospective, multicenter studies are needed to clarify the risks and guide surgical strategies for GBM involving the SVZ.

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External Ventricular Drain Misadministration Events

Operative Neurosurgery 29:345–350, 2025

This systematic review examines misadministration events involving external ventricular drains (EVDs), including the first reported case of blood transfusion through an EVD. It highlights risk factors, advocates for ISO 80369-6 NRFit connectors to prevent misconnections, and recommends enhanced protocols and staff education to improve patient safety.

• External ventricular drains (EVDs) are widely used in neurosurgery but carry risks of misadministration due to connector similarity with IV lines.

• A systematic review identified 7 reports (8 cases) of EVD misadministration, involving drugs like gadolinium, anesthetics, antiepileptics, and, for the first time, blood products.

• The first reported case of blood transfusion into an EVD resulted in patient death, highlighting the severity of such errors.

• Main contributing factors include unfamiliarity with EVD systems, similar appearance to IV tubing, and poor visibility during procedures.

• The new ISO 80369-6 standard and NRFit connectors, with a smaller diameter than Luer connectors, are designed to prevent misconnections.

• Adoption of NRFit connectors, staff training, and clear equipment labeling are key recommended preventive strategies.

• Current guidelines from professional organizations support design changes and staff education but lack universal protocols for EVD management.

• Further research and widespread implementation of standardized connectors are needed to improve patient safety.

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The role of XLIF in spinal revision surgery involving failed interbody implants

Acta Neurochirurgica (2025) 167:221

This review evaluates the use of Extreme Lateral Interbody Fusion (XLIF) for removing failed spinal implants. XLIF offers advantages over traditional approaches, including reduced operative risk, blood loss, and hospital stay, but requires surgical expertise due to potential nerve and vascular complications.

• XLIF (Extreme Lateral Interbody Fusion) is increasingly used for spinal revision surgery to remove failed interbody implants and other foreign bodies.

• A systematic literature review identified only a few published cases (seven documented, four included) using XLIF for this purpose.

• XLIF offers advantages over anterior and posterior approaches, including reduced operative time, less blood loss, shorter hospital stays, and safer navigation around scar tissue and neurovascular structures.

• The technique allows for insertion of larger interbody cages, improving spinal stability and fusion outcomes.

• Most reported complications are minor and transient, such as temporary nerve injury, but careful patient selection and surgical expertise are required.

• XLIF is especially valuable in complex revision cases where traditional approaches pose higher risks due to scar tissue or anatomical challenges.

• Current evidence is limited to case reports and small series; more robust studies are needed to validate safety and efficacy.

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Outcomes After Standardized Burr-Hole Surgery for Chronic Subdural Hematomas: A Population-Based Consecutive Cohort Study of 2655 Patients

Neurosurgery 97:298–309, 2025

This large population-based study of 2655 chronic subdural hematoma patients treated with mostly single burr-hole craniotomy found an 11% recurrence and complication rate, 12% 1-year mortality, and identified male sex, diabetes, antithrombotic use, midline shift, and bilateral surgery as independent recurrence predictors.

• Large cohort study (n=2655) analyzed outcomes after standardized burr-hole craniotomy (BHC) for chronic subdural hematoma (CSDH) at a single center (2006–2022).

• Reoperation for hematoma recurrence occurred in 11% of patients, with most recurrences happening within 23 days.

• Independent predictors of recurrence included male sex, diabetes, preoperative antithrombotic therapy, midline shift, and bilateral hematomas.

• Postoperative complications occurred in 11% (3.9% moderate-to-severe); urinary tract infections, subdural empyema, and seizures were most common.

• 1-year postoperative mortality was 12%.

• Higher Charlson Comorbidity Index and lower Glasgow Coma Scale score were independent predictors of moderate-to-severe complications.

• Minicraniotomy was used in 9.3% of cases, with similar recurrence but slightly higher complication rates compared to BHC.

• Predictive models for recurrence and complications had low performance, suggesting other unmeasured factors are important.

 

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A survival analysis for predictors of implant subsidence following 1- or 2-level transforaminal lumbar interbody fusion

J Neurosurg Spine 43:42–51, 2025

This study found that after 1- or 2-level TLIF, aggressive disc height restoration and taller interbody implants significantly increase the risk of implant subsidence, especially in patients with poor bone quality. Surgeons should balance correction goals with subsidence risk, particularly in those with low Hounsfield unit measurements.

• This study analyzed predictors of interbody implant subsidence after 1- or 2-level transforaminal lumbar interbody fusion (TLIF) using a time-to-event (survival) analysis.

• Aggressive disc height restoration and use of taller interbody implants significantly increased the risk of subsidence.

• Poor baseline bone quality, measured by lower Hounsfield units (HU) on CT, was a strong independent predictor for significant (≥4 mm) subsidence.

• Longer fusion constructs (more instrumented levels) also increased the risk of significant subsidence.

• No significant association was found between cage material (titanium vs PEEK), device geometry, or lumbopelvic parameters and subsidence risk.

• Subsidence occurred in 38.2% of levels (≥2 mm) and significant subsidence in 10.4% (≥4 mm) by last follow-up.

• Clinical implications suggest balancing correction goals with subsidence risk, especially in patients with poor bone quality.

• Further multicenter and prospective studies are recommended to validate these findings.

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Incidence, Management, and Outcomes of Pediatric Infectious Aneurysms

Operative Neurosurgery 29:27–33, 2025

This retrospective study reviews five pediatric cases of infectious intracranial aneurysms (IIAs) secondary to infective endocarditis. IIAs in children are rare but have high morbidity and mortality, with early surgical or endovascular intervention recommended due to frequent failure of medical management and high rerupture rates.

• Pediatric infectious intracranial aneurysms (IIAs) are rare complications, most often secondary to infective endocarditis (IE), and account for 2–14% of pediatric intracranial aneurysms.

• This retrospective study identified 5 pediatric cases of IIA among 151 children treated for IE (3%), with most patients having congenital or acquired heart disease.

• The majority (80%) presented with ruptured aneurysms causing subarachnoid hemorrhage (SAH); one was found incidentally.

• All patients were started on antibiotics, but 80% failed medical management and required surgical or endovascular intervention.

• Mortality was high: 2 of 5 patients (40%) died within a year, and only 2 survivors had good neurological outcomes (mRS <2).

• Early intervention (surgical or endovascular) is recommended for ruptured IIAs due to high rates of rerupture and medical management failure.

• A multidisciplinary approach is essential for optimal outcomes in these complex cases.

• Further studies with larger cohorts are needed to determine the best management strategies.

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Surgical outcomes of unilateral painful foot drop secondary to lumbar disc herniation

J Neurosurg Spine 42:727–736, 2025

This multicenter retrospective study of 75 patients found that prompt surgical intervention for unilateral painful foot drop due to lumbar disc herniation improves outcomes, especially in younger and less frail patients. Delays in surgery reduced the likelihood of recovery, but no specific timing cutoff was identified.

• This multicenter retrospective study analyzed surgical outcomes for unilateral painful foot drop caused by lumbar disc herniation, excluding cauda equina syndrome cases.

• 75 adult patients were included; improvement in muscle strength (MRC grade) was seen in 55%, with 23% achieving full resolution of foot drop.

• Earlier surgery, younger age, and lower frailty scores were associated with better outcomes; for each day surgery was delayed, chance of improvement dropped by 0.2%.

• No specific surgical timing cutoff was identified, but delays reduced likelihood of recovery.

• Patients with more severe initial weakness (lower MRC grade) were more likely to show some improvement, but less likely to achieve full resolution.

• Radicular pain (sciatica) improved in most patients regardless of time to surgery.

• Study limitations include small sample size, retrospective design, and variability between centers.

• Authors recommend early surgical consideration and call for larger prospective studies to refine guidelines.

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Impact of patient positioning on bleeding rate in stereotactic brain biopsies: semi‑sitting versus supine position

Acta Neurochirurgica (2025) 167:159

The study found that using a semi-sitting position (30° head elevation) during stereotactic brain biopsies significantly reduced the rate of hemorrhagic complications compared to the supine position, suggesting patient positioning is a key, modifiable factor for improving safety and outcomes in these neurosurgical procedures.

• Study compared bleeding rates in stereotactic brain biopsies between semi-sitting and supine positions.

• Retrospective analysis of 78 patients: 39 semi-sitting, 39 supine.

• Hemorrhagic complications were significantly lower in the semi-sitting group (7.7%) vs supine (33.3%).

• Semi-sitting position is a potential protective factor against bleeding (OR 0.17, p=0.009).

• Groups were similar in age, sex, tumor type, and biopsy site; more samples were taken in semi-sitting group.

• No symptomatic bleedings occurred in either group.

• Semi-sitting position may reduce intracranial venous pressure, lowering bleeding risk.

• Authors recommend further prospective, multicenter studies to validate findings.

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Risk of late radiation necrosis more than 5 years after stereotactic radiosurgery

J Neurosurg 142:1117–1124, 2025

This study investigates late radiation necrosis (LRN) occurring over 5 years post-stereotactic radiosurgery (SRS). It identifies risk factors, management strategies, and emphasizes the need for long-term follow-up, particularly for patients with a brain V12 Gy > 5 cm³ or history of early RN.

• Late Radiation Necrosis (LRN): LRN is a late complication occurring more than 5 years after stereotactic radiosurgery (SRS) and is associated with new neurological symptoms and specific imaging changes without disease recurrence.

• Study Objective: This study analyzes the incidence and risk factors for LRN occurring more than 5 years after SRS, highlighting that LRN risk persists beyond 5 years.

• Risk Factors: Significant risk factors for LRN include a brain V12 Gy > 5 cm³ and a history of early RN. Higher prescription doses and treatment to multiple lesions also increase LRN risk.

• Incidence and Management: LRN occurred in 8.7% of patients and 7.7% of lesions, with a median onset of 6.1 years post-SRS. Management included steroids, bevacizumab, and surgical resection when necessary.

• Imaging Features: LRN lesions showed T2/FLAIR hyperintensity, cystic changes, and T1-weighted postcontrast enhancement.

• Pathophysiology: LRN shares a similar pathophysiology with early RN, but with distinct features like cystic changes.

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