Russell R. Lonser, MD, Editor

Daniel K. Resnick, MD, Editor

Controversies in spinal surgery are nothing new. Rapid advances in medical technology have often outpaced rational deliberation of the indications and results of new procedures. Spine surgery has seen explosive growth in implantable technologies, as fixation techniques have gone from interspinous process wiring to segmental instrumentation techniques to interbody applications through a variety of portals. The causes of “back pain” treated by spine surgeons have expanded and now include degenerative deformity and the sacroiliac joint. With each technological advance, there is a predictable surge of enthusiasm followed by a period of uncertainty followed, in many cases, by disapproval. It is our responsibility to discuss the potential benefits and drawbacks of emerging technologies, as soon as evidence becomes available. We discuss the emerging technology of sacroiliac joint fusion, the potential rebirth of spinous process fixation, the use of bone morphogenetic protein, and the plusses and minuses of minimally invasive versus maximally corrective surgery for neurologic compromise associated with degenerative deformity.

Similarly, controversies over the management of intracranial pathology have existed since before the inception of neurologic surgery. New insights into the pathobiology of intracranial disease, deeper understanding (or lack thereof) of the natural history of various intracranial lesions, the limited number of large controlled patient studies that examine outcomes, and evolving technologies have been the foundation for these disputes. Here, we discuss the critical vascular controversies surrounding ischemia, including the role of hemicraniectomy for ischemic/hemorrhagic stroke and treatment strategies for moyamoya disease. We examine controversies in cerebral aneurysm management, including endovascular flow diversion after subarachnoid hemorrhage and the management of small incidental cerebrovascular aneurysms. We analyze controversies in surgical neurooncology, including reoperation for recurrent glioblastoma and the surgical management of incidental gliomas. We discuss the various surgical options for medically intractable trigeminal neuralgia. Finally, the management and outcomes for prenatal versus postnatal management are defined for myelomeningocele patients.