Neurological Surgery

The use of prophylactic subgaleal vancomycin powder for preventing surgical site infections (SSI) has gained traction among cranial surgeons. However, its broad application remains controversial as the studies supporting its use are skewed toward high infection risk pathologies and have significant limitations. This study aimed to evaluate the efficacy of vancomycin powder in reducing SSIs in a cohort of patients with nonmalignant cranial pathologies. A retrospective chart review was conducted for 987 patients who underwent cranial surgeries for nonmalignant pathologies between July 2021 and June 2024 at a major academic center. Patients were divided into 2 groups: those who received prophylactic vancomycin powder (682 patients) and those who did not (305 patients). Data on demographics, comorbidities, procedure types, and SSI occurrences were collected. Established infection risk characteristics were nonsignificantly different between groups. There was no significant SSI difference when comparing patients not receiving vancomycin vs those who received the antibiotic (0.3% vs 0.7%, P = .578). There were 6 infections in total, 3/6 (50%) occurred with atypical meningiomas, 2/6 (33%) occurred with schwannomas, and 1/6 (17%) occurred with an amoebic abscess. Supratentorial craniotomies (odds ratio 0.95, P = .810) and posterior fossa craniotomies (odds ratio 1.18, 0.545) were the most common procedures and were nonsignificantly different between the cohorts. Meningiomas represented the largest portion of pathologies and were equally represented in both groups. This study suggests that the routine use of prophylactic vancomycin powder in nonmalignant cranial surgeries may be unnecessary, given an overall low incidence and lack of significant difference in SSIs between groups. These findings advocate for a more tailored approach to antibiotic prophylaxis, weighing the potential benefits against the known risks.

Abstract Background: Central nervous system (CNS) border pathways, including meningeal lymphatics, trigeminal neurovascular networks, and cribriform plate conduits, are increasingly recognized as routes for immune surveillance and therapeutic access to the brain. However, strategies to actively enhance trafficking through these interfaces remain limited, particularly for nanotherapeutic delivery in glioblastoma (GBM). Here, we developed facial dermal based system to deliver immune-modulating nanoparticles through the neuro-lymphatic network. Methods: To overcome physical barriers limiting immunotherapeutic access to CNS and peripheral immune sites, we implemented two mechanistically integrated strategies. First, we established facial intradermal (i.d.) delivery combined with iontophoresis as a minimally invasive approach to enhance CNS trafficking across the brain border interfaces. Iontophoresis utilizes low-intensity electric fields to promote directional transport of charged therapeutics into deeper tissues. Second, we engineered charged nanotherapeutic particles bimodal Spherical Nucleic Acid (bi-SNA) platform designed to leverage electric field-guided transport from the face to the CNS borders while activating cGAS–STING and inhibiting STAT3. This bi-SNA consists of a 15-nm gold core functionalized with a hairpin oligonucleotide containing an unpaired G5 repeat loop flanked by STAT3-decoy palindromic sequences, enabling simultaneous cGAS activation and cytosolic sequestration of STAT3. Results: Iontophoresis-augmented i.d. delivery achieved significantly enhanced nanoparticle trafficking across CNS border pathways compared with i.d administration. IVIS/CT imaging of fluorescent probe-tagged SNA in mouse whole-head demonstrated robust SNA flux from facial injection sites to intracranial compartments, with transport occurring along maxillary–olfactory and temporomandibular–trigeminal neuro-lymphatic routes. I.d. delivery also resulted in accumulation within superficial lymph nodes, indicating engagement of peripheral immune compartments. ICP-MS gold element quantification revealed ∼20-fold higher gold accumulation in the brain and trigeminal nerve and lymph nodes within 12 hours following iontophoresis-assisted i.d delivery compared with passive i.d. (p<0.01). Silver staining of mouse brain histology sections confirmed SNA localization within the meninges, trigeminal nerve branches, maxillary sinus, and cortex. Furthermore, flow cytometry revealed decreased immunosuppressive myeloid populations and increased CD4+ and CD8+ T-cell activation across tumor, dura, and deep cervical lymph nodes. In combination with radiation, bi-SNA facial i.d. treatment significantly reduced tumor burden, enhanced antigen presentation in tumor microglia and myeloid cells, and increased PD-1 expression on T cells, supporting the potential of checkpoint inhibitor combinations. Conclusions: Iontophoresis-assisted facial intradermal delivery enables non-vascular CNS entry of bi-SNA nanotherapeutics by exploiting craniofacial neuronal and lymphatic brain border pathways. Citation Format: Akanksha S. Mahajan, Davin Hickman. Chow, Gaelen Clayton, Seunghyun Kim, Rachel Jarvis, Emma Shen, Clara Foltz, Cao Dai Phung, Eric Leuthardt, Alexander Stegh. Harnessing facial neuronal-lymphatic pathways for face-to-brain delivery of bimodal cGAS-STAT3 Spherical Nucleic Acids for anti-glioma therapy [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Brain Cancer; 2026 Mar 23-25; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2026;86(6_Suppl):Abstract nr A027.

Intrathecal baclofen (ITB) pumps are essential for managing spasticity and dystonia in children; however, they carry risks of hardware infection, withdrawal syndrome, and emergent failure. Management of these complications remains variable across institutions, and no unified, pediatric-specific workflow exists to date. We sought to develop and implement standard work tools (SWTs) to guide the evaluation and treatment of ITB pump infection and withdrawal in pediatric patients. Senior-level pediatric neurosurgery and physical medicine and rehabilitation (PM&R) physicians at a high-volume tertiary children's hospital (Ann and Robert H. Lurie Children's Hospital) collaboratively developed two structured SWTs addressing: (1) diagnosis and care of suspected ITB pump infection; and (2) structured weaning protocols to prevent and manage withdrawal during pump explantation or malfunction. SWTs were disseminated through detailed manuals and real-time clinical decision support. Their clinical utility was assessed through implementation in cases requiring pump interrogation or removal. The SWTs were successfully applied across multidisciplinary teams; collectively, they standardize pump interrogation, laboratory evaluation, drug conversion strategies, ITB dose-based weaning thresholds, and escalation procedures for severe withdrawal or infection. The tools enabled consistent management of both emergent and subacute presentations. We further demonstrate their effectiveness through two representative cases: one involving MSSA pocket infection requiring pump removal and structured withdrawal management, and another involving non-inflammatory wound breakdown with preserved pump function requiring coordinated interdisciplinary care. SWTs improve safety and timeliness in the management of ITB pump infections and baclofen withdrawal in children. The presented tools provide a reproducible framework for first-line providers and pertinent specialists, particularly for those who may not be familiar with key signs and varied presentations. Broader adoption may reduce variability in treatment while optimizing longitudinal ITB therapy outcomes in pediatric patients.

Health-related quality of life (HRQoL) in patients with degenerative cervical myelopathy (DCM) ranks among the lowest across chronic medical conditions. We aim to evaluate the impact of neck pain on postoperative HRQoL after surgical decompression for DCM. We conducted a retrospective analysis of a multicenter international DCM cohort comprising 1047 patients enrolled from 2005 to 2021. Neck pain severity was assessed using the pain intensity subdomain of the Neck Disability Index. Baseline and 1-year HRQoL scores measured using the SF-36 physical component summary (PCS) and mental component summary (MCS) were compared between neck pain and no neck pain cohorts. Multivariable regression models, adjusted for key clinical covariates, were used to examine the association between neck pain severity and HRQoL. Neck pain was present preoperatively in 81.5% of patients. The neck pain group had significantly lower PCS (34.72 ± 9.02 vs 39.56 ± 10.20, P < .001) and MCS scores (40.59 ± 11.73 vs 45.64 ± 12.86, P < .001) compared with the no neck pain group. At 1 year postsurgery, 35.5% reported being pain-free. Increasing neck pain severity was associated with progressively lower PCS (exp β = -3.64, -7.45, and -10.47 for mild, moderate, and severe pain) and MCS scores (exp β = -2.96, -7.69, and -11.80). Persistent moderate and severe neck pain at 1 year independently predicted failure to achieve minimal clinically important difference for PCS [odds ratio = 0.57 (95% CI 0.39-0.83, P < .05) and 0.37 (95% CI 0.25-0.55, P < .05), respectively] and MCS [odds ratio = 0.49 (95% CI 0.34-0.71, P < .05) and 0.60 (95% CI 0.41-0.88, P < .05), respectively]. Model fit predictions for 1-year HRQoL were improved with inclusion of neck pain scores (PCS: χ2 = 37.21, MCS: χ2 = 19.18, both P < .0001). Neck pain is highly prevalent among patients with DCM and is independently associated with poorer postoperative HRQoL. While surgery restores neurological function, optimizing patient-reported outcomes requires adjunctive strategies specifically targeting neck pain.