This month, we spotlight innovation across the neurosurgical spectrum—from optimized discectomy approaches and reconstructive breakthroughs to precision bypasses and rare aneurysm management.

Whether it’s GammaTiles paired with free flap surgery for recurrent GBM, or a case of moyamoya disease with five posterior circulation aneurysms, the application of AI for real-time glioma grading using squash smear cytology each story speaks to the precision, collaboration, and adaptability driving modern neurosurgical care.

As ever, our mission remains: distill the remarkable into the readable.

— Editor, The Short Report on Neurosurgery

In This Issue – May 2025

1. Two-Port Triumph: Biportal Endoscopy Outpaces Uniportal for Far-Lateral Lumbar Disc Herniation – A comparative study breaks down outcomes, pain scores, and surgical efficiency in far lateral lumbar disc herniation.
2. Five Aneurysms, One Brain: Tackling a Rare Moyamoya Emergency – How a staged STA-MCA and OA-PCA bypass stabilized five posterior circulation aneurysms in a single patient.
3. One Surgery, Two Battles: Treating Recurrent GBM with GammaTile and Free Flap Reconstruction – Case combining brachytherapy and microvascular reconstruction in a single-stage glioblastoma surgery.
4. Smear to Smart: AI-Powered Diagnostics in Brain Tumor Surgery – Training a CNN to accurately classify gliomas from squash smear cytology

Two-Port Triumph: Biportal Endoscopy Outpaces Uniportal for Far-Lateral Lumbar Disc Herniation

A recent retrospective study in World Neurosurgery compared two minimally invasive techniques—unilateral biportal endoscopy (UBE) and percutaneous transforaminal endoscopic discectomy (PTED)—for treating far lateral lumbar disc herniation (FLLDH). The study analyzed 42 patients (17 UBE, 25 PTED) over six months, revealing:

• UBE had a shorter operation time (84.3 vs. 108.0 minutes; P = 0.023).
• UBE showed better early pain relief (lower VAS scores at 1-day and 1-month post-op).
• No significant differences in hospital stays, foraminal expansion, or long-term outcomes (6-month VAS/ODI scores were similar).
• High patient satisfaction: 94.1% (UBE) and 92% (PTED) reported good-to-excellent results per modified Macnab criteria.

Both UBE and PTED are safe and effective for FLLDH, with UBE offering quicker procedures and superior early pain relief. Surgeons may consider UBE for technically complex cases or to optimize operative efficiency.

Limitations: Small sample size, retrospective design, and short follow-up period. Larger, prospective studies are needed to confirm long-term efficacy.

Why It Matters: FLLDH accounts for ~10% of lumbar disc herniations and often causes severe radicular pain.

Faster surgery: Likely due to dual-channel flexibility and familiarity with paraspinal approaches.

UBE’s advantages include:

Better early pain control: Possibly from reduced nerve irritation during access.

Broader applicability: UBE may overcome PTED’s limitations at challenging levels like L5-S1.

Five Aneurysms, One Brain: Tackling a Rare Moyamoya Emergency

What do you do when one brain has five aneurysms, all tangled up with moyamoya disease (MMD)? A recent case in JNS Case Lessons offers a high-stakes glimpse into surgical innovation under pressure.

A 54-year-old man presented with a brain hemorrhage and was diagnosed with classic MMD—alongside five aneurysms in the posterior circulation, a rarity even for this condition. Surgeons chose a staged revascularization approach: first, an STA-MCA bypass, then an OA-PCA bypass. These surgeries rerouted blood flow, easing the pressure on delicate vessels and minimizing rupture risk.

The payoff: At 1.5 years post-op, three aneurysms were stable, one shrank, and one disappeared entirely. Plus, the patient regained motor strength and partial language skills, improving his functional independence.

Why it matters: This case reinforces the value of revascularization in MMD with multiple aneurysms—not just to relieve hemodynamic stress but to leverage the brain’s natural ability to redistribute blood and recover.

Key words:

• STA-MCA bypass: Superficial Temporal Artery to Middle Cerebral Artery bypass— This is a direct revascularization technique where a branch of the scalp artery (STA) is connected directly to a brain artery (MCA) to improve blood flow in conditions like moyamoya disease.
• OA-PCA bypass: Occipital Artery to Posterior Cerebral Artery bypass— A less common bypass where the occipital artery (from the back of the scalp) is connected to a branch of the PCA to reroute blood to the brain’s posterior circulation.

One Surgery, Two Battles: Treating Recurrent GBM with GammaTile and Free Flap Reconstruction

Recurrent glioblastoma (GBM) is notoriously tough to treat. Now, a case published in Journal of Neurological Surgery Reports pushes the boundaries of what’s possible—combining radiation and reconstruction in one go.

A 37-year-old woman with recurrent GBM underwent a high-stakes, single-stage surgery involving tumor resection, GammaTile brachytherapy, and a free flap scalp reconstruction using thigh tissue. GammaTiles—tiny collagen patches embedded with Cesium-131—delivered high-dose radiation directly to the resection site immediately after surgery.

The twist: GammaTile’s radiation was absorbed just millimeters away from the free flap tissue. Yet 9 months post-op, the flap remained fully viable—with no signs of tissue damage, infection, or necrosis. This is the first reported case to combine GammaTile therapy and microvascular free flap reconstruction safely in one stage.

Why it matters: This case offers a glimpse into the future of GBM treatment, where oncologic precision meets surgical innovation—allowing for faster healing, fewer surgeries, and potentially better tumor control.

Smear to Smart: AI-Powered Diagnostics in Brain Tumor Surgery

Could AI become the pathologist’s scalpel? A study from WFNS Journal by researchers at NIMHANS, India, suggests so—showcasing a convolutional neural network (CNN) trained to identify brain tumor types from intraoperative squash smears.

Key Findings:

• 91% accuracy for high-grade gliomas, 77% for low-grade (comparable to human pathologists’ 83–95%).
• Lightning-fast results: Diagnoses generated in milliseconds vs. hours for traditional pathology.
• Feature visualization: Heatmaps highlight tumor regions, guiding pathologists to critical areas.

This AI tool isn’t replacing pathologists—it’s empowering them. By flagging high-risk areas instantly, we can focus our expertise where it matters most.

Behind the Tech:

• Dataset: 6,000 high-grade and 4,000 low-grade glioma smear images.
• Model: Custom CNN based on VGG19 architecture, achieving 96% training accuracy.
• Transparency: Heatmaps reveal AI’s decision-making process, enhancing trust.

Limitations & Next Steps:

• Current constraints: Limited to pre-selected, high-quality smear images; real-world variability needs testing.
• Future goals: Expand to other tumors (e.g., meningiomas, schwannomas) and integrate with surgical microscopes for real-time use.

Why It Matters:

Addresses critical shortages: AI could bridge gaps in neuropathologist availability, especially in resource-limited settings.

Reduces surgical delays: Real-time diagnosis during operations minimizes wait times for pathology reports.

Scalable solution: Trained on 10,000 images, the model shows potential for broader CNS tumor applications.

That’s a wrap on this edition of The Short Report on Neurosurgery!

Which of these advancements intrigued you the most? Let’s discuss in the comments! 💬

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