This is a journey through the ideas, tools and frontiers redefining how we understand and operate on the human brain.
Each case, fully anonymized, is told as what it was: a problem, several alternatives and a reasoned decision. The pathology is the example; the focus is how one thinks.
Why the endonasal route changed the risk calculus in midline lesions.
Trigeminal neuralgia: when the cause is a vessel, the answer is not a lifelong drug.
Creating a new natural drainage pathway instead of implanting a permanent shunt.
Twelve topics that account for most of what walks into a neurosurgical clinic, written for the moment you leave an office holding a scan and a word you do not understand. Each one states how many people get better without surgery, which signs cannot wait and what is worth asking.
The real question is not when to operate. It is how many people get better without surgery, and the answer is surprising.
Read →Almost half of all people in their sixties have a narrowed canal on the MRI. Most of them feel nothing.
Read →Three in four people with this problem never had surgery, and nine in ten ended up well.
Read →Three in four primary brain tumours are not malignant. It is the first thing almost nobody says.
Read →Three in every hundred adults have one without knowing. The vast majority never rupture.
Read →In people over eighty it affects nearly one in ten. It is one of the very few treatable causes of cognitive decline.
Read →Of every ten patients who come to surgery, eight went to a dentist first. More than half of them had treatment they did not need.
Read →The commonest tremor is not the one that comes with Parkinson's. And the two are told apart by something you can watch for at home.
Read →If two well-chosen drugs have failed, the chance that the third will work is eleven per cent. That changes the conversation.
Read →Of every four people with tingling in the hands, three do not have carpal tunnel syndrome. The fingers tell you which is which.
Read →No, you do not have to keep them awake. What you have to do is watch for five specific things.
Read →Nearly half of healthy babies have a somewhat flattened head at three months. Telling which one needs surgery is the whole problem.
Read →Informational material; it does not replace medical consultation. Each topic ends with verified links to US public health agencies and to non-profit patient organisations, for anyone who wants to read further.
None of these six technologies, on its own, changed the history of neurosurgery. And yet we operate better today than we did ten years ago.
What changed? Access to knowledge.
It has never been so easy to learn from those with the most experience, to attend international congresses without travelling, to watch surgery in real time, to read complete multicentre studies, or to review the original evidence before adopting a technique.
The tools widened what we can do. Information transformed how we decide.
None of these six technologies decides for the surgeon. Their real value depends on understanding what the evidence demonstrates, what its limitations are, and when to use them… or when not to.
What comes next is of a different nature: that is in 06 · The future.
Tractography reveals the nerve-fiber 'highways' that must be preserved. The route is planned before the first incision.
Fluorescence · 5-ALAThe patient drinks a compound that makes the tumor glow pink under a special light, sharply outlining the tissue to be removed.
4K-3D exoscopeIt replaces the classic microscope with an ultra-high-definition 3D image shared by the entire surgical team.
Intraoperative imagingMRI inside the operating room confirms —without ending the surgery— that the resection was complete.
MonitoringNeurophysiology monitors critical functions in real time and warns before a maneuver can harm them.
Artificial intelligenceFrom image analysis to surgical planning, AI is beginning to assist decisions that once relied on experience alone.
For nearly a century, operating on the brain meant opening it up in order to see. Today, much of the progress lies in the opposite: seeing better to open less —or not at all.
Radiosurgery treats tumors without a single incision. Endoscopy reaches the skull base through the nose. Fluorescence makes a tumor glow to separate it from healthy tissue. These are not gadgets: they are a shift in how decisions are made.
Read the full essay →Not all of this is part of daily practice —yet. But following the field's evolution closely is part of practicing it seriously.
In 2025, implants restored speech to paralyzed patients.
02A brain pacemaker that self-adjusts to the brain's activity.
03Treating tremor from outside the skull, with no incision.
04Sub-millimetric precision and stability beyond the human hand.
05Decisions guided by each tumor's molecular profile.
06Simulating a surgery on a virtual replica before performing it.
07Detecting and classifying disease with unprecedented precision.
08From the OR to predicting outcomes and complications.
One thousand patients with acute back pain at high risk of becoming chronic: supported self-management lowers disability at one year and spinal manipulation alone does not. Pain intensity moved in none of the four arms, and that is worth saying before we refer.
JAMA · December 2025
Read at source →Irradiating the cavity during the same operation added nothing: progression-free survival was unchanged and recurrence remained local in three of every four patients, with more radiation necrosis and more severe seizures. The phase 3 halts a line that phase 1/2 had left looking promising.
The Lancet Oncology · June 2026 · open access
Funded in part by Carl Zeiss Meditec, manufacturer of the intraoperative radiotherapy device under test. The result runs against the sponsor.
Read at source →Earlier blood-pressure trials after thrombectomy failed because they lowered pressure the same way for everyone. Setting the target by degree of reperfusion took 90-day independence from 47% to 60% and reduced haemorrhagic transformation, with no excess symptomatic bleeding or mortality. It costs nothing to apply.
JAMA Neurology · June 2026
Read at source →The first prospective international comparison of the four temporising procedures actually used in the preterm infant with intraventricular haemorrhage. Across 238 neonates the difference is not in complications but in eventual shunt dependence: neuroendoscopic lavage left the fewest shunts at six months.
Journal of Neurosurgery: Pediatrics · December 2025
Read at source →Across 758 patients the robot does not place electrodes more accurately than the stereotactic frame: target, depth and radial errors are indistinguishable, and so are complications. What it buys is 33 minutes per case. A unit without a robot does not implant worse, it implants more slowly.
Acta Neurochirurgica · February 2026 · open access
Read at source →Faced with a large acute epidural haematoma with herniation, leaving the bone out is almost a reflex. The trial finds no functional advantage at six months over craniotomy with flap replacement, and nearly three times more delayed intracranial haemorrhage. With 120 patients it does not prove equivalence, but it shifts the burden of proof.
The Lancet Neurology · June 2026
Read at source →
I am a neurosurgeon. I devote my work to a discipline that, like few others, demands both technical rigor and human care at once.
I trained at the Hospital Militar Central residency, completed a fellowship in endoscopic skull base surgery at Ohio State University and specialized at UBA. Today, beyond operating, I lead and teach. This publication is my way of sharing where all of this is heading.
Interactive tools we build to think about and teach neurosurgery. These are evolving projects —Beta versions— for strictly educational purposes.
A real-time dynamic model: Monro-Kellie pressure-volume, cerebral autoregulation, CO₂ reactivity, the PRx index, tissue oxygenation and optimal CPP, on a patient who responds with pupils, Glasgow score and Cushing's triad.
Open simulator → BETAInteractive 3D model of linear and rotational impact (HIC and BrIC): coup and contrecoup, shear and diffuse axonal injury, on a parenchymal mesh that deforms in real time.
Open simulator → BETAA single-isocentre plan on a 3D head: converging beams in real time, biologically effective dose, Paddick conformity and gradient indices, and brainstem, optic pathway and cochlea doses against their tolerances.
Open simulator → BETAVentriculoperitoneal shunting in real time: the siphon effect standing and lying down, with and without an antisiphon device; six adjustable valves with their pressures, steps and MRI behaviour; and radiographic identification brand by brand.
Open simulator →Educational and outreach tools. They are not medical devices, do not process patient data and do not replace clinical judgment.
