Tag: Surgery

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Guidelines for the Treatment of Adults With WHO Grade II Diffuse Glioma: Update

Neurosurgery 98:984–991, 2026

These updated CNS evidence-based guidelines consolidate current literature on the management of WHO grade II diffuse gliomas, covering imaging, surgical strategies, neuropathology, radiotherapy, chemotherapy, and recurrence. They summarize evidence levels, provide topic-specific recommendations, and identify areas needing higher-quality research to inform clinical decisions.

The document details unchanged, updated, and new recommendations—ranging from MRI protocols and intraoperative mapping to molecular testing and adjuvant therapy—while describing methodology, conflict-of-interest procedures, and plans for periodic revision to ensure clinical relevance.

Scope: Updated evidence-based recommendations for adult WHO grade II diffuse glioma across imaging, surgery, neuropathology/molecular markers, radiotherapy, chemotherapy, and recurrence management.

Methods: Systematic search of MEDLINE/Embase/Cochrane covering Jan 1, 2013–Jan 31, 2020, with recommendations based on evidence rather than consensus.

Imaging (minimum MRI): Minimum evaluation includes T2-weighted and pre- and post-gadolinium T1-weighted MRI; serial imaging is used to detect new enhancement or significant growth suggesting higher-grade transformation.

Imaging (advanced/PET): Diffusion plus perfusion techniques (e.g., DSC/DCE/ASL) are suggested when standard MRI cannot distinguish grade II from higher-grade gliomas; amino-acid PET (FET or FDOPA) may be added when not evident on MRI to help with grading, prognosis (FET), or progression detection (FDOPA).

Surgery: When safe/feasible, resection (gross total or subtotal) is recommended over biopsy alone to reduce progression; extent of resection should be maximized when safely possible (including for IDH-mutant and IDH–wild-type tumors).

Pathology/molecular testing: Diagnosis relies on histopathology from representative tissue; IDH mutation testing is recommended for classification/prognosis, and 1p/19q loss-of-heterozygosity testing is recommended in oligodendroglial cases for prognosis/treatment planning.

Adjuvant therapy (high-risk): For high-risk grade II diffuse glioma (age >40 or <40 without gross total resection), adding chemotherapy to radiotherapy is recommended to improve overall survival (including procarbazine/PCV-based approaches) and is also recommended without decline in neurocognitive function.

Recurrence: At suspected recurrence, advanced imaging (MRS/perfusion/diffusion/PET) is suggested; temozolomide is suggested (often initial choice) and procarbazine may help (strongest evidence in oligodendroglioma); radiation is suggested if not previously given and reirradiation may be considered.

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Comparative Effectiveness of Conservative Management Versus Surgical Fixation in Acute Type II Odontoid Fractures

Neurosurgery 98:61–72, 2026

This retrospective single-center study compares radiological and functional outcomes of conservative versus surgical management for acute type II odontoid fractures in an elderly cohort treated from 2015–2023. Results show surgical fixation markedly increases radiographic union rates, while conservative bracing predominated and delivered superior early pain control with similar long-term functional independence.

Multivariable modeling identified surgery as the strongest positive predictor of union, whereas age ≥80, smoking, osteoporosis, higher frailty, and angulation ≥11° reduced union odds and lowered likelihood of surgical selection. Complication rates and hospital stays were higher after surgery, supporting individualized treatment decisions balancing union probability, pain, frailty, and perioperative risk.

Surgical fixation increases the odds of fracture union in acute type II odontoid fractures (adjusted OR = 6.6), but does not improve long-term functional independence or survival compared to conservative management.

Conservative management (mainly rigid collars) is preferred for elderly or frail patients and achieves similar functional outcomes (modified Rankin Scale ≤2: 75% vs 73%) and better early pain control (75% vs 47%) than surgery, despite lower union rates.

Fracture union rates are significantly higher after surgery (44% vs 10% with conservative treatment, P < .01), but most conservatively managed patients achieve stable nonunion without adverse functional impact.

Advanced age (≥80 years), frailty, smoking, osteoporosis, and fracture angulation ≥11° are all strong negative predictors of fracture union, regardless of treatment approach.

Surgical patients are typically younger, less frail, and have greater fracture displacement or posterior displacement, reflecting selection bias in surgical decision-making.

Complication rates are higher with surgery (40% vs 2% for conservative), and surgical patients have longer hospital stays (median 11 vs 3 days), but most complications do not require reoperation.

Mortality rates at five years are similar between conservative and surgical groups (52% vs 53%), indicating no survival advantage with operative intervention.

Conservative treatment is a safe, effective option for most elderly or frail patients with type II odontoid fractures, reserving surgery for younger, medically fit individuals or those with unstable fracture patterns

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Segmental Lordosis After Open Transforaminal Lumbar Interbody Fusion Using Expandable Oblique Versus Static Anterior Banana Cages

Operative Neurosurgery 30:78–89, 2026

This clinical research article compares segmental and lumbar lordosis outcomes after open transforaminal lumbar interbody fusion (TLIF) with posterior column osteotomy using either static anterior “banana” cages or obliquely placed expandable cages. In a single-surgeon retrospective cohort of 210 patients (327 segments), expandable cages produced a significantly greater median change in segmental lordosis (ΔSL) by 2.0° at six months, persisting after multivariate adjustment and propensity matching.

The study also reports inconsistent effects of cage type on overall lumbar lordosis (ΔLL), with subgroup and matched analyses yielding differing results, and found no difference in subsidence or complication rates. Findings emphasize the influence of preoperative segmental lordosis, segment level (notably L5–S1), and construct length on achieved correction, while noting limitations including retrospective design and lack of clinical outcomes.

Expandable Cages: Expandable obliquely placed cages in open transforaminal lumbar interbody fusion (TLIF) with posterior column osteotomy (PCO) produce a significantly greater median increase in segmental lordosis (ΔSL) of 2.0° compared to static anteriorly placed banana cages, representing a 50% increase.

Statistical Robustness: The greater segmental lordosis achieved with expandable cages remained significant after multivariate regression analysis and propensity score matching, confirming the reliability of the finding.

Overall Lumbar Lordosis (ΔLL): No clear advantage was found between cage types regarding the change in overall lumbar lordosis, with results varying depending on the statistical method used.

Surgical Technique Consistency: All surgeries were performed open with a full PCO using a consistent technique, minimizing confounding variables related to surgical approach or technique.

Preoperative Segmental Lordosis Impact: Segments with lower preoperative segmental lordosis (<15°) experienced the greatest increase in lordosis postoperatively, regardless of cage type.

L5-S1 Segment Benefit: Expandable cages were especially favorable at the L5-S1 segment, likely due to anatomical constraints that make insertion of large static cages more challenging at this level.

Complication and Subsidence Rates: No significant differences were observed between cage types in rates of complications, cage subsidence, or spondylolisthesis correction.

Clinical Outcomes Unclear: The study did not assess clinical outcomes, so the impact of the observed radiographic differences on patient-reported outcomes remains unknown.

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Clinical Outcomes of Decompressive Spine Surgery for Painless Cervical Myelopathy

Neurosurgery 98:161–173, 2026

This multicenter retrospective study analyzes 407 patients from the Michigan Spine Surgery Improvement Collaborative who underwent decompressive surgery for cervical spondylotic myelopathy presenting without neck or arm pain. Patient-reported outcomes (mJOA, PROMIS PF, EQ-5D) and clinical endpoints were assessed at baseline, 90 days, 1 year, and 2 years to quantify functional and quality-of-life changes after surgery.

Results show modest but clinically meaningful improvements in function and quality of life for a subset of patients, with peak MCID rates at one year and sustained patient satisfaction above 80% at two years. Severe preoperative myelopathy predicted worse immediate disposition and higher readmission, although some severe cases still achieved early functional gains.

Painless Cervical Myelopathy (CSM) Surgery: Decompressive spine surgery in patients with CSM but without neck or arm pain led to clinically significant improvements in myelopathic symptoms and physical function for a modest proportion of patients.

Quality of Life Gains: Surgery resulted in increased quality of life, with mean EQ-5D scores higher at all postoperative time points compared to baseline, and over 80% of patients reported sustained satisfaction up to two years after surgery.

Severity-Dependent Outcomes: Patients with severe myelopathy had worse immediate surgical outcomes (lower rates of discharge to home, higher 90-day readmission) and lower quality of life at two years compared to those with mild myelopathy.

Incidence of Postoperative Pain: Despite presenting without pain, 20% of patients developed persistent postoperative neck pain and 14% developed arm pain at two years, rates comparable to those seen in typical CSM surgery cohorts.

Functional Improvement Metrics: At one year, 49% achieved clinically meaningful improvement in physical function (PROMIS PF), 36% in mJOA, and 42% in quality of life (EQ-5D); these improvements were most pronounced at one year and declined by two years for some metrics.

Surgical Approach Differences: Anterior approaches were associated with higher postoperative satisfaction and lower rates of complications like dysphagia compared to posterior or combined approaches.

Study Limitations: Limitations include lack of radiological data, possible misclassification of myelopathy severity, and significant loss to follow-up, affecting long-term outcome interpretation.

Clinical Implication: Surgery may halt progression and provide functional and quality of life benefits even in painless CSM, but patient selection remains challenging and further objective, randomized studies are needed.

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Functional status in long-term survivors after mapping-guided surgery for diffuse low-grade glioma

J Neurosurg 144:139–150, 2026

This clinical study reports long-term functional outcomes in 103 consecutive patients with diffuse low-grade glioma who underwent mapping-guided resections and were followed for at least 15 years. Key findings include high overall survival (83.5%), mean postoperative KPS of 94.8, and 90% return-to-work rate, with low permanent neurological morbidity across 205 resections.

Comparative analysis shows patients who sustained employment had smaller pre/postoperative tumor volumes, greater extent of resection (including more supratotal resections), and less exposure to radiotherapy. The data support early maximal safe resection and postponement of radiotherapy to preserve long-term functional status and professional activity.

Functional Preservation: Long-term survivors of diffuse low-grade glioma (LGG) surgery had high rates of preserved functional status, with 90.7% of surviving patients maintaining a Karnofsky Performance Scale (KPS) score ≥ 80 after an average of 18.2 years follow-up.

Return to Work: 90% of patients were able to return to work after mapping-guided resection, and maintaining professional activity was strongly associated with higher preoperative KPS and greater extent of resection (EOR).

Extent of Resection (EOR): Greater EOR, particularly supratotal or total resections, correlated with better long-term functional outcomes and higher rates of continued employment.

Radiation Therapy Impact: Early or any radiotherapy (RT) was linked to lower rates of return to work and a reduced proportion of patients with KPS ≥ 80 at last follow-up, while chemotherapy did not show this negative association.

Timing of Surgery: Early surgery at diagnosis, especially in patients with higher KPS and smaller tumor volume, increased the chance for maximal resection and long-term preservation of functional status.

Low Neurological Morbidity: Permanent postoperative neurological deficits were rare (1.5% after 205 resections), supporting the safety of maximal resection with intraoperative mapping.

Malignant Transformation: The risk of malignant transformation was lower in patients with greater EOR and those who continued to work, suggesting oncological benefit from radical resection.

Adjuvant Therapy Strategy: A wait-and-watch strategy after maximal safe resection, postponing adjuvant treatments unless necessary, helped preserve long-term quality of life and autonomy.

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Awake surgery for IDH-mutant grade 2 glioma involving the corpus callosum: long-term onco-functional results after callosectomy in 157 consecutive patients

J Neurosurg 143:1280–1289, 2025

This clinical study reports outcomes from 157 consecutive patients with IDH‑mutant grade 2 gliomas infiltrating the corpus callosum who underwent connectome-guided awake surgery with callosectomy. It summarizes surgical technique, extent of resection, complication rates, return-to-work statistics, histology, adjuvant treatments, reoperations, and long-term overall survival.

Comparative analysis contrasts complete (total/supratotal) versus incomplete resections, showing higher extent of resection, greater reoperation potential, and longer median overall survival when callosal tumor was fully removed, while preserved function and a 96.8% return-to-work rate underline favorable onco-functional balance.

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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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Comparative analysis of intraoperative MRI and early postoperative MRI findings in glioma surgery patients

J Neurosurg 142:1289–1297, 2025

The study compares intraoperative MRI (iMRI) and early postoperative MRI (epMRI) in glioma surgery, highlighting iMRI’s accuracy in extent of resection (EOR) and reduced surgically induced contrast enhancement (SICE). iMRI better detects postoperative neurological deficits, with fewer diffusion-weighted imaging abnormalities than epMRI.

• Objective: The study compares intraoperative MRI (iMRI) and early postoperative MRI (epMRI) findings in glioma surgery to assess the extent of resection (EOR) and postoperative neurological deficits.

• Methods: A retrospective analysis of 43 glioma patients who underwent surgery with iMRI, with no additional resection after iMRI, was conducted.

• Results: Discrepancies in EOR were found in 11.1% of nonenhanced and 4.0% of enhanced lesions. iMRI showed more accurate EOR and less surgically induced contrast enhancement (SICE) compared to epMRI.

• Findings: The positive rate of SICE was higher on epMRI (67.9%) than iMRI (25.0%). The positive rate of diffusion-weighted imaging (DWI) abnormality was also higher on epMRI (89.2%) compared to iMRI (73%).

• Clinical Outcomes: Two patients developed new neurological deficits postoperatively, both showing DWI abnormality on both iMRI and epMRI. No deficits were observed in the late-developing group.

• Conclusion: iMRI is more reliable for assessing accurate EOR and detecting postoperative neurological deficits than epMRI, despite higher late-developing DWI abnormalities on epMRI.

• Significance: The study underscores the importance of iMRI in optimizing glioma surgery outcomes and minimizing misinterpretation of residual tumors.

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Natural history, management, and outcomes of cerebellar cavernous malformations: A retrospective study of 130 patients

Neurosurgical Review (2025) 48:381

This study on cerebellar cavernous malformations (CMs) examines their natural history, management, and outcomes. It concludes that conservative management is generally effective for incidental lesions, while surgery is recommended for symptomatic cases, especially in accessible regions, due to the associated hemorrhage risks.

• This study investigates cerebellar cavernous malformations (CMs), focusing on natural history, management, and outcomes in 130 patients from 1990 to 2023.

• Hemorrhage risk for incidental lesions is 1.19%, while rehemorrhage risk for initially hemorrhagic lesions is 8.35%.

• Conservative management is recommended for incidental lesions, with surgery reserved for symptomatic, accessible cases.

• Surgery was performed on 31 patients, primarily for hemorrhage or cerebellar symptoms, with postoperative complications in three patients.

• Lesion location and size significantly influence hemorrhage risk and clinical outcomes, with eloquent regions posing higher risks.

• Long-term outcomes were generally favorable, with most patients experiencing improved or stable functional status.

• Psychological support is important due to potential cognitive and emotional impacts associated with cerebellar dysfunction.

• The study emphasizes the need for risk stratification based on lesion size and subregional anatomy within the cerebellum.

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Clinical and radiographic comparison of robot-assisted single-position versus traditional dual-position lateral lumbar interbody fusion

J Neurosurg Spine 42:443–452, 2025

The study compares robot-assisted single-position (RA-SP) and traditional dual-position (DP) lateral lumbar interbody fusion (LLIF) surgeries, finding RA-SP-LLIF reduces operative and fluoroscopy times with similar clinical and radiographic outcomes, suggesting enhanced surgical efficiency and safety.

• The study compares robot-assisted single-position (RA-SP) lateral lumbar interbody fusion (LLIF) with traditional dual-position LLIF in terms of clinical and radiographic outcomes.

• 59 patients were analyzed, with 31 undergoing RA-SP-LLIF and 28 undergoing traditional LLIF. Surgical parameters like operative duration, blood loss, and fluoroscopy duration were recorded.

• No significant differences were found in postoperative and follow-up times between groups, but both showed improvements in clinical scores such as VAS, ODI, and SF-36.

• RA-SP-LLIF showed significantly greater improvements in lumbar lordosis and segmental lordosis immediately postoperatively, although these differences were not significant at later evaluations.

• The RA-SP-LLIF group had shorter operative and fluoroscopy durations compared to the traditional LLIF group.

• RA-SP-LLIF is considered a promising technique for enhancing surgical efficiency, safety, and precision in lumbar spinal fusion procedures.

• Both procedures improved sagittal alignment parameters, but RA-SP-LLIF reduced surgery and anesthesia times by eliminating the need for repositioning.

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Comparative Efficacy and Safety of Endovascular Versus Surgical Treatment in Spinal Dural Arteriovenous Fistulas A Systematic Review and Meta-analysis

Spine 2025;50:562–574

This systematic review and meta-analysis reveal that surgical treatment for spinal dural arteriovenous fistulas (SDAVFs) achieves higher rates of complete occlusion and successful treatment compared to endovascular approaches, with lower recurrence and retreatment rates, despite similar neurological improvements and periprocedural complications.

• Objective: Compare the efficacy and safety of surgical vs. endovascular treatments for spinal dural arteriovenous fistulas (SDAVFs) through a systematic review and meta-analysis.

• Methods: Searched PubMed, Scopus, and Web of Science databases until July 2024, identifying 1192 articles, with 40 studies meeting inclusion criteria, involving 1818 patients.

• Results: Surgical treatment showed higher rates of complete occlusion (96.8%) and successful treatment (97.5%) compared to endovascular treatment (72.5% and 66.7%, respectively).

• Recurrence and Retreatment: Lower rates in the surgical group, with endovascular treatment showing higher initial treatment failure.

• Neurological Improvement: Both treatments had similar improvements in neurological status and periprocedural complications, but surgery showed greater improvement in the ALS score.

• Conclusion: Surgical treatment is preferred for definitive results in SDAVFs, but decisions should be individualized based on patient-specific factors. Further research is needed.

• Limitations: Potential publication bias and heterogeneity among included studies.

• Key Insight: This study is the most updated and comprehensive meta-analysis on SDAVF treatments, providing valuable insights for clinical and policy decisions.

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The Transtemporal Isthmus Approach for Insular Glioma Surgery

Operative Neurosurgery 28:478–486, 2025

This study presents a transtemporal isthmus approach for insular glioma surgery, achieving maximal safe resection. This method utilizes a widened temporal isthmus to access the insular lobe, ensuring significant tumor removal while preserving neurological function. The approach is shown effective for both low- and high-grade gliomas.

• The study introduces a transtemporal isthmus approach for the resection of insular gliomas, aiming for maximal and safe tumor removal.

• This surgical method involves the use of MRI and functional neuronavigation guidance, along with intraoperative electrophysiological monitoring.

• The approach is particularly beneficial for tumors involving zones III and IV of the Berger-Sanai classification.

• Gross total resection was achieved in 64.9% of low-grade and 87.5% of high-grade gliomas.

• The temporal isthmus is widened by the tumor, providing a surgical corridor for resection.

• The median postoperative Karnofsky performance score was 90, indicating good functional preservation.

• Muscle strength and speech were nearly normal in all patients three months post-surgery.

• The study suggests this approach is effective for safe and maximal tumor resection, while preserving essential functions.

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Natural history and management outcomes of patients with ruptured Spetzler-Martin grade IV and V brain arteriovenous malformations

J Neurosurg 142:667–675, 2025

Study Objective: To explore the natural history and management outcomes of patients with ruptured Spetzler-Martin grade IV and V brain arteriovenous malformations (bAVMs).

• Patient Selection: The study involved 84 patients with ruptured high-grade bAVMs, identified from a database spanning 1990 to 2020.

• Hemorrhagic Risk: Annual hemorrhagic risk was 2.68% for cortical bAVMs and 8.37% for deep-seated bAVMs during natural history.

• Treatment Outcomes: Surgery reduced hemorrhagic risk significantly in cortical bAVMs, while radiosurgery was effective for deep-seated bAVMs. Embolization alone increased hemorrhagic risk.

• Predictors of Success: Surgery and radiosurgery were significant predictors of bAVM obliteration for cortical and deep-seated bAVMs, respectively.

• Management Strategies: Conservative management was compared to surgical interventions, showing similar functional outcomes but differing in obliteration rates.

• Conclusion: Surgery and radiosurgery may be viable options for certain patients, while embolization alone should be avoided

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The gap between surgeon goal and achieved sagittal alignment in adult cervical spine deformity surgery

J Neurosurg Spine 42:309–319, 2025

This study assessed surgeons’ ability to achieve preoperative sagittal alignment goals in adult cervical spine deformity surgeries. Results showed significant deviations from targets, especially in severe deformities, highlighting the need for improved surgical planning and personalized implants.

Study Overview

• Objective: Assess surgeons’ ability to achieve preoperative sagittal alignment goals in CSD surgery.

• Methods: Prospective study with adult CSD patients across 13 North American centers.

• Patient Demographics: Mean age 63.6 years; 51.1% women; 38.6% had previous cervical fusion.

Key Findings

• Alignment Goals: Surgeons failed to meet goals by 17.2 mm for C2–7 SVA, 10.3° for Cobb angle.

• Factors Affecting Outcomes: Greater baseline TK linked to better Cobb angle achievement.

• Surgical Planning: 60% used PACS, 33.3% used spine-specific software.

• Tools and Criteria: Ames/ISSG criteria used by 33.3% of surgeons; others individualized goals.

Challenges and Recommendations

• Severe Deformities: More challenging to achieve alignment goals in severe cases.

• Need for Advancements: Personalized implants could improve intraoperative goal achievement.

• Alignment Correlations: Strong correlation for C7–S1 SVA, weak for C2–7 SVA.

Statistical Analysis

• Offset Groups: Patients categorized by offset magnitude from goal alignment.

• Significant Associations: Lower baseline TS-CL associated with better TS-CL goal achievement.

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Outcomes After Definitive Surgery for Spinal and Sacral Chordoma in 101 Patients Over 20 Years

Neurosurgery 96:494–504, 2025

• Study Objective: Investigate postoperative outcomes of spinal chordoma surgery over 20 years.

• Patient Cohort: 101 patients, average follow-up of 6.0 ± 4.2 years.

• Recurrence and Mortality: 24.8% recurrence, 9.9% mortality.

• Risk Factors: Tumors ≥100 cm³ and mobile spine chordomas linked to worse outcomes.

• Neoadjuvant Radiotherapy: Associated with improved local recurrence-free survival (LRFS).

• Age Impact: Patients ≥65 years at surgery have a higher mortality risk.

• Surgical Outcomes: Pain decreased post-surgery, sensory deficits and weakness remained static.

• Functional Outcomes: 39% of patients pain-free long-term, no significant change in sensory deficits.

• Surgical Complications: 65.3% experienced complications; 32.7% required reoperation.

• Radiotherapy Advances: Newer modalities like stereotactic photon therapy show promising LRFS rates.

• Study Design: Retrospective review from 2003-2023 at a quaternary spinal oncology center.

• Data Analysis: Multivariable Cox regression used to identify predictors of LRFS and OS.

• Surgical Approach: Enneking Appropriate surgery preferred for better outcomes.

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Prone Lateral Transpsoas Approach to the Spine: A Technical Guide for Mastery

Int J Spine Surg 2025, 19 (S1) S19-S27

• The prone lateral transpsoas (PTP) approach offers an alternative to traditional lateral lumbar interbody fusion (LLIF), allowing direct posterior access without repositioning the patient.

• Advantages of PTP include improved segmental lordosis, single-position surgery, and ease of posterior techniques, though it has a distinct learning curve.

• The technical guide aims to shorten the learning curve, optimize surgical workflow, and ensure patient safety through preoperative planning and technical adjustments.

• Preoperative imaging is crucial for assessing anatomical characteristics and guiding surgical approach decisions.

• Patient positioning in PTP involves prone positioning on a radiolucent table, with special attention to stabilizing the pelvis and optimizing working angles.

• Intraoperative monitoring with triggered electromyography (t-EMG) is essential to minimize lumbar plexus injury risk.

• Technical pearls include strategies for retractor positioning, minimizing retraction time, and using intraoperative navigation to enhance safety and efficiency.

• Conclusion: PTP LIF is a viable alternative to traditional methods, offering significant benefits but requiring mastery of its unique technical nuances.

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Outcome prediction following lumbar disc surgery: a longitudinal study of outcome trajectories, prognostic factors, and risk models

J Neurosurg Spine 42:33–42, 2025

This study aimed to 1) describe the 2-year postoperative trajectories of leg pain and overall clinical outcome after surgery for radiculopathy, 2) identify the preoperative prognostic factors that predict trajectories representing poor clinical outcomes, and 3) develop and internally validate multivariable prognostic models to assist with clinical decision-making.

METHODS This retrospective cohort study included patients enrolled in the Canadian Spine Outcomes and Research Network who were diagnosed with lumbar disc pathology and radiculopathy and had undergone lumbar discectomy at one of 18 spine centers. Potential outcome predictors included preoperative demographic, health-related, and clinical prognostic factors. Clinical outcomes were 1) 2-year univariable latent trajectories of leg pain intensity (numeric pain rating scale) and 2) overall outcomes comprising multivariable trajectories showing the combined postoperative courses of leg and back pain intensity (numeric pain rating scale) together with pain-related disability (Oswestry Disability Index). Each outcome model identified a subgroup of patients classified as experiencing a poor outcome based on minimal change in their clinical status after surgery. Multivariable risk model performance and internal validity were evaluated with discrimination and calibration statistics based on bootstrap shrinkage with 500 resamplings.

RESULTS The authors included data from 1142 patients (47.6% female). The trajectory models identified 3 subgroups based on the patients’ postoperative courses of pain or disability: 88.6% of patients in the leg pain model and 71.9% in the overall outcome model experienced a good-to-excellent outcome. The models classified 11.4% (leg pain outcome) and 28.2% (overall outcome) of patients as experiencing a poor clinical outcome, which was defined as minimal improvement in pain or disability after surgery. Eleven individual demographic, health, and clinical factors predicted patients’ poor leg pain and overall outcomes. The performance of the multivariable risk model for leg pain was inadequate, while the overall outcome model had acceptable discrimination, calibration, and internal validity for predicting a poor surgical outcome.

CONCLUSIONS Patients with lumbar radiculopathy experience heterogeneous postoperative trajectories of pain and disability after lumbar discectomy. Individual preoperative factors are associated with postoperative outcomes and can be combined within a multivariable risk model to predict overall patient outcome. These results may inform clinical practice but require external validation before confident clinical implementation.

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Long-term survivors in 976 supratentorial glioblastoma, IDH-wildtype patients

J Neurosurg 142:174–186, 2025

Glioblastoma, isocitrate dehydrogenase (IDH)–wildtype is the most aggressive glioma with poor outcomes. The authors explored survival rates and factors associated with long-term survival in patients harboring a glioblastoma, IDH-wildtype.

METHODS In an observational, retrospective, single-center study, the authors examined the medical records of 976 adults newly diagnosed with supratentorial glioblastomas, IDH-wildtype between January 2000 and January 2021. They analyzed clinical-, imaging-, and treatment-related factors associated with 2-year and 5-year survival.

RESULTS The median overall survival was 11.2 months (12.2 months for patients included after 2005 and the introduction of standard combined chemoradiotherapy). The median progression-free survival was 9.4 months (10.0 months for patients included after 2005). Overall, 17.6% of patients reached a 2-year overall survival, while 2.2% of patients reached a 5-year overall survival. Furthermore, 6.6% of patients survived 2 years without progression, while 1.1% of patients survived 5 years without progression. Two factors that were consistently associated with 2-year and 5-year survival were first-line oncological treatment with standard combined chemoradiotherapy and methylated O 6 -methylguanineDNA methyltransferase promoter. Other factors that were significantly associated with 2-year or 5-year survival were age at diagnosis ≤ 60 years, headaches or signs of raised intracranial pressure at diagnosis, cortical contact of contrast enhancement, no contrast enhancement crossing the midline on initial imaging, total or subtotal tumor resection, and a second line of oncological treatment at recurrence. Within 21 cases of 5-year survival, 18 were confirmed to be glioblastomas, IDH-wildtype, and 7 of the 5-year survivors (38.9%) had additional genetic alterations: 3 cases had an FGFR mutation or fusion, 3 cases had a PIK3CA mutation, 1 case had a PTPN11 mutation, and 1 case had a PMS2 mutation in the context of constitutional mismatch repair deficiency syndrome.

CONCLUSIONS Five-year overall survival in patients with glioblastoma, IDH-wildtype is extremely low. Predictors of a longer survival are mostly treatment factors, emphasizing the importance of a complete oncological treatment plan, when achievable. Glioblastoma, IDH-wildtype 5-year survivors could be screened for actionable targets in case of recurrence.

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Laser Interstitial Thermal Therapy versus Open Surgery for Mesial Temporal Lobe Epilepsy: A Systematic Review and Meta-Analysis

World Neurosurg. (2024) 192:224-235

Epilepsy surgery offers a vital treatment option for drug-resistant mesial temporal lobe epilepsy, with temporal lobe resection (TLR) and magnetic resonanceguided laser interstitial thermal therapy (MRgLITT) being fundamental interventions.

This meta-analysis specifically examines seizure outcomes at extended follow-up periods exceeding 24 months, visual field deficits as measured by perimetry, and complication rates both overall and categorized based on duration as minor (transient <6 months) or major (persistent >6 months) to inform clinical decision-making.

For seizure freedom, TLR was superior, with 72.5% [65.6%, 78.5%] of patients achieving postoperative seizure freedom compared to 57.1% [51.2%, 62.7%] for MRgLITT (P value <0.01). Visual field deficits were observed in 79.4% [59.5%, 91.0%] of TLR patients and 49.8% [23.6%, 76.0%] of MRgLITT patients, a difference not reaching statistical significance (P value: 0.08). Overall complication rates were 11.4% [7.4%, 17.2%] for TLR and 6.5% [3.3%, 12.3%] for MRgLITT (P value 0.15). Major complications occurred in 2.0% [1.1%, 3.09%] of TLR cases and 2.7% [1.4%, 5.2%] of MRgLITT cases (P value 0.54), while minor complications were significantly more frequent with TLR at 9.9% [6.4%, 15.0%] versus MRgLITT’s 4.1% [1.9%, 8.4%] (P value 0.04). MRgLITT had a more favorable outcome regarding confrontation naming, while more studies are needed regarding verbal memory to be able to draw firm conclusions. TLR provides superior seizure freedom but comes with an increased risk of transient complications. Although there was no statistical significance in visual field deficits, the trend suggests a higher frequency with TLR.

The study’s extensive data analysis, including rigorous sensitivity checks, ensures the robustness of these conclusions, reflecting a comprehensive analysis of the available data at this time point.

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Familial Chiari malformation: a systematic review and illustrative cases

J Neurosurg Spine 41:105–114, 2024

Chiari malformations (CMs) are a group of congenital or acquired disorders characterized by hindbrain overcrowding into an underdeveloped posterior cranial fossa. CM is considered largely sporadic—however, there exists growing evidence of transmissible genetic underpinnings. The purpose of this systematic review of all familial studies of CM was to investigate the existence of an inherited component and provide recommendations to manage and monitor at-risk family members.

METHODS This paper includes the following: 1) a unique case report of dizygotic twins who presented at the Toronto Western Hospital Spinal Cord Clinic with symptomatic CM type 1 (CM-1) and syringomyelia; and 2) a systematic review of familial CM. The EMBASE and MEDLINE databases were searched on June 27, 2023, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only articles in the English language concerning the diagnosis of CM in > 1 human family member presented as a case study, case series, or literature review were included.

RESULTS Among the 29 articles included in the final analysis, a total of 34 families with CM were analyzed. An average of 3 cases of CM were found per family among all generations. Eighty-one cases (88%) reported CM-1, whereas the other 11 (12%) cases reported either CM-0, CM-1.5, or tonsillar ectopia. A syrinx was present in 37 (54%) cases, with 14 (38%) of these patients also reporting a skeletal abnormality, the most common comorbidity. Most family members diagnosed with CM were siblings (18; 35%), followed by monozygotic twins/triplets (12; 23%).

CONCLUSIONS Patients most often presented with headaches, sensory disturbances, or generalized symptoms. Overall, there exists mounting evidence for a hereditary component of CM. It is unlikely to be explained by a classic mendelian inheritance pattern, but is rather a polygenic architecture influenced by variable penetrance, cosegregation, and entirely nongenetic factors. For first-degree relatives of those affected by CM, the authors’ findings may influence clinicians to conduct closer clinical and radiographic monitoring, promote patient education, and consider earlier genetic testing.

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