Charlie Burton has spent at least 30 years of his life as a neurosurgeon studying diseases of the spine including disk pathology. He was way ahead of his time in specializing in this area and in distinguishing the multiple factors, from organic to psychological, which contribute to back pain. Over his career, he has developed innovative treatments for these patients with back pain. Surgical Neurology is publishing his comments and concerns about the directions of spine surgery. Surgical Neurology is one of the few warning voices in this runaway train of increasing and more complex spine surgery. We have written about the impending disaster for the spine surgeons as the financial payments for their surgery are about to be reduced or stopped because of the overusage of surgery as a treatment for this constellation of diseases. Few are listening. Read Charlie's editorial on the subject. He is on target.
Tanriverdi et al from Turkey have written a terrific paper on the molecular basis of recovery from head injury. The real message of this paper is in the discussion. Read the abstract and then the discussion. What the authors are saying is that each person's recovery from injury may be related to the genetic composition of their cells, particularly the genes producing the interleukins, which are proteins that are part of the inflammatory response. Obviously, this response is activated after injury. If the genes controlling the interleukins are absent, the injury is less. If antagonists to the interleukin receptors are given, neuronal loss is reduced. This is the future of head injury research as Dave Hovda, a scientist who heads the head injury research program at UCLA, comments. Every individual's response to injury may differ depending on their genetic makeup.
Chacko et al from India report on a molecular marker in tumors used as an indicator of tumor growth and recurrence. We will see more of these articles in the future. This marker, topoisomerase IIα, is important in DNA replication and appears in the S phase or DNA replication phase of the cell cycle. It is used as an indicator of the cell's sensitivity to some anticancer agents. In this study, the authors correlated topoisomerase levels with the recurrence of the tumor, a hemangiopericytoma, and found it to be a better marker than the mitotic index (see Fig. 2). Now all we need in this devastating tumor for which we have no good treatment is the precise target to hit to stop its growth. That time is coming.
Beck et al from Germany have written an excellent article on the computed tomography angiography (3-dimensional) analysis of a consecutive series of patients presenting to their center with ruptured or unruptured intracranial aneurysms. They found that most of the aneurysms are less than 10 mm and even 7 mm in their largest size. Look at Fig. 3. It shows that the pattern of ruptured and unruptured aneurysms is the same when segmented by 2-mm increments in size. This observation indicates that there is no size at which aneurysms rupture in contrast to the ISUIA study results which said that aneurysms must reach 7 mm in size to rupture. Moreover, it is interesting to look at Table 3, which shows that anterior communicating and anterior cerebral aneurysms tend to rupture more frequently than middle cerebral aneurysms when segmented by size. The authors have provided a very challenging study to the ISUIA data. They propose that aneurysms of any size can rupture but postulate that most aneurysms that rupture must grow quickly and rupture. Such aneurysms would be missed in long-term studies. This is a terrific article for journal club and provides a lot of information to debate.
Brell et al from Spain report their experience with stereotactic radiation given in fractions to treat cavernous sinus meningiomas. Seventeen patients had previous subtotal resections, and 13 had no surgery. Only 2 patients showed progression over the 2- to 6-year follow-up which is obviously short. Fifty percent improved clinically, particularly those with cranial nerve deficits. The authors discuss their rationale for fractionation. Lunsford in his comments provides an opposite viewpoint, stating that there is no evidence that fractionation is of value over single-dose stereotactically guided radiation. Gross total removal for cavernous sinus meningiomas advocated by some in the past has too much morbidity to be a treatment option for this disease. Stereotactic radiation with or without subtotal resection is the treatment of choice.
Paolo Cappabianca from Italy has written superb advice for the young neurosurgeon. I agree with everything that Paolo says. One thing that Paolo did not mention was MONEY. He has concentrated on the intangible values that a young neurosurgeon must develop. Yet, the young neurosurgeon is living in a world of diminishing payments for medicine and is facing forces that are directing the young physician to think about what can be done to make the good living as a doctor that they believed was possible. As I have written a number of times, “If you put the patient first, you will never have to worry about money; if you put money first, you will lose both.”
There are a series of articles in this issue devoted to technique developments for neurosurgeons. The neurosurgical group from Helsinki describes their use of a water dissection technique in neurosurgery. You can access the VIDEO of this paper online at doi:10.1016/j.surneu.2005.08.025. Ozisik et al from Turkey present a clear and simple comparison of various means to close cerebrospinal fluid leaks in an animal model. They found that fibrin glue is the best of various approaches including using the CO2 laser, methyl methacrylate, fibrin glue, and n-butyl cyanoacrylate as sealing agents. Liechty et al from the United States report on their success in treating a hardware infection involving a vagal nerve stimulator. They used an irrigation system. See Slavin's comments at the end.
Perez et al from Israel report a new technical method of securing a frontal orbital craniotomy flap with the Craniofix system. Hamada et al from Japan describe a unique approach to closing an orbital AV fistula by directly injecting the superior ophthalmic vein with Surgicel to occlude remnants of the fistula. Agrillo et al from Italy use a triple-screw technique for securing a type II odontoid fracture and a complex C1-C2 fracture, which occurs in elderly people.
There are also a series of interesting studies and case reports that follow the technical section.
Did you know the origin of the caduceus, caput medusae, or other terms we use? Read short study of Lee et al on mythology and the constellations from which many of our medical terms originate.
My editorial this month is on how to develop strategies so that you can change your practice and adapt to the new directions of medicine. The ideas come from actual experience and are ones you can use today.
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