Montel et al from France have performed a thoughtful, well-done study comparing the “coping strategies” of patients with Parkinson's disease treated either with medication or deep brain stimulation (DBS). In spite of the DBS-stimulated patients having better physical outcomes, their own evaluations of the benefit they received from their DBS treatment was no better than the dopatherapy-treated patients. The authors attribute this result to their findings that the DBS-treated patients had higher expectations of success than they believed they achieved. The authors suggest some realistic teaching of patients before a procedure—perhaps from former DBS patients—would be beneficial in helping patients achieve reasonable expectations from surgery. The implications of this study for the surgical treatment of disease are profound. This article should be read by all neurosurgeons in practice and in training. The comments by Slavin at the end are also excellent. This is a first-rate article with profound implications for medicine and surgery.
Tashjian et al from the United States investigated a very fundamental question in cervical spinal stenosis that leads to the selection of the proper operative approach for this disease. What the authors found after doing decompressive cervical laminectomy in patients with spinal stenosis was a posterior migration of the cervical spinal cord on magnetic resonance imaging. Charlie Fager of the Lahey Clinic made this observation when contrast myelography was the imaging method of choice years ago. He, too, demonstrated posterior migration of the spinal cord. He made this point, as the anterior decompressive procedures became more popular, indicating that the anterior operation performed to relieve the compression anteriorly could be achieved by the posterior decompression as the cord migrated back from the anterior osteophytes. The fundamental controversy these data raise is what operation is best for cervical spinal stenosis—anterior decompression and fusion, or posterior laminectomy with or without laminoplasty or fusion? For neurologic outcome, the authors of this study found no correlation between the clinical outcome and the migration of the spinal cord. They cite some articles showing improvement with laminoplasty. It would seem that improvement would be related to the amount of loss of pyramidal fiber tracts and lower motor neurons in the spinal cord before the surgical procedure. Fusion is necessary when instability is demonstrated preoperatively. Anterior decompression becomes the treatment of choice if the anterior compression cannot be overcome by posterior migration of the spinal cord with posterior decompression. So, if any operation is being done to promote clinical improvement or to prevent further clinical deterioration, it should logically be one at the early stage of the disease. If the goal of the surgery is decompression of the spinal cord, this can be achieved anteriorly or posteriorly. The choice of the operative approach should be justified as to the goals to be achieved, and the simplest, least-complicated operation should be selected. Read Weaver's editorial at the end of this issue concerning other factors influencing the choice of procedures in the United States and elsewhere.
Sade et al from the United States are to be congratulated on their excellent results with the very troublesome involvement of the optic canal by meningioma. They found a high percentage (70%) of optic canal invasions with tuberculum sella meningiomas. Their discovery of anterior clinoid hypertrophy from the meningioma makes sense, as does their approach to its removal and opening of the optic canal. The visual improvement they noted in nearly 80% of their patients is remarkable. The discussion contains a review of the relevant literature on this subject. This is an excellent approach to this difficult clinical problem.
Wang et al from China have done a nice anatomical study on the approach to the superior petroclival region. The best way to read this article is to first study Figure 1 and its legend in detail. The photographs are excellent and make the case the authors describe for their approach. This is a nice technique to know.
Stein et al from the United States have constructed a mathematical model that predicts the number of patients with shunted hydrocephalus in the future. At this time, the authors' model predicts that there are 300 000 shunted patients in the United States. Hydrocephalus is probably the most common problem seen by cranial neurosurgeons. It is a very complex problem to treat. To me, the real question for the past 60 years after the development of the ventriculoperitoneal shunt is “Is there a better way to recognize and to treat this disease?” Spectroscopic magnetic resonance has been used to determine alterations in cerebral metabolism resulting from hydrocephalus before it is clinically evident. Work on water transfer to the cerebrospinal fluid through water-transferring (aquaporin) channels is being done to see if the water production leading to hydrocephalus can be stopped. New methods of shunting such as third ventriculostomy have been developed and are successful. This is a very prevalent disease and is still one of the most troubling clinical problems facing neurosurgeons. The authors' diagram in Figure 3 shows the increasing prevalence of this disease. Can we make more progress in finding a cure for this common problem?
Guangming et al from China report on a prospective randomized comparison between no epidural drainage vs epidural drainage postcraniotomy for epilepsy surgery. The drains made no difference in the occurrence of hematomas. In this series, the authors found 42 epidural hematomas in 342 patients, or more than 1 of 10. To me, in cranial surgery, this percentage seems high. If so, why?
Kim et al from Korea describe a very useful technique for sectioning the anterior petroclinoid fold as it attaches to the anterior clinoid process to provide increased visualization of proximal carotid artery aneurysms near the anterior clinoid process.
Turkoglu et al from Turkey have performed an excellent animal study in which they have shown the neuroprotective effect of atorvastatin after a traumatic brain injury. The secondary effects of this injury, which produce free radicals that lead to peroxidation and destruction of the cell membranes, were found to be inhibited by atorvastatin. The authors demonstrated this inhibition ultrastructurally and biochemically. For those taking statins, they may have some extra neuroprotection that they did not expect!
Yanni et al from the United States describe a very practical method of using personal digital cameras through the ocular of the operating microscope. This is a terrific tip on photography that makes this task very simple anywhere in the world.
Albert et al from the United States present a very interesting case report on a young woman with hyperostosis of the skull, raised intracranial pressure, and Arnold-Chiari malformation. Take a look at Figures 1 and 2 and determine how you would treat this problem—then read what the authors did. Their approach makes sense, but is opposite what most would have done.
Should you use hyperbaric oxygen therapy for patients with refractory cerebral edema after stereotactic radiation therapy? Read the article by Wanebo et al and the comments by Goodkin following for an answer to this question.
Belen et al from Turkey report on the early history of peripheral nerve repair. Read the description of Hippocrates' nerve repair using a woman's hair as a suture; it is amazing.
Edgar Weaver from the United States has written a wonderful editorial that clearly describes the problems with health economics in the United States, and how these problems could be fixed. This is the best explanation I have read on the problem. Health care systems have evolved around the world and are related to the local politics and socioeconomics of the country, making it difficult to transfer one system from one country to another. Each system has its own advantages and disadvantages. Weaver describes one of the problems in the “fee for service” system, and how it can be fixed.
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