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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 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 indications, lower lumbar level, small cage size, and posterior cage position. Some risk factors are modifiable.

• A risk score (ETSI) was developed to predict cage subsidence (CS) after TLIF surgery using expandable spacers.

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

• ETSI ranges from -2 to 6 points and shows a moderate ability to classify CS risk (AUROC ≈ 0.68).

• Modifiable risk factors (cage size and position) can reduce CS risk if optimized by the surgeon.

• Higher ETSI scores are associated with increased risk of non-union/pseudarthrosis at 3 and 12 months.

• Anterior placement of the cage lowers subsidence risk, while posterior placement increases it.

• The study included 388 patients with a 3-month CS rate of 31.7%.

• The ETSI is the first comprehensive scoring system for CS risk with expandable TLIF cages.

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Multicentre study of the role of lumbar puncture in the diagnosis of spontaneous subarachnoid haemorrhage

Acta Neurochirurgica (2025) 167:193

A multicentre UK and Ireland study found that 1% of aneurysmal subarachnoid haemorrhage (SAH) cases were diagnosed by lumbar puncture (LP) after a negative CT within 6 hours. LP remains crucial in diagnosing SAH missed by early CT, suggesting NICE guidelines may need reconsideration.

• A multicentre UK and Ireland study assessed the role of lumbar puncture (LP) in diagnosing spontaneous subarachnoid haemorrhage (SAH), especially after negative CT scans.

• Out of 10,187 spontaneous SAH cases, 7% were diagnosed by LP, with 3% of aneurysmal SAH confirmed by LP after a non-diagnostic CT.

• 1% of aneurysmal SAH cases were detected by LP following a negative CT scan performed within 6 hours of symptom onset.

• There was no significant change in diagnostic practice following the introduction of the 2022 NICE guidelines, which recommend not routinely offering LP after a negative CT within 6 hours.

• Concerns remain that relying solely on CT, especially when reported by non-expert radiologists, risks missing SAH cases.

• LP remains important for diagnosing SAH in patients with strong clinical suspicion and negative early CT, potentially impacting future NICE guidance.

• Study limitations include retrospective design, possible under-reporting, and focus on neurosurgical referrals only.

• The findings support continued use of LP in select patients despite new guidelines.

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Measurement of CSF flow and brain motion in Chiari malformation type I subjects undergoing posterior fossa decompression surgery

J Neurosurg 143:13–23, 2025

Advanced MRI techniques show that in Chiari malformation type I, presurgical CSF flow and brain motion measurements better predict improvements after posterior fossa decompression surgery than traditional tonsillar descent metrics, potentially enabling more accurate identification of patients likely to benefit from surgery.

• Chiari malformation type I (CM-I) is defined by ≥5 mm cerebellar tonsil herniation through the foramen magnum, but tonsillar descent does not correlate well with symptom severity or surgical outcome.

• Posterior fossa decompression (PFD) surgery improves symptoms in ~75% of symptomatic CM-I patients, but carries risks, making optimal patient selection important.

• This study used advanced MRI (phase-contrast for CSF flow and DENSE for brain motion) to evaluate 108 CM-I patients, 61 of whom had PFD surgery.

• After PFD, CSF stroke volume increased by 28.9%, brainstem motion decreased by 17.3%, and cerebellar motion decreased by 45.2%.

• Improvements in CSF flow and brain motion after surgery were better predicted by presurgical CSF flow and brain motion, not by the amount of tonsillar descent.

• Presurgical dynamic measures (CSF flow, brain motion) are more informative for predicting surgical benefit than conventional anatomical metrics.

• These quantitative imaging assessments may help identify which patients will benefit most from surgery, improving patient care.

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The efficacy of combining pulsed radiofrequency with low-temperature continuous radiofrequency for the treatment of primary trigeminal neuralgia

J Neurosurg 143:100–110, 2025

High-voltage pulsed radiofrequency (PRF) combined with low-temperature continuous radiofrequency (CRF) significantly improved 12-month response rates and pain scores in primary trigeminal neuralgia compared to PRF alone, with minimal complications. This combined approach offers a promising alternative for patients unresponsive to medication.

High-voltage pulsed radiofrequency (PRF) combined with low-temperature (60°C) continuous radiofrequency (CRF) was compared to high-voltage PRF alone for treating primary trigeminal neuralgia (TN) in a randomized controlled trial.

• 146 patients were randomized to either PRF+CRF or PRF alone, with 12-month response rate as the primary outcome.

• The PRF+CRF group had a significantly higher response rate at 12 months (83.6% vs 67.1%, p = 0.021) and better pain relief at all measured time points.

• Patient satisfaction scores were higher in the PRF+CRF group at 1, 6, and 12 months.

• Facial numbness and masseter muscle weakness were more frequent in the PRF+CRF group but were mild and resolved within months; no serious complications occurred.

• Both treatments were safe, with no cases of anesthesia dolorosa, corneal anesthesia, or keratitis.

• The study was limited by single-center design, open-label nature, and a smaller than expected difference in primary outcome, suggesting the need for larger studies.

• Conclusion: High-voltage PRF combined with low-temperature CRF offers better pain control and satisfaction than PRF alone, with minimal side effects, for patients with refractory TN.

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Stratifying trigeminal neuralgia and characterizing an abnormal property of brain functional organization: a resting-state fMRI and machine learning study

J Neurosurg 143:74–82, 2025

Resting-state fMRI and machine learning revealed distinct brain connectivity and activity differences between classical and idiopathic trigeminal neuralgia (TN) and controls. These findings identify potential neuroimaging biomarkers for TN subtypes, aiding diagnosis and understanding of TN pathophysiology.

Primary trigeminal neuralgia (TN) includes classical (CTN) and idiopathic (ITN) types, sharing clinical features but differing in neurovascular compression (NVC) presence.

• Resting-state fMRI and machine learning were used to analyze brain functional connectivity and spontaneous activity in 50 TN patients (28 CTN, 22 ITN) and 43 controls.

• TN patients showed increased connectivity between the medial prefrontal cortex (mPFC) and left planum temporale, and decreased connectivity between mPFC and left superior frontal gyrus.

• CTN patients had further reduced connectivity between the left insula and left occipital pole, and decreased activity in the right temporal pole compared to ITN.

• TN patients exhibited heightened neural activity in frontal regions compared to controls.

• Machine learning (support vector machine) distinguished TN patients from controls with moderate accuracy (AUC 0.80).

• Findings suggest potential fMRI biomarkers for TN subtypes, aiding understanding of pathophysiology and improving diagnosis.

• Study limitations include small sample size and exclusion of bilateral/secondary TN, warranting further research.

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Effects of the length of preoperative conservative management on postoperative outcomes after primary microvascular decompression for trigeminal neuralgia

J Neurosurg 143:92–99, 2025

Prolonged preoperative conservative management with anticonvulsants in trigeminal neuralgia is associated with worse pain outcomes and higher pain recurrence after microvascular decompression. Early surgical intervention may improve postoperative results and reduce pain recurrence risk in these patients.

• Longer duration of preoperative conservative management (anticonvulsant use) before microvascular decompression (MVD) for trigeminal neuralgia (TN) is linked to worse postoperative pain outcomes and higher risk of pain recurrence.

• Median duration of conservative management before surgery was 1.74 years.

• Patients with longer conservative management had higher final BNI pain scores and greater rates of pain recurrence than those with shorter management.

• Longer conservative management predicted shorter pain-free survival after MVD.

• Younger age and longer conservative management duration were independent predictors of worse postoperative pain and recurrence.

• No significant difference in preoperative pain scores between groups; both had high pain levels pre-surgery.

• Findings suggest early surgical intervention may benefit TN patients who are candidates for MVD.

• Study was retrospective and single-institution, limiting generalizability; further research is needed.

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Deep learning–based segmentation of the trigeminal nerve and surrounding vasculature in trigeminal neuralgia

J Neurosurg 143:83–91, 2025

This study developed and validated deep learning U-Net models for automated 3D segmentation of the trigeminal nerve and surrounding vasculature in MRI of trigeminal neuralgia patients, enabling objective quantification of neurovascular conflict features and potentially improving preoperative evaluation and treatment planning.

• Deep learning (U-Net) models were used to segment the trigeminal nerve and surrounding vasculature in patients with trigeminal neuralgia using high-resolution CISS MRI.

• Six U-Net variants with different encoder backbones were tested; SE-ResNet50 performed best overall (Dice score = 0.775, IoU = 0.681).

• The models quantified anatomical features such as the surface area of neurovascular contact and distance to the contact point, showing no significant difference from manual segmentations.

• The best model achieved 100% sensitivity and specificity in detecting neurovascular conflict in the testing set.

• Automated 3D segmentation allows for objective, quantitative evaluation, improving on subjective and time-intensive manual methods.

• Limitations include inability to distinguish vessel type (artery vs. vein) and data from a single institution; future work should address these.

• The method may help standardize neurovascular conflict assessment and improve treatment selection for trigeminal neuralgia.

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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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Clinical Evaluation of the NaviNetics Stereotactic System Using Intraoperative Portable Surgical Imaging System in DBS Surgery

Operative Neurosurgery 29:93–101, 2025

Intraoperative O-arm imaging with the NaviNetics stereotactic head frame enables accurate, efficient deep brain stimulation (DBS) lead placement in both awake and asleep surgeries, streamlining workflow by eliminating patient transport for imaging and achieving submillimeter accuracy comparable to traditional CT-based methods.

• The study evaluates the NaviNetics stereotactic head frame system with intraoperative O-arm imaging for deep brain stimulation (DBS) surgery.

• Intraoperative O-arm imaging was used for both stereotactic registration and lead placement confirmation in awake and asleep DBS procedures.

• A total of 17 patients were included; 1 had both CT and O-arm, while 16 had only O-arm localization.

• Accuracy of O-arm imaging was comparable to traditional CT, with less than 0.1 mm difference and a mean radial error of 0.71 ± 0.33 mm for 32 leads.

• No surgical complications, lead repositioning, or infections were reported.

• The intraoperative O-arm workflow reduces patient transport, surgical time, and allows real-time confirmation of lead placement.

• Limitations include limited hemorrhage detection by O-arm and lack of direct comparison with stereotactic CT in larger samples.

• The study concludes O-arm imaging is safe, effective, and streamlines DBS surgery without compromising accuracy.

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Minimally Invasive and Cost-Effective Access to Deep-Seated Intracranial Lesions Using 19F Peel-Away Sheath Introducer and “Dynamic” Retraction

Operative Neurosurgery 29:118–124, 2025

This study introduces a minimally invasive, cost-effective technique for resecting deep-seated brain lesions using a 19F peel-away sheath introducer and dynamic retraction. In 13 patients, the method proved safe and effective, achieving high rates of gross total resection with minimal complications and reduced costs.

A novel, cost-effective minimally invasive technique for deep-seated intracranial lesions uses a 19F peel-away sheath introducer and “dynamic” retraction.

• This approach was evaluated in 13 patients with various brain pathologies, including glioblastoma, metastases, cavernous malformations, pilocytic astrocytoma, and colloid cyst.

• Gross total resection was achieved in 11 of 13 cases, with minimal complications and most patients remaining neurologically stable or improved postoperatively.

• The technique involves a small craniotomy, insertion of the 19F introducer using image guidance, and lining the corridor with cottonoid strips after sheath removal for retractorless, dynamic retraction.

• Compared to standard tubular retractor systems, this method reduces cost (introducer: ~$252 vs. commercial systems: $695–$4000) and potentially lessens brain trauma.

• Postoperative imaging showed minimal brain damage, with only one patient exhibiting minor diffusion changes without clinical consequences.

• Limitations include small sample size and retrospective design, but the technique may be especially valuable in resource-limited settings.

• Authors conclude this method is safe, technically feasible, and a viable alternative to more expensive tubular retraction systems for deep brain lesions.

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Incidence, Management, and Outcomes of Pediatric Infectious Aneurysms

Operative Neurosurgery 29:27–33, 2025

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

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

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

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

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

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

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

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

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

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Evaluation of 2 Surgical Techniques—Transposition Versus Interposition Microvascular Decompression for Hemifacial Spasm: A Systematic Review of 19 437 Patients

Neurosurgery 97:16–27, 2025

This systematic review of 19,437 patients compares transposition and interposition microvascular decompression techniques for hemifacial spasm. Both methods show similar efficacy and safety, with no conclusive evidence favoring one. Slightly higher facial nerve weakness was noted with transposition. Prospective trials are needed for definitive comparison.

Hemifacial spasm (HFS) is a rare disorder caused by compression of the facial nerve, leading to involuntary facial muscle contractions.

• Microvascular decompression (MVD) is an effective surgical treatment for HFS, with two main techniques: interposition (placing a prosthesis between nerve and vessel) and transposition (moving the vessel away without direct prosthesis contact).

• A systematic review of 62 studies (19,437 patients) compared outcomes of interposition (18,627 cases) and transposition (810 cases) in MVD for HFS.

• Spasm freedom rates were similar: 90.4% for transposition and 89.6% for interposition.

• Complication rates were similar, though temporary facial nerve weakness/palsy was higher with transposition (9.52% vs 6.03%).

• No conclusive evidence was found that one technique is superior in safety or efficacy; interposition may be preferred in certain clinical situations.

• A prospective trial is needed to determine true differences and optimal indications for each technique.

• The review highlights the need for future studies to stratify outcomes by technique and report prognostic factors.

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Navigated Transcranial Magnetic Stimulation and Diffusion Tensor Imaging Tractography in Insular Glioma Surgery

Operative Neurosurgery 29:62–70, 2025

Navigated transcranial magnetic stimulation (nTMS) and DTI tractography enable precise preoperative risk stratification in insular glioma surgery, identifying patients at higher risk for postoperative motor deficits by assessing resting motor threshold, tumor proximity to the corticospinal tract, and fiber tract integrity, thus improving surgical planning and outcomes.

• Navigated transcranial magnetic stimulation (nTMS) and nTMS-based DTI tractography were evaluated for preoperative risk stratification in insular glioma surgery.

• Thirty-two patients with insular gliomas underwent preoperative nTMS mapping and DTI tractography to assess motor cortex and corticospinal tract (CST) involvement.

• Higher resting motor threshold (RMT) ratios, CST-tumor distances <3 mm, and decreased peritumoral fractional anisotropy (pFA) ratios were significantly associated with new postoperative motor deficits.

• All patients with new postoperative motor deficits had a CST-tumor distance below 3 mm; lower pFA ratios also correlated with deficits.

• One-third of patients with intraoperative ischemic events developed permanent motor deficits, suggesting additional mediating factors such as CST integrity and cortical excitability.

• A risk model combining RMT ratio, CST distance <3 mm, and low pFA ratio predicted an 82% risk for new motor deficits.

• Preoperative nTMS-based DTI tractography may improve individual risk stratification and surgical planning for insular glioma patients.

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Microsurgical clipping for intracranial aneurysms in elderly patients: outcomes comparable to those in younger cohorts

J Neurosurg 143:214–219, 2025

Microsurgical clipping for intracranial aneurysms in patients aged 70 and older showed complication, mortality, and functional dependence rates comparable to younger patients, supporting its safety and efficacy in selected elderly individuals. Careful patient selection remains crucial; further studies are encouraged to confirm these findings.

• Microsurgical clipping for intracranial aneurysms in elderly patients (≥70 years) shows outcomes comparable to those in younger patients (<70 years).

• A retrospective single-center study (2016–2022) matched 50 elderly with 100 younger patients using propensity score matching.

• No significant differences were found between age groups for complications, extended length of stay, nonhome discharge, functional dependence, or mortality.

• Aneurysm characteristics (location, morphology, rupture status) were similar between groups.

• Frailty and comorbidities, rather than age alone, are important predictors of outcomes after clipping.

• Study highlights the safety of microsurgical clipping in well-selected elderly patients, but emphasizes careful patient selection.

• Limitations include single-center design, possible selection bias, and influence of unmeasured confounders.

• Further research is needed to validate findings and guide patient selection for clipping in the elderly.

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Nervus intermedius sectioning for the treatment of geniculate neuralgia

J Neurosurg 143:111–118, 2025

Nervus intermedius (NI) sectioning for geniculate neuralgia (GN) provided pain relief in 81% and complete resolution in 68% of cases, with low complication rates. Combining NI sectioning with microvascular decompression improved outcomes. The study supports NI sectioning as a safe, effective surgical option when medical management fails.

• Geniculate neuralgia (GN) is a rare facial pain syndrome with severe stabbing ear pain, often involving the nervus intermedius (NI) as the primary structure.

• Medical management is first-line, but when ineffective, surgical options like NI sectioning and microvascular decompression (MVD) are considered.

• This study presents the largest case series (47 procedures in 45 patients) of NI sectioning for GN, with most patients also having trigeminal neuralgia or glossopharyngeal neuralgia.

• NI sectioning led to pain improvement (BNI score < IV) in 80.9% and complete pain resolution (BNI I) in 68.1% of procedures at latest follow-up.

• Combining NI sectioning with MVD further improved outcomes, especially in patients with concurrent neuralgias.

• Complications were rare: 2 cases of hearing loss, 1 confirmed permanent vestibular dysfunction, and 3 cases of loss of taste; no permanent facial paralysis or loss of lacrimation.

• Older age predicted worse pain outcomes after surgery.

• The study supports NI sectioning as a safe and effective treatment for GN, especially when tailored with MVD as needed.

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Safety and therapeutic impact of stereotactic biopsy in very elderly patients with brain tumors

J Neurosurg 143:194–203, 2025

Stereotactic brain biopsy in patients aged ≥80 is safe, with high diagnostic yield (96.2%) and low persistent neurological deficit (1.9%). Prebiopsy Karnofsky Performance Status ≥70% predicts full adjuvant therapy and longer survival. Biopsy findings frequently alter management, supporting its use in very elderly brain tumor patients.

• Stereotactic brain biopsy in patients aged ≥80 years is safe and has a high diagnostic yield (96.2%).

• Symptomatic complication rate was 6.2%, with persistent neurological deficit in 1.9% and a procedure-related mortality of 0.5%.

• The biopsy changed the suspected diagnosis in 11.1% of cases, influencing patient management.

• 80.7% of patients received adjuvant treatment after biopsy; 19.3% received palliative care.

• A Karnofsky Performance Status (KPS) score ≥70% was the only significant predictor for receiving full adjuvant therapy and longer overall survival (OS).

• Median OS after biopsy was 5.6 months; longer in patients with PCNSL or methylated MGMT promoter in glioma.

• No significant increase in complications was seen with deep-seated tumors, anticoagulant use, or advanced age (≥85 or ≥90 years).

• The study supports considering biopsy for very elderly patients when technically feasible and patient condition is good.

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Predecompression and postdecompression cognitive and affective changes in Chiari malformation type I

J Neurosurg 143:4–12, 2025

This prospective study found that patients with Chiari malformation type I commonly experience cognitive and psychiatric impairments, particularly in executive function and visuospatial memory. Following posterior fossa decompression surgery, 89% showed significant improvement in cognitive and/or psychiatric symptoms, highlighting the cerebellum’s role in these functions.

• Chiari malformation type I (CM-I) patients often have unrecognized cognitive and psychiatric symptoms, including deficits in executive function, visuospatial memory, and increased depression, anxiety, and related symptoms.

• This prospective study assessed 54 CM-I patients with cognitive or psychiatric complaints before and after posterior fossa decompression (PFD) surgery.

• Preoperatively, patients performed worse than normative samples in executive function and visuospatial memory, and reported more psychiatric symptoms across all measured domains.

• Six months after surgery, 89% of patients showed clinically significant improvements (>1 SD) in cognitive and/or psychiatric domains.

• Improvements were most notable in visuospatial memory and psychiatric symptoms such as depression and anxiety, which normalized to levels seen in the general population.

• Patients with the most severe preoperative deficits experienced the greatest postoperative improvements.

• The findings support a key role for the cerebellum in cognitive and psychiatric dysfunction and suggest that some symptoms in CM-I are potentially treatable with targeted cerebellar intervention.

• Limitations include lack of a control group and focus on symptomatic, self-reporting patients, so results may not generalize to all CM-I cases.

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Prediction of Shunt Malfunction Using Automated Ventricular Volume Analysis and Radiomics

Neurosurgery 97:242–249, 2025

Automated ventricular volume analysis using convolutional neural networks and radiomics, combined with clinical features, improves accuracy in diagnosing hydrocephalus and shunt malfunction from CT scans, outperforming traditional 2D methods and enabling earlier, more reliable detection without requiring prior imaging.

• Automated ventricular volume analysis and radiomics were used to predict shunt malfunction and diagnose hydrocephalus from CT scans.

• Traditional 2D measurements are less sensitive than 3D volumetric analysis for detecting ventricular changes.

• A convolutional neural network (CNN) segmented ventricles, and volumes were compared to age- and sex-matched normative data.

• Volumetric analysis alone achieved up to 73% accuracy (AUC 0.772) for detecting pathology; combining radiomics and clinical data improved accuracy significantly.

• The best model (support vector machine) using selected radiomics features and clinical data reached an AUC of 0.92–0.93 and F1-score of 0.848.

• Automated segmentation is time-efficient, reduces observer variability, and may improve early and accurate diagnosis.

• Limitations include single-institution data, scanner variability, and need for external validation.

• Future work should expand datasets and improve model generalizability, including to MRI and other manufacturers.

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Cerebellopontine Angle Meningiomas: A Multi-Institutional Cohort Study

Neurosurgery 97:105–111, 2025

This multi-institutional study of 95 cerebellopontine angle meningioma cases found that gross total resection, especially with internal auditory canal drilling for intracanalicular invasion, improves symptom control and reduces recurrence. Most patients experienced stable or improved hearing, with postoperative complications and recurrence rates detailed.

• Cerebellopontine angle (CPA) meningiomas are challenging due to their proximity to neurovascular structures and present commonly with hearing loss, ataxia, and headaches.

• Gross total resection (GTR) was achieved in 62.1% of 95 patients; smaller tumor size and drilling the internal auditory canal (IAC) for tumors with intracanalicular invasion were associated with higher GTR rates.

• Most patients had stable or improved hearing postoperatively; only a minority experienced worsening.

• Postoperative complications included cranial nerve dysfunction, CSF leak, and hydrocephalus, but there were no perioperative deaths.

• Tumor progression or recurrence occurred in 25.3% of patients, with higher rates in WHO grade 2 tumors; Simpson grade I/II resection and older age reduced recurrence risk.

• Extent of resection (EOR) is not reliably predicted by tumor size alone; other anatomical factors are important.

• Adjuvant radiation was mainly used for higher-grade tumors with subtotal resection, but most progression cases were managed with observation or salvage therapy.

• Surgical resection is effective for symptom control and reducing recurrence, especially with GTR and appropriate IAC management.

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

J Neurosurg Spine 42:727–736, 2025

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

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

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

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

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

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

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

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

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

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