Neurosurgery

IntroductionSurgical simulation is an appealing adjunct for educating trainees on a variety of spine surgery techniques, especially non-routine skills like lumbar durotomy repair. However, high costs and significant lead time required to obtain surgical simulators restrict their routine use in most training programs. The goal of the present study was to develop and evaluate a low-cost and open-source 3D printed lumbar durotomy repair simulator for resident education. MethodsThe design of a pre-existing open-source 3D printed spine simulator was modified for a durotomy repair simulation. The simulator was then printed using acrylonitrile butadiene styrene (ABS) filament on a Bambu Lab P1S printer. Current neurosurgical residents from a single institution were recruited to participate in a one hour lab session in which they were tasked with repairing a standardized 1.5 centimeter durotomy. Subjects were surveyed before and after their simulation experience. ResultsSeven simulators were produced taking on average 12.2 hours to print and cost approximately $9.51 each once fully assembled. Of the 14 subjects recruited, only 7 (50%) reported prior experience with lumbar durotomy repair. All subjects were able to successfully complete the simulated task. Exit survey results demonstrated that all subjects (100%) agreed the simulation was useful and expressed interest in participating in future simulation experiences. ConclusionsOur study demonstrated a 3D printed simulator for lumbar durotomy repair could be produced at low cost and was highly valued by neurosurgical trainees. Given our simulators low cost and open-source format, we believe it is highly accessible to most, if not all, residency programs, and has the potential to help expedite mastery of lumbar durotomy repair.

IntroductionTransarterial embolization is a well-established adjunct in the management of hypervascular head, neck, and spine tumors. Few case-series have described the role of direct percutaneous embolization (DPE). MethodWe report our experience with DPE (with or without transarterial embolization) in patients with head, neck, and spine tumors treated between 2012-2023. Baseline demographics, angiographic imaging, tumoral pathology, and relevant clinical variables were retrospectively reviewed and descriptively analyzed. ResultA total of 55 patients underwent direct percutaneous embolization (19 of whom also received transarterial embolization either before [n=7] or after [n=12] DPE). The most commonly embolized lesions were malignant carcinomas (n=16), followed by juvenile nasopharyngeal angiofibromas (n=11), paragangliomas (n=8), hemangiomas (n=7), and others (hemangioblastoma, schwannoma, neurofibroma, esthesioneuroblastoma, meningioma and hemangiopericytoma). The most common locations were sinonasal/nasopharyngeal (n=21), followed by scalp/subcutaneous (n=18), carotid body (n=6), spinal/paraspinal (n=4), skull base (n=5), and intracranial (n=1). A median of 4 (interquartile range 4-6) twenty-two-gauge spinal needles were used per embolization with a median fluoroscopy time of 50.5 (23.2-77.8) minutes resulting in median radiation exposure of 3055 (840.5-5053.5) mGy. Seven patients received more than one embolic agent, with n-butyl cyanoacrylate (glue, n=44, 81.5%) being the mostly commonly used embolic, followed by ethylene-vinyl alcohol copolymer (Onyx, n=7, 12.9%), 98% dehydrated ethanol (n=7, 12.9%), sodium tetradecyl sulfate (n=2, 3.7%) and poly-vinyl alcohol particles (n=1, 1.8%). The median volume of embolic agent injected was 5.5(4-7.6) mL resulting in total/near-total (90%-99%) angiographic devascularization in 74.5% cases. The median operative blood-loss was 250(75-700) mL. One patient underwent trans-calavarial DPE for a cerebellar hemangioblastoma and suffered diffuse subarachnoid hemorrhage from profuse tumoral bleeding. One patient had an asymptomatic parent-vessel occlusion from retrograde embolic extension. ConclusionOur single-center study reinforces prior experience that DPE of Sino-nasal carcinomas, angiofibromas and paragangliomas with adhesive and non-adhesive liquid embolic agents is safe, feasible and effective. Further, it suggests that these benefits may also be extended to non-traditional head, neck and spine tumors. Caution must be exercised when applying these techniques to intracranial tumors with robust intratumoral arteriovenous shunting.

BackgroundThe clinical outcomes of microsurgery for spinal cord arteriovenous shunts (SCAVSs) exhibit fluctuations due to varying patient selection criteria, underscoring the importance of a standardized surgical grading system that can effectively stratify the feasibility of SCAVSs resection. MethodsA cohort of 308 consecutive patients with surgically treated SCAVSs was randomly divided into a modeling group and a validation group. The surgical grading system was developed based on the independent risk factors of incomplete resection identified in the modeling group and subsequently verified in the validation group. The systems specificity and sensitivity were tested through Receiver Operating Characteristic (ROC) analyses. ResultsMultivariate analysis indicated that metameric AVSs (p=0.007), AVSs with maximum length [≥]3 cm (p=0.017), embedded AVSs (p=0.032) and anterior sulcal artery supply (p=0.013) were independent risk factors of incomplete resection. Subsequently, each of the four parameters is assigned one point, and the SCAVSs grade is calculated by aggregating all parameter scores. The area under ROC curve (AUC) of modeling group and validation group was 0.856 (95% confidence interval [95% CI], 0.794-0.919) and 0.819 (95% CI, 0.747-0.892) respectively. Across the entire cohort, patients with scores ranging from 0 to 4 exhibited complete resection rates of 88.7%, 66.7%, 30.6%, 4.5% and 6.3%. The corresponding rates of severe treatment-related deterioration were found to be at levels of 6.0%, 12.0%, 12.9%, 31.8% and 25.0 %, respectively. Conclusion: The proposed grading system effectively stratifies the surgical feasibility of SCAVSs based on both the probability of achieving complete resection and the treatment risk. Its simplicity renders it a valuable tool for clinical decision-making, as well as a reference point for evaluating treatment outcomes across different centers and surgical techniques.

BackgroundAwake deep brain stimulation (DBS) surgery with microelectrode recording (MER) and test stimulation offers real-time physiologic feedback to refine lead placement, but its relevance is increasingly debated in an era of advanced imaging and streamlined asleep workflows. ObjectiveTo describe a contemporary framework for awake DBS with MER and to evaluate whether, in our hands, this approach results in a final lead position different from what we would have achieved with asleep DBS. MethodsWe outline a standardized workflow combining high-resolution imaging, confirmatory MER, and intraoperative stimulation mapping for an example context of thalamic targeting for essential tremor. To quantify the impact of the awake approach on surgical decision making, we retrospectively reviewed the first 137 consecutively implanted VIM DBS leads placed (awake) by a single surgeon working with a single intraoperative neurologist. In each case, we recorded whether the final lead was implanted along the planned target, whether it was adjusted in depth along the planned trajectory, or whether it was moved to a parallel track. For the parallel track moves, we compared the final lead position to the initially planned imaging target using co-registered pre- and postoperative imaging. ResultsAmong 137 consecutive leads implanted, 116 were implanted in the planned trajectory, with 49 at the planned depth and 67 at an adjusted depth. Twenty-one of the 137 leads were placed along a parallel trajectory based on intraoperative findings, with seventeen having available imaging for further analysis. Post-operative analysis showed that only 2 of the 17 were moved toward the intended target. The remaining 15 were moved away (13) or equidistant (2) from the intended target. ConclusionFeedback from MER and test stimulation in awake DBS cases frequently informs surgical adjustments that deviate from the planned trajectory, often in response to patient-specific physiology not captured by imaging. In the vast majority of our cases, these adjustments would not have been made using an asleep DBS approach, since moves were not made toward the planned target. This indicates that, in our practice, awake surgery results in adjustment of lead position in response to discovered functional anatomy rather than to correct stereotactic inaccuracy. Our findings underscore the continued utility in our practice of awake DBS with MER in tailoring therapy to individual anatomy and functional organization.

BackgroundAccurate targeting of the ventral intermediate nucleus (Vim) remains a critical challenge in stereotactic thalamotomy for essential tremor (ET) and tremor-dominant Parkinsons disease (TDPD). Indirect atlas-based methods suffer from interindividual anatomical variability and poor visualization of thalamic substructures. We evaluated the clinical impact of a direct targeting strategy enabled by fast gray matter acquisition T1 inversion recovery (FGATIR) imaging in MR-guided focused ultrasound (MRgFUS) thalamotomy. MethodsWe conducted a retrospective cohort study of adult patients who underwent first-time MRgFUS thalamotomy for ET or TDPD at the Oregon Health and Sciences University (Portland, Oregon) between August 2023 and January 2024. Patients treated with FGATIR-guided direct targeting (n=64, male=40) were matched to a cohort treated using indirect targeting combined with physiological mapping (n=52, male=36). Data was collected from intraoperative recordings and postprocedural imaging, as well as one-day, one-month, and three-month follow-up evaluations. Procedural efficiency, lesion and edema characteristics, tract involvement, clinical outcomes, and adverse events were assessed. FindingsFGATIR-guided direct targeting significantly reduced the number of sonications (-22%), total sonication time (-32%), and overall procedural duration (-33%) compared to indirect targeting. Lesion volumes and perilesional edema were smaller in the direct targeting group with less impingement on the internal capsule and medial lemniscus. Direct targeting had higher initial sonication accuracy with a lower incidence of neurologic deficits. Both groups achieved similar tremor improvements. InterpretationFGATIR-based direct targeting improves the safety, precision, and efficiency of MRgFUS thalamotomy without compromising clinical benefit. The FGATIR sequence is widely available on clinical MRI systems, and this method may be adapted for use with other targets for stereotactic ablation in functional neurosurgery. Direct targeting represents a scalable and patient-centered advancement for stereotactic thalamotomy with minimal technological barriers to widespread adoption. FundingOHSU Parkinson Center Pilot Program; Oregon Medical Research Foundation #1029114.

ObjectivesAcademic medical institutions are the gatekeepers of the physician workforce and shape the future of medicine by regulating medical school admissions as well as residency training. Although broadly the field of medicine is seeing more representation from traditionally underrepresented groups, the critical decision-making platform of academic medicine continues to be uncharacteristically homogeneous, represented mainly by white males. This is even more pronounced in surgical subspecialties, such as academic neurosurgery. This study aims to quantify this phenomenon, uncover its driving factors, and define opportunities for improvement. MethodsUsing a mixed research methodology, academic neurosurgical faculty in the U.S were identified, and their demographic data was collected. An internet search using Google Scholar and Scopus was conducted to determine scholarly activity using number of publications and h-index. ResultsWe found a significant increase in female faculty in academic neurosurgery within the last decade. Comparing the faculty rank amongst male and female faculty, we found that the majority of female faculty are at the assistant professor level (n=36/79; 45.6%) while male faculty are more at the full professor rank (n=265/582; 45.5%). A similar trend was seen for under-represented minority neurosurgery faculty. Strong scholarly activity corelated with a departmental chair position for male faculty, however, this trend was not true for female faculty. There was a significant difference in the number of publications and h-index in female vs male faculty, but only when including male faculty outliers at the full professor level. ConclusionSlowly but steadily, academic neurosurgery is making progress towards a more diverse and representative workforce in the U.S that better reflects the patient population. Facilitating timely progression of females and URM neurosurgeons into senior professorship and academic leadership roles will further advance this essential progress.

TitleStandards for Reporting of Diagnostic Accuracy using Intraoperative Neurophysiological Monitoring (STARD-IONM) ObjectiveIntraoperative neurophysiological monitoring (IONM) plays a critical role in preserving functional integrity during surgery, yet it is challenging to compare studies due to methodological heterogeneity and inconsistent reporting. We developed the STARD-IONM extension to improve the transparency, completeness, and comparability of IONM studies. MethodsThe STARD-IONM initiative followed a three-phase consensus. Phase 1 convened a IONM expert panel to discuss and define the rationale and scope. Phase 2 involved structured item-level review of existing STARD items in the context of IONM, applied to published studies with iterative feedback. Phase 3 will include broader community engagement via preprints, outreach to professional societies, and public commentary. ResultsA systematically selected review of IONM studies revealed the underreporting of at key methodological items such as handling missing data (7%), adverse events (11%), and blinding of test and outcomes (22%). A STARD-IONM checklist with recommendations for reporting IONM studies with IONM specific examples were developed. Community feedback emphasized challenges unique to IONM, including the classification of reversible IONM changes, and variability in reference standards. ConclusionsThe STARD-IONM framework addresses critical gaps in the reporting of diagnostic accuracy studies involving IONM. It represents an application of the STARD criteria, wherein the original checklist has been adapted and supplemented with guidelines for IONM studies. SignificanceStandardized reporting will facilitate enhanced adherence to methodological standards, increase reproducibility and strengthen the evidence base for the safe and effective use of IONM, which is expected to improve clinical decision-making.

BackgroundCavernous sinus dural arteriovenous fistulas (CS-DAVFs) present significant treatment challenges when the inferior petrosal sinus (IPS) is not opacified during cerebral angiography. However, the widely accepted transvenous IPS recanalization approach is associated with a high failure rate. The consistently visible superior ophthalmic vein (SOV) offers a promising alternative, though it has yet to be fully evaluated in large-scale studies. MethodsThis retrospective, case-control study was conducted between May 2017 and October 2024. Data collection for this multicenter, population-based study took place across eight tertiary referral centers. Eligible patients were diagnosed with CS- DAVF with occluded IPS. Endovascular treatment via the transvenous SOV approach versus the IPS recanalization approach in patients with occluded IPS. ResultsOf 178 eligible cases, 70 cases (39.3%) were treated using the transvenous SOV approach, while 108 cases (60.7%) underwent the transvenous IPS approach. The initial treatment success rate was significantly higher in the SOV group compared to the IPS group (91.4% vs. 75.9%; odds ratio [OR], 3.38; 95% CI, 1.30-8.35; P = 0.0092). The overall complication rate was 1.4% in the SOV group and 2.8% in the IPS group (OR, 0.51; 95% CI, 0.04-3.47; P > 0.9999). After classifying the SOV approach into simple and complex types, the SOV-simple type further demonstrated significant advantages, including shorter average operation times (126.20 {+/-} 46.99 minutes, P = 0.0197) and a higher initial treatment success rate (95.7%, P = 0.0027) compared to the IPS group. ConclusionThe SOV approach should be considered a first-line treatment for CS- DAVF patients with invisible IPS. These findings establish a new treatment standard, underscoring the importance of precise preoperative classification and individualized surgical planning.

Background and ObjectivesTraditional medical board examinations present clinical information in static vignettes with multiple-choices, fundamentally different from how physicians gather and integrate data in practice. Recent advances in Large Language Models (LLMs) offer promising approaches to creating more realistic clinical interactive conversations. However, these approaches are limited in neurosurgery, where patient communication capacity varies significantly and diagnosis heavily relies on objective data like imaging and neurological examinations. We aimed to develop and evaluate a multi-AI agent conversation framework for neurosurgical case assessment that enables realistic clinical interactions through simulated patients and structured access to objective clinical data. MethodsWe developed a framework to convert 608 Self-Assessment in Neurological Surgery (SANS) first-order diagnosis questions into conversation sessions using three specialized AI agents: Patient AI for subjective information, System AI for objective data, and Clinical AI for diagnostic reasoning. We evaluated GPT-4os diagnostic accuracy across traditional vignettes, patient-only conversations, and patient+system AI interactions, with human benchmark testing from ten neurosurgery residents. ResultsGPT-4o showed significant performance drops from traditional vignettes to conversational formats in both multiple-choice (89.0% to 60.9%, p<0.0001) and free-response scenarios (78.4% to 30.3%, p<0.0001). Adding access to objective data through System AI improved performance (to 67.4%, p=0.0015 and 61.8%, p<0.0001, respectively). Questions requiring image interpretation showed similar patterns but lower accuracy. Residents outperformed GPT-4o in free-response conversations (70.0% vs 28.3%, p=0.0030) using fewer interactions and reported high educational value of the interactive format. ConclusionsThis multi-AI agent framework provides both a more challenging evaluation method for LLMs and an engaging educational tool for neurosurgical training. The significant performance drops in conversational formats suggest that traditional multiple-choice testing may overestimate LLMs clinical reasoning capabilities, while the frameworks interactive nature offers promising applications for enhancing medical education.

Spinal cord injury (SCI) is a devastating neurological injury that results in the profound loss of voluntary motor function and marked reduction in quality of life. Rehabilitation remains as the standard of care for recovery after SCI; however, it often falls short in recovering meaningful motor function. Spinal cord stimulation (SCS) has emerged as a promising neurostimulation approach to fill this gap and recover lost voluntary motor function. Two main approaches of SCS have been designed and implemented for human use: epidural and transcutaneous SCS. Over the last two decades, several clinical studies have shown convincing evidence that both epidural and transcutaneous SCS can be used in conjunction with rehabilitation to improve motor function of individuals after SCI. Yet fundamental clinical questions remain unanswered: when should clinicians choose epidural or transcutaneous SCS, which technique provides the most durable outcomes, and for whom is each therapy best? Without these answers, widespread and meaningful adoption of either approach into clinical practice will remain limited. To address these questions, in this Review, we define the distinct therapeutic goals, intended use cases, clinical parameters, and responder profiles for both epidural and transcutaneous SCS to guide their eventual adoption into clinical practice. We found that indeed epidural and transcutaneous SCS serve distinct therapeutic roles. Epidural SCS is designed as an assistive therapy that can restore muscle activity and single joint movements immediately within one week of implantation, while transcutaneous SCS is designed as a long-term therapeutic device with cumulative functional gains observed over treatment periods of up to 18 weeks. Lastly, epidural SCS produced benefits for all participants (AIS A-D) despite the extent of their injury, while transcutaneous SCS only consistently benefits individuals with incomplete motor injuries (AIS C-D).

Background and ObjectivesThere is growing interest in thalamic sampling during epilepsy stereoelectroencephalography (sEEG). Data on thalamic sEEG safety, accuracy, and anterior (ANT), centromedian (CM), and pulvinar (PUL) nucleus connectomics is scarce. Here, we report the safety, accuracy and connectivity of thalamic sEEG and compare results to epilepsy DBS. MethodsThis single-center study included all patients with epilepsy implanted with thalamic sEEG or DBS between 2018 and 2024. Stereo-EEG surgery used a frameless stereotactic articulating arm, 3D printed stereotactic guide, or robot (sEEG lead diameter 0.8mm). DBS surgery used a rigid frame and cannula (1.81mm outer diameter). Post-surgical complications were identified by chart and imaging review. For each thalamic lead, accuracy was defined as the distance from the nearest electrode contact to the targeted nucleus Morel atlas volume (ANT, CM, or PUL), using an open-source toolbox. Estimated volumes of tissue activation/sampling were calculated for each most proximate contact for thalamocortical connectivity analysis. Connectivity analyses used a normative structural connectome, and connectivity patterns were compared. Results160 thalamic sEEG leads and 188 DBS leads were implanted across 109 and 83 patients, respectively. One sEEG patient (0.9%) developed a symptomatic intraparenchymal hemorrhage with transient weakness of the contralateral upper extremity. Eight patients with DBS had transient post-surgical symptomatic complications, three with radiographic findings. Targeting accuracy was excellent for sEEG and DBS with median proximity of 0.30mm and 0.23mm, respectively; sEEG was associated with greater variability and more outliers (proximity[&ge;]3mm; 4% vs. 0, p=0.004). Thalamocortical connectivity patterns were highly consistent between sEEG and DBS cohorts with excellent overlap for ANT, CM and PUL subgroups (Spearmans {rho}=0.86-0.98, p<1e-5). The ANT subgroup showed preferential connectivity to prefrontal and mesial temporal cortices; CM with perirolandic cortex, supplementary motor area, and subcortical regions; and PUL with mesial and neocortical temporal, and parieto-occipital regions, with some territories of overlap or under-engagement. DiscussionThalamic sEEG demonstrates a favorable safety profile, excellent targeting accuracy, and representative thalamocortical network engagement relative to DBS. Favorable sEEG safety profile may reflect difference in lead cross-sectional area (5.1-fold smaller than DBS cannula). Distinct ANT, CM, and PUL thalamocortical connectivity profiles support individualized, hypothesis-driven targeting.

High-density electrophysiological recording using Neuropixels probes enables single-unit resolution of human neural activity. However, integrating these systems into clinical environments remains challenging. Reported human recordings have been limited to a few centres in the United States utilising variable regulatory, sterilisation and operative techniques. Here, we present human Neuropixels recordings under a nationally managed ethical and regulatory framework in the United Kingdom. We provide a reproducible roadmap to overcome regulatory and equipment constraints. Guided by the IDEAL Stage 2a (Development) framework, we established a frameless intraoperative workflow utilising manufacturer-sterilised probes and a commercially available, clinical-grade setup for Neuropixels insertion including micromanipulator and endoscope holder. We prospectively evaluated this workflow across six participants (mean age 62.5 years) undergoing elective ventriculoperitoneal shunt surgery. Iterative failure-mitigation cycles successfully resolved key technical barriers, including neuronavigation interference and hardware instability. Assessed across three predefined endpoints (clinical safety, procedural timing, and neural data yield), the workflow achieved zero research-related adverse events and maintained a strict 30-minute procedural extension. Progressive technical refinements increased single-unit yield from 25 units during early development to 146 manually curated units. This approach provides a scalable, clinically integrated workflow to safely perform high-density electrophysiology in routine neurosurgical environments.

Cervical nerve blocks require high precision due to the proximity of critical structures, such as the spinal cord and the vertebral and carotid arteries. Training opportunities are limited by the risks associated with fluoroscopy-guided procedures, ethical constraints of cadaveric models, and the high cost of commercial simulators. Three-dimensional (3D) printing offers an accessible and customizable alternative for procedural training. A cervical spine simulator was constructed from a multislice CT scan. The cervical spine (C1-C7) was segmented using 3D Slicer and processed in Meshmixer to generate an anatomical 3D model, which was printed in PLA. Soft tissues were reproduced using a ballistic gel formulation composed of glycerin, gelatin, and propylene glycol. Six physicians participated in a five-week training program performing facet, indirect, and direct cervical root blocks under fluoroscopy. Knowledge was assessed pre- and post-training, performance was assessed weekly using OSATS, and validity was evaluated through a Likert-scale survey. This 3D-printed cervical simulator proved to be a valid, low-cost, and reproducible tool for training fluoroscopy-guided cervical nerve blocks.

BackgroundChronic subdural hematoma (CSDH) is characterized by the collection of blood beneath the dura mater. Traditional treatments involve surgical drainage of the hematoma, but recurrence rates can be high. A highly vascularized neo-membrane irrigated by the middle meningeal artery (MMA) may be involved in CSDH re-accumulation. ObjectiveWe conducted a systematic review and meta-analysis of studies that compared the efficacy and safety of MMA embolization to conventional treatment alone for CSDH. Material and MethodsA systematic search of PubMed, Embase Ovid, and ClinicalTrials.gov identified observational and randomized clinical studies comparing MMA embolization to conventional treatment for chronic subdural hematoma. The efficacy outcomes were hematoma recurrence and good functional outcome (as defined by a modified Rankin Scale score (mRS) of 0-2). Safety outcomes were the rate of major complication and mortality. Heterogeneity among studies were evaluated using the I2 statistic. Analyses were conducted using Cochrane Review Manager software, with risk ratios (RR) and 95% confidence intervals (95% CI) presented for key outcomes. Absolute risk reduction (ARR, 95% CI) 1000 patients were also calculated using GRADEpro software. ResultsThe analysis included data from 13 studies (4 RCTs and 9 observational studies) with a total number of 2960 patients (35.3% in the MMA group and 64.7% in the conventional treatment group). Compared to conventional treatment, MMA embolization decreased risk of hematoma recurrence by 60% (13 studies, RR=0.40, 95% CI 0.25-0.63; I2=50%), for an absolute effect of 119 fewer events/1000 patients (95% CI 70-149), with similar risk of major complications (9 studies, RR=0.82, 95% CI=0.54-1.25) and mortality risk (13 studies, RR=0.90, 95% CI=0.54-1.51). In subgroup analyses by study type, pooled results from RCTs showed similar direction effects as those from observational studies for both efficacy and safety outcomes. ConclusionMMA embolization in CSDH management is a safe and effective approach for CSDH.

Background and AimsNeuropathic pain after peripheral nerve injury (PNI) severely degrades quality of life. Peripheral nerve stimulation (PN-Stim) offers a potential treatment for pain relief after PNI, although its efficacy in managing neuropathic pain post-nerve repair surgery remains unexplored. MethodsWe analyzed 16 consecutive patients aged 18 and above who received PN-Stim implantation post-nerve repair surgery. Patients under 18 years of age, pregnant, and those with PN-Stim for off-label uses were excluded from our study. The primary outcome was pain score reduction, which was evaluated by Visual Analog Scale (VAS). The secondary outcomes included motor functional recovery and opioid usage which were evaluated by manual muscle testing (MMT) and Morphine Milligram Equivalents (MME) quantification, respectively. Statistical analyses utilized paired two-tailed T-tests and Wilcoxon sign tests, contingent on data normalcy. ResultsPain scores decreased significantly post-PN-Stim implantation (mean pre-placement: 7.35, post-placement: 2.56; p < 0.05). MMT scores showed improvement in 13 patients, with two achieving the maximum MMT score (p < 0.05). Chronic opioid usage was observed to decrease in 6 out of 7 patients who were using them (p < 0.05). No significant adverse effects were seen after implantation. InterpretationThe results suggests that PN-Stim is a safe and effective treatment for reducing pain in patients with PNI who have undergone post-nerve repair surgery, without interfering with motor recovery. Future prospective research to explore the role of PN-Stim in pain management and its interaction with functional recovery is warranted.

BackgroundUnruptured arteriovenous malformations (AVMs) carry a 1% risk of annual risk of hemorrhage; however, risk of re-hemorrhage is significantly higher after an initial rupture. Ruptured AVMs can cause significant morbidity and mortality. The Ruptured Arteriovenous Malformation Grading Scale (RAGS) was developed to better predict outcomes in patients with ruptured AVMs. However, the reliability of this scale has yet to be confirmed to support its use in clinical practice. ObjectiveTo determine the intra- and inter-rater reliability of RAGS among those most likely to use it in clinical practice. MethodsA cross-sectional sample of 42 patients with ruptured AVMs was selected via retrospective review, and clinical vignettes were created. Five raters were chosen to assign a RAGS score to all 42 patients to assess the inter-rater reliability of RAGS. After two months, ten patients from the study sample were randomly selected to be re-rated to determine the intra-rater reliability of RAGS. ResultsThe overall agreement rate was 97.2% among all raters. The inter-rater reliability was found to be substantial when measured using Cohen/Congers Kappa (0.73, 95% confidence interval (CI) [0.63, 0.82]), Scott/Fleiss Kappa (0.72, 95% CI [0.62, 0.82]), Krippendorfs Alpha (0.73, 95% CI [.63, 95% CI [0.63, 0.82]), intraclass correlation coefficient (ICC) (0.78, 95% CI [0.68, 0.86]), and Kendalls W (0.79, 95% CI [0.68, 0.86]) and almost perfect using Gwets AC (0.90, 95% CI [0.88, 0.93]). The test-retest percent agreement was between 94.7% and 98.1% among raters. ConclusionsThe RAGS classification system is highly reliable and has substantial to near-perfect agreement among raters with different expertise levels and specialties. This study supports the potential use of RAGS in clinical practice across different institutions. The overall agreement rate was 97.2% among all raters. The inter-rater reliability was found to be substantial when measured using Cohen/Congers Kappa (0.73, 95% confidence interval (CI) [0.63, 0.82]), Scott/Fleiss Kappa (0.72, 95% CI [0.62, 0.82]), Krippendorfs Alpha (0.73, 95% CI [.63, 95% CI [0.63, 0.82]), intraclass correlation coefficient (ICC) (0.78, 95% CI [0.68, 0.86]), and Kendalls W (0.79, 95% CI [0.68, 0.86]) and almost perfect using Gwets AC (0.90, 95% CI [0.88, 0.93]). The test-retest percent agreement was between 94.7% and 98.1% among raters.

Objective: Neuroendoscopy has emerged as a crucial minimally invasive strategy for the treatment of intracranial hemorrhage (ICH). This bibliometric analysis aims to systematically delineate the global research architecture and evolution of neuroendoscopic ICH research over the past two decades. Methods: Relevant publications were retrieved from the Web of Science Core Collection using a reproducible search strategy. Bibliometric tools were applied to analyze contributions from countries, institutions, authors, publications, keywords and journals, enabling the construction of a comprehensive knowledge map and evolutionary framework of this field. Results: A total of 403 articles were identified, involving 2128 authors from 555 institutions across 43 countries. The publication trajectory exhibited fluctuating growth, reflecting the dynamic interplay between clinical demand and technological maturation. China contributed the highest publications and citation impact, followed by the US, jointly anchoring the global influence of the field. The research keywords have evolved from ?intracerebral hemorrhage? and ?initial conservative treatment? to ?augmented reality.? Thematic evolution analysis revealed a clear progression from early emphasis on operative feasibility, safety, and perioperative outcomes toward more rigorous evidence appraisal and the refinement of context-specific clinical indications, accompanied by continuous technological innovation. Conclusion: These findings collectively position neuroendoscopy as a cornerstone of modern ICH management, reshaping clinical strategies toward precision, minimal invasiveness, and multimodal intervention. Future progress will depend on strengthened international collaboration to generate high-quality evidence that supports patient stratification. The integration of emerging technologies, including advanced endoscopic robotics, is expected to further accelerate the translational and clinical landscape of neuroendoscopic ICH therapy.

Directional brain stimulation provides greater control of radial current spread than conventional ring-shaped electrodes. Whether this added flexibility can improve motor function is unclear. Here we examine whether directional and circular stimulation differentially change motor performance in patients with Parkinsons disease. We measured motor behaviors in 31 patients who underwent unilateral subthalamic nucleus brain stimulation surgery (SUNDIAL, NCT03353688) from each of 8 configurations (6 directional contacts and their corresponding rings) during device activation. Objective measures of dexterity, gait, balance, and overall mobility were queried in a double-blind fashion in the practically defined "off" medication state versus preoperative baseline with stimulus amplitude at the center of the therapeutic window. The best versus the worst directional contact on a given row yields significant changes in performance across 5 motor tasks (p<0.001 each task). Specific stimulation directions can worsen function versus baseline, whereas the best direction yields greater improvement than ring stimulation (p=0.005, p=0.001, p=0.007, p<0.001, respectively, across tasks). Although directional DBS improves side effect thresholds versus ring stimulation (p<0.001), the side effect threshold and therapeutic window correlate only modestly with motor improvements. Resting beta power did not predict motor improvements by directional DBS across any of the motor tasks. Optimized directional subthalamic nucleus DBS yields better group-level motor performance than ring stimulation, in addition to known advantages related to tolerability. Prospective studies should evaluate whether these improvements persist over longer time intervals.

Background: Vertebroplasty and balloon kyphoplasty are used for symptomatic vertebral hemangiomas, although comparative evidence is limited. We summarized pain relief, cement leakage, and recurrence after vertebral augmentation and assessed whether direct comparison of the two techniques was feasible. Methods: Five databases were searched from inception to January 2, 2026, with an update on July 5, 2026. Because only one small cohort directly compared vertebroplasty with kyphoplasty, outcomes were pooled as single-arm proportions or, for early pain change, as a mean difference using random-effects models. Prespecified subgroup, sensitivity, small-study effect, and influence analyses were performed. Results: Forty-four studies were included: 33 case series, 10 cohort studies, and one randomized trial. Kyphoplasty-specific evidence comprised one dedicated series and one comparative cohort. Any cement leakage occurred in 10.5% of patients (14 studies; 95% CI 5.7-18.4%), while trim-and-fill gave an exploratory adjusted estimate of 20.4%. Early pain reduction averaged 5.13 points on a 0-10 scale (8 studies; 95% CI 4.48-5.77; I2=89.4%). Complete or near-complete pain relief occurred in 79.4% of patients (10 studies), and recurrence, progression, or retreatment occurred in 3.9% (13 studies). Symptomatic cement leakage was uncommon at 0.4%. Conclusion: The available literature, which is mainly retrospective and vertebroplasty-based, supports substantial pain relief with infrequent symptomatic complications. Kyphoplasty data remain insufficient for a reliable technique comparison. Prospective studies with standardized clinical and imaging outcomes are needed.

Recovery of hand and arm function is critical for improving quality of life in individuals with tetraplegia due to spinal cord injury (SCI). Nerve transfer procedures can restore meaningful hand and arm function in chronic SCI, yet postoperative outcomes vary widely. We conducted a prospective, single-arm, open-label trial to assess the impact of intensive, robot-assisted rehabilitation training on functional recovery and cortical reorganization following nerve transfer. The primary endpoint was assessment of hand and arm function measured by the Box and Blocks Test. We report the results from three participants, AIS A at enrollment, who completed six weeks of intensive robotic training at least 1 year after nerve transfer surgery (NCT04041063). All participants demonstrated minimally important difference improvements in at least one secondary clinical outcome. These improvements were accompanied by cortical reorganization measured by transcranial magnetic stimulation motor mapping, indicating integration of the newly established peripheral motor pathways. No serious adverse events related to surgery or rehabilitation occurred. Although recruitment was limited by the COVID-19 pandemic and precludes definitive conclusions regarding efficacy, these findings suggest that standardized, intensive robotic rehabilitation may enhance functional outcomes after nerve transfer surgery for chronic tetraplegia.