Category: meta-analysis

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Exploring the Diagnostic Test Accuracy of MicroRNAs as Potential Biomarkers for Glioblastoma

Neurosurgery 98:1221–1230, 2026

This systematic review and meta-analysis evaluates microRNA (miRNA)–based liquid biopsies for diagnosing glioblastoma (GBM), synthesizing data from 15 studies and 28 biomarker evaluations across 868 samples. Key diagnostic metrics—pooled sensitivity 0.84 and specificity 0.89—indicate strong potential, with miR-21 showing the highest accuracy among single-miRNA assays.

The report details search strategy, inclusion criteria, statistical methods, subgroup analyses (miRNA type, biofluid source, control type), and study quality assessment. Limitations include methodological heterogeneity, high risk of bias in patient selection, inconsistent reporting (CSF source, IDH status), and small cohort sizes, underscoring need for standardized clinical validation.

Aim Evaluate the diagnostic accuracy of microRNA (miRNA) liquid biopsies (blood/serum/plasma/CSF) for diagnosing glioblastoma (GBM) via systematic review and meta-analysis.

Methods PRISMA-guided searches of Ovid Medline and Embase (updated through Oct 16, 2024); included studies had histologic GBM confirmation and extractable 2×2 diagnostic data; pooled estimates generated using a random-effects bivariate model.

Evidence base 15 included articles (published 2011–2022) provided 28 miRNA evaluations, totaling 868 samples from 551 GBM patients and 811 samples from 578 controls.

Overall accuracy Pooled sensitivity 0.84 and specificity 0.89, with heterogeneity of 66% (sensitivity) and 39% (specificity); pooled AUC 0.89.

Likelihood ratios Pooled PLR 7.26, NLR 0.19, and DOR 40.17, indicating strong overall discriminatory performance.

Key biomarker miR-21 showed the highest pooled performance among assessed groupings (sensitivity 0.90, specificity 0.95).

Subgroups Single miRNAs had higher specificity than multi-miRNA panels, while diagnostic capability did not differ clearly by biofluid source (CSF vs blood) in this dataset.

Limitations All included studies had high risk of bias in patient selection, and many had bias in index test interpretation/flow-timing; limited CSF comparisons and inconsistent qPCR thresholds/normalization contributed to heterogeneity and constrain clinical translation without standardization and validation.

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Diagnosing Cerebrospinal Fluid Shunt Failure: Systematic Review and Meta-Analysis of Noninvasive and Minimally Invasive Tests in Children and Adults

Neurosurgery 98:1206–1220, 2026

This systematic review and meta-analysis evaluates diagnostic performance of noninvasive and minimally invasive tests (X-ray shunt series, CT, MRI, nuclear scintigraphy, thermal flow) for cerebrospinal fluid shunt failure in pediatric and adult patients, synthesizing 33 studies and 8,077 patients. Pooled accuracy was 82%, sensitivity 67%, and specificity 88%, with X-ray series showing lower sensitivity but higher specificity compared with CT.

The analysis highlights substantial study bias—especially in patient selection and reference standards—and concludes no existing test is adequate as a standalone diagnostic for shunt failure, underscoring the need to optimize diagnostic pathways, reduce harm, and develop improved point-of-care functional tests.

Objective Assess diagnostic performance of noninvasive/minimally invasive tests (X-ray shunt series, CT, MRI, nuclear scintigraphy, thermal flow evaluation) for suspected CSF shunt failure in pediatric and adult patients.

Methods Systematic review/meta-analysis (PROSPERO CRD42024596142) including patients with permanent CSF shunts who underwent the above index tests; performance (accuracy, sensitivity, specificity) modeled via meta-regression incorporating test type, age group, follow-up timeframe, and shunt type.

Evidence base PubMed search (Oct 22, 2024) screened 465 articles; 33 studies included, totaling 8077 patients.

Pooled performance Overall pooled accuracy 82%, sensitivity 67%, specificity 88% across included tests.

Key comparative finding (sensitivity) X-ray shunt series had significantly lower sensitivity than CT (OR 0.106, 95% CI 0.056–0.201; overall effect of test type on sensitivity P = .013).

Key comparative finding (specificity) No overall effect of test type on specificity (P = .192), but X-ray shunt series showed higher specificity than CT in subgroup analysis (OR 4.04, 95% CI 1.938–8.424).

Covariates No significant effects of age group, follow-up timeframe, or shunt type on accuracy, sensitivity, or specificity.

Conclusion/limitations No test performed well enough to serve as a standalone diagnostic for shunt failure; evidence limited by high risk of bias, especially in the reference standard domain for most studies.

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Long-term outcomes of microvascular decompression for trigeminal neuralgia in multiple sclerosis

J Neurosurg 144:1122–1133, 2026

This systematic review and meta-analysis evaluates microvascular decompression (MVD) outcomes for trigeminal neuralgia in patients with multiple sclerosis (TN-MS). The authors pooled 30 studies (265 unique TN-MS patients), finding neurovascular compression in 96.6% and a pooled long-term pain-free (BNI I) success rate of about 30%, with low heterogeneity and primarily transient sensory complications.

The report discusses limited, mostly retrospective evidence, methodological limitations, and potential dual mechanisms of TN in MS. Authors conclude MVD yields lower success than in classic TN but remains a reasonable option for selected TN-MS patients with demonstrable neurovascular compression; they call for prospective studies and refined patient selection.

Objective Evaluate long-term pain relief and complications of microvascular decompression (MVD) for trigeminal neuralgia in patients with multiple sclerosis (TN-MS), a group traditionally considered poor candidates for MVD.

Methods Systematic review/meta-analysis (PRISMA) of PubMed, Embase, Scopus, and Web of Science (search June 2024); primary endpoint was long-term pain-free status BNI I at final follow-up using random-effects meta-analysis of proportions.

Evidence base 30 studies were included, covering 429 TN-MS patients treated with MVD, representing 265 unique patients.

Neurovascular compression Compression was identified in 96.6% of reported TN-MS cases (via MRI and/or intraoperative findings).

Long-term efficacy Pooled long-term pain-free outcome (BNI I) after MVD was 30.2% (95% CI 24.2%–36.9%), with low heterogeneity across analyses.

Complications The most commonly reported complication after MVD was transient facial numbness (with other complications variably reported).

Interpretation MVD is less effective in TN-MS than in classic TN, but can still provide meaningful benefit, particularly when neurovascular compression is present.

Conclusion/implication MVD should not be categorically excluded for TN-MS; further prospective studies are needed to improve selection and outcomes.

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Risk Factors and Reoperation Rate in Revision Lumbar Disc Herniation Surgery: A Systematic Review and Meta-Analysis of 1,031,348 Patients

Global Spine Journal 2026, Vol. 16(3) 1633-1647

This systematic review and meta-analysis examines reoperation rates and associated risk factors following primary lumbar disc herniation surgery across 25 studies totaling 1,031,348 patients. Pooled reoperation rate was 8.5% overall (adjusted to 10.3% for publication bias), with rates varying by follow-up: 4% at ≤1 year, 11.1% at 1–5 years, and 8.8% beyond 5 years.

Key risk factors identified include smoking, older age, diabetes, and large annular defects, while sex was not significant. The review highlights heterogeneity across study designs and follow-up durations, recommends careful patient selection, extended conservative management or closer surveillance for high-risk patients, and calls for trials comparing revision techniques.

Objective Estimate the reoperation rate after lumbar disc herniation surgery and identify associated risk factors.

Evidence base 25 studies (including observational studies and 3 RCTs) totaling 1,031,348 patients were included.

Overall reoperation rate Pooled reoperation rate was 8.5% (95% CI 6.2%–11.6%); after trim-and-fill adjustment for publication bias it was 10.3% (95% CI 7.6%–14.0%).

Follow-up pattern Reoperation rates differed by follow-up duration: 4% at ≤1 year, 11.1% at 1–5 years, and 8.8% at >5 years (significant subgroup differences).

Smoking risk Smoking was associated with higher odds of reoperation (OR 1.39, 95% CI 1.09–1.78).

Age risk Older age was associated with higher odds of reoperation (OR 1.52, 95% CI 1.25–1.85).

Annular defect risk Larger annular defect size was associated with higher odds of reoperation (OR 2.19, 95% CI 1.07–4.48).

Other factors Diabetes and certain surgical techniques were linked to higher reoperation risk in individual studies; sex was not a significant predictor (OR 1.22, 95% CI 0.96–1.55).

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Added Value of Adjunctive Middle Meningeal Embolization to Surgical Evacuation for Chronic Subdural Hematoma: Comprehensive Meta-Analysis Based on Controlling Confounders

Neurosurgery 98:303–317, 2026

This meta-analysis evaluates whether adding middle meningeal artery embolization (MMAE) to surgical evacuation improves outcomes in patients with chronic subdural hematoma (CSDH).

Key Insights and Themes

Chronic subdural hematoma (CSDH) is a common neurological disorder with high recurrence rates after surgical evacuation, ranging from 2% to 37%.

Middle meningeal artery embolization (MMAE) has emerged as an adjunct or alternative to surgery, aiming to reduce CSDH recurrence by targeting the vascular supply of the hematoma membranes.

Systematic review and meta-analysis included 17 studies (1814 patients; 939 MMAE+S, 1440 S), comprising randomized trials, matched, and unmatched cohorts, with a mean follow-up of 3 months.

Baseline comparability between MMAE+S and surgery-alone groups was achieved except for higher antithrombotic use in the MMAE+S group (34.9% vs 22.4%).

Recurrence rates were significantly lower in the MMAE+S group compared to surgery alone (4.7% vs 17.7%; relative risk [RR] 0.31, P < .01), a benefit confirmed in randomized and matched studies.

Radiological outcomes (postoperative hematoma thickness, volume, and midline shift) were all significantly reduced in the MMAE+S group.

Functional outcomes, complications, mortality, and hospital stay were similar between groups, indicating no increased risk with adjunctive MMAE.

Timing of embolization affected outcomes: postoperative MMAE was associated with lower recurrence, while preoperative MMAE did not show significant benefit.

Embolic agent selection mattered: liquid embolic agents (e.g., Onyx, Squid) led to better outcomes than particles, with recurrence reduction seen only with liquid agents.

Antithrombotic use, a known risk factor for recurrence, was higher in the MMAE+S group, yet recurrence rates remained lower, suggesting a robust effect of adjunctive MMAE.

Surgical technique variability (burr-hole craniostomy, craniotomy, twist-drill) existed across studies, potentially influencing heterogeneity in outcomes.

Complication rates were low and comparable between groups; most complications were minor, and serious adverse events were rare.

Length of hospital stay did not differ significantly between groups, though some previous studies suggested longer stays with MMAE+S, possibly due to worse initial clinical status.

Cost-effectiveness may favor MMAE+S in the long term, as reduced recurrence and reoperation rates can offset higher initial costs.

Ongoing clinical trials (e.g., CHESS, MEMBRANE, EMPROTECT) are expected to clarify optimal timing, patient selection, and cost-effectiveness of adjunctive MMAE.

Limitations include heterogeneity in surgical and embolization techniques, retrospective study designs, and reliance on aggregate rather than individual patient data.

Areas for future research include optimal timing and materials for MMAE, patient selection, and cost-benefit analyses.

Conclusion

Adjunctive MMAE with surgical evacuation significantly reduces CSDH recurrence and improves radiological outcomes without increasing complications or mortality, supporting its use in high-risk patients.

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Determinants of survival after re-resection for recurrent glioblastoma: a meta-analysis

Acta Neurochirurgica (2026) 168:11

This systematic review and meta-analysis examines prognostic factors affecting survival after re-resection for recurrent glioblastoma, synthesizing data from 30 studies (1,741 pooled patients). Key findings identify gross total resection and MGMT promoter methylation as strong positive predictors, while age and low preoperative KPS associate with poorer outcomes; adjuvant therapies and time to re-resection showed inconsistent effects.

The paper details search methods, risk-of-bias assessment, statistical approaches, sensitivity analyses for IDH status, and study heterogeneity limitations. Conclusions emphasize patient selection for re-resection based on functional status and molecular markers and call for prospective, standardized trials and individual-patient data analyses to refine management of recurrent glioblastoma.

Gross Total Resection (GTR): Achieving GTR at re-resection for recurrent glioblastoma is significantly associated with improved survival compared to subtotal resection (pooled HR ~0.52–0.70, p < 0.001).

MGMT Promoter Methylation: Patients with methylated MGMT promoter status at recurrence have significantly better survival following re-resection (multivariate HR = 0.45, 95% CI: 0.27–0.76, p < 0.01).

Preoperative Karnofsky Performance Status (KPS): A KPS score <70 before re-resection is strongly associated with poorer survival outcomes (HR = 2.25, 95% CI: 1.59–3.19, p < 0.001).

Age: Older age is modestly associated with worse survival after re-resection, but the effect size is small (HR = 1.02, 95% CI: 1.01–1.03, p < 0.001); age alone should not preclude aggressive treatment.

Adjuvant Chemotherapy and Radiotherapy: No significant survival benefit was found for adjuvant chemotherapy (HR = 0.69, p = 0.33), radiotherapy (HR = 0.62, p = 0.50), or combined chemoradiotherapy after re-resection.

Time to Re-resection: Longer time intervals between initial surgery and re-resection did not show a statistically significant association with improved survival (HR = 0.69, p = 0.16).

Personalized Approach: Selection for re-resection should prioritize patients with good performance status, favorable tumor characteristics, and methylated MGMT promoter, with GTR as a key goal.

Evidence Limitations: Most included studies were retrospective with heterogeneity in definitions and reporting; high-quality prospective trials are needed to refine prognostic assessments and treatment strategies.

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Randomized controlled trials comparing cervical disc arthroplasty and anterior cervical discectomy and fusion outcomes in degenerative spine disease: a systematic review and meta-analysis

J Neurosurg Spine 43:703–716, 2025

This systematic review and meta-analysis synthesizes randomized controlled trials comparing cervical disc arthroplasty (CDA) with anterior cervical discectomy and fusion (ACDF) for degenerative cervical disc disease. Across 25 RCTs (4530 patients), CDA demonstrated higher overall and neurological success, reduced adjacent-segment disease and fewer reoperations, but increased heterotopic ossification and longer operative times.

The authors performed multilevel meta-analysis and meta-regression to explore heterogeneity, finding myelopathy inclusion and follow-up completeness influenced results; sensitivity analyses excluding industry-funded trials showed consistent findings. Conclusions emphasize CDA’s potential benefits for selected patients while recommending longer-term and subgroup-specific trials.

Cervical Disc Arthroplasty (CDA) vs. Anterior Cervical Discectomy and Fusion (ACDF): CDA shows comparable or potentially greater overall and neurological success rates compared to ACDF for degenerative cervical spine disease.

Motion Preservation: CDA preserves cervical spine range of motion at the operated level, while ACDF is associated with loss of motion and potentially increased risk of adjacent segment degeneration (ASD).

Adjacent Segment Disease (ASD): CDA is associated with a significantly lower rate of ASD compared to ACDF, suggesting a protective effect against degeneration of adjacent spinal segments.

Reoperation Rates: CDA results in lower total reoperation rates compared to ACDF, indicating fewer subsequent surgical interventions.

Heterotopic Ossification (HO): CDA has a significantly higher rate of HO, a complication where bone forms in soft tissue, which can potentially reduce the motion-preserving benefit of the procedure.

Operative Time: CDA procedures are associated with significantly longer operative times than ACDF, with no significant difference in blood loss or hospital length of stay between the two techniques.

Pain and Disability Outcomes: No significant differences were found between CDA and ACDF in terms of improvement in arm pain, neck pain, or disability scores (Neck Disability Index) as measured by patient-reported outcomes.

Patient Selection: The benefits of CDA over ACDF are most applicable to patients with 1-2 level degenerative disease, preserved cervical alignment, and no significant instability or deformity; findings may not generalize to more complex cases.

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Radiation exposure in XLIF surgery utilizing ultra-low radiation imaging with image enhancement software: a randomized controlled trial

The Spine Journal 25 (2025) 2692−2700

This randomized controlled trial evaluates ultra-low radiation imaging with image enhancement (mFluoro) versus conventional fluoroscopy during single-level XLIF lateral interbody fusion in 57 analyzed patients. Results show marked reductions in OR staff exposure (surgeon −72.1%, assistant −76.1%, scrub nurse −67.5%), lower patient DAP (−66.1%), fewer images, and shorter procedure times without increased complications.

The study used live dosimeters, standardized protocols, and optical reposition-assist technology (LessRay/PULSE) with Cios Spin. Findings support ULRI+IE as an effective strategy to decrease occupational and patient radiation during minimally invasive lateral spine surgery, noting limitations including lack of surgeon blinding and early learning-curve crossovers.

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Central thalamic deep brain stimulation for disorders of consciousness: an individual participant data meta-analysis

J Neurosurg 143:1217–1226, 2025

This individual participant data meta-analysis evaluates central thalamic deep brain stimulation (DBS) for chronic disorders of consciousness, pooling 49 patients from seven centers to assess neurological outcomes via the JFK Coma Recovery Scale–Revised. Results show modest mean CRS-R improvement, with age and shorter delay to implantation predicting better gains, but insufficient evidence that DBS alters the natural recovery trajectory.

The report details heterogeneity in targets, stimulation schedules, and methodological limitations—no randomized controls, selection bias, and variable reporting—highlighting the need for matched comparative studies, standardized outcome metrics, and refined targeting (CL vs CM-Pf/DTTm) to determine DBS efficacy and optimize patient selection.

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Machine Learning–Based Rupture Risk Prediction for Intracranial Aneurysms: A Systematic Review and Meta-Analysis

Neurosurgery 97:1072–1082, 2025

This systematic review and meta-analysis evaluates machine learning (ML) applications for predicting intracranial aneurysm rupture, comparing 124 ML models across 36 retrospective studies (22,462 patients) with the PHASES score. Results show ML—especially deep learning and SVM—achieves higher AUC and specificity than PHASES, with hemodynamic inputs improving test-set specificity but not external validation.

The authors highlight methodological heterogeneity, risks of bias, and overfitting concerns from retrospective single‑center data, urging prospective, standardized studies and external validation before clinical integration of ML rupture‑risk tools.

Machine Learning (ML) Models: ML techniques, including deep learning (DL), support vector machines (SVM), and regression models, show higher specificity and overall diagnostic accuracy than the traditional PHASES score for predicting intracranial aneurysm rupture risk, with comparable sensitivity.

• Deep Learning Performance: DL models achieved the highest sensitivity (up to 0.87), specificity (up to 0.86), and area under the curve (AUC-ROC up to 0.92) among all ML families, indicating strong discriminative ability in rupture risk prediction.

• PHASES Score Limitations: The PHASES score, though widely used, demonstrates lower specificity (0.51) and modest overall discriminative ability (AUC-ROC 0.66), and does not incorporate important risk factors like aneurysm morphology or family history.

• Hemodynamic Parameters: Incorporating hemodynamic variables (e.g., wall shear stress, flow patterns) into ML models improves specificity and accuracy in test sets, but benefits are less pronounced in external validation, possibly due to sample size and generalizability issues.

• Retrospective Data and Overfitting: All included ML models were trained on retrospective, post-rupture data, raising concerns about overfitting and the applicability of these models to pre-rupture clinical decision-making.

• Generalizability Concerns: ML models often perform less well on external validation data due to biases in patient selection, single-center data, and differences in imaging or clinical protocols, while the PHASES score maintains more consistent performance across settings.

• Need for Prospective Validation: There is a critical need for prospective studies and standardized protocols to confirm the clinical utility and reliability of ML-based rupture risk prediction models before integration into routine practice.

• Clinical Implications: ML approaches, especially DL and SVM, have the potential to enhance individualized risk stratification and reduce overtreatment, but methodological challenges and validation in diverse populations remain essential for safe clinical adoption.

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Minimally invasive burr hole craniotomy versus drill hole craniotomy for the management of chronic subdural hematoma: a randomized clinical trial

Neurosurg Focus 59(4):E2, 2025

A randomized trial compared hollow screw (HS) trephination under local anesthesia to enlarged burr hole (BH) trepanation under general anesthesia for chronic subdural hematoma. HS showed similar recurrence and clinical outcomes, but with shorter operation time, hospital stay, and lower costs, supporting its use in older, comorbid patients.

• A randomized clinical trial compared hollow screw (HS) trephination under local anesthesia to enlarged burr hole (BH) craniotomy under general anesthesia for chronic subdural hematoma (cSDH) evacuation.

• 131 patients (mean age 77) were analyzed; both groups were similar in demographics and risk factors.

• HS had a higher, but not statistically significant, recurrence rate compared to BH (HS 47.8% vs BH 31.2%, p = 0.06).

• Clinical outcomes and complication rates were equivalent between HS and BH groups.

• HS procedures were significantly less invasive, with shorter operation times (median 21 vs 33.5 minutes) and shorter hospital stays (median 3.0 vs 4.3 days).

• HS treatment was less costly than BH (806 vs 1884.70 euros per case, excluding infrastructure).

• HS trephination is a reasonable alternative to BH, especially for elderly or multimorbid patients, given similar outcomes and improved efficiency.

• Study limitations include single-center design, limited sample size, and lack of blinding.

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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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Risk Factors of 90-Day Unplanned Readmission After Lumbar Spine Surgery for Degenerative Lumbar Disk Disease: A Systematic Review and Meta-Analysis

Neurosurgery 97:908–916, 2025

This meta-analysis identified a 7.72% 90-day unplanned readmission rate after lumbar spine surgery. Significant risk factors include older age, higher BMI, depression, diabetes, hypertension, renal failure, and ASA grade >2. Enhanced preoperative optimization and targeted strategies for high-risk patients are recommended to reduce readmissions.

• A meta-analysis of 11 studies (648,415 patients) found a 7.72% incidence of unplanned 90-day readmission after lumbar spine surgery.

• Significant risk factors for readmission include older age, higher body mass index (BMI), depression, diabetes mellitus (DM), hypertension (HTN), renal failure, and an American Society of Anesthesiologists (ASA) grade greater than 2.

• Surgical factors such as fusion and laminectomy were not significantly associated with readmission.

• Main causes for readmission included wound infection, wound dehiscence, and implant failure; disk reherniation was the leading cause at 90 days.

• Enhanced preoperative optimization and careful patient selection are recommended, especially for elderly and high-comorbidity patients.

• Targeted preventive strategies may reduce readmissions and improve healthcare resource utilization.

• Limitations include retrospective study designs and insufficient data on some perioperative risk factors.

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Microsurgical Resection Versus Stereotactic Radiosurgery for Trigeminal Schwannoma: A Meta-Analysis of 949 Patient Treatment Outcomes

Neurosurgery 97:545–558, 2025

Meta-analysis of 949 trigeminal schwannoma patients found stereotactic radiosurgery (SRS) led to greater improvement in facial hypesthesia and motor deficits, but surgery was superior for facial pain relief. Both approaches provided similar tumor control. Treatment should be individualized based on patient characteristics, tumor profile, and symptoms.

• Trigeminal schwannomas (TS) are rare, benign nerve sheath tumors, with no clear consensus on optimal treatment between surgical resection and stereotactic radiosurgery (SRS).

• Meta-analysis included 29 retrospective studies with 949 patients: 589 had SRS, 360 had surgery; larger tumors were more likely to be treated surgically.

• SRS led to significantly higher rates of facial hypesthesia (numbness) improvement (44% vs 12%) and lower rates of new hypesthesia (4% vs 15%) compared to surgery.

• Surgery was more effective for improving facial pain (81% vs 58% after SRS).

• Both SRS and surgery provided high and similar tumor control rates (89% SRS vs 91% surgery).

• Trigeminal motor function improved more after SRS, but data were limited.

• Treatment choice should be individualized, considering tumor size, patient characteristics, and presenting symptoms.

• Limitations include retrospective design, heterogeneous data, and lack of standardization for outcome measures.

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Segmental and overall lumbar lordosis after single-level minimally invasive transforaminal lumbar interbody fusion: a systematic review and meta-analysis

J Neurosurg Spine 43:70–82, 2025

This systematic review and meta-analysis found that single-level minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) generally preserves segmental and overall lumbar lordosis, with preoperative alignment and use of expandable cages predicting postoperative lordosis. Greater segmental lordosis improvement was associated with reduced leg pain, but clinical outcome correlations were otherwise limited.

• Single-level minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) generally preserves or slightly increases segmental and overall lumbar lordosis.

• Meta-analysis of 35 studies (1935 patients) showed significant but modest increases in segmental lordosis (mean +2.2°) and lumbar lordosis (mean +2.8°) postoperatively.

• Preoperative alignment and use of expandable cages are significant predictors of postoperative lordosis change.

• Greater improvement in segmental lordosis was associated with larger reductions in postoperative leg pain, but no strong correlation with other clinical outcomes was found.

• Most included studies were retrospective case series, with high heterogeneity in surgical technique and reporting.

• No significant association was found between facetectomy type, operative bed, or fixation technique and changes in lordosis.

• The main goal of MI-TLIF is neural decompression and fusion, not alignment correction; alternative approaches may be needed for major lordosis restoration.

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The diagnostic value of the lumbar infusion test to predict symptomatic improvement after shunting for normal pressure hydrocephalus. A meta‑analysis

Acta Neurochirurgica (2025) 167:180

This meta-analysis found that the lumbar infusion test (LIT) has poor negative predictive value for predicting non-response to shunting in normal pressure hydrocephalus. LIT cannot reliably exclude patients from shunt surgery and should not be used for this purpose in its current form.

• The lumbar infusion test (LIT) is used to predict which normal pressure hydrocephalus (NPH) patients will benefit from CSF shunting.

• This meta-analysis pooled sensitivity, specificity, and negative predictive value (NPV) of LIT from 10 studies.

• Sensitivity of LIT (using Rout) was moderate (77–82%) at lower cutoffs (12–14 mmHg/ml/min), but specificity was low (34–37%).

• Higher Rout cutoff (18 mmHg/ml/min) increased specificity (78%) but decreased sensitivity (37%).

• NPV was consistently low for all cutoffs (≤33%), meaning LIT is poor at ruling out shunt responders.

• No other LIT parameters (e.g., plateau pressure, CSF amplitude) showed better diagnostic value.

• The test cannot be used to exclude patients from shunt implantation due to high false negative rates.

• Future research should focus on improving the negative predictive value of LIT for NPH.

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Comparative Analysis of Efficacy and Safety of Frame-Based, Frameless, and Robot-Assisted Stereotactic Brain Biopsies: A Systematic Review and Meta-Analysis

Operative Neurosurgery 28:749–761, 2025

This systematic review and meta-analysis compares frame-based, frameless, and robot-assisted stereotactic brain biopsies. Robot-assisted biopsies demonstrated non-inferior diagnostic yield and safety compared to traditional methods, with shorter operative times. Complication and mortality rates were similar across all techniques, supporting robot-assisted biopsy as an effective alternative.

• Frame-based stereotactic brain biopsy has been the gold standard for high diagnostic yield and safety, especially for complex or deep-seated lesions.

• Frameless neuronavigation and robot-assisted techniques have emerged as alternatives over the past decade.

• Meta-analysis included 92 studies: 9801 frame-based, 2665 robot-assisted, and 1862 frameless cases.

• Pooled diagnostic yields: robot-assisted 97%, frame-based 95%, frameless 94%; robot-assisted was not inferior.

• Complication and mortality rates were low and similar across all methods.

• Robot-assisted procedures had significantly shorter total operative times (mean 76.6 min) compared to frame-based (132.7 min) and frameless (97.3 min).

• Diagnostic yield for brainstem lesions was comparable between robot-assisted and frame-based approaches.

• Robot-assisted biopsy may offer workflow, comfort, and efficiency advantages, especially for certain patient groups.

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Cognitive impacts of unilateral MR-guided focused ultrasound thalamotomy: a meta-analysis and a call for systematic neuropsychological assessment

J Neurosurg 142:1271–1279, 2025

A meta-analysis of unilateral MR-guided focused ultrasound thalamotomy for pharmacoresistant tremors shows no significant cognitive or emotional decline post-procedure. However, the limited studies and short-term assessments necessitate further research, especially on long-term effects and bilateral procedures.

• Objective: Evaluate cognitive and emotional effects of unilateral MR-guided focused ultrasound (MRgFUS) thalamotomy in patients with pharmacoresistant tremors.

• Methods: Conducted a meta-analysis following PRISMA guidelines, focusing on cognitive functions pre- and post-procedure.

• Results: No significant deterioration in cognitive domains or emotional states post-procedure.

• Sample: Included 112 patients, mostly with essential tremor and some with Parkinson’s disease.

• Findings: MRgFUS thalamotomy is safe concerning cognitive and emotional outcomes, but more research is needed for long-term effects.

• Limitations: Small number of studies, short-term assessments, and potential publication bias.

• Conclusion: Encouraging findings on safety, but further comprehensive investigations are necessary.

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Surgical Management of Acute Subdural Hematoma: A Meta-Analysis

Neurosurgery 96:922–936, 2025

The meta-analysis evaluates surgical interventions for acute subdural hematoma, comparing craniotomy and decompressive craniectomy. It finds similar mortality and functional outcomes in matched cohorts, despite worse baseline parameters in craniectomy patients. The study emphasizes the need for future trials to validate these findings.

• Acute Subdural Hematoma (ASDH) requires urgent surgical intervention, typically through craniotomy (CO) or decompressive craniectomy (DC).

• Meta-analysis included 18 studies with 8886 patients, assessing functional outcomes and mortality rates between CO and DC.

• Functional outcomes showed similar Glasgow Outcome Scale-Extended (GOSE) scores between CO and DC, but Glasgow Outcome Scale (GOS) scores favored CO.

• Mortality analysis indicated lower short-term mortality for CO, but similar long-term mortality between CO and DC in matched cohorts.

• Complications and reoperation rates were comparable between CO and DC, with cerebrospinal fluid diversion more common in DC.

• Quality of Life (QOL) was not thoroughly assessed due to differences in measurement tools and limited data.

• The study highlights the need for further clinical trials to validate findings and address gaps in existing literature

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Development of a unified and comprehensive definition of successful spinal fusion: a systematic review

J Neurosurg Spine 42:403–412, 2025

The document discusses a systematic review aimed at creating a unified definition of successful spinal fusion by integrating clinical symptoms, imaging modalities, and bone healing processes. It proposes a clinical algorithm for evaluating fusion success, emphasizing the need for standardized assessment criteria.

• A systematic review was conducted to develop a unified definition of successful spinal fusion, incorporating clinical symptoms and imaging modalities.

• The review involved 20 studies evaluating 1,324 spinal fusion procedures, resulting in a clinical algorithm for determining fusion success.

• The algorithm stratifies patients as symptomatic or asymptomatic, using specific imaging techniques based on pain type.

• Successful fusion for asymptomatic patients is considered after 12 months, while persistent symptoms indicate failure regardless of radiographic findings.

• Limitations include reliance on imaging and heterogeneous study data, but the algorithm aims to standardize fusion evaluation and improve outcomes.

• Future directions suggest using AI and machine learning for predictive algorithms and evaluating regional differences in fusion assessment.

• The proposed algorithm aims to improve diagnostic accuracy and provide a shared understanding of successful spinal fusion among clinicians.

• Implementation of the algorithm can enhance outcomes research and assess new developments in spinal fusion.

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