In this issue, there are a number of papers on various aspects of spine and spinal cord disease, management of epidural abscess, blood levels of vancomycin in the cerebrospinal fluid (CSF), and operating on people older than 100 years. There is a large series of patients with microvascular decompression for hemifacial spasm in which the complications of the procedure are examined. Also in this issue are papers on interventional approaches to aneurysms and atrioventricular fistulas, plus a large series of gunshot wounds to the peripheral nerves, and others.
In the spine series, Kim et al from Japan demonstrate a technique of splitting the spinous process in the midline longitudinally over several segments and leaving the paraspinal muscles attached. Then they remove the base of the spinous process at the level of the lamina and dissect the muscles off the lamina bilaterally with each paraspinal muscle half still attached to the split spinous process. Next, a laminectomy is done. The authors state that this technique was developed by Watanabe in Ref. 12. On completion of this operation, the spinous processes and attached paraspinous muscles are approximated in the midline. The authors analyzed muscle damage on postoperative computed tomographies (CTs) and with CPK levels. The muscle atrophy on CT was less with the spinous process splitting approach than with a unilateral or bilateral laminectomy in which the muscles were reflected off the lamina. This is a nice study and one that makes sense. I like it. Read it, including Benzel's comments at the end, and see what you think.
Hirabayashi et al from Japan describe the benefits of a thoracic decompressive laminectomy for ossified ligamentum flavum, which produces myelopathy. Only 7 of the 13 patients improved postoperatively. Nancy Epstein summarizes the article very well at the end.
Chang et al from Taiwan present a very nice single case report on the treatment of a patient with cervical osteomyelitis and extension into the thoracic and lumbar spaces. We have all seen this difficult problem. The patient underwent a corpectomy of the diseased cervical segments. A mesh cage and titanium plate was used to replace the bodies and provide stability. Intravenous antibiotics and hyperbaric O2 were used after surgery to treat the extensive infection with success. Read the report and the comments of Maiman at the end.
Cone and his associates from the United States provide another well-researched clinical study of infectious disease. This article deals with the association of spondylodiscitis and infective endocarditis. The description of the cases is instructive in any part of the world. As the authors note, with increasing cardiac valvular surgery, this problem will become more common.
Wang et al from China found that intravascularly administered vancomycin penetrates the ventricular and lumbar CSF within 30 minutes of administration in postcraniotomy patients. The authors postulate that the reason for this penetration is a breakdown of the blood-brain barrier. There is no direct proof that this molecular transfer occurs at the endothelial junction as opposed to the choroid plexus or other sites than the fact that therapeutic levels in CSF are detected. What it does tell us is that vancomycin can be used postoperatively in patients to reach the CSF. Read Cone's comments at the end.
Cavanaugh et al from the United States report a case of a 101-year-old woman with spasms and weakness in her lower extremities from a spinal meningioma at C7 through T1. What would you do for this patient? What would you want done if the patient were you, your wife, or family member? Read the case and the discussion. Then answer the question.
Secer et al from Turkey have written an extensive review of their experience with 2106 patients who had gunshot injuries to their peripheral nerves. The abstract is the first part to read. Then look at the discussion to learn their experience with these problems. Obviously, the article will be of more interest to those doing peripheral nerve repair. Their experience is good as is the article.
Huh et al from Korea report on the complications they saw after operations on 1524 patients with hemifacial spasm using microvascular decompression. This article is an excellent guide to the complications of this procedure for this disease and what factors lead to their resolution. Basically, if nerve damage is seen immediately, the chances of recovery are poor. This is an honest report of a surgical experience.
Loh et al from the United States analyzed their experience pre- and post-3D rotational angiography in the treatment of cerebral aneurysms. Not only has the 3D rotational views on angiography been helpful to the interventionalist in understanding the anatomy of the aneurysm and surrounding vessels but also to the operating surgeon. Both the interventionalist and surgeon have more information, which can only make the procedure safer. Three-dimensional CT angiography is also very useful but when very detailed information about the aneurysm is required, 3D angiography is the gold standard.
Kakino et al from Japan report on 5 cases with proximally obstructed vertebral arteries and reconstitution of the distal vertebral arteries by arterial collaterals. All patients were symptomatic after medical therapy. The authors used a vein graft between the reconstituted portion of the vertebral artery in the intervertebal foramina of the cervical vertebrae and the external carotid artery. Using the external carotid artery prevents temporary occlusion of the common carotid; however, there is usually enough collateral flow from the external carotid to recirculate through the internal carotid if the common carotid is temporarily occluded. It is important that neurovascular surgeons learn these approaches and that detailed 4-vessel angiography of the extracranial and intracranial circulations be performed to learn the vascular anatomy. Starting in 1976 with our first report on occipital artery to posterior inferior cerebellar artery anastomosis and subsequent reports on revascularization of the posterior circulation, today, many of these procedures are used worldwide. Fernando Diaz, who led our work on vertebral artery reconstruction, has made comments at the end. Dr Ogawa and his colleagues in Japan continue to lead neurosurgeons worldwide on surgery for the cerebral vascular system particularly in ischemic disease. This is a fine article from an excellent center and surgeons.
Turgut et al from Turkey review the literature on the treatment of aspergillosis of the brain. Larry Cone's comments at the end are concise and informative. Read the abstract first and then Cone's comments, and if you have further interest, read the rest of the article.
Mohindra et al from India review 2 cases and the literature on their experience with endolymphatic sac tumors of the temporal bone. Read the comments at the end.
Iwai et al from Japan report on their experience using (1) radiosurgery for brain metastases less than 3 cm in diameter, (2) whole brain radiation therapy for patients with more than 10 tumors, and (3) surgical removal followed by boost radiosurgery. Localized recurrence was found in 24% of the 21 patients and new lesions in 48% and leptomeningeal carcinomatosis in 24%. The median time to recurrence was 7 months, and no patient had a recurrence who had a higher radiation dose. What is striking about this report is how bad the outcomes are. Radiation may be helpful in this disease, but still, in this small series, the results are pretty dismal. What all of this tells me is that we have not found the answer for this disease. Yes, radiation probably should be done, but the results are not good. Read comments by Andrews and Lunsford at the end; they are 2 experts in the field.
Clark Watts, a neurosurgeon, former Chairman of Neurosurgery, Editor of the journal Neurosurgery, and now a lawyer, has joined the Surgical Neurology Editorial Board to help inform all of us about medical legal issues. Malpractice and other medical legal concerns are not restricted to the United States. These same legal problems are spreading to all countries of the world, rich and poor. Neurosurgeons from many different countries have expressed an interest in this topic of medical legal issues. In the first of a series of editorials, Clark writes about “Stark Laws” which only exist to my knowledge in the United States (I could be wrong). This is the most reasonable discussion of this topic I have read. No doubt, this issue will come to other countries. Read his discussion and look for more of his explanations of medical legal issues in the future.
This month, my editorial deals with the World Federation of Neurosurgical Societies. The organization is now larger than it was some years ago and is facing distinct challenges to remain relevant to the predominant membership that is from the developing world. This is not the time for politics or self-interest to rule its decisions, or it will fail to meet the needs of its members.
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