This month, there are 2 articles on cell phones and acoustic neuromas. The first, by Khurana et al from Australia concludes that there is enough evidence to link prolonged cell phone use with ipsilateral brain tumors, glioma, and acoustic neuromas. The risk of developing such a tumor doubles with cell phone use. Han et al from the United States reviewed the subject also. Although the authors of this second article recognize that some articles report an association between cell phone use and brain tumors, they find that there are so many variables influencing the conclusion that no final decision can be made. For example, acoustic neuromas are now found more frequently because of better imaging. There are also issues of the subject's retrospective recall on use that can affect the outcome analysis. There are also other considerations that are reviewed in the Discussion. Yet, taken together, there does seem to be suggestive evidence of an association between cell phones and brain tumors that needs further investigation. The controversy is far from settled. Read the articles and make your own decision. What would you decide from the evidence presented?
Scarone et al from France have performed a superb human physiologic study to determine the anatomical and functional network for the cortical loci of writing. The analysis of a writing disturbance is done less frequently than speech abnormalities clinically, so little is known about the pathways serving writing. In a series of 15 patients undergoing surgery for low-grade gliomas in various cortical regions, the authors tested the patients for writing abnormalities preoperatively and postoperatively. All had normal writing preoperatively. Then at awake surgery, they tested speech by electrical stimulation and then resected the tumors to avoid speech impairment. Writing was not tested intraoperatively but was tested postoperatively. Postsurgery, some patients had speech abnormalities, but all had writing difficulties. The text describes the different writing problems produced by resection in the superior parietal region, the supramarginal area, the supplementary motor cortex, the middle and inferior frontal gyri, and the insula. Lesions in each area produce a different effect on writing. The authors have done a detailed evaluation of the literature. The experiment is difficult to perform because there is no ethical way to resect portions of the cortex except during tumor surgery. Vascular lesions—such as infarcts—may cover too much cortex to be useful in a study of a specific lesion area. Yet, this limitation in subject choice is the limitation of the study. An ideal experiment would be to resect various parts of cortex in normal people, a project that is impossible ethically. Thus, the answers to the questions the authors raise themselves about how much the tumor infiltration affects the preoperative plasticity and reorganization of speech and writing cannot be known. Perhaps by using functional imaging in the patients they ultimately take to surgery, this answer can be obtained to the extent of reorganization that tumors produce when compared to “normals.” Read the abstract and conclusions first for a quick summary of this work. This research is excellent. Neurosurgeons and neurologists interested in language and writing functions will quote it for many years. This is a scholarly piece of work. Outstanding science.
Russell et al from the United States have performed a simple but important study: they measured glioma vascularity using catheter-based angiography and correlated this vascularity with tumor grade and survival. The Methods section provides their 4-step grading system for tumor vascularity that they use in evaluating patients with World Health Organization grades 2, 3, and 4 gliomas. They found that increased vascularity was associated with higher-grade tumors and shorter survivals. They conclude that increased vascularity suggests that angiogenesis should be a target for molecular therapy. Although angiography is not used much today in glioma studies, they do make a correlation with magnetic resonance imaging and angiographic vascularity, suggesting that magnetic resonance studies can be similarly used to determine vascularity. This is a first-rate practical study.
Kano et al from the United States report their experience with the use of stereotactic radiosurgery for metastases to the pituitary. This is a very detailed, data-filled study that is an easy read. Half of the patients presented with pituitary dysfunction and the other half with cranial nerve deficits. The median progression-free survival was 15 months, whereas the median survival was just more than 5 months. Obviously, the systemic disease killed these patients before the metastases regrew. Forty-three percent of those radiated in this study had improvement in their diabetes insipidus, whereas 50% improved their neurologic status. To me, the fundamental consideration this study raises is, “Is all of this treatment worth it?” This question is easily answered in many countries with a denial of therapy on economic grounds. In the United States so far, health care rationing has not occurred. Who would decide to deny this treatment if rationing was adopted? Should one person sacrifice his right to life and treatment choices, to pay for others who cannot afford this treatment? Are the economics and costs of unlimited health care practical? Should everyone have the same rationed care or should each individual, according to his/her means, have access to unlimited care? Should everyone all over the world—not only in one country—have rationed care so that all may have the “right to health care”? These are the questions that can be raised about health care in the United States and everywhere at the time of this writing. Read the editorial by Kelly near the end of this issue for a provocative story on this very subject.
Cecchi et al from Italy report on a 9-year follow-up on 16 patients operated on for spinal dural arteriovenous fistulas. They found that over the course of the long-term follow-up of these patients postoperatively, 50% had deteriorated neurologically, specifically in gait and urinary function. Read the comments by Barrow at the end for an excellent perspective on this report.
Kaya et al from Turkey report on a simple but informative study on progesterone and estrogen receptors in cerebral cavernomas. To explore whether bleeding in cavernomas is related to hormones and pregnancy, the authors tested 12 cerebral cavernomas resected from patients for estrogen and progesterone receptors and found none. So estrogen and progesterone do not appear to have special receptors on these cavernomas to account for any change during pregnancy.
Oppenlander et al from the United States report on anterior cervical hyperosteophytosis, the dysphagia it causes, its diagnosis, and its treatment. What is hyperosteophytosis?
There are 3 interesting short reports that follow. One uses plastic reconstruction models of the spine for use in explaining surgery to patients. This idea has interesting implications for surgical planning and for patient education. It is by Madrazo et al from Mexico. The technical note by Shimizu et al from Japan presents a good idea to protect the dura during the drilling of the sphenoid ridge. The third article by Yamamoto et al from Japan describes the use of transesophageal gastrotubing to avoid a gastrostomy in patients with a ventriculoperitoneal shunt who need tube feeding.
Pat Kelly, who is widely known for his outstanding contributions to neurosurgery and his excellent writing, has written an editorial about the challenges and frustrations physicians and neurosurgeons face in health care, not only in the United States, but in every country of the world. Read the letter to the Editor from a young Iranian physician after you read the editorial by Kelly. I suspect that every physician should agree with this young neurosurgeon's idealism. Yet, as of this writing, there are hundreds of thousands of people in the streets of Iran protesting against alleged presidential election corruption that has taken their free democratic choice away from them. That is what Pat Kelly is telling us and what many courageous Iranians and people in other countries are doing by standing up for what they believe, so that they can live the ideals of the young Iranian “everyperson.” What do you think?
The publisher has just informed me that our Impact Factor—a measure of how often articles are cited in Surgical Neurology by others—has reached an all-time high. The increase is 40% for last year's Impact Factor and is an indication of the quality of the articles published in Surgical Neurology. We appreciate the contributions of the authors, the editorial board, and our readers in this success.
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