The article by Heller et al from the United States is a rarity in neurosurgery and probably in medicine. It honestly reports the complications a young neurosurgeon encounters in his/her first postresidency years in practice. This “learning curve” is experienced by all people mastering the art or science of any profession. It is about life. The article is excellent for all to read, regardless of their specialty; the principles apply to everyone. Also, note Gary Mathern's comments at the end. I have written an editorial about “Complications in medicine: who will ever know?” that appears after the article.
Chan et al from Singapore report on their use of a robot to simulate a brain biopsy in an animal system. Why read it? Because it is the future of neurosurgery, surgery, and medicine. The accuracy of this completely robotized surgical system for brain surgery has an error of less than 1 mm and approached 0.5 mm in target error. Read Slavin's comments at the end for a superb analysis of this technology. This is 2009; in 1909, neurosurgery was just beginning. Imaging was done by plain x-rays, and air encephalography (which most younger neurosurgeons have never experienced), was introduced in the 1920s as a huge advance in imaging the brain. Angiography was developed in the 1930s, computed tomography scanning in the 1970s, and magnetic resonance scanning in the 1980s. In 100 years, we have come from the initial primitive performance of surgery on the brain to robotic surgery. These advances indicate the rapid developments in neurosurgery in the past 100 years, with most of the changes coming in the last 30 years. What will robotic neurosurgery be like in 2030 or 2050? What will neurosurgery be like at the end of the century? Obviously, robotic surgery cannot remove a brain tumor yet, nor perform complex neurosurgery. But this is 2009, not 2109. These advances are technical, but similar rapid progress is being made on the molecular side in medicine. This editor has stated on more than one occasion that neurosurgery will be of historic significance by 2100. As with my predictions about “The death of aneurysm surgery” (Surg Neurol 2001;56:348) and “The death of spine surgery as we know it today” (Surg Neurol 2003;60:469), predictions about the passing of surgery as we know it have never been popular. Nonetheless, the accumulating evidence that traditional surgery will disappear, as demonstrated by this article, is overwhelming. Neurosurgery as we know it will change. The only problem with this change is that neurosurgeons and physicians are resistant to change. How do we avoid being left unchanged while the world around us is developing so rapidly? The answer is obvious: open our minds to new ideas, partner with others who think differently, and understand how to use these changes to our advantage, and to the benefit of our patients.
Lehecka et al from Finland report “The rainbow team's” experience in treating internal carotid bifurcation aneurysms. For any aneurysm surgeon or even for an interventionalist, this article is a gem on the anatomy, morphology, and technical difficulties in approaching these aneurysms. The surgical “tips or pearls” are outstanding and can eliminate much of the experience necessary to achieve a high success rate in clipping any aneurysm, including internal carotid bifurcation aneurysms. This article should be read by all residents and neurosurgeons interested in vascular surgery. It is an outstanding piece of work, which indicates the authors' quality of work in treating intracranial aneurysms.
Rijbroek et al from the Netherlands studied the pre- and postoperative cerebral blood flow and cerebral blood volume 1 day before and 1 day after surgery for carotid endarterectomy in 10 patients. They found that the cerebral blood flow increased in both hemispheres and that the ipsilateral blood flow in the middle cerebral artery also increased. The authors used PET to make their determinations. Their patients ranged in age from 44 to 71 years. This study shows what we would have expected biologically: after a carotid endarterectomy, the increased flow that occurs ipsilaterally decreases the steal from other vascular territories that were supplying the ischemic hemisphere. For years, we performed 4-vessel cerebral angiograms on all our patients with cerebral vascular disease. In those with atherosclerotic/ischemic cerebral vascular disease, we saw this vascular steal reversed, but we could not quantitate it. These changes were seen after carotid endarterectomies, vertebral artery surgery, and bypasses of all kinds. What the authors have quantitated is that total cerebral perfusion increases after reversing the stenosis or occlusion in various vascular territories. We may look at a patient with compromised vessels to the brain, but our examinations are normal. So, we assume that the patient is functioning well. But are they? This very subject was the basis of controversy when Peerless wrote his article on how bypass reversed signs of cognitive decline. I have no doubt that he was right, but the methods of selection at that time were not as sophisticated as this article now demonstrates. As Loftus suggests in his comments, we have not yet translated this progress in science to the clinical area. That time is coming.
Yi et al from Korea compared the biomechanical outcomes of patients with anterior cervical discs treated with either inserting Bryan arthroplasty (artificial disk replacement [ADR]) or anterior cervical discectomy without fusion (anterior cervical foraminotomy [ACF]). The study was a retrospective one. The authors found that after ACF, the disc height decreased at the operated level and the segment developed less motion. After arthroplasty (ADR), there was no change in disc height or motion at the operated level. Clinical outcomes were no different with either procedure. To me, the study is interesting and well done, but limited. What is really needed is a comparison of multiple treatment options and a cost benefit analysis: (1) no treatment, (2) physical therapy except pain medication, (3) posterior cervical foraminotomy and discectomy, (4) anterior cervical fusion with and without a graft and/or plate, and (5) arthroplasty. Follow-up should be at 5 to 10 years. In this study, the patients were followed for 13 to 20 months. The study is well done, but needs to be expanded with more groups and a longer time of observation.
Viswanathan et al from the United States write about their experience using lumbar drainage to approach a mesial occipital arteriovenous malformation (AVM) located near the tentorium. First, for an AVM in this location with the terminal feeding vessels seen on the angiogram, embolization is an excellent adjunct to surgery or radiation. I have seen lesions in this location cured by “nidus embolization,” but the patient's young age of 5 years, the interventional capabilities at the institution, the risk associated with this treatment, and the patient's and surgeons' choices all factor into this decision to embolize. In 1988 (Surg Neurol 29:298-306), we published an article on the 3/4-prone operated-side-down approach to the pineal region. In 1960, Poppen (a neurosurgeon at the Lahey Clinic in Boston, Mass) published his Atlas of Neurosurgical Techniques, which is an excellent book. In it, he described placing the patient in a seated position, doing an occipital craniectomy, and retracting the occipital lobe to reach the pineal region. Homonymous hemianopsia was a complication of this approach; to eliminate this complication, we developed the operated-side-down approach with the patient in the 3/4 position. This approach allowed the occipital lobe to fall away from the falx. This brain relaxation was aided by an occipital ventricular drain and by lumbar drainage for the reasons described by the authors of this article. The position allowed 2 surgeons to sit and operate and eliminated the air embolus from the sitting position. This position also will allow the surgeon to reach the mesial inferior temporal lobe with little or no retraction and also the posterior third ventricle down to the superior medullary velum and cerebellum using the spinal drainage the authors suggest.
There are a number of interesting case reports and an editorial by Clark Watts on payment for emergency coverage that probably only applies to the United States.
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