In this issue…

Article Outline

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Vespa et al from the United States present their work integrating modern robotics technology into patient care in the intensive care unit. This is medicine of the present and future. By using a robot, a physician can visit any patient, talk with the patient's family or nurse over the speaker system, visualize the patient, and assess the examination of the patient through a video camera. At the same time, the patient sees the physician on the TV screen in the place of the robot's head. The authors also document cost savings by reduced length of stay. As the number of physicians decreases in the United States and the demand for care rises, in addition to the need to standardize care across the entire spectrum of hospitals in a community, look for this solution to proliferate. This article provides the proof of principle. I have seen it. It works!

Ng et al from Singapore used their cellular phones with picture taking features to photograph images in radiology. They then transferred these images through the digital wireless cellular phones to another physician. Clinical decisions were facilitated by this technology. This idea is cheap, practical, fast, and useful.

Cavallo et al from Italy, Brazil, and Egypt have detailed some excellent ideas for endoscopic neurosurgery and compared the technology to microsurgery, and listed the advantages and disadvantages. Their article emphasizes the use of the endoscope in pituitary surgery. This is a practical article to read for all and contains good information.

Musacchio et al from the United States report an interesting anatomical study. What they state in their discussion is that there are complications from a standard laminectomy for lumbar stenosis, including muscle weakness and atrophy. For a 1-tube unilateral endoscopic approach to spinal stenosis for bilateral decompression at 1 level, they report that ipsilateral facet injury occurs. It makes sense that decompression of the opposite or contralateral foramen is easier and less complicated. Using an endoscope on both sides of a lumbar decompression, a 2-tube approach as they describe it, they decompressed the contralateral foramen. So, it appears that, as with all new approaches, there are problems. Unfortunately, they are not immediately reported. Which approach is best for spinal stenosis? We do not know. This article is particularly interesting if read after the previous article discussing “Tips and Tricks” for endoscopic surgery.

Shields et al from the United States and France present an interesting series of electroencephalographic observations on patients with traumatic brain injury who are emerging from coma. They propose that scalp electroencephalogram can be used as a monitor and predictor of interhemispheric brain signaling in addition to intrahemispheric signaling. This work, as Young describes in the introduction to this article, may be more predictive of a patient's outcome than imaging. Read Young's short summary comments on the significance of this article first, then the abstract, and finally the discussion. It is a complicated area to follow, but the major point of the article has been summarized above.

Gepstein et al from Israel report on their evaluation of patient-controlled anesthesia in 237 patients undergoing lumbar spinal fusion. They found that 90% of their patients were satisfied with patient-controlled anesthesia. Nausea and vomiting were common complications. Read the abstract, introduction, and the discussion to get the relevant parts of the article quickly.

Ramachandran et al from India reviewed the records of 647 cases of chronic subdural hematoma treated at their institution from 1989 to 1999. They were looking for causes of mortality and recurrence. They found that the patient's advanced age, low initial Glasgow Coma Score, and associated diseases were factors in mortality. Recurrence was related to the thickness of the subdural membrane at surgery and the failure of the brain to reexpand after decompression of the hematoma. Subdural drains reduced the recurrence by 87% from the undrained patients. Read the abstract, the results, and the discussion. Amirjamshidi and Zidan have both made some valid comments at the end. Yes, the study is not randomized, but I doubt that there will be a randomized study on a sufficient number of patients to resolve the issue of drainage vs no drainage. So, we are left with a retrospective study, as is this article. The conclusions the authors make are at least intuitively reasonable. The use of a drain to prevent reaccumulation of the subdural fluid is impressive and worthy of note. The authors do mention a study by Sambasivan, also from India, published in Surgical Neurology in 1997, volume 47 beginning on page 418. In that article, Sambasivan reviewed 2300 cases of chronic subdural hematoma. He treated 2215 patients with a subtemporal craniotomy, of 3 to 4 centimeters in diameter, with removal of the apparent outer and inner membranes, a drain which he left for 24 hours, coagulation of the dural edges but not closure, approximation of the temporal muscle, and closure of the scalp. There was a 0.35% recurrence rate and 0.5% mortality in those patients. Sambasivan seems to have the best answer.

Rocchi et al from Italy have a different idea on the management of their patients with chronic subdural hematoma. In selected cases with recurrence and membranes, the authors propose a craniotomy and gentle removal of the membranes. They state they had no morbidity and mortality in their 14 cases. Sambasivan comments on this article and disagrees with the authors' approach based on his experience.

Tsuboi et al from Japan have developed a magnetic resonance technique for determining the exact location for the separation between the intradural and extradural portions of the carotid artery in the cavernous sinus. Read the conclusions first.

Julio Sotelo, 1 of our associate editors and former head of the Neurological and Neurosurgical Institute of Mexico and now newly appointed head of Mexico's National Institute of Health, told me of some research he and his colleagues did on patients with glioblastoma multiforme. This work involved treating patients with chloroquine. Adding chloroquine to conventional surgery, radiation, and chemotherapy produced a doubling of survival. Although the article is retrospective, as the authors Briceño et al describe, its results are interesting enough to encourage a random study and evaluation of chloroquine in glioblastoma multiforme. Read the discussion to learn how the authors believe the drug works.

Csokáy describes a technique to reduce tremor during microsurgery. Read my comments at the end of the article.

Amirjamshidi et al from Iran have written about the causes of intractable hiccups. This is a very nice review of the subject with some case examples.

I have added an article on Editor's notes, a compilation of articles I have read over the past months that I think physicians, particularly in the United States, might find interesting.

Physician morale is a subject of real concern. Read the results of a recent survey that was conducted on the subject and some comments on it.