Surgical intervention is a standard treatment for severe cervical spondylotic myelopathy (CSM), but postoperative outcomes can vary based on socioeconomic characteristics such as insurance status. The aim of this study was to investigate the influence of insurance on patient-reported outcomes (PROs) at 60 months postoperatively. In this prospective cohort study, the Spine CORe™ study group analyzed data from the Quality Outcomes Database (QOD) database. Chi-square and Kruskal-Wallis tests were performed to identify the associations between sociodemographic and clinical variables and insurance type. The chi-square test was also used to examine the influence of insurance type on the achievement of minimal clinically important difference (MCID) for each outcome measure. Statistically significant covariates (p < 0.001) were used in a multivariate linear regression model measuring the influence of insurance type on 60-month changes in scores for neck and arm pain numeric rating scale (NRS), Neck Disability Index (NDI), EQ-5D, and modified Japanese Orthopaedic Association (mJOA) scores. From a dataset of 1085 patients who underwent CSM surgery, 106 patients died during the 5-year follow-up period and 793 had an NDI score at the 5-year follow-up. The follow-up rate was 83% ([793 with NDI + 106 died]/1085 patients). Of the 1085 patients, the authors excluded patients with Veterans Affairs insurance, no insurance, or who were missing baseline PROs, which left 1030 patients with Medicare (n = 408), Medicaid (n = 75), and private (n = 547) insurance with 60-month PROs. Insurance status varied based on demographics and medical comorbidities (each p < 0.05). Medicaid patients had significantly worse scores at baseline and 60 months for arm and neck NRS, NDI, EQ-5D, and mJOA (each p < 0.05). In multivariate analysis after adjustment for relevant covariates, compared with private insurance, only Medicare insurance was associated with lower 60-month EQ-5D scores (β -0.05, 95% CI -0.09 to -0.01; p < 0.05). Otherwise, there was no significant difference in PROs. Medicaid insurance was not significantly associated with differences in any of the outcomes after covariate adjustment compared to private insurance. Despite having worse baseline scores, patients with Medicaid insurance coverage had similar rates of achievement of MCID compared with those with private insurance. These results suggest that patients with CSM who underwent surgery had improvement in PROs for all insurance types.

The volume of spinal surgeries performed in the ambulatory surgery center (ASC) setting continues to increase. This parallels continued growth in minimally invasive spine surgery in which intraoperative navigation offers well-described benefits. However, the use of spinal navigation in the ASC setting has not been well characterized. The aim of this study was to determine how the incorporation of ASC spinal navigation impacts perioperative measures, as well as short- and long-term outcomes, in patients undergoing elective 1- to 2-level spine surgery. A retrospective analysis was conducted using a prospectively maintained registry of patients undergoing elective 1- to 2-level spine surgery with and without intraoperative navigation and O-arm imaging between March 2019 and August 2025 at a single ASC. Demographic characteristics, comorbidities, and perioperative metrics were collected. Baseline and 1-year postoperative patient-reported outcome measures (PROMs), including the numeric rating scale for back pain and leg pain, Oswestry Disability Index, and EQ-5D, were assessed. Perioperative measures included estimated blood loss (EBL), operative duration, discharge status, inpatient transfer, 90-day readmission, and unplanned return to the operating room. Of 280 patients who underwent surgery with navigation, 199 underwent fusion and 81 underwent nonfusion procedures. Of 531 patients who underwent surgery without navigation, 122 underwent fusion and 409 underwent nonfusion procedures. For the fusion cohort, the mean operative duration was 108.14 ± 39.6 minutes in the navigation group compared with 99.49 ± 33.0 minutes in the nonnavigation group (p = 0.044). For the nonfusion cohort, the operative duration was longer in the navigation group compared with the nonnavigation group (74.11 ± 33.6 minutes vs 63.74 ± 23.8 minutes, p = 0.009). For both the nonfusion and fusion cohorts, there was no significant difference in rates of transfer to inpatient, hospital readmission within 90 days, or return to OR within 90 days for the navigation versus nonnavigation groups (p > 0.44 for all). The primary nonfusion procedure type performed with navigation was extraforaminal decompression (56.8% vs 7.1% of nonnavigation group). All PROMs demonstrated significant improvement from baseline to 1 year in both the navigation and nonnavigation groups (p < 0.001 for all). Intraoperative navigation can be safely integrated into the ASC setting without sacrificing efficiency. Favorable perioperative measures, low complication rates, and durable improvements in PROMs support the continued adoption of navigation technology in the outpatient setting.

While surgery for thoracic disc herniation causing spinal cord compression has traditionally been an inpatient procedure, fraught with risk and often requiring multilevel fusion, recent advances in endoscopic surgery challenge this paradigm. This study presents a single-surgeon case series of endoscopic thoracic discectomy performed in an ambulatory setting, outlining 1) the surgical technique, 2) patient selection and characteristics, and 3) postoperative outcomes. The goal of this study was to assess the safety and feasibility of performing endoscopic thoracic discectomy in an ambulatory surgery setting. A single-surgeon retrospective case series of patients undergoing endoscopic thoracic discectomy at an ambulatory surgery center between 2023 and 2025 was analyzed. Giant calcified discs causing spinal cord compression were excluded. Demographics, comorbidities, operative details, and postoperative outcomes were collected. Primary outcomes included surgical site infection, 90-day emergency department visit, readmission, and reoperation. Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29) physical function scores were compared between baseline and 3 months. Descriptive analysis was performed. Of the 39 patients undergoing endoscopic thoracic discectomy at an ambulatory surgery center, the mean age was 54.9 (SD 14.3) years, and 46.2% were male. Discectomy was performed at a single level in 92.3% of cases, most commonly T7-8 (26.2%), T12-L1 (16.7%), and T11-12 (14.3%). Preoperatively, 84.6% of patients had spinal cord compression, 23 (59.0%) were myelopathic, and 24 (61.5%) had a motor deficit. The mean operative duration was 107.6 (SD 46.4) minutes and the mean estimated blood loss was 12.7 (SD 19.1) ml. A dural tear in 1 patient was the only intraoperative complication. Regarding postoperative complications, 2 patients (5.1%) underwent reoperation, for a retained disc fragment in 1 patient and a CSF leak in the other. No surgical site infections were observed. PROMIS-29 physical function scores improved significantly from baseline (mean 35.1 [SD 7.3]) to 3 months (mean 41.6 [SD 8.0]; p = 0.004). In a single-surgeon series, endoscopic thoracic discectomies performed in an ambulatory surgery center were safe and feasible, with low perioperative morbidity, minimal blood loss, and meaningful early functional improvement. Where conventional management typically demands multilevel fusion or costotransversectomy, with a multiday hospital stay, endoscopic techniques offer a transformative alternative, making thoracic disc surgery safe and feasible even in outpatient environments.

In this study, the authors report their experience performing outpatient minimally invasive transforaminal lumbar interbody fusion (miTLIF) in an ambulatory surgery center (ASC) with 2 years of follow-up data. Patients who underwent miTLIF at the authors' ASC from January 2012 through August 2024 were identified. Registry data were analyzed for demographics, surgical data, complications, hospital transfers, readmissions/reoperations, and patient-reported outcomes (PROs). The PRO measures included the Oswestry Disability Index (ODI), numeric rating scale (NRS) for back pain and leg pain, EQ-5D, and EuroQol visual analog scale (EQ-VAS). A total of 485 patients underwent single-level miTLIF in the Semmes Murphey ASC during this time. Of these patients, 179 had been enrolled in the registry and are the subject of this report. Most patients (176 patients, 98.3%) were discharged within a few hours of surgery. The mean patient age was 54 (range 20-75) years. There were 97 females and 82 males. A total of 179 (100%) patients had 3-month follow-up data, 171 (95.5%) had 1-year follow-up data, and 160 (89.4%) had 2-year follow-up data. Preoperatively, the mean back pain NRS, leg pain NRS, ODI, EQ-5D, and EQ-VAS scores were 6.98, 6.52, 44.14, 0.56, and 63.33, respectively. By 3 months postoperatively, the mean back NRS, leg NRS, ODI, EQ-5D, and EQ-VAS scores improved to 2.40, 1.21, 19.37, 0.81, and 81.15, respectively. By 1-year postoperatively, the mean back NRS, leg NRS, ODI, EQ-5D, and EQ-VAS scores were 2.29, 1.62, 12.73, 0.86, and 81.41, respectively. By 2 years postoperatively, the mean back pain NRS, leg pain NRS, ODI, EQ-5D, and EQ-VAS scores were 2.86, 1.98, 13.87, 0.82, and 81.15, respectively. There were 3 durotomies (1.7%), all of which were treated with fibrin glue, and the patients were discharged within a few hours of surgery. One patient (0.56%) had a superficial surgical site infection that required oral antibiotics but no further surgery. One patient (0.56%) developed a postoperative hematoma. One patient (0.56%) was found to have a urinary tract infection postoperatively. There were 4 (2.2%) readmissions and 2 (1.1%) reoperations within 90 days. This is the largest reported series of miTLIFs performed in a single ASC with 2 years of follow-up data. Patients showed significant improvement in a variety of validated PROMs. Complications, 90-day hospital readmissions, and reoperation rates were acceptably low. For carefully selected patients, ASC-based miTLIF appears to be safe, durable, and highly effective.

Acute and chronic CNS pathologies that result in tissue loss remain among the most intractable problems in neurosurgery, with current treatments focused on stabilization and neuroprotection rather than structural repair. Neural interfaces such as recording, stimulating, or replacing neural activity have demonstrated value in restoring function via prostheses and brain-computer interfaces, yet these approaches are constrained by electrode design, bandwidth, and limited biological integration. Engineered neuroglial organoids offer a complementary, biologically based interface strategy. Derived from pluripotent stem cells, neuroglial organoids arrive as 3D constructs containing neurons and glia in intrinsic architecture, capable of vascularization, synaptic connectivity, and integration with host tissue. Building on dissociated stem cell suspensions, organoids act not only as reservoirs of cells but also as living neural interfaces, receiving inputs from host circuits and generating functional outputs. Preclinical studies have demonstrated that transplanted organoids can couple to host sensory pathways, respond to stimulation, and support recovery of motor and cognitive functions. Moreover, emerging work coupling organoid grafts to brain-computer interfaces highlights the potential for closed-loop biological electronic systems, in which engineered devices provide precise recording and stimulation while organoids contribute adaptive, active biological circuits. This combination allows real-time bidirectional communication, allowing the graft to be both monitored and adapted to structurally and functionally integrate into host tissue. In this review, the authors examine neuroglial organoid transplantation through the lens of neural interfacing. They outline lessons from non-CNS organoid transplantation, summarize neurotrauma studies where grafts engage host circuits, and highlight opportunities to integrate organoids with electrodes, stimulation paradigms, and computational models. They also discuss challenges, namely vascularization, immune tolerance, surgical delivery, and manufacturing standards, that parallel those in neural device translation. For neurosurgeons, the appeal of neuroglial organoids lies not only in tissue replacement but in establishing a new class of biological neural interfaces, extending the reach of restorative neurosurgery. By merging living constructs with engineered devices, organoid-based strategies may enable hybrid restorative systems that restore function after neurological injury and disease.

Cerebral encephaloceles are being recognized as an etiology of drug-resistant epilepsy (DRE). Neuroimaging suggests a link between idiopathic intracranial hypertension (IIH), dural sinus stenosis (DSS), and encephaloceles. One hypothesis is that pulsatile CSF forces, secondary to elevated intracranial pressure, contribute to forming prominent arachnoid villi, which create pockets of CSF and develop encephaloceles. The impact of DSS and IIH management with stent placement for seizure control in patients with DRE and encephaloceles remains poorly understood. In this study, the authors explored the clinical outcomes in this patient population. This single-center case series retrospectively analyzed seizure frequency in 12 patients with DRE due to encephaloceles associated with IIH who underwent cerebral venous sinus stent placement between 2018 and 2024 at the University of Kansas Medical Center. Seizure burden was assessed after stent placement. Twelve patients with encephaloceles and DRE met the inclusion criteria. The mean age was 49 years, and 9 patients were female. The mean BMI was 36.7 kg/m2. The mean age of seizure onset was 42.1 years. All patients had signs of IIH on MRI of the brain: empty sella (n = 8), transverse sinus stenosis (n = 12), and enlarged arachnoid granulations (n = 5). Seven patients underwent lumbar puncture with a mean opening pressure of 27.25 cm H2O. All patients had unilateral temporal lobe epilepsy and encephaloceles involving a sphenoid wing. One patient (8.3%) had an additional lesion in the basal temporal lobe, and another patient (8.3%) had bilateral cerebellar encephaloceles. The mean pre-stent venous pressure gradient was 14.25 mm Hg, and the mean post-stent gradient was 1.25 mm Hg; 50% of patients had a post-stent pressure gradient of 0 mm Hg. Following venous sinus stent insertion and additional surgical interventions, the mean seizure frequency decreased to 0.9 seizures per month. Eleven patients (91.7%) experienced > 50% reduction in seizure frequency postprocedure. The impact of endovascular stent placement for DSS and IIH on seizure burden was investigated. Seizure frequency reduction was observed in all patients. This study demonstrates a prominent role of endovascular stent insertion in patients with encephaloceles and DRE that warrants further exploration.

Idiopathic intracranial hypertension (IIH) is characterized by elevated intracranial pressure without an identifiable cause, commonly affecting young obese women. While transverse sinus stenosis (TSS) and empty sella are frequent radiological findings in IIH, the relationship between the severity of empty sella and the extent of TSS remains poorly understood. In this retrospective study, authors analyzed patients with IIH diagnosed by established criteria in 2013-2023 and healthy controls matched for age, sex, and BMI. All patients underwent 3T brain MRI with contrast-enhanced T1-weighted sequences and MR venography within 3 months of IIH diagnosis. Volumetric analysis was performed using FreeSurfer software. Pituitary and sella turcica areas were manually segmented on midsagittal T1-weighted images, and the pituitary/sella turcica (PS) ratio was calculated. TSS severity was assessed using the Farb scoring system (0-8, with lower scores indicating greater stenosis). Statistical analysis included linear regression and receiver operating characteristic (ROC) curve analysis. Patients with IIH (n = 69) demonstrated a significantly lower pituitary volume (48.9 vs 63.3 mm2, p = 0.0023), larger sella turcica area (116 vs 73.1 mm2, p < 0.0001), and reduced PS ratio (0.44 vs 0.86, p < 0.0001) compared to those in healthy controls (n = 15). A significant association was found between a declining PS ratio and increasing TSS severity (R = 0.26, p = 0.03) and normalized total brain volume (R = 0.24, p = 0.044). ROC analysis revealed that the PS ratio had 92.8% sensitivity and 100% specificity in differentiating patients with IIH from healthy controls (area under the curve = 0.981). The PS ratio correlates significantly with TSS severity and brain volume in patients with IIH, suggesting that both findings reflect CSF and interstitial fluid dyshomeostasis. The PS ratio is highly sensitive and specific for IIH and may serve as a noninvasive imaging biomarker for assessing the severity of venous sinus stenosis and intracranial pressure elevation in IIH, particularly useful in settings where MR venography is unavailable. Further research is needed to explore the causative relationship between venous stenosis and empty sella formation.

Pediatric idiopathic intracranial hypertension (IIH) is a rare condition characterized by elevated intracranial pressure (ICP) without an identifiable cause. Although most patients respond to medical therapy, refractory cases might require surgical intervention, particularly if the patient experiences visual deterioration. Data on the outcomes of CSF shunting, optic nerve sheath fenestration (ONSF), and venous sinus stenting (VSS) for patients with pediatric IIH are inconsistent across studies. A literature search was conducted from January 1990 until July 2025 across 3 databases. Eligible studies included patients younger than 18 years with primary, medically refractory IIH with visual impairment who underwent CSF shunt placement, ONSF, or VSS. Primary outcomes included improvement in headache, papilledema, visual acuity, and reoperation rates. Meta-analyses of the proportion of patients whose symptoms improved were performed with subgroup analyses by intervention type. The authors identified and included 54 studies with 150 patients (53% were female; in multipatient studies, the mean age range was 3.2-15 years, the mean BMI was 23.6-32 kg/m2, and the mean opening pressure was 270-550 mm H2O). Procedures comprised CSF shunting (n = 68), ONSF (n = 45), and VSS (n = 37). Across all studies, the headache rate improved by 80% (shunt 83%, ONSF 62%, VSS 84%), papilledema by 88% (shunt 90%, ONSF 88%, VSS 86%), and visual acuity by 67% (shunt 52%, ONSF 82%, VSS 70%). The overall reintervention rate was 22% (shunt 24%, ONSF 5%, VSS 30%). No primary outcome subgroup differences were statistically significant. Symptom and ophthalmological improvement were similar across surgical modalities in pediatric patients with IIH with vision-threatening papilledema. ONSF offers high visual acuity preservation with low reintervention rates, making it well suited for urgent vision preservation. CSF shunt placement provides global intracranial pressure control that alleviates associated symptoms, but it is associated with frequent revisions. VSS is effective for patients with venous sinus stenosis and a pressure gradient and thus requires these important prerequisites before stent placement. Larger, pediatric-specific comparative studies are needed to optimize surgical decision-making.

Venopathic intracranial hypertension (VIH) is a condition of elevated intracranial pressure (ICP) associated with venous sinus stenosis. Venous sinus stenting (VSS) can reconstitute outflow, yet physiological biomarkers to aid patient selection and assess treatment response remain limited. This study assessed intraoperative transcranial Doppler ultrasonography (TCD) and quantitative angiography as tools for detecting cerebral hemodynamic changes during VSS in patients with VIH. The authors retrospectively analyzed 11 consecutive patients with VIH who underwent VSS using intraoperative TCD monitoring and quantitative angiographic assessment. Bilateral middle cerebral arteries (MCAs) were insonated via transtemporal windows to record the mean flow velocity (MFV) and pulsatility index (PI) before and after stent placement. In a subset of 5 patients, time to peak (TTP) contrast opacification was measured in the internal carotid artery (ICA), anterior cerebral artery (ACA), and MCA using standardized injection parameters. One-sample, 1-tailed t-tests compared pre- and postoperative changes against zero to determine significance. The median patient age was 37 (IQR 29.5-40) years, 90.9% were female, and the median BMI was 33.9 kg/m2. Stenosis was most common in the transverse-sigmoid sinus junction (72.7%). After stenting, MFV increased in all patients (left MCA: mean +6.73 [SD 10.45] cm/sec, p = 0.029; right MCA: mean +7.44 [SD 10.61] cm/sec, p = 0.021). PI decreased in most patients (left MCA: mean -0.058 [SD 0.101], p = 0.053; right MCA: mean -0.071 [SD 0.169], p = 0.109) but without statistical significance. The quantitative angiography analysis demonstrated variable mean TTP changes, with reductions in the ICA (-0.32 seconds, p = 0.178) and ACA (-0.48 seconds, p = 0.197), and a slight change in the MCA (+0.21 seconds, p = 0.666). Limitations of the study included patient-specific physiology and procedural factors, including region-of-interest measurements, bone overlay, and potential interference from TCD probes. Consistent patterns of MFV increase after VSS, suggesting that TCD may be a robust modality for real-time assessment of arterial inflow hemodynamics in VIH. In contrast, the quantitative angiography analysis revealed heterogeneous arterial transit changes, potentially limited by sensitivity to imaging conditions. These findings support the potential complementary use of TCD and quantitative angiography for physiological monitoring in venous outflow disorders, favoring TCD as the more reliable modality. Both methods are promising, low-risk clinical tools for prospective studies seeking to refine patient selection strategies in VSS.

The aim of this study was to evaluate the impact of conscious deep breathing on intracranial venous sinus pressures (VSPs) in awake patients undergoing cerebral venography and venous manometry for suspected cerebral venous congestion (CVC). Authors of this retrospective study conducted a chart review of adult patients who, between 2023 and 2025, had undergone cerebral venography and manometry for high clinical suspicion of CVC and had been instructed to engage in deep breathing after baseline VSP measurement at the torcular Herophili. Both the inspiratory and expiratory phases were standardized to 5 seconds in duration to achieve a rate of 6 breaths/minute. After 5 cycles, torcular pressure measurements were repeated. VSP changes before and after deep breathing were assessed for a fast or slow return to baseline. Statistically significant differences between pressure measurements before and after 5 deep breathing cycles as well as differences in blood pressure measurements before and after diagnostic cerebral venography and manometry were assessed using the paired Wilcoxon signed-rank test. All 28 patients included in the study exhibited a reduction in torcular VSP after 5 deep breathing cycles, with a median pressure change of -2.5 (IQR -2.0, -4.0) mm Hg. The median torcular pressure decreased from 8.5 (IQR 5.75, 12) to 5 (2, 9) mm Hg, a change that was statistically significant (p = 3.5 × 10-6). The majority of patients (92.86%) returned to baseline pressures within 5 seconds of deep breathing cessation, whereas 7.14% showed a prolonged return to baseline (>15 seconds), resolving within 2 minutes. As insights into the mechanisms and effects behind CVC grow, noninvasive therapies that improve venous outflow, such as deep breathing, may be impactful to patients, potentially delaying or even obviating the need for surgical treatments. Where surgery is needed, deep breathing may allow for tighter VSP control. Understanding VSPs may thus improve the medical and surgical management of patients with venopathic intracranial hypertension. More research is needed to understand these phenomena.