Month: October 2025

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Sixto Obrador (1911–1978), Spain’s father of neurosurgery: his quest to raise its practice to world-class scientific standards

J Neurosurg 143:1137–1148, 2025

Sixto Obrador Alcalde (1911–1978) is profiled as the architect of modern scientific neurosurgery in Spain, tracing his international training, prolific surgical career, and institutional leadership. The article documents his return from Anglo‑American mentorships to build neurosurgical departments, perform over 5,000 intracranial tumor surgeries, and publish extensively, emphasizing rigorous scientific practice and resident research training.

The paper reviews Obrador’s organizational achievements: founding Spanish neurosurgical units, cofounding SLEN, contributing to WFNS and EANS, and helping establish referral hospitals integrating clinical and basic neuroscience. It highlights his commitment to education, multidisciplinary collaboration, and translating Cajal’s scientific legacy into a national neurosurgical standard.

• Pioneer of Spanish Neurosurgery: Sixto Obrador (1911–1978) established neurosurgery as a distinct specialty in Spain, raising its scientific and clinical standards to international levels despite the country’s postwar hardships and late start due to the Spanish Civil War.

• Influence of the Cajal School: Obrador revived the scientific legacy of Santiago Ramón y Cajal and Pío del Río-Hortega, integrating neuropathology and neurophysiology into neurosurgical practice and emphasizing research as a core component of training.

• International Training and Mentorship: He received extensive training in neurophysiology and neurosurgery in the UK, US, and Mexico under renowned figures like Charles Sherrington, Hugh Cairns, Norman Dott, and John Fulton, which shaped his scientific approach.

• Institution Building: Obrador founded and organized several leading neurosurgical departments and hospitals in Madrid, including the first Institute of Neurosurgery, La Princesa Hospital, Fundación Jiménez Diaz, La Paz Hospital, and the Ramón y Cajal Hospital.

• Surgical and Scientific Output: He performed over 5,000 brain tumor surgeries, published more than 400 scientific papers, and authored Spain’s first neurosurgery textbook, establishing benchmarks for surgical outcomes and research in the field.

• Advances in Neurosurgical Techniques: Obrador introduced and developed techniques such as the first successful hemispherectomy in Europe, stereotactic procedures for movement disorders, and the use of intraoperative hypothermia, contributing to reduced mortality rates.

• Professional Leadership and International Collaboration: He co-founded the Portuguese-Spanish Society of Neurosurgery (SLEN), played key roles in the World Federation of Neurosurgical Societies (WFNS) and the European Association of Neurosurgical Societies (EANS), and promoted Spanish neurosurgery internationally.

• Legacy in Education and Research: Obrador’s main legacy is the integration of scientific research and multidisciplinary training in Spanish neurosurgery, influencing generations of neurosurgeons and establishing Spain as a respected center for neurosurgical excellence.

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Comparative effectiveness of standalone middle meningeal artery embolization versus surgical evacuation in noncritical patients with nonacute subdural hematomas

Neurosurg Focus 59(4):E8, 2025

This retrospective propensity score–matched cohort study compares standalone middle meningeal artery embolization (sMMAE) with standard surgical evacuation for nonacute subdural hematomas (NASDH) in noncritical patients treated from 2017–2024. Primary outcome was reintervention for recurrence; secondary outcomes included hospital length of stay (LOS), new neurological deficits, and adverse events.

After matching 85 patients per group, reintervention rates did not differ significantly (IRR 1.38, p=0.41). sMMAE was associated with shorter median LOS (4 vs 6 days, p=0.003) and fewer noncardiorespiratory medical adverse events, suggesting sMMAE may be a less-invasive option in selected patients while larger trials are needed.

• Standalone Middle Meningeal Artery Embolization (sMMAE) vs. Surgery: sMMAE for nonacute subdural hematoma (NASDH) showed no significant difference in reintervention rates due to hematoma recurrence compared to surgical evacuation (incidence rate ratio [IRR] 1.38, p = 0.41).

• Hospital Length of Stay: Patients treated with sMMAE had a significantly shorter hospital stay (median 4 days) compared to those who underwent surgical evacuation (median 6 days, p = 0.003).

• Adverse Events: sMMAE was associated with a lower risk of other medical (non-neurological, non-cardiorespiratory) adverse events (1.1% vs 15.2%; relative risk [RR] 0.07, p = 0.013), with no significant differences in new neurological deficits or cardiorespiratory/neurological adverse events between groups.

• Patient Selection: The findings apply to noncritical NASDH patients (midline shift < 10 mm, no coma) who are eligible for either intervention; results do not extend to patients with larger or rapidly deteriorating hematomas.

• Propensity Score Matching: Groups were balanced for key confounders (age, sex, comorbidities, hematoma characteristics) using propensity score matching, enhancing comparability of outcomes.

• Mortality: Mortality rates during follow-up were similar between groups and deaths were unrelated to the primary outcome of recurrence.

• Study Limitations: Limitations include retrospective design, moderate sample size, incomplete long-term clinical outcome data, and potential residual confounding by indication or procedural heterogeneity.

• Clinical Implication: sMMAE may offer a less invasive alternative to surgery with shorter hospitalization and fewer medical complications for selected NASDH patients, but larger studies are needed to confirm noninferiority and guide patient selection.

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Microsurgical anatomy of the fiber tracts and vascular structures lateral to the internal capsule

J Neurosurg 143:1068–1076, 2025

This microsurgical study maps white matter fiber tracts and vascular anatomy from the brain’s lateral surface to the internal capsule using perfused cadaveric specimens and Klingler fiber dissection. Key tracts (AF, SLF II/III, FAT, MdLF, UF, IFOF) and vascular elements (MCA segments, LSAs, LSVs, venous drainage groups) are described with measurements and surgical landmarks.

Findings emphasize trajectories relevant to Kocher’s point, the spatial relationships of LSAs/LSVs to the putamen and internal capsule, and implications for minimizing functional and vascular injury during neurosurgical approaches and revascularization procedures.

• Anatomical Focus: The study investigates the microanatomy of white matter fiber tracts and vascular structures lateral to the internal capsule, using fiber dissection and vessel perfusion techniques on human cadaveric brains.

• Key Structures: Major fiber tracts identified include the arcuate fasciculus (AF), superior longitudinal fasciculus (SLF), frontal aslant tract (FAT), middle longitudinal fasciculus (MdLF), uncinate fasciculus (UF), and inferior fronto-occipital fasciculus (IFOF); the main vascular structures are branches of the middle cerebral artery (MCA) and lenticulostriate arteries (LSAs), each accompanied by lenticulostriate veins (LSVs).

• Vascular Territories: Superficial arteries supply only the gray matter of the lateral brain surface, while deeper white matter and basal ganglia receive blood from LSAs originating from the M1 segment of the MCA; there is no direct communication between insular arteries and LSAs, with the external capsule marking their vascular boundary.

• Surgical Implications: Kocher’s point, a standard neurosurgical entry site, traverses the posterior middle frontal gyrus, SLF III, external capsule, and basal ganglia, avoiding major arteries, veins, and critical fiber tracts such as the AF and internal capsule, thus minimizing functional risk.

• Clinical Relevance: Understanding the course of LSAs and LSVs is crucial for safe neurosurgical procedures in the basal ganglia and insular region, as injury to these vessels can cause severe neurological deficits; the study provides anatomical evidence supporting the safety of the Kocher’s point approach.

• Functional Anatomy: The AF is essential for language by connecting Broca’s and Wernicke’s areas; the internal capsule is critical for motor and sensory information transfer between cortex and brainstem/spinal cord.

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Impact of GLP-1 receptor agonists on idiopathic intracranial hypertension clinical and neurosurgical outcomes

J Neurosurg 143:1037–1047, 2025

This multicenter propensity-matched cohort study examines the association between glucagon-like peptide-1 receptor agonist (GLP-1-RA) therapy and clinical, neurosurgical, and mortality outcomes in adult patients with idiopathic intracranial hypertension (IIH) using the TriNetX electronic health record network. Outcomes at 6 months and 1 year include BMI change, new-onset headaches, visual and cognitive deficits, acetazolamide use, surgical interventions, and mortality.

Findings show greater weight loss and significantly lower odds of visual and cognitive deficits, acetazolamide use, shunt placement at one year, and markedly reduced all-cause mortality among GLP-1-RA users. The authors highlight biological plausibility, acknowledge limitations of retrospective administrative data, and call for randomized prospective trials to confirm causality and optimize treatment strategies.

• GLP-1 receptor agonists (GLP-1-RAs) are associated with significantly improved clinical outcomes in idiopathic intracranial hypertension (IIH), including reduced visual and cognitive deficits, headaches, acetazolamide use, need for shunt placement, and mortality compared to matched controls.

• Weight loss achieved with GLP-1-RAs is greater than with standard care: mean BMI reduction of 1.083 kg/m² at 6 months and 1.635 kg/m² at 1 year, versus 0.695 and 0.758 kg/m² in controls, respectively (p < 0.001).

• Odds of new-onset symptoms are significantly lower with GLP-1-RA treatment at 6 months for headache (OR 0.660), visual deficits (OR 0.423), cognitive deficits (OR 0.368), and acetazolamide use (OR 0.295); most effects persist at 1 year, including a significant reduction in shunt placement (OR 0.375).

• Mortality rates are substantially reduced in the GLP-1-RA group at both 6 months (OR 0.060) and 1 year (OR 0.115), with statistical significance confirmed by Kaplan-Meier survival analysis.

• Mechanisms of benefit may include both weight reduction and direct pharmacological effects, such as reduced cerebrospinal fluid secretion via GLP-1 receptors in the choroid plexus, and anti-inflammatory/neuroprotective actions in the brain.

• GLP-1-RA therapy allows for decreased reliance on acetazolamide, which is associated with more adverse effects, and offers a favorable safety profile—most commonly transient nausea.

• Study limitations include retrospective design, reliance on de-identified administrative data, inability to assess patient adherence, dosage, or causality, and residual confounding despite propensity score matching.

• Future directions call for larger, prospective randomized controlled trials to validate efficacy, clarify mechanisms (weight loss vs. direct CNS effects), and refine IIH treatment strategies.

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Decreasing delayed cerebral infarction after aneurysmal subarachnoid hemorrhage using active blood clearance and prevention of delayed cerebral ischemia: results of a 16-year patient registry

J Neurosurg 143:928–938, 2025

Active blood clearance and prevention of delayed cerebral ischemia (ABCD) after aneurysmal subarachnoid hemorrhage significantly reduced delayed cerebral infarction rates and improved outcomes in high-risk patients, using methods like intrathecal irrigation, urokinase, and nimodipine, according to a 16-year registry study.

Active blood clearance and prevention of delayed cerebral ischemia (ABCD) was introduced for patients with aneurysmal subarachnoid hemorrhage (aSAH) to reduce delayed cerebral infarction (DCI) using methods like intrathecal irrigation, fibrinolysis with urokinase, and intrathecal nimodipine.

• Four ABCD methods were developed: stereotactic catheter ventriculocisternostomy (STX-VCS), intraoperative cisternoventricular catheter (CVC), ventriculolumbar irrigation (VLI), and lumbo-lumbar irrigation (LLI).

• Implementation of ABCD in high-risk patients led to a significant reduction in DCI rates from 21.2% to 7.7% and a 70% decrease in per-patient DCI burden.

• Patients selected for ABCD had higher initial blood load and worse clinical status, but still showed improved outcomes, especially those with high Hijdra scores (≥30).

• Pressure-controlled VLI and intraoperative CVC emerged as the most practical and widely applicable ABCD techniques.

• Complication rates were low and ABCD was considered safe, with rare adverse events and no increase in infection rates.

• The study suggests ABCD outperforms previous DCI prevention strategies and recommends multicenter trials for further validation.

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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 Associated With Revision Microdiscectomy or Subsequent Spinal Fusion Within Two Years of Index Lumbar Microdiscectomy

Spine 2025;50:1392–1399

This large retrospective study found that within two years of lumbar microdiscectomy, 5.5% required revision surgery and 6.6% required spinal fusion. Age 40–59, female sex, and at least one Charlson Comorbidity Index (CCI) comorbidity significantly increased the risk of subsequent fusion, but not revision microdiscectomy.

Revision microdiscectomy rates after index lumbar microdiscectomy were 3.5% at one year and 5.5% at two years.

• Lumbar fusion rates were 2.9% at one year and 6.6% at two years after index surgery.

• Age 40–59, female sex, and presence of at least one Charlson Comorbidity Index (CCI) comorbidity significantly increased risk of lumbar fusion, but not revision microdiscectomy.

• Having ≥1 CCI comorbidity increased the likelihood of needing fusion by about 80%.

• Specific comorbidities (e.g., congestive heart failure, peripheral/cerebrovascular disease, diabetes) were strong predictors for time-to-fusion.

• Age, sex, and CCI score were not predictive of time-to-revision microdiscectomy.

• Results suggest CCI may help identify patients at higher risk for spinal fusion after microdiscectomy.

• Findings may guide surgeons in perioperative decision-making and patient counseling.

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Development and Validation of Interpretable Machine Learning Models Incorporating Paraspinal Muscle Quality to Predict Cage Subsidence Risk Following Posterior Lumbar Interbody Fusion

Spine 2025;50:1375–1385

This multicenter retrospective study developed and validated an interpretable LightGBM machine learning model incorporating paraspinal muscle quality and bone metrics to accurately predict cage subsidence risk after PLIF. Key risk factors included lower psoas muscle index, higher fat infiltration, reduced bone density, and suboptimal cage parameters.

• A machine learning model (LightGBM) was developed to predict cage subsidence risk after PLIF, achieving high accuracy (AUC 0.9752, 92% accuracy, F1 score 0.92).

• Key independent risk factors include lower psoas muscle index (PMI), higher fat infiltration (FI), reduced bone density (HU value, VBQ), suboptimal cage position/height, and greater postoperative changes in intervertebral height (IH) and segmental angle (SA).

• Paraspinal muscle quality was a major contributor; removing muscle indicators reduced model accuracy substantially.

• Patients with cage subsidence had poorer paraspinal muscle and bone quality compared to those without subsidence.

• The model was externally validated and deployed as a web-based tool for real-time, individualized clinical risk assessment.

• Findings support personalized surgical planning and risk mitigation strategies for PLIF patients.

• The study emphasizes a multifactorial approach, integrating skeletal, muscular, and surgical parameters for optimal prediction.

• Limitations include retrospective design, use of a single cage type, and lack of comorbidity indices; further prospective studies are needed.

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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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Long-term outcomes of peripheral nerve field stimulation in patients with refractory trigeminal neuralgia: a cohort study

J Neurosurg 143:982–986, 2025

Peripheral nerve field stimulation (PNFS) for refractory trigeminal neuralgia showed high long-term treatment failure, especially in females, with frequent complications and revisions. Only half of male patients reported lasting benefit. PNFS should be considered cautiously for this condition.

Peripheral nerve field stimulation (PNFS) was studied for refractory trigeminal neuralgia with a long-term follow-up.

Fifteen patients (6 male, 9 female; median age 70) were included, with a median follow-up of 93 months.

PNFS had a high rate of long-term treatment failure, especially in females.

The median time to treatment failure was 2 years (5.1 years in males, 1.5 years in females; p = 0.003).

Only 3 patients (all male) reported ongoing benefit.

Complications and revision surgeries were common (4 patients, 7 revisions).

No significant differences in outcomes were found between classic and secondary trigeminal neuralgia or by patient age.

PNFS should be considered cautiously due to limited long-term efficacy and frequent complications.

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

Neurosurgery 00:1–9, 2025 (Published Online, October 15, 2025)

Resection of white matter tracts (WMTs) in language-critical glioma surgery robustly predicts permanent postoperative language deficits, particularly when parietal and temporal segments are involved. Frontal lobe WMTs are often safely resectable. Anatomical stratification enhances prediction, supporting data-driven, segment-specific surgical planning.

Resecting language-associated white matter tracts (WMTs) in glioma surgery robustly predicts permanent postoperative language deficits (PLDs).

• Frontal lobe WMT segments (e.g., arcuate fasciculus, IFOF, UF, SLF, FAT) are often resectable without causing PLDs.

• Resections in the temporoparietal junction (TPJ) and middle temporal lobe (MTL) significantly increase the risk of PLDs.

• Anatomically stratifying resections to parietal and temporal tracts improves prediction accuracy for PLDs (PPV increases to 50%).

• Volume of tract resected does not correlate with risk of PLDs; specific tract location is more important.

• Broca area and underlying white matter can often be resected safely, challenging traditional localizationist models.

• Combining imaging data with intraoperative mapping remains essential due to some nonfunctional tract segments leading to low PPV.

• Study limitations include small sample size, operator variability in tractography, and need for multicenter validation.

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The Case Series of Contralateral Interhemispheric Transfalcine Approach to Medial Parietooccipital Pathologies: Surgical Technique and Results

Operative Neurosurgery 29:495–504, 2025

This retrospective case series evaluates the contralateral interhemispheric transfalcine approach (PITTA) for medial parietooccipital and peritrigonal brain lesions. The technique offers improved visualization and minimized brain manipulation, with acceptable complication rates, but requires careful venous management and is best suited for experienced neurosurgeons.

The contralateral interhemispheric transfalcine (PITTA) approach is used for challenging medial parietooccipital and peritrigonal brain lesions.

• A retrospective study of 19 cases showed PITTA was applied to vascular lesions (AVMs) and tumors (glioblastomas, meningiomas, metastases, pilocytic astrocytoma).

• The approach improves visualization and reduces manipulation of eloquent cortex and white matter compared to traditional ipsilateral approaches.

• Mean surgery time was about 4 hours 15 minutes, and most patients had temporary neurological deficits that resolved within days.

• Superior sagittal sinus injury and small vein sacrifice occurred in a few cases but were managed without lasting complications.

• No new visual deficits or permanent ipsilateral parietal lobe injuries were observed; most complications were minor and transient.

• PITTA is technically demanding and best suited for experienced neurosurgeons; careful preoperative planning and venous anatomy assessment are critical.

• The study concludes PITTA is a valuable option for selected cases, but larger prospective studies are needed to compare it with standard approaches.

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Development and internal validation of a risk score for subsidence of expandable spacers in transforaminal lumbar interbody fusion (TLIF) surgery

Brain and Spine 5 (2025) 104322

This study developed and internally validated the Expandable TLIF Subsidence Index (ETSI) to predict risk of cage subsidence after TLIF surgery with expandable spacers. Key risk factors include high ASA score, non-degenerative indication, lower lumbar levels, small cage size, and posterior cage position.

• A risk score (Expandable TLIF Subsidence Index, ETSI) was developed to predict cage subsidence (CS) after transforaminal lumbar interbody fusion (TLIF) using expandable spacers.

• The study analyzed 388 patients (482 levels), finding a 31.7% CS rate at 3 months.

• Independent risk factors for CS included high ASA score, non-degenerative surgical indication, lower lumbar level, small cage size, and posterior cage position.

• The ETSI score ranges from -2 to 6; higher scores indicate higher CS risk (each point increases CS odds by about 2x).

• Modifiable risk factors (cage size and position) can reduce CS risk if addressed during surgery.

• Higher ETSI scores are also associated with increased risk of non-union/pseudarthrosis.

• The ETSI demonstrated moderate predictive performance (AUROC ≈ 0.68).

• The score may aid surgical planning and should be externally validated in future studies.

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Cervical deformity correction: comparison of neurological, radiographic, and patient-reported outcome measures by three-column osteotomy level

J Neurosurg Spine 43:433–442, 2025

Three-column osteotomy (3CO) for cervical deformity at C7–T1 is linked to higher neurological deficits, less radiographic correction, and worse Neck Disability Index outcomes compared to T2–6 levels. Surgeons should prefer 3CO below T1 when feasible for better neurological and functional results.

• Study compared outcomes of three-column osteotomy (3CO) for cervical deformity at C7–T1 vs T2–6 levels.

• Patients with 3CO at C7–T1 had higher rates of new postoperative neurological deficits (56% vs 18%).

• T2–6 3CO resulted in greater radiographic correction (T1 slope and C2–T4 SVA) than C7–T1 3CO.

• Neck Disability Index (NDI) improved after T2–6 3CO but worsened after C7–T1 3CO at 1 year.

• All patients with neurological deficits had at least partial recovery; 20% achieved complete recovery.

• 3CO level selection is multifactorial, but caudal to T1 is recommended when feasible due to better outcomes.

• Study limitations include retrospective design and single-institution data.

• Largest study to date comparing neurological, radiographic, and patient-reported outcomes by 3CO level.

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Factors associated with poor prognosis in elderly biopsy‑only glioblastoma patients

Acta Neurochirurgica (2025) 167:273

In elderly glioblastoma patients undergoing biopsy only, poor preoperative performance status, central tumor location, and larger tumor volume were associated with reduced three-month survival and lower treatment completion rates, highlighting the need for careful preoperative assessment and personalized counseling in this vulnerable group.

Study investigated elderly patients (>65 years) with glioblastoma (GBM) who underwent biopsy only, not surgical resection.

• Median overall survival (OS) was 4.6 months; only half completed oncological treatment.

• Poor preoperative performance status (PS), central tumor location, and larger tumor volume were independently associated with reduced three-month survival.

• Poor PS was the only independent predictor for not completing oncological treatment; these patients had very poor survival (median OS 1.6 months).

• Completion of treatment was linked to longer survival (median OS 8.3 months for completers vs. 3.5 months for non-completers).

• Findings suggest limited benefit of biopsy and oncological treatment in elderly GBM patients with poor PS.

• Results can help guide preoperative counseling and decision-making for this vulnerable patient group.

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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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Evaluation of Discrepancy Between Radiographic Success and Patient Satisfaction in Adult Spinal Deformity Surgery

Neurosurgery 97:821–828, 2025

Despite radiographic success in adult spinal deformity surgery, 24.1% of patients remained dissatisfied, mainly due to postoperative lumbar stiffness-related disability. Satisfaction was not linked to radiographic parameters but was independently predicted by the modified lumbar stiffness disability index, highlighting the importance of counseling patients about this trade-off.

• About 24.1% of patients were dissatisfied with adult spinal deformity (ASD) surgery despite radiographic success.

• Radiographic success was defined as optimal alignment, no mechanical complications, and no revision surgery.

• Patient satisfaction was measured using SRS-22; scores <4.0 indicated less satisfaction.

• Clinical outcomes (pain, disability, quality of life) improved after surgery, but lumbar stiffness (M-LSDI) worsened.

• No significant differences in radiographic parameters were found between satisfied and less satisfied groups.

• High postoperative lumbar stiffness (M-LSDI score) was the single independent risk factor for dissatisfaction.

• Longer fusion length was associated with higher lumbar stiffness and lower satisfaction.

• Patients should be informed about the trade-off between pain relief and increased lumbar stiffness before surgery.

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Novel Delivery System Significantly Improves Technical Success and Safety of the Endovascular Clip System (eCLIPs) While Maintaining Efficacy for the Treatment of Wide-Necked Bifurcation Aneurysms

Neurosurgery 97:963–970, 2025

A prospective registry study found that the new eCLIPs electrolytic bifurcation system (eB) for wide-necked bifurcation aneurysms significantly improved technical success and safety over the prior generation, while maintaining high efficacy, with 96% satisfactory occlusion and low rates of neurological complications and retreatment.

• The eCLIPs device is an endovascular implant designed to treat wide-necked bifurcation aneurysms (WNBAs).

• This study compares two generations: the first-generation eCLIPs bifurcation remodeling system (eBRS) and the newer eCLIPs electrolytic bifurcation system (eB).

• A prospective registry included 280 patients; the eB system showed higher implantation success (92% vs 81% for eBRS, P = .007).

• Both systems achieved high rates of satisfactory aneurysm occlusion (mRROC 1+2: 96%).

• The eB system had lower all-cause (1.1%) and neurological (0.5%) death rates compared to eBRS (7% and 5%, respectively).

• Stroke and repeat procedure rates were low for both devices, with eB performing better (stroke: ~1.7%, repeat procedure: 2.2% vs 8.9% for eBRS).

• eCLIPs compares favorably in safety and efficacy to other devices like WEB and stent-assisted coiling.

• The eB system offers improved procedural success and safety, making eCLIPs a strong option for WNBAs; further studies are recommended.

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Volume of parasagittal dura is associated with blood markers of systemic inflammation

Acta Neurochirurgica (2025) 167:255

Higher blood C-reactive protein (CRP), a marker of systemic inflammation, is significantly correlated with lower volume of the parasagittal dura (PSD). This suggests PSD volume may serve as a potential imaging marker of systemic inflammation. No significant association was found between PSD volume and subjective sleep quality.

• The study investigated the relationship between the volume of the parasagittal dura (PSD) and blood markers of systemic inflammation, mainly C-reactive protein (CRP).

• 76 patients underwent intrathecal contrast-enhanced MRI to measure PSD volume and CSF clearance, alongside blood tests for inflammatory markers.

• Higher CRP levels were significantly correlated with lower PSD volume, suggesting an association between systemic inflammation and PSD morphology.

• This inverse relationship was significant even after adjusting for confounders such as age, sex, and diagnosis.

• Other blood markers (hemoglobin, erythrocyte volume fraction) showed initial correlations with PSD volume, but these were not significant after accounting for confounders.

• Impaired sleep quality was associated with higher CRP but not with PSD volume.

• The findings suggest PSD volume may serve as a potential imaging marker of systemic inflammation, but causality remains unclear.

• Further research is needed to clarify mechanisms and clinical implications of the PSD-inflammation link.

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Intraoperative vancomycin for preventing infection after open spine surgery: a systematic review and meta-analysis of randomized controlled trials

J Neurosurg Spine 43:509–518, 2025

A meta-analysis of seven randomized controlled trials found that intraoperative vancomycin use in open spine surgery did not significantly reduce rates of superficial or deep surgical site infections. Further large-scale studies are needed to clarify its efficacy and inform clinical guidelines.

• A systematic review and meta-analysis of 7 randomized controlled trials (RCTs) with 2235 patients assessed the efficacy of intraoperative vancomycin in preventing infections after open spine surgery.

• No significant reduction in overall surgical site infections (SSI), deep infections, or superficial infections was found with intraoperative vancomycin compared to control.

• Subgroup analyses showed no benefit in either instrumented or uninstrumented spine surgeries.

• There was no significant shift toward gram-negative or culture-negative infections with vancomycin use.

• Potential risks include local cytotoxicity and possible impairment of bone healing and spinal fusion.

• Current evidence is limited by small sample sizes, heterogeneity in vancomycin administration, and variable follow-up durations.

• The study concludes intraoperative vancomycin may not reduce infection risk and further large RCTs are warranted.

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