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Background: Steroids are used ubiquitously in the preoperative management of patients with brain tumor. The rate of improvement in focal deficits with steroids and the prognostic value of such a response are not known., Objective: To determine the rate at which focal neurological deficits respond to preoperative corticosteroids in patients with brain metastases and whether such an improvement could predict long-term recovery of neurological function after surgery., Methods: Patients with brain metastases and related deficits in language, visual field, or motor domains who received corticosteroids before surgery were identified. Characteristics between steroid responders and nonresponders were compared., Results: Ninety six patients demonstrated a visual field (13 patients), language (19), or motor (64) deficit and received dexamethasone in the week before surgery (average cumulative dose 43 mg; average duration 2.7 days). 38.5% of patients' deficits improved with steroids before surgery, while 82.3% of patients improved by follow-up. Motor deficits were more likely to improve both preoperatively ( P = .014) and postoperatively ( P = .010). All 37 responders remained improved at follow-up whereas 42 of 59 (71%) of nonresponders ultimately improved ( P < .001). All other clinical characteristics, including dose and duration, were similar between groups., Conclusion: A response to steroids before surgery is highly predictive of long-term improvement postoperatively in brain metastasis patients with focal neurological deficits. Lack of a response portends a somewhat less favorable prognosis. Duration and intensity of therapy do not seem to affect the likelihood of response., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Background: Managing cancer pain once it is refractory to conventional treatment continues to challenge caregivers committed to serving those who are suffering from a malignancy. Although neuromodulation has a role in the treatment of cancer pain for some patients, these therapies may not be suitable for all patients. Therefore, neuroablative procedures, which were once a mainstay in treating intractable cancer pain, are again on the rise. This guideline serves as a systematic review of the literature of the outcomes following neuroablative procedures., Objective: To establish clinical practice guidelines for the use of neuroablative procedures to treat patients with cancer pain., Methods: A systematic review of neuroablative procedures used to treat patients with cancer pain from 1980 to April 2019 was performed using the United States National Library of Medicine PubMed database, EMBASE, and Cochrane CENTRAL. After inclusion criteria were established, full text articles that met the inclusion criteria were reviewed by 2 members of the task force and the quality of the evidence was graded., Results: In total, 14 646 relevant abstracts were identified by the literature search, from which 189 met initial screening criteria. After full text review, 58 of the 189 articles were included and subdivided into 4 different clinical scenarios. These include unilateral somatic nociceptive/neuropathic body cancer pain, craniofacial cancer pain, midline subdiaphragmatic visceral cancer pain, and disseminated cancer pain. Class II and III evidence was available for these 4 clinical scenarios. Level III recommendations were developed for the use of neuroablative procedures to treat patients with cancer pain., Conclusion: Neuroablative procedures may be an option for treating patients with refractory cancer pain. Serious adverse events were reported in some studies, but were relatively uncommon. Improved imaging, refinements in technique and the availability of new lesioning modalities may minimize the risks of neuroablation even further.The full guidelines can be accessed at https://www.cns.org/guidelines/browse-guidelines-detail/guidelines-on-neuroablative-procedures-patients-wi., (Copyright © 2020 by the Congress of Neurological Surgeons.)

Background: Maximal safe resection remains a key principle in infiltrating glioma management. Stimulation mapping is a key adjunct for minimizing functional morbidity while "fence-post" procedures use catheters or dye to mark the tumor border at the start of the procedure prior to brain shift., Objective: To report a novel technique using stereotactically placed electrodes to guide tumor resection near critical descending subcortical fibers., Methods: Navigated electrodes were placed prior to tumor resection along the deep margin bordering presumed eloquent tracts. Stimulation was administered through these depth electrodes for subcortical motor and language mapping., Results: Twelve patients were included in this preliminary technical report. Seven patients (7/12, 58%) were in asleep cases, while the other 5 cases (5/12, 42%) were performed awake. Mapping of motor fibers was performed in 8 cases, and language mapping was done in 1 case. In 3 cases, both motor and language mapping were performed using the same depth electrode spanning corticospinal tract and the arcuate fasciculus., Conclusion: Stereotactic depth electrode placement coupled with stimulation mapping of white matter tracts can be used concomitantly to demarcate the border between deep tumor margins and eloquent brain, thus helping to maximize extent of resection while minimizing functional morbidity., (Copyright © 2020 by the Congress of Neurological Surgeons.)

Background: Attending surgeons have dual obligations to deliver high-quality health care and train residents. In modern healthcare, lean principles are increasingly applied to processes preceding and following surgery. However, surgeons have limited data regarding variability and waste during any given operation., Objective: To measure variability and waste during the following key functional neurosurgery procedures: retrosigmoid craniectomy (microvascular decompression [MVD] and internal neurolysis) and deep brain stimulation (DBS). Additionally, we correlate variability with residents' self-reported readiness for the surgical steps. The aim is to guide surgeons as they balance operative safety and efficiency with training obligations., Methods: For each operation (retrosigmoid craniectomy and DBS), a standard workflow, segmenting the operation into components, was defined. We observed a representative sample of operations, timing the components, with a focus on variability. To assess perceptions of safety and risk among surgeons of various training levels, a survey was administered. Survey results were correlated with operative variability, attempting to identify areas for increasing value without compromising trainee experience., Results: A sampling of each operation (n = 36) was observed during the study period. For MVD, craniectomy had the highest mean duration and standard deviation, whereas the MVD itself had the lowest mean duration and standard deviation. For DBS, the segments with largest standard deviation in duration were registration and electrode placement. For many steps of both procedures, there was a statistically significant relationship between increasing level of training and increasing perception of safety., Conclusion: This proof-of-concept study introduces an educational and process-improvement tool that can be used to aid surgeons in increasing the efficiency of patient care., (Copyright © 2019 by the Congress of Neurological Surgeons.)

Background: Infection is one of the most common complications of deep brain stimulation (DBS). Long-term infection rates beyond the immediate postoperative period are rarely evaluated., Objective: To study short- and long-term DBS-related infection rates; to evaluate any potential seasonality associated with DBS-related infections., Methods: We retrospectively reviewed all DBS surgeries performed in a 5-yr period at 1 hospital by a single surgeon. Infection rates and clinical characteristics were analyzed. Postoperative "infections" were defined as occurring within 6 mo of implantation of DBS hardware, while "erosions" were defined as transcutaneous exposure of hardware at ≥6 mo after implantation. Based on the date of surgery preceding an infection, rates of infection were calculated on a monthly and seasonal basis and compared using Chi square and logistic regression analyses., Results: A total of 443 patients underwent 592 operations; 311 patients underwent primary DBS placement with 632 electrodes. Primary DBS placement infection incidence was 2.6%. DBS procedure infection and infection rate by electrode were 2.9% and 3.2%, respectively. Infectious complications presented later than 6 mo postoperatively in 38% of infected patients Summer (July-September) infection rate was significantly higher than other seasons (P = .002). The odds ratio of an infection related to a surgery performed in August was found to be 4.15 compared to other months (P = .021)., Conclusion: There is a persistent risk of DBS infection and erosion beyond the first year of DBS implantation. Start of the academic year was associated with increased infection rate at our institution.

Background: Delivery of higher value healthcare is an ultimate government and public goal. Improving efficiency by standardization of surgical steps can improve patient outcomes, reduce costs, and lead to higher value healthcare. Lean principles and methodology have improved timeliness in perioperative medicine; however, process mapping of surgery itself has not been performed., Objective: To apply Plan/Do/Study/Act (PDSA) cycles methodology to lumbar posterior instrumented fusion (PIF) using lean principles to create a standard work flow, identify waste, remove intraoperative variability, and examine feasibility among pilot cases., Methods: Process maps for 5 PIF procedures were created by a PDSA cycle from 1 faculty neurosurgeon at 1 institution. Plan, modularize PIF into basic components; Do, map and time components; Study, analyze results; and Act, identify waste. Waste inventories, spaghetti diagrams, and chartings of time spent per step were created. Procedural steps were broadly defined in order to compare steps despite the variability in PIF and were analyzed with box and whisker plots to evaluate variability., Results: Temporal variabilities in duration of decompression vs closure and hardware vs closure were significantly different (P = .003). Variability in procedural step duration was smallest for closure and largest for exposure. Wastes including waiting and instrument defects accounted for 15% and 66% of all waste, respectively., Conclusion: This pilot series demonstrates that lean principles can standardize surgical workflows and identify waste. Though time and labor intensive, lean principles and PDSA methodology can be applied to operative steps, not just the perioperative period.

Background: Quality improvement projects increasingly emphasize standardization of surgical work flow to optimize operative room efficiency. Removing special cause variability resulting from nonsurgical waste is an obvious target; however, resident surgical education must be maintained, even in the setting of process improvement., Objective: To describe the impact of resident-identified "risky" or "uncomfortable" procedural steps on operative time during transforaminal lumbar interbody fusion (TLIF)., Methods: TLIF procedure steps were defined. An 8 2-part questions survey regarding comfort level and perceived risk assessment at each step was developed and completed by junior (17) and senior residents (10), and by faculty (6) from orthopedic, and neurological surgery. A risk matrix was constructed defining 2 zones: a "danger zone"; responses were high risk (3-5) and low comfort (1-3), and a "safe zone"; responses were low risk (1-2) and high comfort (4-5). One-tailed Chi-square with Yates correction was performed., Results: Risk matrix analysis showed a statistical difference among "danger zone" respondents between junior resident and faculty groups for exposure, pedicle screw placement, neural decompression, interbody placement, posterolateral fusion, and hemostasis. A radar graph identifies percent of respondents who fall within the "danger zone"., Conclusion: Resident perception of surgical complexity can be evaluated for procedural steps using a risk matrix survey. For TLIF, residents may assign more risk and may be less comfortable performing steps in a training-level-dependent manner. Identification of particular high-risk or uncomfortable steps should prompt strict faculty oversight to improve patient safety, monitor resident education, and reduce operative time., (Copyright © 2017 by the Congress of Neurological Surgeons)

Background: Anterior communicating artery (A-comm) aneurysm is one of the most common intracranial aneurysms. Treatments include neurosurgical clipping or endovascular embolization., Objective: To retrospectively examine the long-term results of Neuroform stent-assisted coil embolization of incidental A-comms, with a focus on stent-associated stenosis, long-term angiographic aneurysm occlusion outcome, delayed stent-related thromboembolus, subsequent subarachnoid hemorrhage from the treated aneurysm, and procedural complications., Methods: Between January 7, 2003 and June 16, 2009, 44 Neuroform stents were placed as an adjunct to embolization of A-comms. Patient charts were reviewed retrospectively. Angiographic follow-up of at least 3 months (up to 6.5 years, mean 65 weeks) was available for 33 patients. Aneurysm occlusion success was determined using the Raymond classification for aneurysm remnants., Results: Referencing the last angiogram in the follow-up course, complete occlusion, dog-ear residual, residual neck, and residual aneurysm were found in 24, 2, 3, and 4 patients, respectively. Stenosis (45% and asymptomatic) of the artery where the stent had been placed was found in 1 patient. One patient had delayed transient ischemic attack after dual antiplatelet therapy was stopped prematurely. Retreatment based on the presence of residual aneurysm was performed or recommended in 2 patients. In 2 patients with residual or recurrent aneurysm filling, their age or clinical condition did not warrant retreatment., Conclusion: Neuroform stent-assisted embolization provides long-term control of A-comms with a low incidence of aneurysm growth after treatment. The need for retreatment is uncommon, and retreatment is safe if performed. Subsequent bleeding from treated aneurysms was not observed in this study.

Objective: The author presents data to support the continued need for ablative procedures, particularly cordotomy, in the management of cancer-related pain., Methods: Fifty-one patients with cancer-related body or face pain were treated with computed tomography-guided radiofrequency ablation of the spinothalamic tract or trigeminal tract nucleus in the upper cervical region of the spinal cord. Forty-one patients underwent a unilateral cervical cordotomy, and 10 patients underwent a trigeminal tractotomy-nucleotomy. Three methods to assess patient pain were used: degree of pain relief, Visual Analog Scale, and total sleeping hours. The Karnofsky scale was used to measure the patient's level of function pre- and postprocedure., Results: After surgical intervention, patients reported initial and 6-months follow-up pain relief as 98 and 80%, respectively., Conclusion: Computed tomography-guided ablation of the upper cervical spinal cord is a safe and effective procedure to treat cancer pain involving the body or face. There remains a need for ablative procedures, in particular cordotomy, in the management of cancer-related pain.