World Neurosurg
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Craniofacial resection has been considered the gold standard in the management of malignancies involving the anterior skull base, where the goal of surgery is negative margins with minimal morbidity. In recent years, there has been growing enthusiasm for purely endoscopic techniques for craniofacial malignancies. Given recent advancements in open surgical approaches, there is a need to review the technique of open craniofacial resection in the modern surgical era. ⋯ Since its introduction more than 50 years ago, craniofacial resection has undergone several important technical advancements concurrent to the introduction of endoscopy. With these improvements, our results indicate good oncologic disease control with minimal morbidity for extensive malignancies invading the intracranial cavity. With improvements in both open and endoscopic techniques, there is a need to reassess outcomes to determine relative indications.
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Clinical neurosurgery is an endangered academic discipline. Neurosurgeons have competition from many directions: orthopedists, ear, nose and throat surgeons, plastic surgeons, radio-oncologists, and interventional radiologists, among others. Academic centers are no longer the only sites of neurosurgical education at the attending level, and neurosurgery is not felt to be an indispensible part of an undergraduate medical curriculum. ⋯ When this consideration is combined with the existing shortage of neurosurgeons across the country, academic neurosurgery departments must logically focus on how best to allocate resources between "routine" clinical services and research objectives. We suggest here that new relationships may be required between university centers and community health care providers. Restructuring of the neurosurgical workforce may be necessary if academic neurosurgery is to develop as a specialty of comprehensive expertise in the challenging neurological disease entities that are its research objectives.
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Dialysis-associated destructive spondyloarthropathy (DSA) is the major bony complication of end-stage renal disease, most commonly found in the lower cervical region. The risk factors for developing dialysis-associated DSA include duration of hemodialysis and patient age. Patients with DSA have a higher incidence of osteoporosis and poor bone mineral density, which may place them at greater risk of atraumatic fractures, instrumentation failure, and neurologic compromise. ⋯ Patients with renal osteodystrophy present a challenge for the spine surgeon due to compromised bone density. Hardware failure at the bone-construct interface is common in these patients, with revision surgery needed in 22% of published cases. Longer constructs with circumferential instrumentation and halo immobilization may minimize the risk of pseudoarthrosis and construct pull-out.
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Radiosurgery has emerged as an important primary treatment means of typical trigeminal neuralgia. Despite its high safety and efficacy, the likelihood of recurrence is significant, potentially requiring salvage treatment. Posterior fossa exploration and microvascular decompression is an option for salvage treatment. Results are presented regarding a single-surgeon experience, and a grading scale is proposed for postirradiation surgical findings. ⋯ Microvascular decompression can be performed in the postradiosurgery setting safely with high efficacy. Dissection typically was not significantly more difficult in comparison to procedures performed without prior history of radiosurgery intervention.