Nancy Epstein from the United States, a member of Surgical Neurology's Editorial Board, reports on her experience in using silver impregnated dressings compared to iodine- or alcohol-based dressings to prevent postoperative wound infections. The results are clear. The silver dressings resulted in zero postoperative infections. This is a simple, yet practical study. Read Ron Pawl's comments for some historical perspective on silver for wound care.
Iwatsuki et al from Japan have written a fine article on an improved technique for treating spinal stenosis using a unilateral approach for bilateral decompression. This article is worth reading in entirety. It provides an excellent review of the literature and the unresolved controversies of whether fusion is beneficial or not in this disease. By using a unilateral laminotomy with a microscope, the laminar bone is removed on the ipsilateral side and then, after repositioning the scope with some additional lateral muscle retraction, the lamina of the contralateral side is undercut to widen the canal. The authors report high postoperative satisfaction from the patients with this operation. Read Weinstein's comments at the end. This approach seems very reasonable to me. It has also been used endoscopically with success.
Zhao et al from China report on 30 patients collected over a 10-year period with multiple cavernomas in each patient. The interesting point the authors make is that patients with multiple cavernomas are more likely to have symptoms than those with solitary lesions. Thus, those with multiple lesions must be monitored more carefully than the ones with single lesion. The authors use a “locating catheter” to target deep lesions before their removal. This catheter, a ventricular shunt catheter, is very helpful in marking one of the lesions to be removed using neuronavigation before removing a second lesion. Removal of the second lesion may alter the brain position and make finding the deep lesion with neuronavigation difficult because of brain shift. This is an easy article to read with lots of practical surgical tips.
Kamel et al from Ireland report on the resolution of cranial nerve palsies from posterior communicating or internal carotid aneurysms when treated with endovascular coiling or balloon occlusion. Actually, two thirds of the patients had resolution of third, fourth, or sixth nerve palsies. A short time of the cranial nerve deficit, a partial deficit, the smaller the size of the aneurysm, and third nerve involvement—all were favorable for recovery. Older age, prolonged deficit, large and giant size of the aneurysm, and involvement of the fourth and sixth cranial nerves were all unfavorable factors in recovery. These results compared well with other historical reports from surgical treatment. This is a very interesting study with a relatively large number of patients indicating that endovascular approaches to aneurysms result in similar outcomes as surgical ones about resolution of cranial nerve deficits.
Laghmari et al from Morocco compare microvascular decompression of the fifth nerve, percutaneous balloon compression of the trigeminal ganglia, and thermocoagulation of the ganglia as treatments for trigeminal neuralgia. They found that microvascular decompression had fewer complications than the other procedures. Their discussion provides an excellent summary of the recent literature on these various approaches. To me, it does not appear that any of these procedures are superior to each other except for microvascular decompression in terms of producing less sensory deficit. What this article says to me is that our repeated discussions of this subject are not useful. The decision on which approach to use depends on the patient and the expertise of the surgeon.
Santoro et al from Italy report on a series of 210 patients with pituitary tumors treated surgically with biochemical cure as the measure of success. In a nicely written study, the authors show that basically two thirds of the patients with pituitary tumors are cured by surgery. There was no mortality, and the less than 10% complications were all treatable. Prolactinomas were more difficult to cure and had a higher recurrence rate. This study provides results similar to those of others as Van Gilder notes in his comments. This is a very nice summary of where we stand surgically with this disease.
Park et al from Korea describe their experience with an anterior high cervical approach to the upper cervical spine. Read Pagni's comments at the end after the abstract, then read the technique in the methods section. What is the best approach to high cervical lesions? As Pagni states, “We do not know.”
Da Silva et al from the United States provide a very nice review of a topic receiving increasing attention—bone health. As our population ages worldwide, osteoporosis and osteopenia become more common diseases. Also, we see that the drugs we use long term to treat the various diseases can lead to bone fractures. The authors review the effects of anticonvulsants, steroids, anticoagulants, and chemotherapeutic agents on bone health. These are all drugs we use as neurosurgeons. They provide a nice table of prevention and treatment protocols for us to use. This is a nice easy-to-read review.
Nathal from Mexico describes how he has used his own design of an “arachnoid knife.” He uses a no. 18 needle attached to a syringe or a long shaft. This is a very good idea. The needle is always sharp. It is simple and low in cost. I have used diamond knives, which are expensive and steel knives that are good but also costly. I like this idea.
Kaya et al from Turkey provide another simple technical idea that is easy for all of us to use. First, they fill a rubber ball with plaster of Paris, then remove the covering and use the plaster ball as a head model for stereotactic practice. They can also place metal targets in the ball after removing a section of the plaster to use as precise targets.
Ozisik et al from Turkey have done a very good study evaluating the protective effect of methylprednisolone sodium succinate (MPSS) or erythropoietin (EPO) in traumatic head injuries in rats. Erythropoietin is known for its action in stimulating the production of red cells, but it also has been found to have a neuroprotective action. The authors found that MPSS does prevent structural damage to the brain in less myelenated axons. EPO and MPSS also increase 2 gene pathways, the proteins which stop cell death, or apoptosis. These 2 agents also prevent lipid peroxidation, thus having an antioxidant effect. Oxidants are molecules released during disturbed cell metabolism that directly injure cell membranes. So antioxidants such as EPO and MPSS prevent cell membrane damage after cell injury. This article is well done. It is a very easy and quick way to learn about what is being done molecularly in brain injury. The best way to read this article is to start from this summary and then read the abstract, followed by reading the discussion, which has the summary of the work in this field.
Fujita et al from Japan report on a series of 6 cases in Japanese women with subarachnoid hemorrhage-associated cardiomyopathy. So far, this is a presentation that is unique in Japanese women but obviously can occur elsewhere. This report is another example of the psych-neuro-endocrine system and stress producing other organ disease (There is, by the way, a journal entitled Psychoneuro-endodrinology). As I have mentioned before, this field will become of major importance in the 21st century. Read the introduction, the case report, and the discussion for the principles of this article.
Mel Cheatham, who heads Surgical Neurology's effort to help others in countries around the world, has another terrific story of a neurosurgeon who has devoted part of his life to others—Merwin Bagan. We want to hear your stories or those of others you know. We know that neurosurgeons all over the world are doing this good work. Send an e-mail to Mel and he will be happy to receive it. Also, if you would like to volunteer to do this kind of work, ask him and he will help get you started.
This month, I have written several short editorials on why we as older neurosurgeons may misunderstand the younger generations, on the treatment of spinal stenosis, and on the death of a friend and colleague and a long-time valued reviewer for Surgical Neurology, John Van Gilder.
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