Shachar Zion Shemesh

Background: Fibromyalgia may be documented after years of regional pain, but the localized presentations associated with subsequent fibromyalgia documentation in pain-clinic practice remain poorly defined. Documentation in health records may reflect delayed recognition rather than biological disease onset. Objective: To quantify subsequent fibromyalgia documentation after isolated, localized non-fibromyalgia pain presentations and to describe associated demographic and diagnostic patterns without inferring causality or biological progression. Methods: We conducted a retrospective longitudinal cohort study of 58,650 patients seen from June 2009 to June 2021, with follow-up through June 2026. Inclusion required exactly one localized non-fibromyalgia pain category on the first observed pain-clinic day, no non-negated fibromyalgia signal on that day, and at least five years of observed follow-up. A fibromyalgia signal was defined as at least one prespecified, non-negated fibromyalgia expression on a patient-day. Bilingual rule-based dictionaries identified pain categories and fibromyalgia. Proportions used patient-level denominators and Wilson confidence intervals. Results: Among 23,103 isolated-index patients, 13,391 had a five-year potential observation window and 2,783 had observed five-year follow-up. Later fibromyalgia was documented in 299 patients (10.74%, 95% CI 9.65– 11.95) after a median 4.49 years. Patients with later documentation were younger than those without it. Sex-stratified proportions were 10.91% in women and 8.30% in men; these descriptive estimates do not establish an independent sex effect. High point estimates in small subgroups were imprecise. Conclusion: Selected localized pain documentation phenotypes were associated with subsequent fibromyalgia documentation. These patterns may support earlier clinical assessment but do not establish biological progression or causality.

Xanthogranulomas (XGs) of the choroid plexus are uncommon benign inflammatory lesions, usually discovered incidentally within the ventricular system. Although most remain asymptomatic, larger lesio...

Background: Childhood scalp irradiation for tinea capitis (TC) increases the long-term risk of intracranial meningiomas. It remains unclear whether prior TC irradiation affects meningiomas’ response to stereotactic radiosurgery (SRS). We compared TC-irradiated and sporadic meningiomas treated with SRS. Methods: Among 539 meningioma patients treated with SRS from 2010 to 2023, 204 met criteria for volumetric analysis (median follow-up 64.6 months, interquartile range [IQR] 32.8-107.8). Of these, 61 (29.9%) had childhood scalp irradiation for TC, while 143 (70.1%) had no prior cranial irradiation. Tumor volumes were measured on T1-weighted gadolinium-enhanced MRI baseline and at last follow-up, or prior to surgery. Treatment response was assessed as percent volume change, as a binary study-defined “good response” (≥29% reduction), and RANO-aligned categories. Predictors of response and surgical intervention were evaluated using multivariable regression. Results: Tinea capitis-irradiated patients were older (median 67.6 vs 62.8 years, P < .001) and more commonly had multiple meningiomas (73.8% vs 11.9%, P < .001) than nonirradiated patients. Baseline tumor volume was similar between groups (P = .516), as was the need for surgical resection (P = .535). Multivariable analysis showed that TC irradiation independently predicted poorer volumetric response (a 38.7% relative volume change, P = .026) and a lower likelihood of achieving the study-defined “good response,” although this was not statistically significant. Tinea capitis irradiation was not associated with progression-free survival. Conclusions: Childhood TC irradiation-related meningiomas are a distinct subgroup characterized by multifocality and reduced volumetric response to SRS. These findings suggest a potentially treatment-resistant phenotype, supporting the need for individualized management.

Background: Same-day or post-admission cancellation of elective surgery is associated with inefficient operating room utilization, patient distress, and disruption of coordinated perioperative care. Functional neurosurgery is particularly vulnerable to late-stage cancellation because procedural readiness depends on parallel clinical, anatomical, medication-related, device-related, and systemic considerations. Objective: This paper aims to describe the implementation of a structured preoperative review framework for functional neurosurgery and to evaluate its association with late-stage surgical cancellation after patient admission. Methods: We performed a retrospective single-center before-and-after study of consecutive functional neurosurgical procedures scheduled at Sheba Medical Center between January 2020 and December 2025. The ABCDE framework was introduced in 2023 as a structured workflow model organized around five domains: Anatomy, Bacteria, Clotting, Devices, and Elsewhere. Included procedures were deep brain stimulation, vagus nerve stimulation, focused ultrasound, intrathecal pump implantation or replacement, implantable pulse generator replacement, spinal cord stimulation, peripheral nerve stimulation, and other palliative neuromodulation procedures. The primary endpoint was late-stage cancellation, defined as cancellation after hospital admission and initiation of operative preparation. The primary comparison was between 2020–2022 and 2023–2025. A sensitivity analysis excluded 2020 because of pandemic-era disruption. Results: A total of 867 procedures were scheduled. Late-stage cancellation occurred in 16 of 407 pre-implementation procedures and 5 of 460 post-implementation procedures, corresponding to rates of 3.9% and 1.1%, respectively. The absolute risk difference was −2.8 percentage points (95% CI, −5.2 to −0.8), and the relative risk for cancellation after implementation was 0.28 (95% CI, 0.10 to 0.75). A two-sided Fisher’s exact test comparing cancellation versus non-cancellation across the pre-implementation and post-implementation periods was statistically significant (16/407 vs. 5/460; p = 0.0074). After excluding 2020, the direction of effect remained similar, but the difference was not statistically significant: 8 of 302 procedures in 2021–2022 were canceled compared with 5 of 460 in 2023–2025 (2.6% vs. 1.1%; p = 0.15). Detailed source-level attribution was incomplete for 10 of 21 cancellation events, and domain-level analyses should therefore be interpreted descriptively. Conclusions: Implementation of the ABCDE framework was associated with fewer late-stage surgical cancellations in this single-center before-and-after study. Because the design is observational, the number of events is small, and the study period overlaps with pandemic-era disruption and post-pandemic service stabilization, the findings should be interpreted as hypothesis-generating rather than causal. The framework may provide a practical structure for standardizing preoperative review in functional neurosurgery, but prospective studies with formal adherence tracking and procedure-specific analyses are needed.

Background: Pain is a prominent and disabling manifestation of inflammatory bowel disease (IBD), including abdominal, pelvic, musculoskeletal, axial, and neuropathic pain phenotypes. Patients referred to pain clinics represent a selected subgroup with clinically meaningful, persistent, refractory, or diagnostically complex pain. Objective: To characterize pain phenotypes, treatment patterns, interventional pain-care exposure, and utilization burden among patients with IBD evaluated in tertiary pain-clinic settings and to explore differences between Crohn’s disease and ulcerative colitis patients. Methods: We performed a retrospective electronic medical-record cohort study of patients with documented IBD who were evaluated in pain-clinic settings between 24 October 2010 and 14 May 2026. Repeated clinical entries were aggregated into unique visit dates and patient-level variables. IBD diagnosis, pain phenotypes, treatment documentation, interventional procedures, and pain-clinic utilization were summarized descriptively using counts, percentages, means, medians, interquartile ranges, and ranges as appropriate. Crohn’s disease and ulcerative colitis subgroups were compared using univariable odds ratios with 95% confidence intervals and two-sided p-values. Because repeated clinical entries could belong to the same patient, the primary analytic unit was the patient rather than the individual note. Results: The source dataset included 19,615 clinical entries representing 7053 unique pain-clinic visits among 596 unique patients with IBD. The cohort included 314 patients with Crohn’s disease (52.7%), 247 with ulcerative colitis (41.4%), and 35 with IBD-unclassified (5.9%). The mean number of pain-clinic visits per patient was 11.8, with a median of four visits (interquartile range, 1–11). The dominant patient-level pain phenotypes were limb or peripheral joint pain (395/596, 66.3%), back or axial spine pain (358/596, 60.1%), and abdominal or pelvic pain (246/596, 41.3%). Overall, 437 patients (73.3%) had documentation of at least one interventional pain procedure. Compared with ulcerative colitis, Crohn’s disease was associated with higher documentation of abdominal or pelvic pain (148/314, 47.1% vs. 82/247, 33.2%; odds ratio, 1.79; 95% confidence interval, 1.27–2.53; p = 0.001) and fibromyalgia-like or widespread pain (83/314, 26.4% vs. 39/247, 15.8%; odds ratio, 1.92; 95% confidence interval, 1.25–2.93; p = 0.0027). In contrast, radiofrequency procedures (59/314, 18.8% vs. 78/247, 31.6%; odds ratio, 0.50; 95% confidence interval, 0.34–0.74; p = 0.0005) and facet or medial branch procedures (79/314, 25.2% vs. 87/247, 35.2%; odds ratio, 0.62; 95% confidence interval, 0.43–0.89; p = 0.012) were less frequently documented in Crohn’s disease than in ulcerative colitis. Conclusions: Among patients with IBD referred to tertiary pain-clinic evaluation, pain was heterogeneous and predominantly musculoskeletal, axial, neuropathic, and procedurally targetable rather than exclusively visceral. These findings support structured, mechanism-based pain assessment integrated with gastroenterology, rheumatology, and pain-medicine care.

Objective: On 28 February 2026, Israel entered direct large-scale hostilities with Iran under Operation Roaring Lion. The opening phase was characterized by repeated missile alerts, civilian protected-space instructions, and rapid reorganization of hospital activity into protected areas. We observed an apparent increase in strict spontaneous intracerebral hemorrhage admissions during March 2026 within our linked neurology/neurosurgery services dataset. The aim of this preliminary single-center study was to determine whether March 2026 was temporally associated with a higher proportional burden of strict spontaneous intracerebral hemorrhage admissions compared with March cohorts from the preceding decade and whether this pattern was also observed for acute ischemic stroke or non-traumatic subarachnoid hemorrhage. Methods: We performed a retrospective observational cohort study of all unique March admissions captured within a linked neurology/neurosurgery services dataset from 2016 through 2026. Hospitalizations were deduplicated by admission number. March 2026 was treated as the first full March occurring after the onset of direct Israel–Iran hostilities on 28 February 2026. Strict spontaneous ICH was defined using diagnosis-text phenotyping that included intraparenchymal or intracerebral hemorrhage terminology while excluding trauma, subarachnoid hemorrhage, subdural hematoma, aneurysm, arteriovenous malformation, tumor-related hemorrhage, cavernoma, venous sinus thrombosis, dissection, and other clearly secondary etiologies. Comparator phenotypes included acute ischemic stroke and non-traumatic subarachnoid hemorrhage (SAH). Results: Across 3855 unique March admissions, 68 met criteria for strict spontaneous ICH. In March 2026, 9 of 223 admissions (4.0%) were classified as strict spontaneous ICH, compared with 59 of 3632 admissions (1.6%) across March 2016–2025, yielding a rate ratio of 2.48 (95% CI 1.25–4.94; p = 0.015). Patients with strict spontaneous ICH in March 2026 were older (mean age 72.3 vs. 65.8 years), and 7 of 9 cases (77.8%) occurred in patients aged ≥70 years compared with 25 of 59 (42.4%) historically (p = 0.073). Acute ischemic stroke did not increase in March 2026 (7.6% vs. 9.4%; p = 0.475), and non-traumatic SAH showed only a non-significant numerical increase (2.7% vs. 1.4%; p = 0.147). Sensitivity analyses showed a directionally consistent but statistically non-significant increase when March 2026 was compared with March 2025 alone (4.0% vs. 1.2%; rate ratio 3.36, 95% CI 0.92–12.27; p = 0.076) and with a rolling 3-year March baseline from 2023 through 2025 (4.0% vs. 2.1%; rate ratio 1.93, 95% CI 0.88–4.23; p = 0.143). In-hospital mortality among strict spontaneous ICH patients was 1 of 9 (11.1%) in March 2026 versus 4 of 59 (6.8%) in March 2016–2025. Conclusions: In this preliminary single-center neurology/neurosurgery services cohort, March 2026 showed a higher proportional burden of strict spontaneous intracerebral hemorrhage admissions than March cohorts from the preceding decade, while acute ischemic stroke did not increase. Sensitivity analyses using March 2025 alone and a rolling 3-year March baseline were directionally consistent but did not reach statistical significance. These findings should therefore be interpreted as a hypothesis-generating temporal association rather than evidence of causality or population-level incidence. Wartime-related psychological stress, sleep disruption, altered healthcare access, blood pressure dysregulation, and medication nonadherence are biologically plausible contributors, but individual-level blood pressure, medication exposure, body mass index, time-to-admission, direct stress exposure, and detailed outcome data were not available in the present dataset. Multicenter, hospital-wide, and registry-based validation with seasonal and systems-level sensitivity analyses is required.

BACKGROUND Background: Patients with persistent spinal pain after spine surgery may undergo prolonged medication escalation and repeated procedures before referral for spinal cord stimulation (SCS) or neuromodulation evaluation. OBJECTIVE Objective: To develop and internally evaluate referral-support models for future SCS/neuromodulation documentation among patients with failed back surgery syndrome/persistent spinal pain syndrome type 2 in a tertiary pain clinic. METHODS Methods: We performed a retrospective patient-level electronic health-record analysis using two prespecified horizons. The index model used features available at or before the earliest FBSS/post-spine-surgery pain-clinic presentation. The 90-day landmark model used features accumulated within the first 90 days of tertiary pain-clinic care. Penalized logistic regression was the primary model; random forest and histogram gradient boosting were exploratory. Leakage-prone future variables, no-variance predictors, and exact duplicates were excluded. Performance was assessed using AUROC, AUPRC, Brier score, calibration, threshold metrics, feature importance, and decision curves. RESULTS Results: The index cohort included 572 patients; 116 (20.3%) had future SCS/neuromodulation documentation. The primary index model achieved random test AUROC 0.633 (95% CI, 0.476-0.772), AUPRC 0.310, and Brier score 0.161. The 90-day landmark cohort included 557 patients; 101 (18.1%) had future SCS documentation. The primary 90-day model achieved random test AUROC 0.772 (95% CI, 0.636-0.876), AUPRC 0.423, and Brier score 0.129. Temporal tests were underpowered, with only 10 and 6 events. CONCLUSIONS Conclusions: A 90-day landmark referral-support model demonstrated encouraging internal random-test performance for future SCS pathway entry, but external and prospective validation are required before workflow implementation.

Background: Trigeminal neuralgia (TN), a facial pain disorder classically characterized by recurrent brief electric-shock-like paroxysms in one or more trigeminal divisions, frequently traverses dental pathways before specialist evaluation. Conversely, dental extraction, endodontic treatment, implant procedures, and third-molar surgery may injure the inferior alveolar, superior alveolar, mental, or lingual nerves and generate painful post-traumatic trigeminal neuropathy. We sought to define the diagnostic interface between classical TN and post-dental/alveolar nerve-related trigeminal pain in a tertiary referral cohort. Methods: We performed a retrospective single-center diagnostic-pathway study using a clinical dataset comprising 672 unique patients. A dental-interface trigeminal candidate cohort was assembled from aggregated patient-level source notes and adjudicated into five prespecified phenotypes: confirmed alveolar neuropathy, post-extraction neuropathic onset, odontogenic diagnostic misclassification, mixed/uncertain dental-interface pain, and clean classical TN. Extracted variables included demographics, trigeminal branch documentation, sensory deficit, dental procedure history, post-extraction onset, MRI and neurovascular conflict language, secondary structural disease, TN-directed medication exposure, invasive treatment exposure, documented outcomes, and time from first specialist documentation to first dated invasive treatment. Results: Among 201 dental-interface trigeminal candidates, 19 patients (9.5%) had confirmed alveolar neuropathy, 31 (15.4%) had post-extraction neuropathic onset, 20 (10.0%) represented odontogenic diagnostic misclassification, 115 (57.2%) remained mixed/uncertain, and 16 (8.0%) fulfilled a clean classical TN phenotype. Overall, 114 patients (56.7%) carried explicit TN terminology somewhere in the chart. Non-classical alveolar/post-dental syndromes comprised 70 patients (34.8%). Compared with clean classical TN, this non-classical group had higher rates of documented oral sensory deficit (38.6% vs. 0.0%, p = 0.002), post-extraction onset (52.9% vs. 0.0%, p < 0.001), extraction history (61.4% vs. 0.0%, p < 0.001), and secondary structural disease (22.9% vs. 0.0%, p = 0.035). Neurovascular conflict or vascular-loop language did not distinguish non-classical alveolar/post-dental syndromes from clean classical TN (38.6% vs. 37.5%, p = 1.000). Conclusions: A substantial minority of tertiary dental-interface trigeminal referrals represented alveolar/post-dental syndromes rather than clean classical TN, even while carrying TN labels and accumulating TN-directed treatment exposure. Post-extraction onset, lower-lip/chin or intraoral sensory change, and pain persisting despite extraction should prompt careful phenotyping before classical TN-directed escalation. The alveolar–trigeminal interface can be operationalized as a recognizable diagnostic pathway with direct implications for multidisciplinary facial-pain evaluation.