Kuo CH, Wang CY, Chen YS
… +7 more, Kuo YH, Chang CC, Wu CL, Fay LY, Tu TH, Huang WC, Wu JC
Neurosurgery
· 2026 Mar · PMID 41805172
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BACKGROUND AND OBJECTIVES: The skipped, in-between indexed, level theoretically has higher chances of adjacent segment disease (ASD), especially in between 2 anterior cervical diskectomy and fusion (ACDF) constructs. How...BACKGROUND AND OBJECTIVES: The skipped, in-between indexed, level theoretically has higher chances of adjacent segment disease (ASD), especially in between 2 anterior cervical diskectomy and fusion (ACDF) constructs. However, this inference remains unclear. The objective was to compare cervical disk arthroplasty (CDA) with ACDF for noncontiguous cervical disk problems. METHODS: Consecutive patients who underwent skip-level anterior cervical diskectomies for symptomatic disk herniations or spondylosis involving noncontiguous pathologies of the subaxial cervical spine were retrospectively analyzed and divided into 2 groups: CDA and ACDF. Clinical and radiological outcomes were analyzed, including comparison of the range of motion (ROM), cervical lordosis, C2-7 Cobb angle, sagittal vertical axis, and T1 slopes. RESULTS: A total of 70 patients, 33 CDA vs 37 ACDF, completed at least 2 years of follow-up. Patients of the CDA group were younger (54.9 ± 8.6 vs 62.3 ± 9.9 years, P-value < .01) than ACDF. The incidences of radiological ASD were lower in the CDA than ACDF (18.2% vs 40.5%, P = .04) groups. One patient in the ACDF group had worsened symptoms caused by ASD of the initially skipped level that required a secondary surgery, whereas there were no reoperations for CDA. The ROM of both the skipped level and overall cervical spine (C2-7) were higher in the CDA group than those of the ACDF group (P-values = .04 and .01, respectively) at 2-year postoperation. The complication rates were no different between the 2 groups. CONCLUSION: Both skip-level CDA and ACDF can restore cervical lordosis, while the overall cervical ROM was well preserved in the CDA group but almost eliminated in the ACDF group. Skip-level CDA not only preserves motion at the indexed but also at the in-between skipped level, with lower incidences of ASD and higher ROM than ACDF. Therefore, to avoid a three-level fusion in the long run, CDA is the superior option for noncontiguous disk herniations or spondylosis that require surgery.
Di Cosmo L, El Choueiri J, Pellicanò F
… +9 more, Ozsut O, Antonino JR, Feffer EB, Ghosh S, Darwiche A, Imbrogno CP, Cuervo SN, Chibbaro S, Zaed I
Neurosurgery
· 2026 Mar · PMID 41805168
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BACKGROUND AND OBJECTIVES: Decompressive craniectomy (DC) is used to control intracranial pressure in severe pediatric traumatic brain injury (TBI), although evidence of its benefit in pediatric patients remains conflict...BACKGROUND AND OBJECTIVES: Decompressive craniectomy (DC) is used to control intracranial pressure in severe pediatric traumatic brain injury (TBI), although evidence of its benefit in pediatric patients remains conflicted. To address this, this meta-analysis evaluates the outcomes of DC vs medical management (MM) in pediatric severe TBI. METHODS: Following PRISMA guidelines, databases were searched through October 2025 for studies comparing DC and MM in patients younger than 18 years with severe TBI. Randomized control trials and prospective and retrospective studies reporting at least one clinical outcome were included. Random-effects models were applied, with relative risks used for dichotomous outcomes and mean differences for continuous outcomes. RESULTS: Our analysis included 553 DC and 2336 MM patients, with 1 randomized trial and 10 observational studies. Pooled analyses showed no significant difference in good functional outcomes between DC and MM, whether based on the Glasgow Outcome Scale or study-specific definitions or mortality (1.06, 95% CI 0.69-1.64; P = .78). Subgroup analyses of Glasgow Outcome Scale scores at discharge and 30 days corroborated these findings. DC was associated with a significantly longer intensive care unit stay (mean differences, 6.2 days, 95% CI 4.4-8.0; P < .001) and a similar trend toward longer hospital stay (mean differences, 4.0 days, 95% CI -0.6 to 8.7; P = .09), which became significant on sensitivity analysis. Reported complication rates, when reported, were low and comparable across groups. CONCLUSION: In children with severe TBI, DC does not appear to provide clear survival or functional advantages over MM and is significantly associated with longer intensive care unit and hospital stays. However, these findings should be interpreted with caution as the current literature mainly composed of small and heterogeneous retrospective studies. Further large, prospective, multicenter studies are needed to confirm these findings, refine surgical indications, and establish pediatric-specific management guidelines.
Bekelman NJ, Ghaith AK, Khalilullah T
… +6 more, Yang L, Momeni A, Davidson AA, Theodore N, Xu R, Lubelski D
Neurosurgery
· 2026 Mar · PMID 41789922
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BACKGROUND AND OBJECTIVES: Spinal glomus arteriovenous malformations are rare intramedullary vascular lesions that can cause progressive myelopathy. Treatment strategies include microsurgical resection, endovascular embo...BACKGROUND AND OBJECTIVES: Spinal glomus arteriovenous malformations are rare intramedullary vascular lesions that can cause progressive myelopathy. Treatment strategies include microsurgical resection, endovascular embolization, and stereotactic radiosurgery. However, comparative effectiveness data remain limited, and previous meta-analyses are outdated. This study systematically compares the clinical and radiographic outcomes of surgery, embolization, and radiosurgery in the treatment of spinal glomus arteriovenous malformations. METHODS: A systematic review and meta-analysis were conducted in accordance with preferred reporting items for systematic reviews and meta-analyses guidelines. Four electronic databases were searched for English-language reports with ≥3 patients and intervention-specific outcome data. Pooled proportions were calculated using random-effects models for 4 endpoints: (1) complete nidus obliteration, (2) partial obliteration, (3) neurologic symptom improvement, and (4) treatment-related complications. Subgroup analyses compared surgery with vs without preoperative embolization. Meta-regression evaluated temporal trends in treatment efficacy. RESULTS: Thirty-six studies comprising 462 patients were included. Patients underwent surgery (51%), embolization (35%), or radiosurgery (14%). Complete obliteration was most likely to occur after surgery (77%), compared with embolization (39%) and radiosurgery (16%) (P < .001). No significant differences were found between treatment modalities in partial obliteration (P = .19), symptom improvement (P = .94), or complication rates (P = .35). Among surgical patients, preoperative embolization did not affect the rate of complete obliteration (P = .55). Meta-regression demonstrated an increase in complete obliteration rates after embolization over time. CONCLUSION: A surgical strategy (resection ± preoperative embolization) yielded the highest obliteration rate in selected, typically compact lesions, without an increased risk of complications compared with embolization or radiosurgery. These rates, particularly for radiosurgery, may increase with longer follow-up lengths. Improvements in embolization techniques over time suggest a growing role for endovascular therapy, particularly as an adjunct to surgery. However, heterogeneity in lesion classification limits the ability to draw definitive treatment recommendations. Standardized diagnostic and outcome reporting frameworks are needed to guide future studies.
Alfonzo Horowitz M, Khalifeh JM, Yang X
… +19 more, Das O, Selim O, Khalilullah T, Al-Mistarehi AH, Hansen L, Ahmed AK, Makri SC, Zhang L, Acharya S, Rincon-Torroella J, Theodore N, Lee S, Gross J, Romo CG, Meyer CF, Pratilas CA, Blakeley J, Belzberg A, Lubelski D
Neurosurgery
· 2026 Feb · PMID 41757904
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BACKGROUND AND OBJECTIVES: Malignant peripheral nerve sheath tumors (MPNST) are aggressive soft tissue sarcomas with peripheral nerve differentiation. A wide surgical resection with negative margins is the mainstay of tr...BACKGROUND AND OBJECTIVES: Malignant peripheral nerve sheath tumors (MPNST) are aggressive soft tissue sarcomas with peripheral nerve differentiation. A wide surgical resection with negative margins is the mainstay of treatment but is not always curative. Here, we present clinical outcomes of patients who underwent surgical resection for MPNST. METHODS: We identified and collected data on patients who underwent surgical resection for their MPNST at The Johns Hopkins Hospital, from 2010 to 2024. We generated Kaplan-Meier curves and performed univariable and multivariable analyses to determine factors associated with progression-free survival (PFS) and overall survival (OS). RESULTS: We identified 123 MPNST patients. On univariable analysis, older age (hazard ratio [HR] 1.02), radiation-induced etiology (HR 1.59), spinal tumors (HR 3.27), high-grade pathology (HR 2.6), and postoperative complications (HR 3.07) were each associated with worse OS. Neurofibromatosis type 1 (NF1)-related etiology (HR 0.54), gross total resection (HR 0.48), negative margins (HR 0.58), R0 resection status (HR 0.46), and preoperative ambulatory status (HR 0.26) were each associated with improved OS. The results of the univariable analysis were similar for PFS and for OS and PFS within the NF1-related subgroup. On multivariable analysis, nonextremity MPNST (Spine adjusted hazard ratio [aHR] 3.28, Brachial Plexus aHR 5.51, Head/Neck aHR 6.23), recurrent tumor status (aHR: 2.64), and postoperative complications (aHR 3.27) were independently significantly associated with poor OS. CONCLUSION: MPNST are aggressive sarcomas that present challenges in diagnosis and treatment. In our series, NF1-related MPNST patients had the highest OS, likely associated with close monitoring for MPNST among the high-risk NF1-population. Nonextremity tumor locations, recurrent tumors, and postoperative complications were associated with inferior OS and PFS. Multi-institutional studies are warranted to investigate the impact of these prognostic factors in a larger, more heterogeneous MPNST patient cohort and examine the utility of surveillance in the neurofibromatosis patient population under a multidisciplinary team.
Hafazalla K, Carreras A, Filo J
… +8 more, Patil S, Guzylak V, Momin A, Patel P, Self DM, Gooch MR, Harrop J, Jallo J
Neurosurgery
· 2026 Feb · PMID 41757892
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BACKGROUND AND OBJECTIVES: Adverse events after cranioplasty remain a significant burden in postsurgical care, often necessitating reoperations. Identifying predictors of reoperation could optimize care. We investigated...BACKGROUND AND OBJECTIVES: Adverse events after cranioplasty remain a significant burden in postsurgical care, often necessitating reoperations. Identifying predictors of reoperation could optimize care. We investigated reoperation after cranioplasty and factors that correlate. METHODS: A retrospective analysis of 318 cranioplasty patients at our single institution was conducted. Clinical demographics, preoperative and perioperative parameters, and postoperative outcomes of patients were collected from electronic health records. Univariable and multivariable logistic regression were conducted to identify significant predictors of reoperation after cranioplasty. Patients who had previous cranioplasties or the bone flap replaced during the craniectomy were excluded. RESULTS: Of 318 cranioplasty patients, 62 (19.4%) required reoperation. These patients had shorter time intervals between craniectomy and cranioplasty relative to patients who did not require reoperation (median of 86 vs 140 days, IQR: 31-164 and 79-211, P ≤ .01). The reoperation group also had a greater frequency of cranioplasties done during their index hemicraniectomy hospital stay (21.3% vs 10.9%, P = .03), longer time interval to restarting antiplatelets or anticoagulants (median of 34 vs 11 days, IQR 18-102 and 7-16, P = .03), greater number of preoperative ventriculoperitoneal shunt patients (26.2% vs 12.9%, P = .01), and lower utilization of autologous bone implant (62.3% vs 80.0%, P ≤ .01). On multivariable analysis, use of autologous bone implant (odds ratio: 0.38 [0.15-0.94], P = .03) and postoperative subgaleal drain use (odds ratio: 0.35 [0.13-0.91], P = .03) were associated with a lower odds of reoperation, while greater fluid collection on postoperative computed tomography was linked to a higher odds of reoperation (odds ratio: 1.05 [1.01-1.11], P = .02). CONCLUSION: Autologous bone implant, postoperative subgaleal drain use, and fluid collection on postoperative computed tomography are independent predictors of reoperations after cranioplasty. Further assessment of these factors may be beneficial for predictive modeling and surgical management of patients requiring cranioplasty.
Wolfson DI, Deutsch H, DeWald CJ
… +4 more, Fontes RBV, O'Toole JE, Traynelis VC, Fessler RG
Neurosurgery
· 2026 Feb · PMID 41744503
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The 1990s pedicle screw litigation saga was a pivotal clash between medical innovation, regulatory oversight, and legal accountability. The controversy arose from the widespread use of pedicle screws, which became a stan...The 1990s pedicle screw litigation saga was a pivotal clash between medical innovation, regulatory oversight, and legal accountability. The controversy arose from the widespread use of pedicle screws, which became a standard practice despite lacking explicit Food and Drug Administration approval for spinal applications. This regulatory ambiguity was ignited by a 1993 ABC 20/20 segment that triggered an avalanche of mass tort litigation. This article dissects the landmark legal battle, analyzing the Food and Drug Administration's slow reclassification and the contrasting strategies of key industry players, AcroMed and Sofamor Danek. We evaluate the lasting impact on legal precedents, clinical practice around off-label use, and the regulatory pathways for new devices. This history offers a cautionary tale on the tension between legal accountability and innovation, with enduring relevance for today's debates on medical regulation and patient rights.
Yoo SJ, Shin JJ, Jang HJ
… +6 more, Kim KH, Park JY, Kuh SU, Chin DK, Kim KS, Moon BJ
Neurosurgery
· 2026 Feb · PMID 41744502
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BACKGROUND AND OBJECTIVES: This study compared the surgical outcomes of open-door (OD) and double-door (DD) laminoplasties in patients with cervical ossification of the posterior longitudinal ligament (OPLL). METHODS: Th...BACKGROUND AND OBJECTIVES: This study compared the surgical outcomes of open-door (OD) and double-door (DD) laminoplasties in patients with cervical ossification of the posterior longitudinal ligament (OPLL). METHODS: This single-center study included 62 patients in the OD group and 47 patients in the DD group, all of whom were evaluated over a 10-year follow-up period. We assessed demographics, surgical levels, occupying ratio, K-line classification, type of OPLL, C2-C7 Cobb angle, cervical OPLL volume, and range of motion (ROM). Clinical outcomes were assessed using visual analog scale score, Japanese Orthopedic Association (JOA) score, and recovery rate. RESULTS: No significant differences were observed in age, sex, symptom duration, comorbidities, K-line type, and canal-occupying ratio. Six patients in each group underwent reoperation. The C2-7 Cobb angle remained similar preoperatively, immediately after surgery, or 2 years after surgery. At the 10-year follow-up, the extension angle and ROM were significantly lower in the DD group, although the overall ROM change from baseline was not significant different. OPLL volume was significantly greater in the OD group at 10 years. The visual analog scale scores for the neck and arm were significantly lower in the DD group than in the OD group immediately after surgery, with no difference between the groups at 10 years postsurgery. The JOA scores showed a similar improvement at 10 years postoperatively. CONCLUSION: Both laminoplasty methods were effective for long-term treatment of cervical OPLL, providing similar clinical outcomes and improvement in the JOA score over a 10-year follow-up period. However, the ROM decreased significantly more in the DD group than in the OD group, especially in patients younger than 50 years of age. These findings suggest that, although both techniques are viable options, patient age and preservation of cervical ROM may be important considerations in the choice of surgical method.
Jain B, Abikenari MA, Sadeghzadeh S
… +7 more, Shah A, Yoo KH, Azad TD, Hani U, Ratliff JK, Ramayya AG, Veeravagu A
Neurosurgery
· 2026 Feb · PMID 41718492
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BACKGROUND AND OBJECTIVES: Spinal cord stimulation (SCS) effectively manages chronic pain and degenerative spine conditions. Paddle SCS often necessitates inpatient care because of surgical complexity, yet the impact of...BACKGROUND AND OBJECTIVES: Spinal cord stimulation (SCS) effectively manages chronic pain and degenerative spine conditions. Paddle SCS often necessitates inpatient care because of surgical complexity, yet the impact of procedural setting on outcomes, costs, and disparities remains unclear. This study evaluates total costs, 90-day readmission and complication rates, and socioeconomic disparities in paddle SCS delivery. METHODS: Using Merative MarketScan data (2007-2023), we retrospectively identified adults undergoing initial paddle lead SCS implantation. Outcomes were total costs, 90-day readmission, and complication rates. Multivariable regression adjusted for age, sex, insurance, geographic region, surgery year, and Elixhauser comorbidity index. Propensity score matching minimized confounding, and longitudinal analyses assessed temporal outcome trends. RESULTS: Of 13 704 patients, 89.4% underwent outpatient procedures. Inpatients had higher comorbidities (Elixhauser comorbidity index: 1.47 vs 0.55, P < .001). After propensity score matching, complication (4.76% vs 3.51%, P = .093) and readmission rates (16.54% vs 16.88%, P = .804) were similar between groups, but inpatient procedures incurred significantly higher costs (difference = $5341.15, P = .001). Over 17 years, readmissions declined from 18% to 5% (-0.76% annually, P < .001), complications decreased from 4% to 0% (-0.33% annually, P < .001), yet costs rose annually by $912 (P < .001). Cost disparities were influenced by age (-$347/year, inpatient), insurance type ($10 940 higher for outpatient high-deductible plans), and region (North Central vs Northeast: -$13 505, inpatient). Readmissions varied by sex (female odds ratio [OR] = 1.206, outpatient), age (OR = 0.982/year, inpatient), and region (North Central OR = 0.506 vs Northeast). Southern inpatient patients had higher complication risks (OR = 3.878). CONCLUSION: Outpatient paddle SCS demonstrates equivalent short-term safety at substantially lower cost for appropriately selected patients. Inpatient implantation remains appropriate for select higher-risk patients at the surgical team's discretion, and payer policies should consider preserving coverage across both settings when clinically indicated to ensure access and equity.
Monteiro A, Jaikumar V, Lim J
… +30 more, Kuo CC, Kim LJ, Levitt MR, Barros G, Boulos AS, Paul AR, Hanel RA, Sauvageau E, Cortez GM, Benalia VHC, Nickele C, Johnson K, Jabbour PM, El Naamani K, Schirmer CM, Haussen DC, Grossberg JA, Mohammaden MH, Jovin TG, Khalife J, Kan PT, Colasurdo M, McGrath M, Ross C, Yeradi M, Devaraju M, Stafstrom I, Davies JM, Levy EI, Siddiqui AH
Neurosurgery
· 2026 Feb · PMID 41718491
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BACKGROUND AND OBJECTIVES: Middle cerebral artery bifurcation (MCAb) aneurysms have primarily been managed through microsurgical clipping (MC). However, the effectiveness and safety of evolving neurointerventional method...BACKGROUND AND OBJECTIVES: Middle cerebral artery bifurcation (MCAb) aneurysms have primarily been managed through microsurgical clipping (MC). However, the effectiveness and safety of evolving neurointerventional methods warrant a comprehensive examination and comparison with MC. We investigated patient and MCAb aneurysm characteristics and compared imaging outcomes for MC, simple coiling (SC), stent-assisted coiling (SAC), flow-diverting stent placement (FD), and endosaccular flow disruption. METHODS: A retrospective review of MCAb aneurysm databases from 10 US centers was conducted to identify patients treated between January 2008 and January 2023. Primary analyses compared data across all 5 treatment modalities individually and for MC vs endovascular modalities. Secondary analyses consisted of pairwise comparisons between these modalities for saccular MCAb aneurysms. RESULTS: We analyzed data for 1060 patients with 1060 MCAb aneurysms (MC = 722, SC = 134, SAC = 106, FD = 34, and endosaccular flow disruption = 64). The treatment groups differed significantly in mean patient age (P < .001), sex distribution (P = .044), and baseline mRS score (P < .001). No treatment preference was noted for recurrent aneurysms. Ruptured aneurysms were most common in SC and least common in FD (P < .001). Wide-necked aneurysms were most frequent in FD (P < .001). Intraoperative complications were similar, although SAC had more vasospasm (P = .006) and device-related complications (P = .010), and FD had more thromboembolic events (P = .047). Postoperative complications varied (P = .007): MC had more vasospasm (P = .043). Follow-up durations varied significantly (P < .001). Follow-up complications differed (P = .012): FD had more transient ischemic attacks (P = .042) and ischemic strokes (P < .001); SC had more aneurysmal rehemorrhage (P = .027). Immediate and final aneurysmal occlusion was considerably better with MC (P < .001), followed closely by SAC. CONCLUSION: MC remained the preferred modality for treating both unruptured and ruptured MCAb aneurysms, demonstrating superior immediate and final angiographic occlusion rates with minimal intraoperative and postoperative complications. SAC showed similar safety but was technically more challenging, FD had higher ischemic event rates, and SC had more delayed reruptures.
Wang P, Zhang Y, You Q
… +12 more, Cheng X, Yang F, Deng Y, Ouyang Y, He J, Tian Y, Yuan X, Xu W, Jia L, Xiao Y, You C, Fang F
Neurosurgery
· 2026 Feb · PMID 41705842
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BACKGROUND AND OBJECTIVES: Postoperative hypotension is a common modifiable risk factor linked to adverse outcomes. However, the association between postoperative hypotension and mortality in brain tumor resection patien...BACKGROUND AND OBJECTIVES: Postoperative hypotension is a common modifiable risk factor linked to adverse outcomes. However, the association between postoperative hypotension and mortality in brain tumor resection patients is still unclear. This study aims to explore the association between postoperative hypotension and mortality, and to identify the critical blood pressure thresholds for managing postoperative care in this patient group. METHODS: We conducted a retrospective cohort study on patients who had craniotomy for brain tumors at West China Hospital, Sichuan University, from January 1, 2011, to May 31, 2024. Postoperative blood pressure was categorized by the lowest mean arterial pressure (MAP) within 72 hours after surgery, using 5-mm Hg intervals (≤50, 50-55, 55-60, 60-65, 65-70, 70-75, 75-80, >80 mm Hg). The outcome was postoperative morbidity. RESULTS: This study included 23 680 patients who underwent craniotomy for brain tumors, with 558 (2.4%) experiencing 30-day mortality. The findings showed that postoperative hypotension is associated with increased mortality, with an L-shaped relationship for the lowest MAP. Specifically, compared with the reference group (MAP 60-65 mm Hg), the adjusted odds ratios (OR) for 30-day mortality were MAP ≤50 mm Hg (OR 8.96, 95% CI: 5.92-13.54), MAP 50 to 55 mm Hg (OR 2.43, 95% CI: 1.42-4.15), and MAP 55 to 60 mm Hg (OR 2.15, 95% CI: 1.51-3.07). No significant differences were found in higher MAP ranges. In addition, postoperative hypotension was associated with acute kidney injury, myocardial infarction, hospital-acquired infection, pneumonia, intracranial infection, bloodstream infection, urinary tract infection, and deep vein thrombosis. No significant differences were found in blood pressure variability metrics between the survival and 30-day mortality groups. CONCLUSION: Postoperative hypotension was independently associated with an increased risk of increased mortality and complications in brain tumor craniotomy. An L-shaped relationship was observed between postoperative MAP and mortality risk, with a marked inflection point at 65 mm Hg.
Ran KR, Bishara A, Xia Y
… +14 more, Nair SK, Oak A, Abdulrahim M, Theodore N, Witham TF, Bydon A, Lubelski D, Jackson CM, Caplan JM, Huang J, Gailloud P, Gonzalez LF, Tamargo RJ, Xu R
Neurosurgery
· 2026 Feb · PMID 41705829
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BACKGROUND AND OBJECTIVES: Treatment of symptomatic spinal dural arteriovenous fistulas (SDAVF) reduces spinal cord injury and prevents irreversible neurological deficits. It remains unclear whether endovascular emboliza...BACKGROUND AND OBJECTIVES: Treatment of symptomatic spinal dural arteriovenous fistulas (SDAVF) reduces spinal cord injury and prevents irreversible neurological deficits. It remains unclear whether endovascular embolization vs open surgical treatment of SDAVF is associated with better neurological outcomes. We aimed to compare neurological outcomes between patients who underwent endovascular embolization vs open surgical treatment as primary treatment of SDAVF. METHODS: Patients who underwent endovascular embolization or open surgical treatment as primary treatment of SDAVFs at our institution between 2012 and 2023 were retrospectively identified. The primary outcome assessed was neurological status measured using the Frankel grade and Nurick classification systems. Outcomes at final follow-up were compared with preintervention neurological status. RESULTS: A total of 48 patients (63.8 ± 11.1 years, 75.0% men) met study inclusion criteria. Endovascular embolization was performed in 29 patients, and open surgical treatment was performed in 19 patients. Baseline neurological function was similar for both treatment groups. At final follow-up, similar rates of Frankel (20.7% vs 21.1%, P > .999) and Nurick grade (55.2% vs 57.9%, P > .999) improvement were observed in endovascular vs open surgical treatment groups. Patients who underwent endovascular embolization had a shorter hospital stay (3.1 ± 2.3 vs 5.3 ± 1.8 days; mean difference = 2.2 days, 95% CI 0.93-3.42, P = .001). Reintervention for symptomatic SDAVF was required for 3 (10.3%) patients who underwent endovascular embolization and 0 (0.0%) patients who underwent open surgical treatment (P = .267). CONCLUSION: Both endovascular embolization and open surgical treatment significantly improved neurological symptoms among patients with SDAVF, and similar neurological outcomes were achieved at final follow-up. Although high recurrence rates have been reported with endovascular treatment, they may be similar to open surgery in the hands of experienced operators. Treatment selection should be guided by multidisciplinary discussion of patient-specific risk factors.
Bell RS, Lumba-Brown A, Wright DW
… +28 more, Stein DM, Mangat HS, Aarabi B, Adelson PD, Armonda RA, Benjamin J, Boone D, Davis S, Dengler B, Ecklund J, Ghajar J, Grant G, Harris O, Hoffer A, Kitagawa R, Latham K, Neal CJ, Okonkwo DO, Pannell D, Puffer R, Rosenfeld JV, Rosenthal G, Rubiano AM, Shackelford S, Stippler M, Talbot M, Valadka A, Hawryluk GWJ
Neurosurgery
· 2026 Mar · PMID 41697054
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BACKGROUND: Penetrating traumatic brain injury (pTBI) is an important wounding mechanism which is seen increasingly as a result of violent crime and armed conflicts. pTBI is very challenging to manage as it is often high...BACKGROUND: Penetrating traumatic brain injury (pTBI) is an important wounding mechanism which is seen increasingly as a result of violent crime and armed conflicts. pTBI is very challenging to manage as it is often highly complex yet requires expeditious treatment. Treatment algorithms thus can assist even experienced clinicians to avoid pitfalls while caring for these patients. METHODS: To supplement the evidence-based recommendations produced in conjunction with the Brain Trauma Foundation Guidelines for the Management of Penetrating Brain Injury, Second Edition, we developed protocols for care to help bridge limitations of published evidence with care decisions required at the bedside. Our working group of over 30 diverse expert panelists identified care, care pathways and key decisions relevant to pTBI care through discussion. A rigorous, blinded Delphi consensus process was then applied. Items achieving at least an 80% consensus vote were incorporated into the treatment algorithms. Consensus voting also approved the final versions of the care pathways. RESULTS: To meet the needs of diverse pTBI patients we created a Master Care Pathway relevant to all patients. We also created 'Toolkits' designed to address care issues that only some patients will have. Toolkits for surgical management, protruding foreign bodies, severe injury, skull base injury and vascular injury were developed. In addition, a futility assessment is provided to assist with delineating the small proportion of patients for whom initial non-aggressive care might be considered with the recognition that avoidance of nihilism is critical to achieving best outcomes in pTBI victims. CONCLUSIONS: Care pathways are presented which reflect suggestions for care that aim to inspire thoughtful management. The algorithms also aim to avoids potential pitfalls in management to help achieve best possible outcomes for pTBI patients.
Bell RS, Selph S, Ghajar J
… +32 more, Aarabi B, Lumba-Brown A, Mangat HS, Wright DW, Dengler B, Stein DM, Pannell D, Ecklund J, Shackelford S, Pappas M, Totten AM, Adelson PD, Armonda RA, Benjamin J, Boone D, Davis S, Grant G, Harris O, Hoffer A, Kitagawa R, Latham K, Neal CJ, Okonkwo DO, Puffer R, Rosenfeld JV, Rosenthal G, Rubiano AM, Stippler M, Talbot M, Valadka A, Wright J, Hawryluk GWJ
Neurosurgery
· 2026 Mar · PMID 41697053
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BACKGROUND: Penetrating traumatic brain injury (pTBI) affects civilian and military populations resulting in significant morbidity, mortality, and health care costs. No up-to-date and evidence-based guidelines exist to a...BACKGROUND: Penetrating traumatic brain injury (pTBI) affects civilian and military populations resulting in significant morbidity, mortality, and health care costs. No up-to-date and evidence-based guidelines exist to assist modern medical and surgical management of these complex injuries. METHODS: A preliminary literature search informed a need for updated guidelines. Methodologists experienced in TBI guidelines supported 2 co-chairs, a diverse steering committee and three expert working groups. Over half of our panelists were active service military or military veterans and they addressed twenty-six Key Questions (KQs). We searched Ovid MEDLINE®, EMBASE, and Cochrane CENTRAL from inception to August 31, 2022, reference lists, and clinical trial registries. Penetrating, perforating and tangential penetrating brain injuries were included. Predefined criteria were used to identify studies; pre-specified methods were used to assess study quality and strength of evidence for key outcomes. Effects were analyzed qualitatively and quantitatively where appropriate. RESULTS: 125 studies provided evidence and another 80 studies provided contextual data for these guidelines. In general there was a paucity of literature and most of the identified evidence was judged to be high risk of bias due to study design. We did not identify any studies meeting inclusion criteria for 12 KQs. The highest quality evidence, rated moderate in strength, was identified for four KQs that covered: cerebral angiography vs computed tomography angiography, the relationship between bihemispheric injury in adult pTBI and mortality, the ability of the Surviving Penetrating Injury to the Brain (SPIN) score to predict mortality, and the relationship between infection and cerebrospinal fluid fistula. Evidence for most KQs came from case series. CONCLUSIONS: The development of up-to-date evidence and consensus based clinical care guidelines and algorithms for pTBI provide guidance to care providers in the prehospital and emergency medicine, surgical and intensive care settings. Few moderately strong conclusions on the benefit of specific management strategies for penetrating brain injury could be made. Detailed reporting of patient outcomes in future studies could advance the field by providing greater evidence for specific treatments by patient population, mechanism of injury, severity of injury, and specific interventions employed.
Gupta S, Gal ZT, Touray J
… +14 more, Luiselli GA, Ceesay A, Manneh EK, Cham M, Rolston JD, Chrenek R, Bah MG, Golby AJ, Esene IN, Arnaout O, Sanchez C, Janneh L, Smith TR, Jabang JN
Neurosurgery
· 2026 Feb · PMID 41697048
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BACKGROUND AND OBJECTIVES: Access to specialty surgical care is growing in many low-income countries, but it remains unclear how hospital workforces can leverage technology to manage large numbers of increasingly complex...BACKGROUND AND OBJECTIVES: Access to specialty surgical care is growing in many low-income countries, but it remains unclear how hospital workforces can leverage technology to manage large numbers of increasingly complex patients. Large language models (LLMs) may be helpful for this type of clinical decision support, but their real-world performance and safety remain uncertain. The objective of this study was to evaluate feasibility, usability, and potential benefits and risks of an LLM-based assistant for postoperative neurosurgical care in the Gambia. METHODS: A prospective, single-arm implementation study was conducted at the Edward Francis Small Teaching Hospital. A convenience sample of 4 medical officers (MOs) and 5 nurses assigned to the neurosurgical service participated. A prompted GPT-4o Turbo was deployed on OpenAI Pro accounts to support performance. Usability, helpfulness, and safety were the primary outcomes. Cost-effectiveness was a secondary outcome. RESULTS: Participants completed 75 LLM-assisted interactions on 9 postoperative neurosurgery patients. Usability metrics indicated a moderately high cognitive workload, marginally acceptable usability of the LLM system, and high perceived ease of use. Management plan quality improved in 45 of 75 mock rounds interactions (60%), with a mean improvement of 8.5% (P < .001) on mock rounds scoring rubrics. The improvement was greater for MOs (21.0% change) than nurses (6.5% change). In hypothetical case dilemmas, MO plan accuracy improved by 22.7% (P = .001), and critical errors declined from 33.3% to 0%. Fourteen care changes for 9 patients were attributed to LLM suggestions, including 6 that potentially prevented major morbidity. No unsafe outputs were detected. Exploratory cost analysis suggested potential savings from clinical care changes exceeded the labor costs involved in LLM use. CONCLUSION: LLM use was associated with improved plan quality without observed safety concerns, while also prompting clinically meaningful care changes. Larger, controlled studies are needed to determine generalizability, durability of benefit, and patient-centered outcomes.