The article by Aryan et al from the United States describes the use of an anterior plate for anterior lumbar diskectomy and fusion (ALDF) as an alternative to using a posterior fusion with ALDF. Technically, the replacement of the posterior fusion with an anterior plate had similar outcomes and complications in their experience. So, I guess the conclusions would be, as the authors state, that the plate “was safe and effective for the surgical treatment of patients with degenerative disc disease of the lumber spine….” But that conclusion hides some other reported aspects in this article that trouble me. First, why are they doing this operation? They state that all patients presented with “discograph positive back pain localized to one lumbar segment.” In the age range of the patients operated on, most would have had abnormal diskograms anyway. So, they are operating on patients with back pain, most of whom have radicular pain. This symptom complex leads me to question why they are doing such an extensive operation for these symptoms. Instability does not seem to be a part of the symptom complex. Secondly, as the authors' state, the follow-up was short, 1 year, during which there was a significant improvement in pain scales in both groups. Thirdly, they state “patients who undergo ALDF with the plate still suffer from posterior micromotion that may be a source of back pain....” Now, the problem I have with this statement is that I do not understand the cause for the back pain to begin with; and secondly, how do I prove micromotion to explain the pain? Is micromotion an excuse for surgery and for not investigating further the causes of the patient's pain? This article is typical of what is being reported by spine surgeons. I encountered this same reasoning with skull base surgeons who would show a preoperative computed tomography and a postoperative one indicating that the tumor was gone. However, nothing was said about the patient's history or postoperative course. This approach avoids serious consideration in the spine of why the patient has symptoms in the first place. Yes, we can do a procedure, but is it necessary? I have no doubt that the technique reported by the authors works and may be a good addition to our approaches. My problem is, “Is it necessary in the first place?” This article does not answer that question.
In a very nicely done study, Park et al from Korea studied the effect of the gravity-assisted valve and its effect on ventricular drainage postoperatively. They measured the ventricular volume postoperatively and compared it with the preoperative value. If the valve was displaced with an anterior angle instead of being parallel with the body axis, the gravity drainage mechanism was less effective in emptying the ventricles. So, we have another factor to consider in shunt function.
Nguyen et al from the United States have evaluated the factors that may be involved in recanalization of coiled aneurysms. The article is well done. The authors found a higher rate of recanalization in younger patients, in larger aneurysms, and in ruptured aneurysms. The discussion provides a good perspective on this problem. But, I have another. If you look at Table 2 of that article, you will see that only 40% of aneurysms were completely obliterated at the initial coiling. Others have reported similar results. About 41% had a residual neck. The remaining 13% still demonstrated an aneurysm dome or only had partial treatment. Gerard Debrun maintained that “tight packing” of the coils in aneurysms is key to obliteration. If you look at an aneurysm that has been coiled and can see through the coils, it is not tightly packed. This technical expertise is the difference between skilled coilers and those who are less experienced. It is understandable that in complex aneurysms the inexperienced may be reluctant to tightly pack the coils. The same reasoning would apply to ruptured aneurysms as the authors reported. So, I agree with the analysis the authors made. I think the reason for the recanalization may be as fundamental as the experience of the interventionalist. All neurosurgeons are not excellent at clipping aneurysms. Neither are all interventionalists skilled at coiling. That is the principle we need to keep in mind.
Raza et al from the United States present a controversial alternative to the treatment of large arteriovenous malformations. They propose repeated treatments to the nidus at lower radiation doses to prevent the complications of high-dose radiation for the whole lesion. Read Friedman's and Lunsford's comments at the end that advocate an opposite approach. Then read the discussion for a nice overview of the controversy. There is no solution to this controversy at this time.
Jha et al from India report on the use of endoscopic third ventriculostomy for hydrocephalus caused by tuberculous meningitis. This disease is dismal to treat, and the authors have shown that it works except in the more advanced conditions. It is certainly worth a try.
Kennedy et al from Australia report on 4 cases of nocardial brain abscesses. Read Cone's scholarly comments at the end. Also the discussion is an excellent review of this subject.
Lustgarten et al from Venezuela report on the use of BioGlue to prevent cerebrospinal fluid leak in complex cranial facial surgeries. There were no cerebrospinal fluid leaks using BioGlue. The authors provide a valuable experience in dealing with a difficult clinical problem. Read Goodrich's comments at the end for an expert's analysis of this article.
The cardiac and imaging literature are reporting examples of coronary plaques that have been imaged to show potential rupture, macrophage activity in the plaque, lipid content, and other features of the atherosclerotic plaque. Kawahara et al from Japan have used gadolinium-based magnetic resonance to image the carotid plaques in patients and to detect what they believe to be potentially threatening lesions. This is a good article that is on the forefront of a new approach to carotid plaque dynamics. Loftus' comments at the end are excellent. Also, the discussion will provide you with a nice summary of the evolving science of atherosclerosis. As usual the cardiac field is leading the way in this disease.
Will giving selenium and Vitamin E as antioxidants help diminish the effects of head injury? Read the work by Kıymaz et al on this subject. They are from Turkey. Neuronal rescue will occupy the major focus of attention for neurosurgeons and neurologists in the 21st century.
There are a number of interesting case reports for your consideration in this issue.
Did you realize that you will live into your 80s or 90s? Have you thought about what you will do with the rest of your life? Read my editorial on this subject in this issue. Also look into what Mel Cheatham has done with the rest of his life—read his editorial on volunteerism. There will be more comments like these in the future from Mel and others.
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