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Background: Distal obstruction of ventriculoperitoneal (VP) shunts is a major problem in the treatment of hydrocephalus. To avoid this complication, we describe a simple method using the falciform ligament to place and hold the distal catheter in the right subdiaphragmatic space, preventing catheter migration and distal obstruction., Materials and Methods: We retrospectively collected data of all VP shunt insertion and revision for adults with idiopathic normal-pressure hydrocephalus between November 2011 and September 2013. All of these were done using the "falciform technique," with the distal catheter portion performed laparoscopically. No exclusion criteria were applied. A neurosurgeon and a laparoscopic surgeon were involved in each case. The falciform ligament was used to tether the distal catheter above the liver, with the distal tip of the catheter reaching the hepatic flexure to allow for drainage directly into the right paracolic gutter. Baseline, operative, and postoperative data were collected and analyzed., Results: In total, 58 patients underwent a shunt procedure during the period of study. The majority (74%) underwent new VP shunt placement, and 26% underwent revision and replacement for catheter obstruction. The female to male ratio was 1.14:1. Mean age was 67.3±17.5 years. Revisions due to distal catheter obstruction were subsequent to previous surgery placement. Median follow-up was 329 days. Three patients (5%) had proximal catheter obstruction requiring shunt revision. None of the patients (0%) was found to have distal obstruction at the end of the study period at the most recent follow-up., Conclusions: The faparoscopic falciform technique significantly reduces the rate of distal VP shunt obstruction in adults with idiopathic normal-pressure hydrocephalus. Continued follow-up is needed to confirm long-term patency of the catheter.

We present a unique application of the gold fiducial as a preoperative, radiographic marker placed in the thoracic spine and used for intraoperative localization. In comparison to percutaneous vertebroplasty marking of thoracic spinal levels with polymethyl methacrylate (PMMA) cement, implantation of the gold fiducial is technically facile with a minimal learning curve. The fiducial markers are also associated with significantly less financial resources. Following 2013 Current Procedural Terminology (CPT) coding, the cost of vertebroplasty under fluoroscopic guidance, $3195·43, or under computed tomography (CT) guidance, $3232·54, is more than double the cost of the gold fiducial implantation - $1237·55 and $1267·03, under similar imaging techniques, respectively. In the first description of gold fiducials in the thoracic spine, we conclude that the marker is a safe and cost-effective method for preoperative localization of the thoracic levels.

Stereotactic radiosurgery is a modern addition to the armamentarium of treatment options for intracranial and extracranial lesions. It is increasingly being used as an adjuvant to surgery, conventional radiation therapy, and chemotherapy as well as being used as primary treatment. Since the introduction of the Gamma Knife (Elekta, Stockholm, Sweden) system, many more stereotactic radiosurgery machines have become available. The objective of this review is to compare and contrast the various currently available stereotactic radiosurgery platforms.

Although the definitive treatment for neuropathic pain remains elusive, scientific investigation continues to provide the field with better and better therapies. As our understanding of the neurophysiologic mechanisms of pain improves, pharmaceutic therapies have become more effective even as side effects are minimized. Surgical therapies have become more precise and less invasive. Advances in neurophysiology have given rise to new advances in the field of neuro-modulation. As this therapy continues to emerge, ablative procedures recede as therapies offering minimal invasiveness, reversible mechanisms, and long-standing relief emerge to the forefront of treatment for neuropathic pain.

Objective: To determine the kinetics of blood clot resolution in human cerebrospinal fluid., Methods: Computed tomographic scans of 17 adult patients with intraventricular hemorrhages were analyzed. Intraventricular clot volume was determined and analyzed over time to determine both a standardized percentage rate and an absolute rate of clot resolution. Results were analyzed by use of regression for cross sectional time-series data. To determine the kinetics of intraventricular clot resolution, the effect of the clot volume on the percentage rate of clot resolution, clot half-life, and absolute rate of clot resolution was analyzed. The potential effect of age, sex, type of hemorrhage, and treatment with external ventricular drainage on the percentage rate of clot resolution was assessed., Results: The percentage rate of clot resolution was 10.8% per day (95% confidence interval, 9.05-12.61 %), and it was independent of initial clot volume, age, sex, type of underlying hemorrhage, and use of external ventricular drainage. The absolute rate of clot resolution varied directly with the maximal clot volume (R2 = 0.88; P < 0.001). The percentage clot resolution data are consistent with events during the first 24 to 48 hours that antagonize clot resolution., Conclusion: These findings demonstrate that intraventricular blood clot resolution in patients with intraventricular hemorrhage follows first-order kinetics. The thrombolytic enzyme system responsible for intraventricular clot resolution seems to be saturated at 24 to 48 hours after the initial hemorrhage.

The nineteenth century witnessed significant discoveries in the understanding of the peripheral nerve response to injury. Unfortunately, these discoveries were not widely accepted and several physiologically implausible nerve repair procedures survived into the first decades of the twentieth century. The surgical experience in World War I winnowed out most of these unsound techniques and laid the foundations for modern direct nerve repair. The surgical experience of World War II led to a rational classification of nerve injuries and refined the timing for surgical intervention. Major postwar developments that led to the modern era include improved nerve grafting techniques, intraoperative nerve action potential recording, and strategies for the repair of brachial plexus lesions.

This report describes the case of a woman in whom multiple compression fractures of the lower thoracic and lumbar spine occurred in association with long-term corticosteroid therapy for systemic lupus erythematosus. Pain markedly limited the patient's mobility and daily activities, and conservative therapy with bracing and narcotic analgesics gave little improvement. Affected vertebrae were treated with polymethylmethacrylate, introduced percutaneously under fluoroscopic guidance. The resulting reinforcement of the fractured vertebral bodies eliminated the pain and the need for narcotic analgesics. The utilization of percutaneous verterbroplasty as a therapeutic alternative for the treatment of pain resulting from osteoporotic compression fractures is described.

Intraventricular hemorrhage (IVH) frequently occurs in the setting of intracerebral and subarachnoid hemorrhage, and is an independent and significant contributor to morbidity and mortality in both conditions. Present therapy of IVH is directed at treating the associated complications of obstructive and communicating hydrocephalus. These therapies are often inadequate to treat the complications and do not remedy the underlying IVH. Intraventricular thrombolysis is a promising but unproven new therapy that directly addresses the IVH and may reduce the incidence of obstructive and communicating hydrocephalus.

Neurosurgeons have for the most part abdicated a role in thoracic outlet surgery and have left the diagnosis and treatment of these patients to thoracic, vascular, and general surgeons. We view this as unfortunate. Neurosurgeons are well-positioned to diagnose these conditions. The major source of confusion with regard to diagnosis is cervical spine disease or peripheral nerve entrapment diseases with which neurosurgeons are quite familiar. Orthopedic consultations with regard to shoulder pathology are encouraged. The supraclavicular approach to treatment is one with which most neurosurgeons will be comfortable. However, the transaxillary approach is also one which neurosurgeons should be able to master readily. Working with long instruments in deep holes is a familiar surgical environment. It should be stressed, however, that part of the reason for the controversy concerning TOS stems from the fact that the morbidity rate from the transaxillary approach is high in some centers. We believe this results from inadequate technique. Neurosurgeons with training that emphasizes a high regard for neural tissue should be able to master both approaches. Thoracic outlet syndrome is a disease that most neurosurgeons will see on a regular basis. Thus, it needs to be recognized, and patients need to be analyzed from a neurologic perspective. The differential diagnosis should be considered thoughtfully. Operative intervention by experienced surgeons in properly selected patients will yield satisfying results.