Faculty Bibliography

BACKGROUND AND OBJECTIVES/OBJECTIVE:Intradural extramedullary spinal tumors (IDEMs) are ideally managed with gross total resection (GTR) for optimal local disease control in the absence of established adjuvant regimens. In this retrospective cohort study, we investigated the utility of morphology-based analysis of optimal IDEM resection quality compared with current linear measurement benchmarks. METHODS:Tumors were manually segmented from preoperative contrast-enhanced MRI. Morphological features of sphericity, elongation, and volume were extracted from masks, along with manual anteroposterior, craniocaudal, and transverse linear measurements. Optimal resection was defined as Simpson Grade 1 or 2 for meningiomas or en bloc GTR for myxopapillary ependymomas (MPEs) and was predicted for dorsal and ventral spinal meningiomas plus conus and nonconus MPEs. RESULTS:We identified 103 tumors, including 71 meningiomas and 32 MPEs. Linear measurement did not reliably predict optimal resection across anatomic subtypes of meningiomas or MPEs (all P > .05). Instead, optimal resection was determined by higher sphericity across meningiomas and, specifically, dorsal meningiomas (optimal resection median 0.80 (IQR: 0.77-0.82) vs suboptimal 0.76 (0.72-0.77), P = .027). Shape features were not predictive in ventral meningiomas. En bloc GTR was limited to nonconus MPEs, in which sphericity again emerged as a predictor (0.74 (0.69-0.77) for en bloc vs 0.68 (0.64-0.72) for piecemeal, P = .047), likely reflecting resectability for encapsulated tumors. After excluding patients with <1 year of surveillance to determine nonrecurrence, 62 patients without genetic syndromes remained for recurrence analysis with a median follow-up of 36.1 months. Optimal resection was associated with significantly lower recurrence (optimal 8.6% vs suboptimal 29.6%, P = .045). This protective effect remained, although statistically insignificant after adjusting for adjuvant radiation and tumor grade (recurrence odds ratio = 0.22, 95% CI: 0.04-1.07, P = .077). CONCLUSION/CONCLUSIONS:IDEM tumor morphology is predictive of optimal resection for dorsal meningiomas and nonconus MPEs, whereas linear measurements offer less consistent predictive value. Morphological assessment is feasible with standard MRI and may be further automated.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Multiple-choice questions are the primary assessment format for neurosurgical board certification. Creating high-quality examination questions requires significant expert time and resources. The goal of this study was to develop an automated system to generate board-style neurosurgical multiple-choice questions using state-of-the-art vision-language models and compare their quality with authentic self-assessment questions. METHODS:articles. We generated 89 587 synthetic questions: 45 689 with GPT-4o and 43 898 with Claude. Each question was associated with a single image extracted from the articles' figures. We evaluated the quality of synthetic questions through 5 surveys comparing 20 synthetic questions (10 from each model) with 10 authentic questions from the Self-Assessment for Neurological Surgeons (SANS) question bank. Each survey was completed by a neurosurgery resident and an attending who guessed the source [human vs artificial intelligence (AI)-generated] and rated suitability for board examination use. We also evaluated the question-answering performance of the generalist GPT-4o and the specialized CNS-Obsidian. RESULTS:). CONCLUSION/CONCLUSIONS:Although quality gaps exist between AI-generated and human-created neurosurgical board examination questions, our approach demonstrates the potential of vision-language models to augment assessment development in specialized medical fields, reducing the burden on examination boards and credentialing organizations.

BACKGROUND AND OBJECTIVES/OBJECTIVE:The objective of this study was to compare sociodemographic factors, presenting characteristics, and outcomes between cohorts of patients receiving surgery for spinal metastases at 2 neighboring institutions, 1 private and 1 public, affiliated with a single major academic medical center in a large metropolitan area. METHODS:This analysis included all patients who underwent decompressive surgery for extradural spinal metastases. Sociodemographic factors, treatment characteristics, and outcomes were compared between those treated at a private hospital and a neighboring public hospital using Rao-Scott χ 2 tests for categorical variables, Student t tests for continuous variables, and the Kaplan-Meier product-limit method for overall survival and progression-free survival. RESULTS:Compared with those treated at our private hospital, patients treated at our public hospital were more often younger ( P = .005), of Black or Hispanic race (72.6% vs 19%, P < .001), and uninsured (16% vs 5.6%, P = .005). They more frequently presented with epidural spinal cord compression grade 3 (76% vs 56.8%, P = .027), were nonambulatory before surgery (56.9% vs 13.5%, P < .001), and had increased neurological impairment as denoted by American Spinal Injury Association Impairment Scale grades of A, B, or C (39.2% vs 7.5%). Patients treated at our public hospital had shorter median follow-up time (92 vs 302.5 days, P = .004). Multivariate analysis did not reveal a significant difference in overall survival or progression-free survival between hospitals, instead demonstrating associations with primary tumor histology and number of spinal metastases ( P < .05). CONCLUSION/CONCLUSIONS:There were substantial disparities in sociodemographic factors, presenting local disease burden, and postoperative neurological outcome but no difference in survival outcome, between patients treated at our public and private hospitals. These findings underscore the need for more equitable screening, surveillance, and referral structures.

Study DesignSystematic review and meta-analysis.ObjectivesWe sought to evaluate the association between pre-treatment symptom duration and outcomes in patients undergoing radiotherapy (RT)/surgery for metastatic epidural spinal cord compression (MESCC).MethodsA systematic review included publications evaluating the association between pre-treatment symptom duration and outcomes after RT/surgery in adults with MESCC. Primary exposure was pre-treatment symptom duration. Outcomes were motor-recovery, ambulation, survival and local control. Pooled-effect-estimates were calculated.Results Of 4639 studies, 37 met the inclusion criteria (26-RT,11-surgery). RT: All studies defined symptom duration as time from motor-weakness onset to RT. Longer symptom duration was associated with improved motor-recovery (Pooled-effect-estimate=2.08, 95%CI:1.68-2.58,p<0.001) and decreased mortality-risk (improved-survival)((Pooled-effect-estimate=0.72, 95%CI:0.69-0.76,p<0.001). Although longer symptom duration was consistently associated with better ambulation and lower local recurrence, few studies precluded meta-analysis. Surgery: Symptom duration was defined as time from neurological-deficit onset to surgery in 7/11 studies; three-studies used ambulatory status, and one-study used both. Longer symptom duration was associated with increased risk-of-death (worse-survival)(Pooled-effect-estimate=1.28, 95%CI:0.54-3.03,p=0.575), though statistically insignificantly. Meta-analysis for motor-recovery wasn't feasible, but most studies found longer symptom duration worsened motor-recovery, while ambulation findings were inconsistent.ConclusionSymptom duration was associated with differing outcome patterns by treatment modality. In RT cohorts, longer symptom duration was associated with improved survival and motor recovery. In surgical cohorts, it trended toward worse survival, though this did not reach statistical significance. Most surgical studies suggested an inverse association between symptom duration and motor recovery. These findings are exploratory, and should be interpreted in context of treatment selection-bias and between-cohort heterogeneity.

PURPOSE/OBJECTIVE:Spinal metastases may progress to debilitating pain, spinal instability, and neurological deficits. Timely referral is essential, yet delays are common because patients often first present to non-spine clinicians where red flags rarely expedite referral and guidelines primarily target spine specialists. We aimed to develop a staging-based referral tool to support non-spine clinicians in recognizing progression and guiding referral urgency. METHODS:We defined the Spinal Metastasis Staging (SMS) system as four stages: SMS I, asymptomatic; SMS II, inflammatory pain; SMS III, mechanical pain and/or spinal instability; and SMS IV, neurological deficits and/or high-grade spinal cord compression. Stages were translated into a referral algorithm organized by urgency and presented as a pocket map. The tool was refined through regional and international multidisciplinary expert panels, and feasibility was evaluated in an international survey. RESULTS:Panels endorsed the four-stage SMS system and referral algorithm. Among all survey respondents (n = 120), high acceptability was reported. Among non-spine clinicians (n = 32), 94% found the tool easy to understand, 91% considered the format suitable for clinical use, and 91% anticipated improved referrals. Overall, 88% would use the tool at least occasionally, including 55% who would use it frequently or always. CONCLUSION/CONCLUSIONS:The SMS staging system and referral tool (link) was rated feasible by expert panels and survey respondents. However, only 32 of 120 survey respondents (27%) were non-spine clinicians, so findings in this group are preliminary and may overstate acceptance. The tool should be considered provisional: prospective studies are needed to validate effects on referral and patient outcomes.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Myxopapillary ependymomas (MPE) and intradural lumbosacral schwannomas may be challenging to distinguish based on presenting characteristics and preoperative imaging. Accurate differentiation is crucial, as MPEs carry a risk of cerebrospinal fluid dissemination and warrant earlier intervention, a more tailored surgical strategy, consideration for adjuvant radiation, and frequent surveillance. Here, we describe our institutional experience with these tumors and develop a radiomics-based machine learning model to help distinguish them on preoperative imaging. METHODS:Institutional surgical records from 2011 to 2025 were queried and clinical data were extracted for the retrospective cohort analysis. Tumors were manually segmented in ITK-Snap from T1 postcontrast images, and radiomics features were extracted using the PyRadiomics package. An ensemble of random forest, k-nearest neighbors, and naive Bayes classifiers was trained on a subset of radiomics features using nested cross-validation. RESULTS:< .001) in MPEs, likely due to longitudinal tumor growth along the filum. Excluding scoliotic patients did not significantly alter discrimination, suggesting robustness to vertebral column malalignment that may coexist with intradural tumors. CONCLUSION/CONCLUSIONS:A radiomics-based machine learning model demonstrated excellent discriminative ability between MPE and lumbosacral schwannoma, achieving high accuracy and robustness to vertebral alignment variations. These results suggest that radiomics-based models may be developed into a useful tool for preoperative planning and patient counseling.

BACKGROUND/UNASSIGNED:Thoracic disc herniations are rare and challenging to treat surgically due to their complex regional anatomy, and conventional open approaches are associated with considerable morbidity. While full endoscopic approaches have demonstrated success in the cervical and lumbar spine, their role in the thoracic spine is not as well defined. We performed a systematic review of the literature on full endoscopic surgery for thoracic disc herniations in order to elucidate its safety, efficacy, and potential benefit over conventional open approaches. METHODS/UNASSIGNED:The PubMed, Web of Science, and Embase databases were queried from inception to February 2026. Studies describing endoscopic approaches to thoracic disc herniations in at least 5 adult patients with reported postoperative outcomes were included. Exclusion criteria included exclusive reporting of open/thoracoscopic approaches, cadaveric studies, and non-English studies. Data on patient characteristics, operative variables, and perioperative outcomes were extracted. RESULTS/UNASSIGNED:. 0%) were comparable between cohorts, as were pain and functional outcomes. CONCLUSIONS/UNASSIGNED:Full endoscopic approaches to thoracic disc herniations are safe and effective alternatives to traditional open approaches in carefully selected patients, offering meaningful advantages with comparable postoperative outcomes. High quality, direct comparative, multicenter studies are needed to better define their margin of benefit.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Intramedullary spinal cord tumor (IMSCT) resection carries a high risk of postoperative neurological deficit because of neural tract manipulation and myelotomy. Although short-term and long-term neurological recovery represent key treatment outcomes, current prognostication methods are lacking and would benefit from further complex analysis. METHODS:From March 2009 to August 2025, all adult IMSCT resections at our institution were reviewed. Demographic, oncologic, and perioperative data were extracted from electronic medical records. This included preoperative and follow-up neurological examination data in the form of American Spinal Injury Association Impairment Scale (AIS) grading, Modified McCormick Scale (MMCS), and ambulatory status. Independent ambulation served as the primary outcome for 4 machine learning models. Each model was sequentially evaluated using area under the receiver operating characteristic curve (AUROC). RESULTS:Fifty-four patients underwent 55 surgeries for IMSCT resection. Encapsulated lesions predominated IMSCT pathology, with grade II ependymoma comprising 28 (50.9%) resections, 5 hemangioblastomas (9.1%), and 5 cavernous hemangiomas (9.1%). Gross total resection was achieved in 36 cases (65.5%), with encapsulated tumors more readily achieving gross total resection vs unencapsulated (84.6% vs 18.8%, P < .01). By 4 weeks, conversion of MMCS, but not AIS grade, significantly correlated with concurrent ambulatory conversion (P < .01 vs P = .15). At 6 months, both AIS grade conversion (P < .01) and MMCS conversion (P < .01) significantly correlated with ambulatory conversion. For predicting ambulation at latest follow-up from 4 weeks postoperatively, the comprehensive granular model achieved an AUROC of 0.833, outperforming the AIS grade (0.583), American Spinal Injury Association Motor Score (0.667), and MMCS (0.667) models. By the 6-month follow-up, the comprehensive granular model achieved strong discrimination (AUROC 1.00). CONCLUSION/CONCLUSIONS:Follow-up IMSCT data demonstrate a postoperative lability that stabilizes by 6 months into a reliably modeled outcome. By enhancing the granularity of recovery data, accurate independent ambulation modeling may improve counseling for patients with IMSCT.

Vertebral metastatic disease results from many types of cancer and can have a devastating impact on patient mobility, psychological health, quality of life, and ultimately overall patient survival. However, the development of radiotherapy and surgical techniques has rapidly surged in conjunction with ongoing advances in basic science and translational studies. In this review, we discuss the paradigm shift in our understanding of the epidemiology and treatment algorithms for spinal oncology, ranging from preoperative optimization strategies, radiation and surgical techniques, the utilization of molecular markers and targeted therapeutics in medical oncology, and prognostication tools that underscore a new multidisciplinary approach to spinal oncology care.