This Week in Neurosurgery — Sep 30, 2026

This AudioScholar briefing is generated by artificial intelligence for healthcare professionals and trainees. It is not medical advice.

Welcome to This Week in Neurosurgery. This week we're covering 10 notable papers spanning degenerative cervical spine surgery, infection and thromboprophylaxis in neurosurgical and neurocritical care, cerebrovascular disease from aneurysm prevalence to moyamoya revascularisation, and a couple of practical advances in skull base surgery and bedside diagnostics. Let's dive in.

We start with the cervical spine, where two papers approach the same clinical decision from different angles. In World Neurosurgery, Farahbakhsh and colleagues pooled 52 studies comparing anterior with posterior surgery for degenerative cervical myelopathy, excluding ossification of the posterior longitudinal ligament, covering more than 22,000 anterior and nearly 20,000 posterior procedures [1]. The headline is that functional recovery was essentially a wash. Neck Disability Index and modified Japanese Orthopaedic Association scores differed between approaches by margins well below the accepted minimal clinically important difference at every time point out to beyond a year. What separated the approaches was the complication and radiographic profile. Anterior surgery was associated with roughly two thirds lower odds of C5 palsy in multilevel cases, similarly lower odds of persistent neck pain and of infection, about half the odds of thrombotic complications, and about 90 millilitres less blood loss, along with roughly six degrees more lordotic correction. The trade-off was dysphagia, where anterior surgery carried close to four times the odds. The authors grade the certainty of evidence as low, so this is best read as a framework for counselling patients about distinct risk profiles rather than evidence that one approach is superior.

That matters alongside a study in Neurosurgery from Lee and colleagues, who asked whether preoperative cervical kyphosis is truly a fixed deformity and therefore a reason to avoid laminoplasty [2]. They reviewed 850 consecutive laminoplasty patients with serial standing neutral, flexion and extension radiographs out to five years. Across the whole cohort the neutral alignment was remarkably stable, with no significant change immediately after surgery or at five years. But in the small kyphotic subgroup, just 32 patients, alignment shifted significantly towards lordosis within the first month after decompression and held that correction out to five years. Patients with ossification of the posterior longitudinal ligament had consistently less range of motion but followed the same longitudinal pattern. The authors conclude that mild neutral-position kyphosis may represent a reversible compensatory posture rather than a structural deformity, which would widen the candidate pool for posterior decompression. It is retrospective, single-centre, and the kyphotic subgroup is small, so it reopens the selection question rather than settling it.

Three papers this week converge on perioperative complications, and particularly on infection. In World Neurosurgery, Yang and colleagues used propensity score matching on nearly 900 patients with external ventricular drains to ask what concurrent lumbar spinal drainage adds [4]. After matching 267 pairs, concurrent lumbar drainage was independently associated with roughly four times the odds of postoperative intracranial infection, a finding that held across every sensitivity analysis they ran. The secondary outcomes moved in the same direction, with about twice the odds of pulmonary infection, around five times the odds of bacteraemia, more reoperations, and a median intensive care stay three days longer. It is observational, so indication bias is impossible to exclude, but the consistency is hard to ignore and the authors argue for tighter adherence to indications and closer surveillance when both drains are in place. That sits well beside a meta-analysis from Lu and colleagues, also in World Neurosurgery, pooling 16 studies and more than 100,000 patients with traumatic brain injury [6]. The pooled incidence of intracranial infection was about 13 percent overall and rose to roughly 19 percent among those undergoing neurosurgical intervention. The risk factors are the ones most of us would predict but now have pooled weight behind them, including cerebrospinal fluid leak, open injury, skull base and frontal fractures, external ventricular drain insertion, intracranial pressure monitoring, posterior fossa surgery, operative time of four hours or more, and sepsis. The quality of the underlying observational literature limits how firmly any single factor can be weighted.

Staying with perioperative risk, Acta Neurochirurgica reports a natural experiment from Ritter and colleagues, who compared outcomes across nearly 4,900 neurosurgical patients before and after a hospital-wide switch from enoxaparin to tinzaparin for venous thromboembolism prophylaxis [3]. Overall event rates were low, around one percent, and postoperative rebleeding requiring evacuation did not differ between the agents. In the moderate-to-high risk stratum, venous thromboembolism occurred about twice as often with tinzaparin, driven almost entirely by pulmonary embolism rather than deep vein thrombosis. The authors are careful with their own result, noting that the rise coincided with increased CT angiography use and showed no clean temporal step change at the switch, so detection bias is a live explanation. They explicitly frame this as hypothesis-generating rather than as evidence that either agent is superior.

On the cerebrovascular side, three papers address very different points on the disease course. Kobata and colleagues in World Neurosurgery revisited rebleeding after subarachnoid haemorrhage in 940 consecutive patients, most of them poor grade, across more than two decades [5]. Rebleeding occurred in just under a quarter of patients, peaked immediately after ictus and then fell exponentially, with roughly half of episodes happening before hospital arrival. Systolic pressure on arrival was substantially higher in those who rebled, with a median around 178 compared with about 148 millimetres of mercury. When they split patients into 20 millimetre increments, rebleeding rose in the group above 180, while mortality was highest in those at or below 100, and the band between about 100 and 160 was associated with the most favourable outcomes. This is observational and pressure may be marking severity as much as causing rebleeding, but it adds granularity to where a target range might reasonably sit.

Further upstream, Zhang and colleagues screened more than 4,700 community-dwelling adults aged 35 to 75 in Beijing with magnetic resonance angiography and found an unruptured aneurysm prevalence of about nine percent [7]. Older age, female sex, hypertension and diabetes each raised the odds modestly, while a family history of aneurysm or subarachnoid haemorrhage roughly doubled them. Their clinical prediction nomogram discriminated well, but it is a single urban and suburban sample and the authors stress that external validation is required before anyone leans on it for screening decisions. And in a much smaller study, Khan and colleagues reviewed 24 adults undergoing moyamoya revascularisation across 39 procedures [10]. Neurological deficits occurred after about six in ten first-stage procedures, though most of those resolved before discharge, and the rate fell to about three in ten at the second stage. Neither surgical technique nor Suzuki stage predicted deficits. The strongest discriminators were anaesthesia duration beyond eight hours and lower preoperative haemoglobin, though neither reached significance on univariate testing and the model's discrimination was modest. With 24 patients, this is a signal to test prospectively, not a basis for changing perioperative protocols.

Two final papers offer practical tools. Zohney and colleagues in World Neurosurgery prospectively followed 32 patients undergoing revision endoscopic endonasal surgery for recurrent or residual pituitary neuroendocrine tumours [8]. Gross total resection was achieved in just under half, and the determinant was anatomy rather than the fact of recurrence itself. Tumour morphology, cavernous sinus invasion, size and extrasellar extension all tracked strongly with extent of resection, and their proposed MRI-based resectability score stratified accordingly, with over ninety percent gross total resection in the lowest class and none at all in the highest two. Visual improvement occurred in just over three quarters of patients with preoperative deficits, and intraoperative cerebrospinal fluid leak occurred in about a fifth. It is a small single-centre series and the authors say plainly that external validation is needed. Meanwhile in Neurosurgery, Sadeh and colleagues tested a rapid beta-2-transferrin lateral flow immunoassay across 399 assay runs using cerebrospinal fluid from external ventricular drains [9]. Raw cerebrospinal fluid tested positive in all 232 runs, dilutions down to one in a hundred remained positive, and there were no false positives among saline or non-cerebrospinal fluid drain controls. Median time to a positive result was around 14 minutes for undiluted fluid. This is a feasibility study in a clean sample set, and the real test will be messy rhinorrhoea, otorrhoea and wound drainage, which the authors acknowledge.

If you only have time for one paper this week, make it the anterior versus posterior meta-analysis in World Neurosurgery [1]. It settles, as far as low-certainty pooled observational data can, that the approach choice in non-ossification degenerative cervical myelopathy is not a question of functional recovery but of which complication profile a given patient can best tolerate.

Here is what this week's evidence adds up to in neurosurgery. First, in degenerative cervical myelopathy the pooled literature now points to equivalent functional outcomes between anterior and posterior surgery, with the real divergence in C5 palsy, infection and neck pain on one side and dysphagia on the other, though the certainty of that evidence is low. Second, a large longitudinal radiographic series suggests mild preoperative cervical kyphosis may be reversible after laminoplasty rather than fixed, which challenges a long-standing selection criterion on the strength of a 32-patient subgroup. Third, concurrent lumbar drainage alongside an external ventricular drain was associated with roughly quadrupled odds of intracranial infection in a matched cohort, consistent with pooled traumatic brain injury data identifying drains, leaks and long operations as key risks, but both are observational. Fourth, the tinzaparin signal in neurosurgical thromboprophylaxis is confounded by changing imaging practice and the authors themselves call it hypothesis-generating. And finally, the Beijing prevalence survey puts unruptured aneurysm prevalence at around nine percent in screened middle-aged and older adults, a figure with real implications for screening debates but one that needs replication outside a single city before it carries weight.

That's your roundup for This Week in Neurosurgery. The full transcript and references are available on the episode page in your AudioScholar library. This is an AI-curated summary — for clinical decisions, always consult primary sources and current guidelines. See you next week.

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This is an automated summary generated by artificial intelligence, which can make mistakes. Always review the original source materials.