Rengachary et al from the United States report a fascinating historical case from the 17th century about human resuscitation after a hanging “until death.” The medical, social and legal implications of this case are very interesting to read 300 years later.
Karol et al from Argentina have written a carefully done and documented clinical study that is a model for all to read. Their subject matter is radiofrequency thermocoagulation for trigeminal neuralgia. They studied the clinical symptoms in detail and found rare V1 lesions with most of the V1 pain from V2 or V3 trigeminal neuralgia. They did include patients who failed other treatments but did exclude patients with atypical trigeminal neuralgia. The authors mapped the trigeminal ganglion in detail to target the spot for thermocoagulation. Their lesions were smaller than those that are used traditionally. Their long-term results were the same as those reported in other series, but their complications were exceptionally low—no doubt because of their carefully detailed technique. This is an outstanding study. It shows that you do not have to do molecular biology to produce careful, well-thought-out, scientific work. It is just good science, good thinking, careful observation and good reporting. Those facts alone make it interesting to read regardless of your special area of interest.
Antic et al from Serbia report their experience with surgical treatment of trigeminal neuralgia in medically intractable patients with multiple sclerosis. In 8 patients, the authors performed microvascular decompression with partial sensory nerve section of the fifth nerve in the posterior fossa near the brainstem or sensory nerve section alone. The authors do not believe that microvascular decompression has long-term value basically from literature experience. So they did a fifth nerve sensory section in all of their patients but did do a microvascular decompression in 5 also. Nine years after surgery, 75% of their patients were pain-free. They had no significant surgical complications. They were not equipped to do percutaneous rhizotomies. Karol, who wrote the preceding article on radiofrequency trigeminal lesions for trigeminal neuralgia, comments that the procedure he describes above will provide good pain relief for these patients. The choice of procedure depends on the knowledge and equipment each neurosurgeon has.
Cho et al from South Korea have written an excellent article dealing with cancer patients presenting with metastasis to the spine. The patients could not qualify for traditional radiation therapy. Their patients had instability of the spine because of the effects of the tumor on the vertebral column, progressive spinal deformity, progressive neurologic deficit or intractable pain. In their Discussion, the authors review the alternative treatment choices. They propose a transpedicular approach after laminectomy followed by stabilization of the spine. They know that they cannot cure the primary disease. They are using palliative surgery and choosing an approach that has low risks and complications. The statistics they cite in the first paragraph of the article are astounding: “Forty (40%) percent of cancer patients develop spinal metastases annually, and 10% to 20% of those patients have spinal cord compression.” That means that 5% of all patients with cancer each year, or 25000 patients, will develop spinal cord compression. That is a higher number of patients than those with primary brain tumors each year and represents a large market of patients for neurosurgeons to treat. “Fifty percent (50%) of patients with known cancer who develop back pain have vertebral metastases.” Their article demonstrates good clinical judgment. This is a good article to read in treating a complex clinical problem.
Murakami et al from a highly experienced vascular neurosurgical group in Sendai, Japan, report their results with a troubling problem of ischemic events after occlusion of the internal carotid artery for internal carotid artery (ICA) aneurysm. These patients underwent extracranial intracranial (EC-IC) bypass followed by carotid occlusion. They studied their patients carefully with trial balloon occlusions to select those who developed hemisphere ischemia. These patients then underwent high or low flow saphenous vein or superficial temporal artery bypasses, respectively, before carotid occlusion. Still 10% of their patients had a postoperative ischemic complication, mostly from small branch occlusions off the carotid artery to basal ganglia structures. The closer the aneurysm was to the clinoid, the higher the chance of ischemic complications. Truly cavernous aneurysms had a low chance of such events. The authors did not use preoperative or postoperative antiplatelet agents. This drug omission may explain the occurrence of these ischemic events. I am not so sure of the comments of Amin-Hanjani about attributing the ischemic events to this omission. A report that is similar to that of these authors in which antiplatelet agents are used would settle this problem, but such a study is unlikely to be done. So, most would use the antiplatelet agents. This is an important report because it honestly documents experience with a very troubling problem faced by vascular neurosurgeons.
Fujimura et al from Japan have written another excellent article from their wide cerebrovascular experience on Moyamoya disease. Professor Jiro Suzuki was the neurosurgeon who recognized this disease at their center more than 40 years ago. The authors investigated the occurrence of symptomatic hyperperfusion in the hemisphere in which revascularization, including a superficial temporal artery-middle cerebral artery bypass and encephaloduromyosynangiosis, were done as the treatment of Moyamoya disease. In all the patients they evaluated, 21 of 58 developed hyperperfusion on the operated side as determined by single-photon emission computed tomographic evaluation. The treatment of these patients presenting with postoperative ischemic symptoms was blood pressure control and the use of free radical scavengers to counteract the reactive oxygen molecules that are produced during ischemia-reperfusion injury. The results of this treatment are good. Their Discussion details the reasons behind their therapeutic options. This is excellent scientific work.
Tseng et al from Taiwan report an interesting approach to the medial temporal region of which I was not aware. Others have written about this approach actually by going over the cerebellum in a suboccipital approach and sectioning the tentorium to get to the medial temporal region. That approach seemed to involve 2 major brain compartments to me and seemed complicated. The authors' approach requires retraction of the occipital lobe at the level of the torcula and moving anteriorly along the tent to the medial temporal region and lesion. Some also advocate sectioning the tentorium from this approach to gain more room. I reported years ago the three-fourth prone operated side down approach to the pineal region. That approach could also be used for medial temporal region lesions. The advantage of the three-fourth prone operated side down approach is that there is no retraction required for the occipital lobe that falls away from the falx being on the “down side” or it can be relaxed with ventricular drainage. This is a nice report to read and a surgical approach to keep in mind.
Maeda et al from Japan evaluated 17 patients presenting with various symptoms of a malignant glioma. On careful preoperative testing, the authors found significant spelling deficits in 15 patients who had no motor deficits on clinical examination. All patients were at a Karnofsky Performance Status of 80 or more. Their work indicates that with detailed testing, subtle deficits can be found. Read the comments of Ashby at the end for a perspective of a neuro-oncologist-neurologist on this work.
Marjamaa et al from Finland preformed a nice animal study comparing the outcome of platinum coil occlusion of experimental aneurysms with that in which polyglycolic-polylactic acid–coated coils—which promote thrombosis because of the coating on the coils—were used. The polyglycolic-polylactic acid coil-treated group showed a higher incidence of aneurysm thrombosis and endothelialization than those treated with platinum coils. This animal model appears to be a good model for evaluating the results of various endovascular treatments of aneurysms.
Maroon et al from the United States describe the use of a pneumatically (air pressure) driven Kerrison rongeur for laminectomies. The instrument is easy to use and reduces hand fatigue as they report.
Csókay et al from Hungary describe an additional hand support tool to reduce each surgeon's hand tremor during microsurgery.
Read the case report by Gupta et al from India on 2 cases with similar clinical histories and radiographic images but 2 different pathologic diagnoses. Again, the principle is to obtain a tissue diagnosis before treatment.
There are a number of other interesting case reports in this issue also. Clark Watts has written an article on a very troubling aspect of malpractice in which non-neurosurgeons can testify against neurosurgeons.
Mel Cheatham adds to his series on doctors who are volunteering their services in countries in which there is a great need, and in which they get, in return, a huge personal satisfaction. This article is about the needs in Africa for neurosurgeons.
I have written an editorial about fear and the crisis mentality that is being used politically to further the socialistic agendas of some. This method is being used to herd the public into health care and economic decisions worldwide from which they will ultimately suffer. I have also written a brief note about an article by Rengachary et al mentioned at the beginning of this editorial.
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