Brandon Michael Edelbach

Spinal cord stimulation (SCS) is an established therapy for refractory back and leg pain, traditionally utilizing laminectomy-placed paddle leads or percutaneous cylindrical leads. Although percutaneous systems reduce soft tissue injury, they suffer higher migration rates and less precise dorsal column targeting. Minimally invasive surgical (MIS) techniques using tubular retractors combine the stability of paddle electrodes with reduced surgical trauma. Here, we describe a paramedian METRx tubular technique designed to minimize disruption of the posterior tension band while preserving paddle lead advantages. From January 2024 to April 2025, the senior author implanted paddle leads in 130 patients undergoing an SCS trial. Six patients (five men and one woman; mean age 67.7±6.4 years; mean BMI 34.9±4.7 kg/m²) underwent definitive paddle lead placement via a 3 cm paramedian incision and sequential dilation to a 22 mm METRx working channel. Neurosensory monitoring (somatosensory evoked potential (SSEP)/motor evoked potential (MEP)) was maintained throughout. Docking was performed at T7-T11 (four at T8-T9, one at T7-T8, and one at T10-T11). Under direct microscopic/endoscopic visualization, hemilaminectomy and flavectomy expose the dorsal epidural space. Boston Scientific paddle leads (Marlborough, Massachusetts, United States) were fluoroscopically confirmed, anchored to the interspinous ligament, tunneled subfascially to the gluteal pocket, and connected to an implantable pulse generator. All six paddle leads were successfully positioned without intraoperative complications. The mean estimated blood loss was 25 mL, and the mean operative time was 56.0±10.6 minutes. At the first postoperative follow-up (mean 2.9±3.1 months), no lead migrations, revisions, or infections were observed. The average Visual Analog Scale (VAS) pain score improved to 4.5±1.3. Importantly, with the paramedian approach, the midline supraspinous and interspinous ligaments were preserved, thereby reducing the osteoligamentous insult compared to midline or open microdissection techniques. The paramedian METRx tubular technique for paddle lead SCS placement is safe, efficient, and reproducible, with minimal blood loss and operative time. By sparing key posterior tension band structures, it may enhance postoperative recovery and preserve spinal stability. Prospective, controlled studies comparing paramedian versus midline MIS approaches are warranted to further elucidate clinical benefits and long-term outcomes.

Endoscopic spine surgery offers a minimally invasive alternative to traditional microsurgical techniques across a spectrum of pathologies, namely discectomy, interbody fusion, and laminectomy, by leveraging small incisions, reduced tissue disruption, and direct visualization. Endoscopic discectomy yields shorter operative times, lower infection rates, and comparable pain and functional outcomes versus open microdiscectomy. Similarly, endoscopic laminectomy for lumbar stenosis provides equivalent decompression with less postoperative pain and faster mobilization than microscopic or open approaches. In the realm of interbody fusion, endoscopic techniques (including transforaminal lumbar interbody fusion, lateral lumbar interbody fusion, and extreme lateral interbody fusion (XLIF) variants) achieve fusion rates and radiographic corrections on par with minimally invasive surgical (MIS) techniques, while further minimizing blood loss, length of stay, and anesthesia exposure. We present a 67-year-old male patient with prior T10-11 and T11-12 fusions, hemilaminectomies, and dorsal column stimulator hardware who developed adjacent-segment L3-4 stenosis. An endoscopic XLIF was performed under fluoroscopic and neuromonitoring guidance. The patient experienced an uncomplicated procedure with immediate preservation of neurologic function and postoperative imaging confirming ideal cage placement and alignment. Endoscopic spine surgery, exemplified by this XLIF case, combines the benefits of MIS with an expanded view of the surgical field. With proper patient selection and adherence to evolving technical guidelines, these techniques continue to offer promising outcomes, reinforcing their role as a transformative modality in modern spine surgery.

BACKGROUND AND OBJECTIVES: Despite a substantial body of literature describing the efficacy of revascularization compared with conventional management of moyamoya disease (MMD), the impact of the timing of revascularization relative to stroke onset remains inadequately characterized. The aim of this review was to synthesize existing research to guide clinicians in the optimal timing of revascularization in symptomatic MMD. METHODS: A comprehensive literature review was performed to identify studies reporting on timing of revascularization. Studies were divided into revascularization within 3 months of stroke, between 3 and 6 months of stroke, or >6 months from stroke event. RESULTS: A total of 3049 cases and 3151 treated cerebral hemispheres were included. There were 91 individuals (2.98%) in the 3 months to intervention cohort, 152 (4.92%) individuals in the 3 to 6 months to the intervention cohort, and 2806 (92.0%) individuals in the >6 months to the intervention cohort. The average follow-up time was 43.8 ± 35.19 months. Clinical improvement was reported in 83.4% of cases overall. The 3-to-6-month poststroke preoperative interval has the highest frequency of clinical improvement (90.2%), followed by the >6-month preoperative interval (83.4%). The preoperative interval of P = .013) and increased frequency of worse clinical outcome (Mean difference: 20.1, SE: 7.38, P = .006) in the 6 months cohort was found to be associated with a reduced frequency of worse clinical outcome (Mean difference −1.81, SE: 0.349, P = .001). CONCLUSION: The findings of this meta-analysis suggest that, in cases where it is clinically feasible to delay revascularization following an acute neurological event in patients with MMD, postponing intervention is warranted.

Introduction: Chiari II malformation (CM-II) is a congenital malformation characterized by the caudal displacement of the cerebellar tonsils, inferior cerebellar vermis, and fourth ventricle through the foramen magnum. Although rare, the association between CM-II and the development of a variety of mass lesions within the fourth ventricle and craniocervical junction has been described in the literature. Case Presentation: We present the case of a 9-year-old boy with a history of mid-lumbar myelomeningocele, CM-II, and ventriculoperitoneal shunt-dependent hydrocephalus who was discovered to have a syringomyelia and numerous spherical/ovoid masses within the caudal fourth ventricle and dorsal cervicomedullary subarachnoid space on a surveillance brain MRI. On questioning, the patient endorsed a longstanding history of poor bilateral hand dexterity and grip strength. After further imaging workup, the patient underwent suboccipital craniectomy and C1 laminectomy for resection of the mass lesions arising from the fourth ventricular choroid plexus (CP) and performance of an expansile pericranial duraplasty. The patient tolerated surgery well and had progressive improvement in hand dexterity/strength as well as radiographic improvement in the cervical cord syrinx after surgery. Pathologic analysis of the resected mass lesions demonstrated the lesions to be predominantly characterized by dense nodular fibrosis of the CP stromal cores which we are describing as choroid plexus papillary fibrosis. A minority of the lesional stromal cores were noted to be edematous, imparting a more “reticular” appearance. There were no features to suggest a neoplastic or infectious process. Conclusion: This combination of dysplastic/reactive CP histologic findings has not been previously reported in an extramedullary location. The unique pathology of this patient’s CP lesions will be discussed, and previously reported fourth ventricular mass lesions seen in association with CM-II will be reviewed.

Background: Primary intracranial sarcomas (PIS) are rare tumors with mesenchymal origins. These tumors have a heterogeneous clinical presentation and are associated with a poor prognosis. Case Description: This report highlights the complexities associated with PIS by focusing on a 26-year-old male with recurrent tumor growth facing unique challenges regarding diagnosis and treatment options . A high-grade spindle-celled neoplasm with sarcomatous features characterized the patient’s tumor. There were additional morphologic changes, including multinucleated giant cells and rare foci with eosinophilic spheroids. Genomic analysis revealed a DICER1-associated PIS. Treatment involved endovascular embolization, multiple surgical interventions, intrathecal etoposide injections, and oral pazopanib with adjuvant radiation therapy. Conclusion: This case additionally highlights an unusual association between PIS and anomalous hypervascularity, refractory hemorrhage, and subdural effusions, a presentation that is increasingly being reported in this type of tumor.

Optic chiasm decompression for preservation of vision is often the primary surgical goal for patients with pituitary tumors. Descent of the diaphragma sellae (DS) is an intraoperative surrogate marker of adequate chiasm decompression. DS may not always descend in an obvious or symmetrical manner, leaving uncertainty to whether the operation was successful. We propose a technique of intentionally incising the DS to ensure adequate chiasm decompression. Here we present patients with pituitary tumors who underwent transsphenoidal surgery and DS incision when the DS was not easily identified and/or did not descend. The approximately 3-mm incision under endoscopic guidance allowed for direct visualization of the suprasellar cistern and optic chiasm. Cerebrospinal fluid (CSF) leak was repaired using a nasoseptal flap in 4 cases, while intradural substitute and thrombin glue were utilized in another case. Five patients with pituitary macroadenomas (average size: 6.4 cm³) had endoscopic endonasal transsphenoidal resection. Vision improved in all cases postoperatively. There were no postoperative complications or CSF leaks at 1 year. Diaphragma sellotomy ensures chiasm decompression with minimal risk to the patient with current reconstructive techniques and without the need for intraoperative magnetic resonance imaging (iMRI) and reduction of the need for repeated surgical intervention.

Leiomyosarcomas (LMSs) is a type of sarcoma that arises from smooth muscle and generally presents in the abdomen.

Background: Trigeminal neuralgia (TN) is a debilitating pain that affects the dermatomes associated with the trigeminal nerve (V1, V2, and V3). Unfortunately, many medical treatments and surgical procedures fail to sufficiently modulate the pain associated with this condition. Case Description: This study presents two extreme cases of refractory TN (RTN) that progressed to atypical facial pain and describes successful mitigation of the neuralgia of said cases by percutaneous implantation of upper cervical spinal cord stimulation (SCS). The SCS was designed to target the descending spinal trigeminal tract. Conclusion: Together, these cases collaborate with the limited literature and further delineate the use and potential advantages of SCS in the treatment of RTN.

Given the complex and multifaceted nature of resecting giant tumors in the anterior, middle, and, to a lesser extent, the posterior fossa, we present two example strategies for navigating the intricacies of such tumors. The foundational premise of these two approaches is based on a two-stage method that aims to improve the visualization and excision of the tumor. In the first case, we utilized a combined endoscopic endonasal approach and a staged modified pterional, pretemporal, with extradural clinoidectomy, and transcavernous approach to successfully remove a giant pituitary adenoma. In the second case, we performed a modified right-sided pterional approach with pretemporal access and extradural clinoidectomy. This was followed by a transcortical, transventricular approach to excise a giant anterior clinoid meningioma. These cases demonstrate the importance of performing staged operations to address the challenges posed by these giant tumors.