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Expanding neurosurgery

The 2014 AANS Presidential Address

William T. Couldwell, Vance Mortimer and Kristin L. Kraus

The history of medicine is replete with innovations in neurosurgery that have spurred further developments across the medical spectrum. Surgeons treating pathologies in the head and spine have broken ground with new approaches, techniques, and technologies since ancient times. Neurosurgeons occupy a vital nexus in patient care, interfacing with the clinical symptoms and signs afflicting patients, the pathology at surgery, and imaging studies. No other physicians occupy this role within the nervous system. This power of observation and the ability to intercede place neurosurgeons in a unique position for impacting disease. Yet despite these pioneering achievements, more recently, forces in the workplace may be challenging neurosurgery's opportunities to contribute to the future growth of the neurosciences and medicine. The authors posit that, in the current health care climate, revenue generation by neurosurgical clinical activity is valued by the system more than neurosurgical research and academic output. Without providing the talented stream of new neurosurgeons with the opportunities and, in fact, the directive to achieve beyond simple financial success, the specialty is missing the opportunity to optimize its progress. The authors contend that the key to remaining relevant with the incorporation of new technologies to the treatment of neurosurgical patients will be to be flexible, open-minded, and nimble with the adaptation of new procedures by training and encouraging neurosurgical residents to pursue new or neglected areas of the specialty. Only by doing so can neurosurgery continue to expand.

Free access

Silvia Gesheva, William T. Couldwell, Vance Mortimer, Philipp Taussky and Ramesh Grandhi

Dural arteriovenous fistulae (dAVFs) are vascular anomalies formed by abnormal connections between branches of dural arteries and dural veins or dural venous sinus(es). These pathologic shunts constitute 10%–15% of all intracranial arteriovenous malformations. The hallmark of malignant dAVFs is the presence of cortical venous drainage, a finding that increases the likelihood of nonhemorrhagic neurologic deficit, intracranial hemorrhage, and mortality if left unaddressed. Endovascular approaches have become the primary modality for the treatment of dAVFs. The authors present a case of staged endovascular transarterial embolization of a malignant dAVF running parallel to the left transverse sinus in a patient with headaches and pulsatile tinnitus. The fistula was completely treated using Onyx and n-butyl cyanoacrylate.

The video can be found here:

Open access

Christopher Wilkerson, Vance Mortimer, Andrew T. Dailey and Marcus D. Mazur

Spinal instability may arise as a consequence of decompressive lumbar surgery. An oblique lumbar interbody fusion combined with pedicle screw fixation can provide indirect decompression on neural elements, stabilization of mobile spondylolisthesis, and restoration of segmental lordosis. Minimally invasive techniques may facilitate a shorter hospitalization and faster recovery than a traditional open revision operation. The authors describe the use of an anterior interbody fusion via an oblique retroperitoneal approach and posterior pedicle screw fixation to treat a 67-year-old woman who developed L3–4 and L4–5 unstable spondylolisthesis after a lumbar laminectomy.

The video can be found here:

Free access

Michael Karsy, Daxa M. Patel, Kyle Halvorson, Vance Mortimer and Robert J. Bollo

Anterior two-thirds corpus callosotomy is a common palliative surgical intervention most commonly employed in patients with atonic or drop seizures. Recently, stereotactic laser ablation of the corpus callosum without a craniotomy has shown promise in achieving similar outcomes with fewer side effects and shorter hospitalizations. The authors demonstrate ablation of the anterior two-thirds corpus callosum in a patient with Lennox-Gastaut syndrome and drug-resistant drop seizures. Technical nuances of laser ablation with 3 laser fibers are described. Postoperatively, the patient showed a significant reduction in seizure frequency and severity over a 9-month follow-up period.

The video can be found here: