Plasticity of the nervous system is a concept now gaining clinical application for individuals with brain and spinal cord injury. I asked Maxwell Boakye from the United States to write a short summary of the basic observations behind neuroplasticity and what is known from its clinical applications to problems, such as “stroke” or spinal cord injury. This is an excellent summary with practical information for the neurosurgeon.
Karol et al from Argentina describe a very thoughtful, logical approach to using percutaneous radiofrequency thermocoagulation in trigeminal neuralgia. The authors have introduced us to a new system to map the Gasserian ganglion. Using their map acquired from stimulating the ganglion, the authors can determine the precise location to be subjected to radiofrequency thermocoagulation. Thus, they are able to reduce the complications from radiofrequency-produced lesions resulting in better patient outcomes.
Hauck et al from the US report on the endovascular treatment of a selected group of patients with giant aneurysms that could not be clipped. The authors have excellent results in 15 patients so treated with low complications. Giant aneurysms are the most difficult aneurysms to treat. These authors have extensive experience in the surgery of intracranial aneurysms, including giant aneurysms, and are credible observers. This article is an excellent analysis of an approach to this difficult problem. I totally agree with their recommendations and approach.
Figueiredo et al from Brazil report on a complex basilar bifurcation aneurysm that was too difficult to treat endovascularly but was treated surgically. The authors describe a unique skull-base approach to this lesion and did an excellent job with this case. I asked Juha Hernesniemi and his colleagues from Finland to comment—in general—about the use of skull-base approaches for cerebral aneurysms. As you will read in their editorial—which appears after the Figueiredo article—they have found few situations in which skull-base approaches were necessary in the treatment of 10 000 aneurysms. Drake and Peerless, the early pioneers in aneurysm surgery, also believed the same—skull-base approaches were rarely necessary. This has been my experience. The interesting part of the commentary from Finland is the authors' view of the future of aneurysmal surgery. Read it and see if you agree or disagree.
Chen et al from China evaluated a 16-row multislice computed tomography for use in a computed tomography angiogram (compared with a 2-dimensional DSA) in looking at cerebral aneurysms. The authors found that both techniques are equally good.
Izawa et al from Japan address a very important controversy in the management of AVMs. Does embolization before radiosurgery reduce the rate of obliteration compared to radiosurgery alone? This is a good article in a small number of patients. The low number represents the main criticism of this work. However, the Discussion is superb and worth reading, along with a look at Table 2 of the article. There are no studies to equal this one that have been published—even the 2 reviewers admit the lack of good data. The point of this article is that preradiation embolization does not reduce the rate of obliteration. On the other hand, the Discussion raises the problems that are faced in doing a study of this controversial issue.
Cosar et al from Turkey have done an animal experiment on rabbits with vasospasm. They postulated that increased sympathetic nervous system activity causes the release of norepinephrine, affecting the cerebral vessels. Norepinephrine causes an increased vasoconstriction to already sensitive central nervous system vessels in vasospasm. If the action of norepinephrine is blocked, the end result is that there is less tissue ischemia. This result is what the authors showed. In recent years, Surgical Neurology has published a number of articles on the causes of vasospasm; the causes are multifactorial. The sympathetic nervous system link to vasospasm reported in this article adds another level of complexity to the vasospasm dilemma.
Our Iranian colleagues, Sadrolsadat et al, have produced another practical, well-done, scientific article. They have compared general anesthesia and spinal anesthesia by subarachnoid injection of bupivacaine in a randomized study of patients with lumbar disk surgery. Both techniques were acceptable. The authors' Discussion is an excellent summary of all the points for and against each method. In the end, you can do either general anesthesia or spinal anesthesia, depending upon the circumstances in which you work.
Lad et al from the United States examined data from nearly 139,000 patients admitted with cervical spondylotic myelopathy comparing 1993 to 1997 and 1998 to 2002 data. They found a 7× increase in fusions between the 2 periods. Mortality and morbidity figures were the same in both periods. Why has this increase occurred? Are the results better with fusions? We do not know and we need to know.
Zhang et al from China noted in a series of patients with hemifacial spasm that they also had sinus bradycardia. After neurovascular decompression, the sinus bradycardia improved. Read the Discussion for the authors' explanation of the neurovascular mechanisms causing sinus bradycardia.
Liang et al from China reviewed the use of blood-salvaging techniques during surgery to avoid the use of transfusions. Their conclusion is that blood-salvaging techniques can be used in neurosurgery. The Discussion has the details you want to know.
Agnes Walker, wife of Earl Walker, who was a pioneering neurosurgeon in the world, is a star in her own right. She is a leader in developing neuroscience nursing with Dr Paul Bucy, the founder and first editor of Surgical Neurology. If you read Walker's editorial on the causes of the nursing shortage, you will appreciate that she is a direct, no-nonsense person, and a visionary. Her comments on the nursing shortage are right. Nursing school administrations are like medical school administrations in the sense that they are always behind the trends in society because they are hired to not upset the system. Nurses are highly educated and valuable members of a health care team. They need to be empowered to initiate treatment in the important minutes before the doctor arrives at the patient's bedside. Nurses are stimulated by these challenges of urgent patient care and are often more accomplished in dealing with them than the doctors. I always empowered nurses to take action and told them that I would always back them up. The patient comes first and I wanted them to act. They were highly involved with our educational programs and were eager to learn more about what they were being asked to do, just as you would expect would occur with empowerment and responsibility. We never had a shortage of nurses in our intensive care unit, and it was such an attractive position for nurses that there was a waiting list to take the vacancies. Nurses need to feel that they are an important part of the health care team because they are.
Nakamura et al from Japan present 2 rare but interesting cases of malignant nongerminomatous germ cell tumors of the pineal region. Read this short case report to understand their approach. The use of preoperative chemotherapy and radiation therapy before resection is an important step. They diagnosed recurrence by using a methionine-based positron-emission tomography scanning to guide their treatment plans.
Lefebvre et al from France have written about the use of linezolid, a new antibiotic that has been little used for central nervous system infections. In their cases with subdural empyema, both patients were not responsive to standard antibiotics but had a dramatic improvement with linezolid. Cone's comments at the end are scholarly and educational.
Also in this issue are the abstracts of the Belgian Society of Neurosurgery Meeting. I have written a short editorial on one of the articles given at the meeting on complete removal of tumors and longevity. Is the evidence now here to make the statement that gross total removal must be done for all tumors?
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