Suzuki et al from Japan evaluated the tolerability, safety, and efficacy of an antivasospasm drug named Fasudil. The purpose of the study was to look for drug toxicity and to observe outcomes. The authors did not intend this trial to be a randomized study. Fasudil inhibits kinases in muscle that are critical in the biochemical pathway that produces muscle contraction. For this reason this drug is valuable in treating vasospasm. This study is well done. Macdonald's comments at the end are good. This drug obviously appears effective against vasospasm and has low toxicity. Thus, a randomized evaluation of this drug would be worthwhile.
Strojnik et al from Slovenia have written an excellent article on the correlation of the prognosis of patients with gliomas with the levels of a tumor cell protein measured immunohistochemically from tumor samples. They found that nestin, the protein, has high correlation with the grade of malignancy of the tumor. It also turns out that nestin is found in stem cells but not in normal brain parenchymal cells, suggesting that the tumor cells are behaving like stem cells. The concentration of nestin is highest in the tumor periphery where the advancing and dividing cells are located. What this study shows is that even with similar histologic appearances of glioblastomas, for example, their biologic activity may be different and can be predicted by the amount of nestin found in the tumor samples. Such a marker can be used as a therapeutic guide. This work also leads the way to the genetic understanding of different gliomas. From this information we can develop targets to reach with molecular therapies. Read the comments at the end. Although the article may be complicated in its entirety, you can get the message by reading this note and then the abstract, the comments at the end, the introduction, and if you have further interest, the discussion. This is a first-class piece of work.
Orlando et al from Italy report on the use of an antibiotic prophylactic treatment preoperatively and postoperatively in patients undergoing endoscopic, endonasal, transphenoidal surgery. This team is a very experienced group of neurosurgeons. Their infection rate is low but is similar to Kelly's, one of the commentators, who uses a similar but less expensive prophylactic treatment. The authors report a lower incidence of meningitis and sinusitis than is found in other studies. Post's comments at the end suggest that the cerebrospinal fluid (CSF) leak complication may be less with regular transphenoidal surgery. The authors report a 0.5% to 14% incidence of CSF leak in the literature with regular transphenoidal surgery. How would you like to have a 1 in 7 chance of a CSF leak after a surgical procedure? To me this high rate of CSF leak is unacceptable as reported in the literature. We need to aim for zero complications and zero mortality and morbidity. Then, we have an excellent product to sell to the public. What neurosurgeons and physicians may accept as usual in their practices, to the public, that is, you and I, is unacceptable. This article is trying to reach that goal of zero complications and has excellent results. Kelly's call for a randomized study is reasonable.
Huang et al from China have used a rigid endoscope to open noncommunicating arachnoid cysts into the ventricle or the subarachnoid space. They only treated symptomatic patients and report good results. In China, the use of cisternography is probably easier and cheaper because access to a magnetic resonance (MR) that can give CSF flow measurements is not easy. Also endoscopic treatment is probably less costly than a shunt and more definitive for the mobile population of patients they see. This is a good article with useful information. Is it better than shunting? We do not know. Read Cappabianca's comments at the end.
Malik et al from India review their experience with 61 patients who had a posterior fossa hematoma. This is one of the largest series in the literature. The authors found that patients with a good Glasgow Coma Scale score or children usually had a good prognosis without surgical intervention, whereas hydrocephalus preoperatively in these patients was an ominous sign. For the practitioner who sees a patient with an acute posterior fossa extradural hematoma, the decision to make is between surgical and nonsurgical intervention. Do you wait, obtain regular computed tomographic scans, trust the nurses to report signs of posterior fossa compression and deterioration, and then rush the patient to the operating room? To me, this is a risky decision path. First, the signs of posterior fossa compression are often missed. Rising blood pressure, falling pulse rate, sleepiness, and maybe cranial nerve signs are not easily recognized and can occur quickly. The chances for rapid surgery and removal of the clot become low, and the patient will suffer irreparable damage. Frequent computed tomographies may be available in large hospitals, but even then, obtaining the scans and reading them takes time. So, for a busy practicing neurosurgeon in a hospital that may have the above limitations, I believe that the safe course is quick decompression of the clot. The surgery can be done in 30 minutes, and this problem is resolved. To do the surgery quickly, the patient can be placed either prone or on the side or even supine with the shoulder elevated and the head turned to expose the correct suboccipital side. After shaving, prepping, and draping, a linear, paramedian incision should be made in the suboccipital area and carried to the bone. A curved cerebellar retractor is placed to retract all the muscle, and a burr hole is made in the posterior fossa. The burr hole is enlarged with a rongeur to expose the hematoma that is immediately drained. Time is important! There will probably never be a randomized study on this subject. So, what is the best judgment with the least cost and the lowest risk? I favor the surgical plan I outlined.
Ishiwata et al from Japan report on their experience with optimum needle placement for laser lumbar diskectomy. They found that if the needle was in the “middle zone” of the disk adjacent to the disk center and on the side of the symptoms, then the best results would be achieved. It is hard to evaluate laser diskectomy because it is not a procedure widely used in the United States by neurosurgeons. Choy from the United States initiated the procedure and reported his experience in “Percutaneous laser disc decompression [PLDD]: a 17 year experience” (Photomed Laser Surg. 2004; 22:407-410). He reported performing 2400 PLDDs in 1275 patients in 18.5 years. He had an 89% success rate according to MacNab's criteria (excellent, no pain and normal work; good, some back and leg pain that interferes with work) (J Bone and Joint Surg. 1971; 53A:891-903). Choy had 0.4% complications, all diskitis, which disappeared with antibiotic treatment. Most of his patients were back at work in 5 to 6 days. The hypothesis as to why the procedure works is based on the concept that water is not compressible and that because the disk is 60% water it cannot be compressed. By removing some disk material, the intradiskal pressure will decrease, and the offending fragment will fall back into the disk space away from the nerve root. Pressure measurements in the disk have been made to verify this hypothesis and MR examination has confirmed that the disk does fall back into the disk space. He has also used the PLDD in patients with spinal stenosis. The reasoning is that if a bulging disk that is part of the spinal stenotic segment is decompressed using the laser, the bulging disk goes back into the empty disk space created by the laser and the total stenotic segment is now more open. From what I can determine by reading the articles, the problem is patient selection. In his review, Choy includes patients with back pain with or without radiation into the leg. He also states that no free fragment should be found on MR, as this finding would be a contraindication to laser diskectomy. He realizes that MR may miss free fragments 20% of the time. I would like to see a larger spectrum of physicians using and reporting on this technique to be able to better understand its value. Over the years there have been many reported great treatments for lumbar disk disease. Yet, the standard diskectomy still prevails as the best treatment.
Sanus et al from Turkey have found that human leukocyte antigens on the surface of cavernomas are significantly different than those found on control noncavernoma cells. This is another step in the development of genetic answers to the diseases we treat. We cannot do anything with this information yet, but it is a step into the future. Read the abstract, the end of the first paragraph in the discussion, and Awad's comments for the essence of this article.
Dario et al from Italy found no antibacterial activity associated with baclofen. As Slavin states in his comments at the end, I, too, was surprised to learn from this article that local anesthetics and other nonantibiotic drugs have antibacterial activity. Read this note and the first few lines of the discussion. Preventing infection with implanted pumps and devices is very important when they are used. Slavin's comments at the end are very interesting, especially for companies making these devices.
Jung et al from Korea discuss a troubling clinical problem for those who enter the ventricle in tumor removal or for other reasons. Some of their patients developed postoperative subdural fluid collections that can be difficult to treat. The authors used Gelfoam with fibrin glue to seal the ventricular defect. In 2 cases they sealed the cortical opening to the ventricle. Their results appear good in eliminating subdural fluid collections. So, what should the practicing neurosurgeon do after entering the ventricle? I am not sure that I have seen a high incidence of this problem, and if so it is probably not symptomatic; for those who are symptomatic, shunting has been the choice of treatment. What we do not know from this article is whether the “seal” they used worked. The authors did not do radiographic studies to determine if the seal prevented an actual fluid exchange between the resection cavity and the ventricle. In my experience in removing colloid cysts transcortically or transcallosally, the subdural fluid collections tend to occur more than in other surgeries. So, with all the reservations I have about this article, it may be a technique to consider in some circumstances. I would like proof that the repair does not allow fluid to accumulate between the resection cavity and the ventricle. Then, I would be more convinced of its value.
Roth et al from Israel report a retrospective study of patients who had distal shunt placements with conventional open abdominal procedures or with laparoscopic placement. There was no selection process for either approach that we are told. It appears that those with previous abdominal surgery represent a higher percentage of the laparoscopic group than the conventional surgery group. It is hard to know what to conclude from this mixture of patients, except that the complications are equivalent between the 2 groups. The authors concluded that laparoscopy should be used in those patients who have had multiple distal revisions, previous abdominal surgery, or chronic inflammatory bowel diseases. I do not see how one can make these points from the data they present. The question is this: “Has technology made a difference, a significant difference in the placement of the distal ends of shunts?” From this study I am not persuaded that laparoscopy is significantly advantageous; but, intuitively, it does make sense and appears to be the same as an open surgical approach. Yet, as Bergsneider concludes in his comments, laparoscopic placement may be useful in selected patients.
Rajshekhar and Muliyil from India have evaluated the outcomes of patients after cervical corpectomy for cervical spinal stenosis. They found that the subjective patient perceived outcome score (PPOS) was similar to the objectively determined Nurick score in determining the outcomes of their patients. However, in 13% of their patients they had better PPOSs than Nurick scores, although the patient was not objectively better. The authors argue that the PPOS should be used in evaluating patients. Pawl, in his comments, states that the objective score is better than the subjective measure for many reasons that he details. A subjective evaluation is subject to many variables and influences that cannot be controlled. I think his comments make sense.
Sahjpaul from Canada has an especially interesting case report of a patient who experienced an esophageal perforation from an anterior cervical screw used in plate fixation after cervical corpectomy. The complication is rare. However, Cole's and Portnoy's comments at the end are on target. First, Portnoy asks if the initial corpectomy was indicated and what the alternatives were. Cole suggests that if you are going to use a screw for fixation of a plate, there are some steps to take to ensure that the screw is tight and will not pull out of the bone. These are very instructive comments. There are some other interesting case reports also that follow in this issue.
I have included an editorial entitled “Random thoughts on the life on other planets, traffic fatalities, and how socialized medicine is working worldwide.” This editorial contains quotes from news items and literature from around the world. The news reports tell us all what is happening in many parts of the world and why it is important to know what is happening.
I have asked Ron Pawl, a neurosurgeon who has specialized in spine surgery for 30 or more years and who was also President of the American Pain Society, to write his analysis of the SPORT trial and subsequent editorials written by the AANS and prominent Canadian orthopedists on this subject. You may be suprised by what he says.
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