This week in Neurosurgery

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Welcome to This Week in Neurosurgery. This week we're covering 10 notable papers spanning who really benefits from cranial surgery, refinements in deep brain stimulation, and the economics and risks of spine surgery, along with a look at shunts and intrasaccular devices. Let's dive in.

Our first theme is patient selection: three observational studies ask which patients gain most from an operation, and the answers are more nuanced than a single imaging threshold. In Neurosurgery, Shibahashi and colleagues analysed the Japan Trauma Data Bank, looking at just over eighteen hundred adults with large supratentorial acute subdural hematomas, over fifty cubic centimetres and more than a centimetre thick, who arrived with a Glasgow Coma Scale score between 6 and 15 [1]. The cohort was old, with a median age of 79, and craniotomy rates varied enormously between hospitals, from none at all to over 80 percent. After propensity matching, patients who had a craniotomy were substantially more likely to survive to discharge, with an absolute gain of about fifteen percentage points, but there was no difference in favourable neurological outcome at discharge, which stayed under a fifth in both groups. The survival benefit concentrated in patients aged 65 and older and in those with a coma score of 6 to 12, while patients scoring 13 to 15 showed no apparent survival gain. The authors argue that thickness alone is a poor trigger and that age and neurological severity belong in the decision. This is registry data, so unmeasured confounding remains, and the trade of more survivors without more good functional outcomes is a question families and surgeons will weigh differently. Also in Neurosurgery, Chung and colleagues used the TriNetX network to study Cushing's disease [2]. Patients with Cushing's had roughly double the risk of cerebrovascular disease compared with matched controls, including more than twice the risk of ischaemic stroke. Among patients with Cushing's, pituitary adenoma excision was associated with about a third less cerebrovascular disease, half the ischaemic stroke risk, and roughly half the mortality, with around one stroke-related event avoided for every 26 patients treated. Sensitivity analyses comparing curative and noncurative resection trended the same way but were not statistically significant, which tempers any claim that biochemical remission drives the benefit. Rounding out the theme, Marincovich and colleagues, again in Neurosurgery, reviewed 290 patients with type 1 trigeminal neuralgia treated with microvascular decompression or radiosurgery over more than two decades at one centre [3]. Decompression patients were younger and, after adjustment, had better initial pain relief, about a third the recurrence rate, far less numbness, and a much larger drop in medication use. The price was a complication rate of about 14 percent, mostly minor, against no complications with radiosurgery. Preoperative imaging of neurovascular conflict predicted lower recurrence after decompression. As a single-centre retrospective series with a large age gap between groups, it supports rather than settles the familiar view of decompression for fit patients and radiosurgery as the noninvasive alternative.

Our second theme is deep brain stimulation, where two studies examine the logistics of implantation. In the Journal of Neurosurgery, Uppalapati and colleagues compared a same-day, low-amplitude activation protocol at the time of generator implantation with their historical pathway of waiting for an outpatient programming visit, across 561 consecutive, predominantly unilateral procedures [4]. The no-stimulation gap shrank from a median of about two and a half weeks to essentially zero. Immediate activation met the noninferiority criterion for six-month adverse events, and unadjusted event rates were strikingly lower, about 4 percent versus about 20 percent. Settings also proved more durable, with just over three quarters of immediate-activation patients keeping their initial programming at six months versus just over half of delayed patients. The authors are careful to note that this does not establish the safety of full therapeutic activation or any motor benefit, that bilateral cases had more short-term speech and confusion events, and that historical controls invite era effects. In Neurosurgical Focus, Ponce and colleagues reported a prospective multicentre single-arm study of 60 patients implanted with a new floor-mounted robotic navigation system [5]. Mean tip error was under a millimetre, there were no complications or returns to theatre, and operative time and length of stay were in line with published series. Without a comparator arm and with a modest sample, it shows feasibility and accuracy rather than superiority over frame-based stereotaxy.

Our third theme is spine surgery, viewed through cost, consent, and a new class of drugs. In Neurosurgery, Whitmore and colleagues performed an economic evaluation of the randomised Cervical Spondylotic Myelopathy Surgical Trial, covering 144 United States patients with one-year cost data [6]. Posterior decompression and fusion was the most expensive option, with total societal costs around 62 thousand dollars, versus about 53 thousand for anterior fusion and about 47 thousand for laminoplasty. Laminoplasty also produced the largest quality-of-life gains, clearly better than posterior fusion and numerically better than anterior surgery, and at a willingness-to-pay of 150 thousand dollars per quality-adjusted life-year it was almost certainly cost-effective against both. Caveats include a one-year horizon, an as-treated analysis, and the fact that the choice between laminoplasty and posterior fusion was left to the surgeon rather than randomised. In the Journal of Clinical Neuroscience, Ghodke and colleagues pooled nineteen series of irrigated uniportal and biportal endoscopic lumbar surgery covering nearly seven thousand operations [7]. Recognised dural tears occurred in close to 3 percent of operations overall, but in about one in a hundred disc herniation cases versus about one in twenty stenosis decompressions, a roughly four-and-a-half-fold difference in odds. Uniportal and biportal techniques did not differ significantly, at very low certainty, and conversion and delayed fistula were uncommon. The authors frame those figures as a reasonable basis for consent, while stressing wide heterogeneity between series. Finally, a scoping review in World Neurosurgery by Diamandi and colleagues mapped 48 studies of GLP-1 receptor agonists across neurosurgery [8]. Nine in ten of those studies were retrospective and only five were randomised. Signals were most consistent for lower pseudarthrosis after spinal fusion and for idiopathic intracranial hypertension, with less papilledema, fewer leaks and fewer shunts, though some spine studies reported more postoperative complications and overlapping database cohorts limit causal inference. For now this is hypothesis-generating evidence.

Our last theme covers devices and teams in hydrocephalus and aneurysm care. In the Journal of Neurosurgery, Perez-Chadid and colleagues used TriNetX to match about nine thousand patients whose first ventriculoperitoneal shunt included a same-day general surgery abdominal procedure against the same number of neurosurgery-only cases [9]. General surgery involvement was associated with fewer reoperations at 90 days, about 2.7 versus 4.6 percent, fewer mechanical complications, and half as many conversions to alternative diversion, with no difference in mortality, infection, or seizures. Coding-based identification of what the general surgeon actually did is a real limitation, and the authors stop at supporting consideration of a multidisciplinary approach. In Neurosurgery, Griessenauer and colleagues compared the Woven Endobridge and the Contour device using two registries, with propensity matching [10]. Complete and adequate occlusion, functional outcome, retreatment, and thromboembolic complications did not differ significantly, although the Contour group was smaller and most aneurysms were small and unruptured, so equivalence in ruptured or complex lesions remains untested.

If you only have time for one paper this week, make it the Japanese acute subdural hematoma registry study in Neurosurgery [1]. It reopens a question many surgeons consider settled, suggesting that in an ageing population the survival benefit of craniotomy depends heavily on age and coma score, and that more survivors does not necessarily mean more good recoveries.

That's your roundup for This Week in Neurosurgery. The full transcript and references are available on the episode page. See you next week.

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