Executive Summary
This week's digest highlights: Preliminary evidence; confirm full-text methods and endpoints before changing practice. Preliminary evidence; confirm full-text methods and endpoints before changing practice. Routine postoperative activity restrictions after lumbar microdiscectomy are not supported by evidence; patients can be encouraged to resume normal activities as tolerated...
Owen briefs you on what matters in this week's digest.
Think chief-resident chalk talk: what matters, what changes practice, and where to spend your reading time.
Tumor / Skull Base
Vision Outcomes Following Endoscopic and Microscopic Transsphenoidal Resection of Sellar/Parasellar Lesions - A Systematic Review of the Literature.
Research • Tumor / Skull Base • World neurosurgery • 2026-05-12
Preliminary evidence; confirm full-text methods and endpoints before changing practice.
Study snapshot
Design
Systematic review
Population
Patients undergoing transsphenoidal resection of sellar or parasellar lesions
Intervention
Transsphenoidal surgery (endoscopic or microscopic)
Comparator
None (single-arm synthesis)
Primary outcome
Postoperative visual outcomes (improved, normalized, unchanged, worsened)
Why it matters
Visual outcomes after transsphenoidal surgery for sellar/parasellar lesions were known to improve in many patients, but reporting was inconsistent. This systematic review of 236 studies found that 76% of patients with preoperative visual loss improved postoperatively, with 73% improvement in visual field defects and 64% in visual acuity. Clinicians should counsel patients that most experience visual improvement, but standardized outcome reporting is needed.
Practice change
Confirms current practice that transsphenoidal surgery improves vision in most patients, but highlights need for standardized reporting.
More context
Key details
- Systematic review of 236 studies following PRISMA guidelines.
- Pituitary adenomas accounted for 80% of cases, craniopharyngiomas 14%, meningiomas 4%.
- Preoperative visual loss, field defects, and acuity impairment present in 55%, 51%, and 37% of patients, respectively.
High-yield
Postoperative visual improvement occurred in 76% of patients with preoperative visual loss, 73% with visual field defects, and 64% with visual acuity impairment.
Clinical context
Transsphenoidal surgery is the standard approach for sellar lesions, but visual outcome reporting is inconsistent. This review summarizes available data to guide patient counseling.
Limitations
High heterogeneity across studies in definitions and reporting of visual outcomes.Publication bias may overestimate improvement rates.
Methodological critique
High heterogeneity and incomplete outcome reporting limit the strength of pooled estimates.
Teaching pearl
When counseling patients with sellar lesions and visual deficits, you can expect improvement in about three-quarters of cases, but warn that 2-11% may worsen.
Funding and COI
Not stated
Spine
Lumbar Microdiscectomy and Postoperative Activity Restrictions: A Randomized Controlled Trial.
Research • Spine • Spine • 2026-04-23
Routine postoperative activity restrictions after lumbar microdiscectomy are not supported by evidence; patients can be encouraged to resume normal activities as tolerated.
Study snapshot
Design
Multicenter, single-blind, randomized controlled trial
Population
Adults 18-75 years undergoing unilateral lumbar microdiscectomy for radiculopathy with concordant MRI findings
Intervention
Postoperative activity restrictions (limited sitting, bending, lifting, twisting for 1 month)
Comparator
No specific restrictions (encouraged to resume normal activities)
Primary outcome
Composite of ≥18-point VAS back improvement, ≥25-point VAS leg improvement, ≥15-point ODI improvement, and no reoperation at 12 months
Why it matters
Postoperative activity restrictions after lumbar microdiscectomy are common but lack evidence. This RCT found no difference in primary composite outcome (41.6% vs 36.4%, p=0.45) or reherniation rates (10.1% vs 14.1%, p=0.61) between restricted and unrestricted groups. Surgeons can consider eliminating routine activity restrictions, as they do not improve outcomes and adherence is poor.
Practice change
May support eliminating routine activity restrictions after lumbar microdiscectomy, as they do not improve outcomes.
More context
Key details
- RCT at 3 centers in Australia; 200 patients randomized to restricted (n=101) or unrestricted (n=99) activity for 1 month post-microdiscectomy.
High-yield
See source article for primary outcome data.
Clinical context
Postoperative activity restrictions after lumbar microdiscectomy are commonly prescribed to prevent reherniation, but evidence is lacking. This trial aimed to assess their efficacy.
Limitations
High attrition (29%) and poor adherence to restrictions (10%) limit the ability to detect true differences.Single-blinded design (patients aware of group assignment) may introduce bias.
Methodological critique
High attrition (29%) and poor adherence weaken the intention-to-treat analysis.
Teaching pearl
Activity restrictions after lumbar microdiscectomy do not improve outcomes and patients rarely follow them anyway. Focus on early mobilization and reassurance.
Funding and COI
Not stated
Functional
Impact of Subthalamic Nucleus Deep Brain Stimulation on Gastrointestinal Symptoms and Gastric Emptying in Parkinson's Disease: A Systematic Review and Meta-Analysis.
Research • Functional • Neuromodulation : journal of the International Neuromodulation Society • 2025-09-05
STN-DBS may be considered for PD patients with significant GI symptoms, as it provides sustained improvement in gastric motility and symptom scores up to months.
Study snapshot
Design
Systematic review and meta-analysis
Population
Patients with Parkinson's disease undergoing bilateral STN-DBS
Intervention
Bilateral subthalamic nucleus deep brain stimulation (STN-DBS)
Comparator
Pre-DBS baseline (medication on/off states)
Primary outcome
Changes in gastrointestinal domain of Non-Motor Symptoms Scale (NMSS-GI) and 13CO2 excretion time (Tmax)
Why it matters
Before this study, the effect of STN-DBS on gastrointestinal symptoms in Parkinson's disease was unclear. This meta-analysis of 379 patients shows that STN-DBS significantly reduces GI symptoms (NMSS-GI domain) and improves gastric emptying (Tmax13CO2) with sustained benefits up to 12 months. Clinicians should consider STN-DBS as a potential adjunctive therapy for PD patients with bothersome GI symptoms, though long-term data are needed.
Practice change
Confirms current practice; STN-DBS may be considered for PD patients with GI symptoms, but further long-term studies are needed.
More context
Key details
- Systematic review and meta-analysis of 8 observational studies (N=379) evaluating bilateral STN-DBS for GI symptoms in PD.
High-yield
See source article for primary outcome data.
Clinical context
Gastrointestinal symptoms are common non-motor features in Parkinson's disease, affecting quality of life. The effect of STN-DBS on GI motility has been unclear.
Limitations
All included studies were observational, introducing potential selection bias.Heterogeneity in GI symptom assessment and gastric emptying measurement methods across studies.
Methodological critique
Meta-analysis of observational studies with moderate heterogeneity; no randomized controlled trials included.
Teaching pearl
When evaluating PD patients for DBS, consider autonomic symptoms like GI dysfunction as potential non-motor targets; STN-DBS may improve gastric motility beyond motor benefits.
Funding and COI
Not stated
General Neurosurgery
Initial data from the prospectively randomized G-MEMBRANE trial and systematic review on the embolization of the middle meningeal artery in the treatment of chronic subdural hematomas.
Research • General Neurosurgery • Scientific reports • 2026-06-13
May consider adjunctive MMAE for cSDH evacuation in selected patients, but await full trial results for definitive guidance.
Study snapshot
Design
Randomized controlled trial (interim analysis) with systematic review
Population
Adults with symptomatic chronic subdural hematoma requiring surgical evacuation
Intervention
Burr hole evacuation plus middle meningeal artery embolization (MMAE)
Comparator
Burr hole evacuation alone
Primary outcome
Recurrence within 3 months (defined by volume, midline shift, or need for reoperation)
Why it matters
Before this study, MMAE for cSDH showed promise in retrospective series but lacked randomized evidence. This interim analysis of the G-MEMBRANE RCT and systematic review provides early randomized data suggesting MMAE may reduce recurrence. Clinicians should await full results before changing practice, but may consider MMAE for high-risk patients in experienced centers.
Practice change
May support considering MMAE as an adjunct to surgical evacuation for cSDH, but full results are needed before widespread adoption.
More context
Key details
- G-MEMBRANE is a randomized controlled trial comparing burr hole evacuation alone vs evacuation plus MMAE for cSDH.
- Interim analysis triggered early stopping due to significant reduction in recurrence (p<0.0031).
- High dropout rate of 31.2% due to patient non-compliance and logistical issues.
- Systematic review of RCTs on MMAE for cSDH was also performed.
High-yield
See source article for primary outcome data.
Clinical context
Chronic subdural hematoma recurrence after burr hole evacuation ranges from -40%. MMAE has been proposed as an adjunct to reduce recurrence.
Limitations
Interim analysis with high dropout rate (31.2%) limits generalizability.Single-center design and lack of blinding due to visible embolization material.
Methodological critique
High dropout rate and single-center design limit internal validity.
Funding and COI
Funded by German Social Accident Insurance (research project FR341)
Basic Science
TBI Biomarker Improvements Following Rodent Decompressive Craniectomy and Motor Outcome Validation of Early Cranioplasty.
Research • Basic Science • The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association • 2025-07-15
Preclinical evidence; no immediate practice change pending clinical validation.
Study snapshot
Design
Basic science (preclinical)
Population
CD1 mice and Long-Evans rats with moderate-to-severe TBI
Intervention
Decompressive craniectomy followed by early or delayed alloplastic cranioplasty
Comparator
Sham, TBI only, TBI-DC without cranioplasty
Primary outcome
GFAP and UCH-L1 levels; motor performance on beam walk
Why it matters
Before this study, the utility of neuroinflammatory biomarkers GFAP and UCH-L1 in decompressive craniectomy (DC) patients and the optimal timing of cranioplasty for motor recovery were unclear. This study demonstrates that DC reduces acute biomarker elevation and that early cranioplasty improves motor outcomes in a rodent TBI model. Clinicians may consider early cranioplasty to enhance neurological recovery after DC, though human validation is needed.
Practice change
Does not change current clinical practice but may inform future translational work.
More context
Key details
- Rodent model used closed cortical impact to induce moderate-to-severe TBI.
- GFAP and UCH-L1 were quantified in CD1 mice in sham, TBI, and TBI-DC groups.
- Early cranioplasty group received alloplastic cranioplasty soon after DC.
- Beam walk test assessed motor proficiency in Long-Evans rats.
- 2-way ANOVA with Dunnett's post hoc test determined group differences.
- By day 7, biomarker levels converged (P>.05), indicating acute neuroinflammation resolution.
High-yield
See source article for primary outcome data.
Clinical context
Decompressive craniectomy is used to manage moderate-to-severe TBI, but the utility of biomarkers GFAP and UCH-L and optimal cranioplasty timing are unclear.
Limitations
Preclinical rodent model may not fully replicate human TBI pathophysiology.Small sample sizes and lack of blinding or randomization details limit internal validity.
Methodological critique
Preclinical study with limited generalizability and no blinding or randomization details.
Teaching pearl
When counseling residents on TBI management, emphasize that decompressive craniectomy may reduce acute neuroinflammatory biomarkers, and early cranioplasty could be considered to optimize motor recovery, though these findings are preliminary and require clinical translation.
Funding and COI
Not stated
Trials to Know
Stereotactic Radiosurgery Dose Escalation for Brain Metastases
Trial • Trials to Know • ClinicalTrials.gov • 2026-07-05
Why it matters
This phase I trial evaluates dose escalation of stereotactic radiosurgery (SRS) for brain metastases, aiming to improve local control while minimizing toxicity. For neurosurgeons, it addresses the critical question of optimal SRS dosing in an era of increasing use of SRS alone, potentially expanding treatment options for patients with limited intracranial disease.
More context
Key details
- Phase I, recruiting
IA Lidocaine and Methylprednisolone for Headache Associated With Subarachnoid Hemorrhage
Trial • Trials to Know • ClinicalTrials.gov • 2026-07-05
Why it matters
This Phase 2 trial tests intra-arterial lidocaine and methylprednisolone for refractory headache after subarachnoid hemorrhage (SAH), a common and debilitating complication with limited treatment options. If effective, this targeted intervention could reduce opioid use and improve recovery in SAH patients, addressing a significant gap in post-hemorrhagic pain management.
More context
Key details
- Phase 2, recruiting
ASP2246 for Post-Stroke Movement Disorders
Trial • Trials to Know • ClinicalTrials.gov • 2026-07-05
Why it matters
This phase 1/2 trial evaluates ASP2246, a novel agent, combined with brain surgery and rehabilitation for chronic ischemic stroke patients with persistent movement problems. It addresses the gap in effective treatments for motor deficits beyond the acute phase, potentially offering a new surgical intervention strategy for neurosurgeons managing post-stroke disability.
More context
Key details
- Phase 1/2, recruiting
From the Preprint Wire
Virtual RNS Implantation: From Intracranial Connectivity to Optimized Lead Placement
Preprint • From the Preprint Wire • medrxiv • 2026-06-22
Why it matters
This unreviewed preprint proposes a novel method using pre-implantation intracranial EEG connectivity to predict responsive neurostimulation (RNS) outcomes and generate patient-specific 3D maps for optimal lead placement. For neurosurgeons, this could transform RNS surgical planning from a trial-and-error approach to a network-guided strategy, potentially improving seizure outcomes in drug-resistant epilepsy.
More context
Key details
- Developed a composite score combining standard deviation and kurtosis of interictal iEEG connectivity distributions to predict RNS outcome.
- Validated across three independent epilepsy centers (HUP, NYU, UCSF) with 68% accuracy in the validation cohort (55% sensitivity, 88% specificity).
- Generated patient-specific 3D maps of predicted RNS efficacy for 200 simulated lead configurations, showing responders had higher spatial scores in favorable regions.
DeepPLL: Synchronizing Non-Invasive Brain Stimulation with Deep Brain Stimulation
Preprint • From the Preprint Wire • medrxiv • 2026-06-22
Why it matters
This unreviewed preprint introduces a novel open-source device that synchronizes deep brain stimulation (DBS) with non-invasive transcranial alternating current stimulation (tACS) in real time. For neurosurgeons, this could enable multi-site network modulation without additional invasive implants, potentially expanding therapeutic options for conditions like Parkinson's disease.
More context
Key details
- DeepPLL uses an isolated analog front-end to extract DBS EEG artifacts and a phase-locked loop for timing stabilization.
- The system offers 1-degree phase resolution and low-jitter TTL outputs for driving external stimulators.
- Feasibility was demonstrated in two individuals with Parkinson's disease undergoing subthalamic DBS.