This Week in Neurosurgery — Jul 2, 2026

Welcome to This Week in Neurosurgery. This week we're covering 10 notable papers spanning motion preservation in spine surgery, advanced intraoperative mapping and oncology, and critical updates in vascular and skull base interventions. Let's dive in.

We begin with a major focus on spine surgery, where several new studies this week evaluate the long-term comparative durability of motion-preserving technologies against traditional fusion techniques in both the lumbar and cervical spine. In the lumbar spine, the optimal surgical treatment for stenosis with degenerative spondylolisthesis has long been debated. To address this, VanHorn and colleagues published the three-year results of the Total Posterior Spine System, or TOPS, investigational device exemption trial in Neurosurgical Focus [1]. This randomized, controlled, multicenter trial enrolled 321 patients across 37 sites, randomizing them in a two-to-one ratio to either decompression with TOPS facet arthroplasty or decompression plus open interbody fusion. Eligible patients were between 35 and 80 years old, had failed at least six months of nonsurgical treatment, and suffered from significant disability and leg pain. At the three-year mark, 179 patients in the arthroplasty group and 74 in the fusion group were analyzed. The primary composite clinical success score—which required no reoperations or injections, no major device-related adverse events, a substantial improvement in the Oswestry Disability Index, and no new neurological deficits—was achieved by 76 percent of the arthroplasty group compared to just under 57 percent of the fusion group. Furthermore, the rate of reoperation or lumbar injection was significantly lower for those receiving arthroplasty, at 14 percent compared to 25 percent in the fusion cohort. Arthroplasty also yielded a higher rate of clinically meaningful back pain reduction, with 85 percent of patients reaching the minimal clinically important difference compared to 72 percent in the fusion group. Although long-term follow-up remains essential, these findings suggest that posterior lumbar facet arthroplasty offers superior clinical outcomes and a lower rate of secondary interventions compared to traditional fusion.

This theme of motion preservation is further explored in a systematic review and meta-analysis of lumbar total disc replacement versus interbody fusion for degenerative disc disease, also published in Neurosurgical Focus by Patel and colleagues [2]. Pooling data from 13 randomized controlled trials encompassing over 2,300 patients with a mean follow-up of 44 months, the investigators found that total disc replacement was associated with a significantly lower risk of overall complications, at 31 percent compared to 35 percent for fusion, and a near-halving of the reoperation risk. This reduction in revisions was primarily driven by a lower risk of adjacent segment disease—which fell from over eight percent with fusion to under four percent with disc replacement—and a dramatic reduction in pseudarthrosis. While functional pain and disability scores were superior in the disc replacement group during early and intermediate follow-up, these outcomes converged with fusion by five years. However, patient satisfaction remained high, and those undergoing disc replacement had a significantly lower rate of long-term narcotic use, at 39 percent compared to 56 percent in the fusion group. Ultimately, the principal advantage of lumbar total disc replacement appears to be its mechanical durability and reduced revision burden rather than a permanent superiority in functional scores.

Moving cranially, three papers in Neurosurgical Focus address motion preservation in the cervical spine. First, Sulman and colleagues [3] conducted a comprehensive, level-matched meta-analysis of FDA investigational device exemption studies and international randomized trials with over five years of follow-up. By separating one-level and two-level procedures to avoid cohort duplication and non-level-matched pooling, they analyzed 16 high-quality studies. For one-level procedures, cervical disc arthroplasty was associated with a 55 percent lower odds of reoperation for adjacent segment disease compared to anterior cervical discectomy and fusion, or ACDF. For contiguous two-level procedures, arthroplasty reduced the odds of adjacent segment reoperation by 49 percent. All-cause reoperations were similarly reduced by 42 percent in one-level arthroplasties and by 52 percent in two-level arthroplasties over a mean follow-up of seven years.

These meta-analytic findings are strongly supported by a large-scale, real-world analysis by Sbaih and colleagues [5], who utilized the TriNetX database to compare cervical disc replacement and ACDF using propensity score matching. They identified over 9,400 matched pairs of adult patients undergoing surgery for degenerative indications. At all follow-up intervals ranging from six months to five years, patients who underwent cervical disc replacement had a 38 percent lower risk of requiring an anterior reoperation and a 36 percent lower risk of developing new-onset cervical pain. Furthermore, the disc replacement group demonstrated a 38 percent lower risk of surgical site infections at the one-, two-, and five-year marks, and a 34 percent lower risk of long-term opioid use at five years. While the authors caution that retrospective electronic health record analyses have inherent limitations, these results reinforce that motion preservation is a highly viable alternative to fusion that reduces adjacent segment pathology and long-term morbidity.

To better understand the nuances within cervical arthroplasty itself, Moller and colleagues [8] analyzed national spine registry data to compare reoperation risks between 650 patients who underwent a primary one-level cervical disc arthroplasty and 159 patients who underwent a contiguous two-level arthroplasty. Over a mean follow-up of several years, they found no statistical difference in all-cause reoperation rates between the two cohorts. Interestingly, the five-year incidence of reoperations for adjacent segment disease was significantly higher in the one-level group, at nearly five percent, compared to just over one percent in the two-level group. The authors suggest this unexpected finding might stem from surgeon selection bias, where an adjacent, mildly degenerative level is left untreated during single-level procedures under the assumption that motion preservation will protect it, or it may simply reflect the natural history of cervical spondylosis. Regardless, this registry-based study is the first large, real-world analysis outside of highly controlled clinical trials to demonstrate equivalent all-cause revision rates between one-level and two-level cervical arthroplasty.

Turning our attention to neuro-oncology and intraoperative mapping, we highlight three studies addressing pediatric immunotherapy, spinal malignancies, and the biological factors influencing subcortical motor mapping. In Nature Medicine, Gomez and colleagues [7] published the results of the ReMIND trial, an open-label, phase one adaptive dose-finding study evaluating autologous, systemically administered trivalent T cells targeting three tumor-associated antigens: WT1, PRAME, and survivin. This study enrolled pediatric patients with newly diagnosed diffuse intrinsic pontine glioma or relapsed non-brainstem central nervous system malignancies. While the therapy was generally well tolerated, two patients experienced tumor swelling, and one patient with diffuse intrinsic pontine glioma suffered a fatal dose-limiting toxicity involving hydrocephalus, tumor edema, and respiratory failure. Although the primary endpoints were safety and feasibility, encouraging preliminary efficacy signals were observed. Three patients with relapsed malignancies remain alive without disease at 31, 41, and 51 months post-infusion, including one patient who achieved a complete response.

For primary spinal osteosarcoma, a rare and highly morbid malignancy that frequently involves critical neurovascular structures, Khalilullah and colleagues [9] conducted a multivariable analysis using the National Cancer Database from 2004 to 2023. Among 899 surgically treated patients, 76 percent received perioperative chemotherapy. While the addition of chemotherapy was associated with superior early survival on unadjusted analysis—particularly in high-grade tumors—this survival advantage was attenuated after adjusting for baseline characteristics. Notably, in low-grade osteosarcomas, the combination of surgery and chemotherapy was associated with lower mortality in multivariable models. The authors suggest that while chemotherapy remains critical in high-grade spinal osteosarcoma, its role in low-grade disease, where toxicity may outweigh the benefit, warrants further investigation and careful patient selection.

In Operative Neurosurgery, Berger and colleagues [10] evaluated how tumor biology influences intraoperative electrophysiological mapping during the resection of intra-axial tumors adjacent to the corticospinal tract. Analyzing 187 patients who achieved a gross total resection, they compared continuous dynamic stimulation via a cavitron ultrasonic surgical aspirator, or CUSA, with traditional stationary ball-tip stimulation. While both stimulation techniques demonstrated comparable distance-to-threshold behavior, the correlation between preoperative tumor-to-tract distance and intraoperative motor-evoked potential thresholds was significantly modified by isocitrate dehydrogenase-1, or IDH1, mutation status. The correlation was much stronger in IDH1-mutant tumors than in IDH1-wildtype tumors. This suggests that distance-based subcortical mapping is highly reliable in IDH1-mutant gliomas, whereas the greater variability in IDH1-wildtype tumors likely reflects their susceptibility to intraoperative brain shift and different biological characteristics, reinforcing the need for continuous, real-time electrophysiological feedback.

Finally, we review critical updates in vascular and skull base neurosurgery, focusing on antiplatelet management after flow diversion and optimal techniques for dural closure. In Neurosurgery, Cuoco and colleagues [4] address the ongoing debate regarding the duration of dual antiplatelet therapy, or DAPT, after Pipeline Embolization Device treatment for intracranial aneurysms. In a retrospective cohort study of 257 patients, they compared an early termination group of 155 patients who received three months of DAPT against a standard group of 102 patients who received six months or more of DAPT. Following DAPT discontinuation, total complications were significantly lower in the three-month early termination cohort at roughly one percent compared to nearly ten percent in the standard cohort, driven primarily by a reduction in minor thromboembolic events. Furthermore, the complete aneurysm occlusion rate at six months was significantly higher in the three-month cohort, at 83 percent compared to 71 percent in the standard group, suggesting that a shorter three-month course of DAPT is safe and does not compromise efficacy.

To prevent cerebrospinal fluid leaks after craniotomy, Yu and colleagues [6] published a Bayesian network meta-analysis in Acta Neurochirurgica comparing various dural sealants across 11 randomized controlled trials involving over 3,000 patients. Compared with conventional dural closure alone, TissuePatchDural, autologous materials, and synthetic hydrogels all significantly reduced the risk of postoperative cerebrospinal fluid leaks. TissuePatchDural demonstrated the highest probability of preventing leaks, with a SUCRA value of 90.5 percent, while autologous materials showed a favorable probability for preventing postoperative meningitis.

If you only have time for one paper this week, make it the level-matched meta-analysis of cervical disc arthroplasty versus fusion by Sulman and colleagues in Neurosurgical Focus [3]. By rigorously separating one-level and two-level procedures and pooling long-term data over seven years, this study provides the clearest evidence yet that cervical arthroplasty cuts long-term reoperation risks for adjacent segment disease and all-cause revisions by roughly half compared to standard fusion.

Here are the key takeaways from this week in Neurosurgery.

First, in both the cervical and lumbar spine, motion-preserving arthroplasty consistently reduces long-term reoperation rates and adjacent segment disease compared to fusion, while showing comparable or superior functional outcomes.

Second, a three-month course of dual antiplatelet therapy after Pipeline embolization of intracranial aneurysms is safe, reduces minor complications, and does not compromise long-term occlusion rates compared to a six-month course.

Third, when performing dural closure after craniotomy, the use of TissuePatchDural or autologous materials significantly reduces the risk of cerebrospinal fluid leaks and postoperative meningitis compared to conventional closure alone.

Fourth, subcortical motor mapping thresholds are significantly more reliable and predictable in IDH1-mutant gliomas than in IDH1-wildtype tumors, highlighting the need for real-time electrophysiological monitoring to account for brain shift and biological variability in wildtype cases.

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.