Search Results (105)

Background/Objectives: Adult patients supported with extracorporeal membrane oxygenation (ECMO) frequently require invasive diagnostic, therapeutic, surgical, or bedside procedures during ongoing extracorporeal support. These procedures are clinically challenging because ECMO-related anticoagulation, platelet dysfunction, acquired coagulopathy, and circuit-related coagulation activation may increase both bleeding and thrombotic risks. This systematic review evaluated the safety of invasive procedures performed during adult ECMO support, excluding tracheostomy/tracheotomy because this procedure has recently been addressed in a dedicated systematic review. Methods: A systematic search of PubMed/MEDLINE and Scopus was performed. The final bibliographic data collection was completed in April 2026. Studies were eligible if they included adult ECMO or extracorporeal life support patients undergoing invasive procedures during ongoing ECMO support, or with ECMO used as procedural support, and reported at least one procedure-specific safety outcome. Primary outcomes were procedure-related complications, bleeding, major bleeding, and transfusion requirements. Secondary outcomes included thrombotic and circuit-related complications, oxygenator exchange, reintervention, reoperation, procedural failure, ECMO duration, intensive care unit and hospital length of stay, and mortality. Results: The final qualitative synthesis included 46 studies, comprising 26 studies from PubMed/MEDLINE and 20 additional unique studies from Scopus. Included procedures were grouped into six domains: airway, bronchoscopic, and tracheobronchial procedures; thoracic surgery and lung resections; abdominal surgery, gastrointestinal endoscopy, and decompressive laparotomy; lung transplantation and perioperative extracorporeal life support; cardiovascular, vascular, pulmonary embolism-related, and mechanical circulatory support-related procedures; and mixed non-cardiac surgery. Airway and bronchoscopic procedures generally showed high procedural success in selected cohorts, although registry-level tracheal procedure data reported hemorrhagic complications in 26.0% and surgical-site bleeding in 13.0%. Emergency thoracic and abdominal procedures carried the highest bleeding, transfusion, reintervention, and mortality burden. Lung transplantation studies showed that ECMO can be integrated into perioperative pathways, but hemothorax, transfusion, thromboembolism, and anticoagulation strategy remained central safety issues. Conclusions: Invasive procedures during adult ECMO are feasible in selected patients and experienced centers, but procedural safety varies markedly by procedure type, urgency, baseline disease severity, and anticoagulation strategy. A procedure-centered, multidisciplinary approach with individualized anticoagulation management and careful planning is essential. Full article

Background/Objectives: To determine whether ESS provides superior clinical, radiologic, or perioperative outcomes compared with non-ESS surgical strategies in lumbar spondylolisthesis. Methods: We conducted a PRISMA-guided systematic review and meta-analysis comparing ESS with non-ESS strategies specifically for lumbar spondylolisthesis. PubMed, Web of Science, Scopus, and CENTRAL were searched from inception to December 2025, plus reference-list screening. Primary outcomes were mean change in VAS back pain, VAS leg pain, and Oswestry Disability Index (ODI); secondary outcomes included radiologic measures (disc height, lumbar lordosis angle, fusion rate) and perioperative outcomes (blood loss, operative time, length of stay, complications). Results: Eighteen studies (16 retrospective cohorts, 1 RCT, 1 case–control) involving 1200 patients with lumbar spondylolisthesis (2019–2025) were included. ESS showed no significant differences versus non-ESS in mean change in VAS back pain (13 studies; MD −0.07), VAS leg pain (14 studies; MD 0.08), or ODI (12 studies; MD 0.51). No statistically significant differences were detected in radiological outcomes (disc height, lumbar lordosis angle, and fusion rate). ESS was associated with reduced blood loss (MD −132.98) and shorter hospital stay (MD −2.86 days), with no difference in operative time (MD 3.96) or postoperative complications (RR 0.86). Subgroup analyses compared endoscopic fusion with MIS fusion, open fusion, and non-endoscopic decompression. Endoscopic versus MIS fusion showed lower blood loss (MD: −50.9 mL) and shorter hospital stay (MD: −1.4 days) but longer operative time (MD: +17.2 min), with no differences in clinical outcomes. Comparisons involving decompression and open fusion were limited by the small number of studies and should be considered exploratory. Conclusions: For lumbar spondylolisthesis, no statistically significant differences were detected between ESS and non-endoscopic approaches in pain, disability, radiologic outcomes, or complication rates, with potential perioperative advantages in blood loss and length of stay. However, these findings should be interpreted cautiously because the available evidence is predominantly retrospective, procedurally heterogeneous, and affected by substantial variation in follow-up duration. Full article

Background and Clinical Significance: Mandibular cystic lesions are heterogeneous in biologic behavior, radiologic appearance, and surgical management. Treatment selection is influenced by lesion extent, cortical bone condition, structural stability, and proximity to adjacent teeth and vital anatomical structures. In large mandibular lesions, case-specific decision-making may range from staged decompression or marsupialization to single-stage enucleation, peripheral ostectomy, graft-assisted reconstruction, and preventive mandibular plating (PMP). Case Presentation: In the first case, a 60-year-old female presented with bilateral mandibular lesions: a dentigerous cyst on the right side, treated with marsupialization followed by enucleation, and a contralateral glandular odontogenic cyst (GOC) managed with primary enucleation alone. The second case involved a large, unilateral odontogenic keratocyst (OKC) managed with a radical approach, including enucleation followed by peripheral ostectomy and PMP. Histopathologic evaluation was performed in both cases to confirm diagnosis and support definitive treatment planning. Radiologic follow-up at 1 year demonstrated bone regeneration in all treated sites. Conclusions: This case report presents two different clinical cases involving three mandibular cystic lesions managed according to case-specific surgical indications and evaluated with standardized postoperative panoramic and CBCT imaging; limited supportive assessment of trabecular bone remodeling was also performed to further characterize radiologic healing patterns. The authors aimed to descriptively document postoperative bone condition, radiologic healing, and patient safety in these cases, and to highlight the most important surgical and radiological findings that may influence case-specific clinical decision-making. Full article

Background: Optimal biliary drainage in unresectable malignant hilar obstruction remains challenging, particularly in Bismuth type III disease due to complex biliary anatomy. Emerging evidence suggests that the adequacy of biliary decompression may be more important than the drainage modality itself in determining clinical outcomes. Aim: To compare the effectiveness of endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) in unresectable Bismuth type III malignant hilar obstruction, with particular emphasis on drainage adequacy. Methods: This retrospective two-center study included 199 patients with unresectable Bismuth type III malignant hilar obstruction (ERCP: n = 102; PTBD: n = 97). Drainage adequacy was defined as decompression of at least 50% of the non-atrophic liver using a segment-based anatomical approach. Bilirubin response was evaluated at predefined time points (days 7, 14, and 28). The primary outcome was biochemical response, while secondary outcomes included reintervention, complications, hospital stay, receipt of systemic therapy, and mortality. Results: Baseline characteristics were comparable between groups (mean age 66.8 ± 11.2 vs. 68.4 ± 10.7 years, p = 0.412; male sex 58.3% vs. 61.5%, p = 0.721). PTBD achieved significantly higher rates of adequate drainage than ERCP (p = 0.006). Although biochemical response rates were numerically higher in the PTBD group, multivariable analysis identified drainage adequacy—rather than drainage modality—as the strongest independent predictor of treatment success. Reintervention rates were significantly higher and time to reintervention significantly shorter in the ERCP group (p < 0.001). Cholangitis and post-procedural pain scores were more frequent following PTBD, whereas post-ERCP pancreatitis occurred exclusively after ERCP. No significant differences were observed in 30-day or 1-year mortality between groups. Conclusions: In unresectable Bismuth type III malignant hilar obstruction, drainage adequacy appears to be the principal determinant of clinical success. Although PTBD more frequently achieves adequate biliary decompression, outcomes seem to depend primarily on the effectiveness of drainage rather than the drainage modality itself. Full article

Background/Objectives: Intraoperative ultrasound was explored in the 1980s to assess lumbar spinal decompression; however, conventional probes require large bony windows and are poorly suited for minimally invasive surgery. This technical note evaluates the feasibility of intraoperative intraspinal endosonography (IOISES) using a miniaturized linear ultrasound probe introduced directly into the spinal canal through a microsurgical access corridor. Methods: This observational feasibility study included two patients undergoing lumbar spine surgery (microdiscectomy for disc herniation and decompression for spinal stenosis). After decompression and hemostasis, a miniaturized linear probe (Fujifilm L51K) connected to an Arietta A65 system was inserted into the spinal canal via an extended interlaminar approach. Imaging was performed prior to wound closure. The primary outcome was the technical feasibility of probe insertion and image acquisition. The secondary outcomes included intraoperative usability, visualization of neural structures, and integration into the surgical workflow. Results: Probe insertion and imaging were successful in both cases (100%). IOISES enabled high-resolution visualization of the dural sac and nerve roots, allowing intraoperative visualization of the extent of decompression. Probe handling and rotation were feasible without forced manipulation. No adverse events occurred, and the technique was integrated into the surgical workflow without prolonging operative time. Conclusions: IOISES is technically feasible and enables real-time intraspinal visualization during minimally invasive spinal surgery. This approach represents a shift from extraspinal to intraspinal ultrasound imaging. Further studies are required to evaluate reproducibility and clinical impact. Full article

Background: Trigeminal neuralgia (TN) is clinically defined, but patients presenting to tertiary practice with trigeminal-region pain are often diagnostically heterogeneous and may follow prolonged medication, dental, imaging, and procedural pathways before a stable phenotype is established. We aimed to characterize diagnostic phenotypes, secondary causes, and treatment-escalation patterns in a large retrospective tertiary-center trigeminal pain cohort derived from routine free-text clinical documentation. Methods: We conducted a retrospective single-center cohort study based on a clinical dataset containing 18,007 note fragments linked to 672 unique patient records between 12 October 2010 and 21 April 2026. A rule-based natural-language-processing-assisted chart review framework was used to identify patients with trigeminal pain and to extract documentation-derived demographic features, pain distribution, secondary causes, dental pathway variables, imaging signals, medication exposure, procedures, and outcome language. Patients were grouped into primary/classical TN, secondary TN/trigeminal pain, and dental-first or mimic pathways using predefined operational criteria. Results: A total of 455 patients met criteria for the analytic trigeminal pain cohort; 311 (68.4%) carried explicit TN terminology. Mean age was 58.7 years, median age 60 years, and 267 of 428 patients with recoverable sex data (62.4%) were women. Trigeminal branch involvement could be extracted in 351 patients (77.1%), with V2 involvement documented in 256 (56.3%), V3 involvement in 218 (47.9%), and V1 involvement in 138 (30.3%). The final NLP-derived phenotypic distribution comprised 201 primary/classical TN cases (44.2%), 146 secondary TN/trigeminal pain cases (32.1%), and 108 dental-first or mimic presentations (23.7%). MRI was documented in 384 patients (84.4%), neurovascular conflict or vascular loop in 253 (55.6%), multiple-sclerosis-related disease in 69 (15.2%), and tumor-related trigeminal involvement in 84 (18.5%). Prior dental evaluation was identified in 169 patients (37.1%), and prior dental procedures in 114 (25.1%). Carbamazepine exposure was documented in 367 patients (80.7%), pregabalin in 221 (48.6%), gabapentin in 150 (33.0%), oxcarbazepine in 116 (25.5%), and phenytoin in 73 (16.0%). At least one invasive or image-guided procedure was documented in 390 patients (85.7%), including nerve blocks/injections in 355 (78.0%), radiofrequency procedures in 126 (27.7%), balloon compression in 90 (19.8%), microvascular decompression in 113 (24.8%), and stereotactic radiosurgery in 55 (12.1%). Dental-first patients were significantly more likely to have undergone prior dental procedures (65.7% vs. 3.5% in primary/classical TN and 24.7% in secondary TN; p < 0.001), whereas secondary TN/trigeminal pain was associated with higher use of radiofrequency procedures (36.3%; p = 0.017), higher use of stereotactic radiosurgery (19.9%; p = 0.002), higher recurrence documentation (70.5%; p = 0.001), and a higher rate of complete pain relief documented at last follow-up (46.6%; p = 0.004). Conclusions: In tertiary practice, trigeminal pain is substantially broader than a formal TN label. Secondary disease and dental-first pathways account for a large fraction of referrals, and management is characterized by heavy medication burden, frequent escalation, and recurrent retreatment. A structured phenotyping approach may help convert routine clinical documentation into a clinically meaningful framework for diagnostic triage and treatment selection, although imaging and outcome variables require cautious interpretation when derived from retrospective free text. Full article

Delayed decompression for metastatic epidural spinal cord compression (MESCC) is a common real-world problem, yet short-interval recovery after patients have already remained nonambulatory for at least 48 h is poorly defined. We retrospectively evaluated 41 surgically selected patients with MRI-confirmed epidural MESCC (Bilsky grade 2–3) and preoperative nonambulatory neurological deficit (Frankel grades A–C) lasting at least 48 h. The primary outcome was early neurological improvement, defined as a gain of at least one Frankel grade by postoperative days 10–14. The secondary outcome was early ambulation recovery, defined as postoperative Frankel grade D or E at the same interval. Early neurological improvement occurred in 20/41 patients (48.8%), and early ambulation recovery occurred in 15/41 (36.6%). No patient received postoperative index-level radiotherapy before the POD10–14 neurological assessment. Recovery was most common among patients with baseline Frankel grade C. In exploratory adjusted Firth-penalized models, ECOG performance status 3–4 was associated with lower odds of both outcomes. Rapid-growth tumors, classified using a pragmatic adapted growth-category framework, were associated with lower odds of early neurological improvement. Baseline Frankel grade C favored early ambulation recovery. Higher standardized HALP showed an exploratory association with early neurological improvement but did not alter the main clinical interpretation. Meaningful early recovery was observed in a subset of surgically selected MESCC patients despite delayed surgery, although these findings do not establish equivalence to earlier surgery or isolate the effect of surgery from multimodal oncologic care. Full article

Background and Objectives: Urosepsis is a common cause of sepsis in adults and is associated with substantial morbidity and mortality, particularly when urinary obstruction delays timely source control. The roles of diagnostic uncertainty at presentation, microbiological phenotypes (including multidrug resistance), and biomarkers in shaping management pathways and outcomes warrant further evaluation. Materials and Methods: This retrospective, single-center, observational study included 154 consecutive adult patients hospitalized for urosepsis. Sepsis was defined according to the Sepsis-3 criteria. Baseline clinical modifiers at admission were encoded as binary variables (e.g., malignancy, urinary tract obstruction/altered anatomy, immunocompromised status, acute kidney injury [AKI], and diagnostic uncertainty). Microbiology was standardized into pathogen groups (Gram-negative, Gram-positive, or no isolate), infection complexity (mono- vs. polymicrobial), and multidrug-resistant organism (MDRO) status. Procedures were categorized as no procedure, urinary tract decompression, or other source controls. Biomarkers (C-reactive protein [CRP], procalcitonin [PCT], and creatinine) were analyzed at admission and, when available, during hospitalization. The primary outcomes were in-hospital mortality, ICU admission, and absence/delay of source control. Results: The median age was 68 years, and 60.4% of patients were male. The in-hospital mortality and ICU admission rates were 7.1% and 3.9%, respectively. Diagnostic uncertainty was present in 9.8% and was associated with a higher likelihood of no invasive intervention (86.7% vs. 43.9%, p = 0.002) and a lower rate of urinary tract decompression (13.3% vs. 45.3%, p = 0.01). Gram-negative pathogens predominated (50.0%), and MDROs were identified in 18.2% and were associated with prior urological interventions (53.6% vs. 24.6%, p = 0.003) and higher admission PCT levels (8.6 vs. 3.2 ng/mL, p = 0.04). Bacteremia was associated with mortality (14.5% vs. 2.2%, odds ratio [OR] 7.64, p = 0.007). Mortality was higher in Gram-positive infections (21.7% vs. 4.6%, OR 5.79, p = 0.012) and in patients with AKI at admission (25.0% vs. 5.7%; OR, 5.54; p = 0.043). Conclusions: Urosepsis exhibits distinct clinical and microbiological phenotypes that influence its management and outcomes. Diagnostic uncertainty at presentation was associated with reduced early source control measures, whereas MDRO infections were clustered with prior urological interventions and higher systemic inflammatory burdens. Bacteremia, Gram-positive pathogens, and AKI at admission were associated with an increased in-hospital mortality risk. These findings support a multidimensional early assessment strategy integrating clinical presentation, microbiological risk, biomarkers, and rapid evaluation of obstruction to facilitate timely source control. Full article

Background/Objective: Postoperative recovery after spine surgery varies substantially and cannot be fully explained by structural pathology alone. This study evaluates postoperative outcomes using a structured 2 × 2 Surgical Trauma Gradient integrating exposure-related invasiveness (minimally invasive vs. open) and biomechanical strategy (decompression vs. fusion), and examines the modifying role of Type-D personality. Methods: This observational cohort study included 200 patients undergoing elective spine surgery. Patients were stratified into four surgical subgroups: minimally invasive decompression, open decompression, minimally invasive fusion, and open fusion. Primary outcomes included pain intensity (Visual Analog Scale), functional disability (Oswestry Disability Index), patient satisfaction (Patient Satisfaction Index), and postoperative complications at 12-month follow-up. Surgical invasiveness was modeled both categorically and as an ordinal gradient. Multivariable regression, logistic regression, interaction analysis, and longitudinal mixed-effects models were applied. Results: Postoperative outcomes demonstrated a consistent gradient across increasing surgical burden. In multivariable models, higher surgical invasiveness independently predicted greater residual pain (β = 0.69; 95% CI 0.55–0.82; p < 0.001) and higher functional disability (β = 6.20; 95% CI 5.10–7.30; p < 0.001). Increasing invasiveness was also associated with lower patient satisfaction (β = −0.38; 95% CI −0.47 to −0.29; p < 0.001) and higher complication risk (OR = 1.64; 95% CI 1.12–2.41; p = 0.01). Type-D personality independently predicted worse postoperative pain (β = 0.41; p = 0.008) and significantly modified the association between surgical burden and pain (interaction β = 0.22; p = 0.012). Conclusions: Postoperative outcomes follow a structured Surgical Trauma Gradient influenced by both surgical burden and psychosocial vulnerability, particularly Type-D personality. Integrating these dimensions may improve perioperative risk stratification and support individualized treatment strategies. Full article

Background: Aneurysmal subarachnoid hemorrhage (aSAH) remains a devastating neurological condition, with patients presenting with poor-grade aSAH having a particularly limited potential for recovery. Data on outcome trajectories after microsurgical clipping in this subgroup are scarce. The objective of this study was to analyze the functional outcomes in patients with poor-grade aSAH treated with microsurgical clipping, and to identify clinical factors associated with recovery. Methods: This retrospective study included 38 patients (median age 55 years; 60.5% female) with World Federation of Neurosurgical Societies (WFNS) grades 4–5, who underwent microsurgical clipping at a single tertiary care centre between 2016 and 2023. Functional outcome was assessed using the modified Rankin Scale (mRS) at hospital discharge and 6 months follow-up, and functional outcome was analyzed in relation to clinical variables (delayed cerebral ischemia (DCI), intracerebral hemorrhage (ICH), initial seizures, the need for decompressive craniectomy) using correlation and group comparison analyses. Results: The indication for microsurgical clipping was primarily driven by the need for ICH evacuation (50%) or by aneurysm configuration (47.5%). Microsurgical aneurysm clipping was performed on the day of hemorrhage in 25 patients (65.8%), with 16 patients (42.1%) undergoing immediate surgery following direct transfer from the emergency department to the operating theatre. ICH was present in 60.5% and IVH in 92.1%. Decompressive craniectomy was performed in 42.1%. DCI occurred in 21.6% of patients. In-hospital mortality was 15.8%, increasing to 22.6% at 6 months follow-up. Good functional outcome (mRS 0–2) was observed in 10.5% of patients at discharge and improved to 25.8% at 6 months. At hospital discharge, higher mRS scores were associated with the need for immediate aneurysm repair (p = 0.04), primary decompressive craniectomy (p = 0.02), and DCI (p = 0.006). Primary decompressive craniectomy (p = 0.04), reflecting greater disease severity, and DCI (p = 0.002) remained associated with worse functional outcome at 6 months. Conclusions: In poor-grade aSAH patients undergoing microsurgical clipping, mortality remains substantial; however, functional recovery may extend beyond hospital discharge. The need for immediate surgical intervention and primary decompressive craniectomy likely reflects a particularly severe hemorrhagic burden in patients and is associated with worse early functional outcomes, whereas DCI remains an important factor in overall functional recovery. Full article

Objectives: This scoping review synthesized the available evidence on bedside ultrasonography used to confirm short-term nasogastric tube (NGT) placement in adults. Methods: The review followed JBI Collaboration methodology. Searches were conducted in CINAHL, Embase, LILACS, PubMed, and Scopus, as well as in gray literature sources (Google Scholar and ProQuest Dissertation & Thesis Global). Primary studies and clinical guidelines addressing bedside ultrasonography for short-term NGT placement in adults (≥18 years) were eligible, with no limits on language or publication year. Data were extracted and narratively summarized with the I-AIM framework (Indication, Acquisition, Interpretation, and Decision-Making). Results: Twenty-nine studies met the inclusion criteria. Most were single-center observational studies performed in intensive care units or emergency departments. Ultrasound was primarily used for confirmation prior to enteral nutrition initiation, while gastric decompression was less frequently reported. Acquisition protocols varied, although supine positioning, convex abdominal probes, and linear cervical probes were most commonly described. The gastric antrum and esophagus were the principal anatomical landmarks, with interpretation based on direct tube visualization and dynamic fogging; color Doppler was occasionally used. Radiography remained the reference standard in most studies, and only a minority initiated feeding based solely on ultrasound findings. Reported facilitators included bedside feasibility, absence of radiation exposure, and timeliness. Barriers included operator dependency, limited visualization in patients with obesity or gas interposition, protocol heterogeneity, and the limited methodological robustness of available studies. Conclusions: Current evidence suggests that ultrasonography may represent a feasible, radiation-free bedside approach for confirmation of NGT placement. Evidence from selected studies suggests that, with structured training, healthcare professionals may achieve diagnostic accuracy in specific clinical settings, although further robust multicenter investigations are needed to confirm these findings. Full article

Background: Chronic sclerosing osteomyelitis of Garré (CSO) is a rare, non-suppurative form of primary chronic osteomyelitis characterized by reactive periosteal bone formation and cortical thickening. It most commonly involves the mandibular bones, whereas long-bone localization is uncommon. Material and Methods: We report a 4-year-old girl who developed progressive right thigh pain and limping six months after receiving intramuscular ampicillin injections. Subsequent evaluation revealed femoral changes consistent with chronic sclerosing osteomyelitis. Surgical decompression and targeted antimicrobial therapy were performed. Results: Microbiological analysis of intraoperative specimens obtained prior to antibiotic therapy yielded Staphylococcus epidermidis (S. epidermidis) and Staphylococcus capitis (S. capitis). After three years of follow-up, the patient exhibited no functional impairment or growth disturbance of the affected limb. Conclusions: Although coagulase-negative staphylococci (CoNS) are commonly regarded as skin commensals, their repeated isolation from deep surgical specimens, together with clinical findings and response to treatment, raises the possibility of their involvement in the disease process in this case. Full article

Background and Clinical Significance: Deep thalamic and periventricular lesions are uncommon in adults but can result in significant loss of function because of their convergence on three interdependent processes: thalamocortical state regulation, throughput of periventricular long association systems, and ventricular compartmental compliance. The resulting combination of executive control collapse, retrieval-weighted language fragility, and load-sensitive gait instability may occur early after a lesion forms an atrial/posterior horn interface, and pressure-linked autonomic symptoms may be late to develop. Screening deficits will likely be minimal and therefore underreported. Objective/Aim: To present a thalamic–atrial/posterior horn tumor case with quantified load-sensitive cognitive–language–gait dysfunction and to detail a physiology-guided, sequence-driven decompression approach emphasizing ventricular relaxation and perforator-preserving, interface-limited thalamic resection. Case Presentation: A 56-year-old female patient experienced a 3-month, rapidly progressive decline in her cognitive and language abilities. The clinical progression was not stepwise or punctuated by a single “sentinel” event. She had a moderate level of cognitive impairment consistent with both Broca’s and Wernicke’s aphasias (MoCA: 22/30) and suffered from significant interference effects and increased cost of task-switching. Her ability to generate novel responses and name objects was significantly impaired; however, she was able to repeat words and phrases appropriately. In addition, she exhibited a severe sustained attention signature and a high error rate during dual-task performance, indicating severe gait instability, although her overall global anchors were nearly neutral (GCS 15; FOUR 15/16; NIHSS 2). Nausea and vomiting occurred simultaneously with the cognitive and language decline, suggesting decreased intracranial compliance. MRI revealed a heterogeneous left-sided thalamic tumor extending into the posterior horn of the lateral ventricle. The tumor caused deformation of the lateral ventricle and midline displacement. The patient underwent microsurgical intervention using a physiology-conscious sequence of graded cerebrospinal fluid (CSF) equilibration and primary mechanical removal of the tumor from the ventricular system. Additionally, decompression of the thalamus was performed in a manner that was cognizant of the boundaries formed by the perforating arteries of the thalamus. Early resolution of pressure symptoms was noted postoperatively. Objective measures demonstrated significant improvement in the patient’s executive functioning, language skills, attentional errors, and dual-task performance stability. The patient remained functionally independent at discharge and at subsequent follow-up visits. Surveillance imaging did not demonstrate any evidence of tumor recurrence. Conclusions: The clinical presentation described above is supportive of a model in which the synergy between deep network damage and distortion of the posterior ventricular compartment amplifies network dysfunction. Additionally, the use of quantitative stress-phenotyping makes it possible to identify deep network pathology early in its course. Finally, the physiology-guided decompression approach that was used in this case has the potential to increase functional reserve in patients with pathology that requires millimeter transitions. Full article

Background/Objectives: Surgical site infection (SSI) remains a significant complication following spine surgery, yet the optimal duration of prophylactic antibiotic administration remains debated. We investigated the association between prophylactic antibiotic duration and SSI rates following spine surgery using a nationwide claims database. Methods: This retrospective cohort study analyzed data from the Health Insurance Review and Assessment Service quality assessment database across four assessment waves (2014–2020, sixth to ninth). Adult patients (aged ≥19 years) undergoing elective spine surgery (decompression, instrumented fusion, vertebroplasty, or kyphoplasty) were categorized into two groups based on prophylactic antibiotic duration: <24 h or ≥24 h. Surgery type was the primary surgical categorization, while surgery site (cervical, thoracic, lumbar) was assessed separately in supplemental analyses. Primary outcomes included SSI, non-surgical-site infections, and total postoperative infections within 3 months. Multivariable logistic regression was performed to identify independent predictors of infection. Results: Of 82,840 patients included, 19,988 (24.1%) discontinued prophylactic antibiotics within 24 h and 62,852 (75.9%) continued antibiotics for ≥24 h. The <24 h group demonstrated significantly lower SSI rates compared to the ≥24 h group (0.16% vs. 1.47%, p < 0.05). After adjustment for confounders, prolonged antibiotic prophylaxis (≥24 h) was associated with increased odds of SSI (adjusted odds ratio [aOR] = 10.73, 95% CI = 7.30–15.79), non-surgical-site infections (aOR = 16.06, 95% CI = 13.11–19.67), and total postoperative infections (aOR = 17.82, 95% CI = 14.83–21.42). Conclusions: In this nationwide cohort, early discontinuation of prophylactic antibiotics within 24 h was not associated with increased SSI risk. Prolonged antibiotic prophylaxis beyond 24 h was associated with higher SSI rates, although confounding by indication likely contributed to this finding. These results are consistent with current guideline recommendations for limiting prophylactic antibiotic duration to 24 h or less in routine spine surgery, while recognizing that individualized approaches may be warranted in some high-risk patients. Full article

Background: Decompressive craniectomy (DC) is a life-saving intervention for refractory intracranial pressure (ICP). While outcomes in adults are well documented, pediatric data, especially concerning pupillomotor dysfunction, remain limited. Anisocoria is generally considered a marker of severe neurological compromise, but its clinical relevance in children undergoing DC has not been adequately studied. Methods: We retrospectively reviewed 25 pediatric patients treated with DC between 2004 and 2024. Demographic, radiological and clinical data included age, sex, hospital stay, operative time, etiology, side of craniectomy, preoperative midline (ML) shift, Marshall score, Rotterdam score, Glasgow Coma Scale (GCS) and pupillary status before surgery. Functional outcomes were assessed using the pediatric version of the Glasgow Outcome Scale Extended (pGOS-E) at discharge, after 3 months, 1, 2 and 4 years. Results: The majority of patients were school-aged children with a median age of 10 (range 0–17) years. Traumatic brain injury accounted for 16 cases and represented the leading etiology for DC. Pupillomotor dysfunction (anisocoria or bilateral fixed pupillary dilatation) was observed in 15 of 25 patients, 47% of whom died during hospitalization, demonstrating a significant association with in-hospital mortality (p = 0.02). However, survivors with primary pupillomotor dysfunction demonstrated a favorable recovery at 12 months with a median pGOS-E of 6 (range 4–8), indicating moderate disability. A preoperative ML-shift > 5 mm was not associated with lower pGOS-E scores during follow-up (p > 0.05). Bone flap autolysis was observed in 12 out of 14 children (86%) receiving autologous cranioplasty, and 8 (57%) patients required revision surgery with synthetic material. Conclusions: In pediatric patients, pupillomotor dysfunction is associated with higher early mortality but does not reliably exclude favorable long-term outcomes. Compared with adult cohorts, children appear to have a greater potential for neurological recovery, suggesting that severe initial clinical findings alone should not preclude timely surgical intervention. Full article