The most significant problems facing physicians in every country of the world are: (1) decreasing payment for their services, (2) increasing government control of medicine, and (3) declining quality of health care because of these and other factors. Dr Clark Watts, our legal neurosurgical member of the Editorial Board, has written one of the best essays on how physicians have lost autonomy and respect in the United States. My guess is that similar factors, plus a large dose of socialistic governments, have affected physicians worldwide. As the US health care system progresses to Socialism, it is approaching that which I have seen in many of the countries I have visited around the world. The key question is what doctors can do about it. Watts has some answers, but group action is the only choice I see. Read how he outlines how the government has limited doctors' action to correct those problems. Still, group power is the only chance doctors have worldwide.
Yao et al from China provide us with an interesting short review of the work being done on neural and tumor stem cells and their direct relationship to the formation of brain tumors. Recent evidence cited by the authors suggests that brain tumors are derived from stem cells and not from the dedifferentiation of mature cells into malignant cells as we have been taught for decades. The authors, from Ying Mao's laboratory at Huashan Hospital in Shanghai, provide us with strong evidence that the stem cell origin of brain tumors is the probable pathway to tumor formation. I have written an introduction to this article for those who want a short review. The article offers a more detailed explanation of their work supporting the tumor stem cell hypothesis. This is excellent work and is the type of breakthrough in molecular science that will allow us to go beyond the limited therapies we now use to treat these tumors. This is the 21st century answer to malignant glioma-targeted molecular therapy.
Limbrick et al from the United States report a small but excellent study on the treatment of brain metastases from different cancers. The authors selected good-functioning patients who then had surgical resection followed by stereotactic radiosurgery to the resected cavity or the residual tumor. They performed a retrospective analysis of the outcome of this treatment on these 15 patients. They did the study because of the damaging effects of whole brain radiation on the cognitive abilities of patients. The median survival of their patients was 20 months, which is a very long survival. Whole brain radiation was given as supplement to selected patients. This study is one of the few to indicate that surgery plus SRS alone is more effective than surgery followed by whole brain radiation. Read Lunsford and DeSalles' comments at the end of the article. They admit that the other studies on this subject are flawed. This is a small series, but the data are very convincing. The Discussion offers a very good rationale in explaining why we should use this treatment and how to present this treatment option to your patients.
Kitano et al from Japan report on the removal of suprasellar craniopharyngiomas through an extended transsphenoidal approach. To me, craniopharyngiomas are difficult and frustrating tumors for the neurosurgeon to treat. More than once, using a transcranial approach, I have been enticed into removing more of the tumor as it begins to come out easily, only to find that it is stuck to the hypothalamus or carotid arteries or undersurface of the chiasm that I cannot see. I was skeptical of the transsphenoidal approach, but Kitano et al provide an excellent rationale for this approach and a detailed description of how to make this operation successful. Their hypothesis is based on the belief that the transsphenoidal approach is a better way to visualize this tumor and its attachments; I totally agree. They still encounter the endocrine disturbances associated with all the neurosurgical approaches to this tumor. Dr. Martin Weiss, an experienced transsphenoidal neurosurgeon, agrees with the authors. This is a good piece of work and is worth reading.
Gathinji et al from the United States present a very provocative paper on the association of preoperative depression with decreased patient survival after resection of malignant astrocytomas of the brain. This is an excellent observational study. The authors found that those patients diagnosed preoperatively as depressed had a worse outcome and shorter survival. In their Discussion the authors address the multiple explanations for this relationship. They state that the association between preoperative depression and decreased survival is also found in non–central nervous system tumors. The cause of the relationship of depression and decreased survival is unknown. To me, this is another observation of the relationship of the central nervous system to other organs and to the body's disease state. This is a huge area to study for the future. Dr Mantosh Dewan, professor of psychiatry at State University of New York's (SUNY) Upstate Medical Center in Syracuse, New York, believes, as written in his comments, that this association should be pursued. This is an interesting article to read. You will read more about these associations in the future.
Sanus et al from Turkey report on 25 patients with delayed facial nerve palsy after head injury in which no temporal bone fracture was found. The authors relied on electroneurography as their testing mode. Electroneurography is basically a nerve conduction study measuring the speed of conduction of impulses down a peripheral nerve. When the nerve fiber is degenerated, it will not conduct impulses. It is used in median nerve testing for carpal tunnel syndrome and is part of electromyography testing. Using electroneurography, they state that others have reported that if greater than 90% of the nerve fibers show degeneration (determined by reduced conduction velocities) within the first 2 weeks of the trauma, the recovery of facial nerve function was poor. The authors started all their patients on methylprednisolone and when 90% of facial nerve degeneration was seen, surgical decompression of the facial nerve was performed. Seventy-seven percent (77%) of those who underwent surgical decompression had total or near total recovery of facial nerve function. Those who were treated medically had a lower percentage of recovery. So what should we do if a patient develops delayed facial nerve palsy? It appears that surgical decompression is better than observation.
Moskowitz et al from the United States and Canada found that patients with aneurysmal subrachnoid hemorrhage, who were taking statins on admission, had less vasospasm compared with those not on the drug. The difference was not statistically significant. The authors calculated that a study requiring 4000 patients would be necessary to demonstrate a significant difference in vasospasm between treated and nontreated patients. That is why we have not seen large studies reported. So, will you use statins as a treatment of vasospasm on your patients? Read Dr Loch Macdonald's comments at the end.
Lv et al from China report their experience with occlusion of the patent vessel, including the dissecting aneurysm on the P2 segment of the posterior cerebral artery endovascularly. There were no posttreatment ischemic complications by occluding the P2 vessel, which means that the collateral circulation was adequate in all their 8 patients. They did no preocclusion testing to see if a deficit would occur. We would all like to know that the collateral circulation would support occlusion in all cases. So, testing for ischemia would be nice, but this experience provides comfort that others have occluded the vessel without this evidence successfully.
Menovsky et al from Belgium and The Netherlands report their observations in the use of neurosurgical cottonoids on the brain. Basically, they found that all cottonoids stick to the brain tissue and when removed do contain some brain tissue. Each surgeon may use cottonoids differently. For use under a retractor, I use Vaseline-impregnated gauze cut in the same sizes as cottonoids. This gauze has little thickness, and when removed, does not take the brain tissue with it. In other cases, such as the removal of meningiomas, in which I do not usually use retraction, I use cottonoids between the tumor and the brain, adding cottonoid on top of cottonoid as I progressively surround the tumor and remove it while coagulating all the branching feeders between the tumor and brain as I progressively reach the bottom of the tumor. In this case, the cottonoids provide protection for the surgeon from damaging the adjacent edematous brain and promote coagulation of the small bleeders by just providing pressure and bulk on the brain. They are then irrigated off starting with the most superficial cottonoid, until the last cottonoid on the brain is removed. These last cottonoids do contain some brain tissue to my observation.
Dr Nancy Epstein from the United States has a short editorial on minimally invasive posterior cervical laminoforaminotomy vs an open approach. Which approach is the best?
Kurt et al from Turkey produced spinal cord injury in rats by placing an aneurysm clip across the spinal cord temporarily. The treated animals were given methylprednisolone and infliximab, a tumor necrosis factor inhibitor. Both of these agents prevent the destruction of cell membranes by the free radicals that are produced by the factors that inflammatory cells release at the site of the injury. The authors were able to measure the reduction in a specific molecule that is released after cell wall damage after the injury in the treated animals.
Dr Moises Gaviria, who is a psychiatrist, and his colleague Bi Ade, provide a short informative review of the surgical procedures used to treat psychiatric disorders. These disorders include obsessive-compulsive disorder, resistant depression, and anxiety disorders. This is an excellent review of the subject from the psychiatrist's point-of-view.
Dr Mel Cheatham describes the contributions of Dr Albert Schweitzer to the developing world in another editorial—which is apart of the Profiles in Volunteerism series. Dr Schweitzer was a fine example of a person helping others.
There is an interesting Letter to the Editor on a hereditary autosomal-dominant genetically identified locus that produces leads to pressure palsies.
I have added some comments about articles I have read in the Editor's Notes section at the end. These are some interesting articles. Read the one on how doctors are being paid in England not to refer patients to the hospital! You may find these selections interesting.
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