This month, there are some very innovative articles to read. A new approach to the cervical spine that avoids complications of the anterior diskectomy, long-term results of peripheral nerve stimulation for neuropathic pain, a comparison of endoscopic and traditional microscopic transsphenoidal surgery for pituitary tumors, a clever idea for determining the site of cerebrospinal fluid (CSF) leaks without the complications of intrathecal injection, an observation on the disappearance of vasospasm with high mean arterial pressures, the comparison of the cost of clipping and coiling in developing countries, the use of a cadaver vein graft for extracranial/intracranial (EC/IC) bypass, experience with 500 posterior fossa surgeries, the removal of 114 foramen magnum meningiomas, and many more interesting articles.
I asked Bernard George, one of the members of our editorial board, to write an article on his innovative approach to the cervical spine. He and his colleagues led by Chibbaro et al from France describe their approach to the cervical spine for cervical myeloradiculopathy without instability. They approach the spine laterally by separating the sternocleidomastoid muscle laterally and the vascular carotid jugular complex medially to reach the transverse processes on the most affected side. Then, the vertebral bodies are drilled from the lateral approach on one side or even extending to the opposite side. Disks or spondylotic pathologic condition can be removed without the need for instrumentation. Complications are minimal. Horner syndrome is one that is temporary in a small number of patients. If you are not familiar with this approach, read about it. It is one approach to the anterior cervical spine that makes sense to me.
Yi et al from Korea evaluated the occurrence of adjacent segment disease (ASD) in patients receiving a single-level cervical arthroplasty using the Bryan disk prosthesis. The authors found that after a mean follow-up of 24 months, 12.5% of the patients showed radiologic evidence of ASD starting at 16 months after surgery. The Bryan and other cervical disk prostheses were supposed to prevent ASD, but obviously from this study, the 1 tested did not. The authors ask the question in their discussion if there are any other factors that produce ASD besides biomechanical stress—an important fundamental question. What is the answer? Read the comments by Epstein at the end of the article.
Van Calenbergh et al from Belgium and Denmark report on a 10- to 20-year follow-up of 10 patients with peripheral nerve stimulators for neuropathic pain. Of 10, 6 had excellent or moderate continued chronic neuropathic pain relief. The physiologic reasons for these results are not well understood. Read the comments by Slavin and Pawl for an excellent perspective on this article. D'Haens et al from Belgium compared the traditional transsphenoidal microsurgical approach to functioning pituitary adenomas with the endoscopic technique. The series is a historical one with the microsurgical group done earlier than the endoscopic one. Thus, a more established procedure was compared to an evolving one; however, both were done by the same experienced neurosurgeons.
Both groups had similar distributions of functioning tumors and about equal numbers on both groups had previous surgery. Endoscopic surgery resulted in a higher endocrinological remission rate than microsurgery but had a higher incidence of CSF leakage. Read and decide which approach you prefer. Or does it matter if you become good at one and use it?
Hai-sheng et al from China address a complex clinical problem of localizing the site of a CSF leak with a very simple, 100% successful technique. Using topical fluorescein, the authors were able to locate the site of the CSF leakage thru the nose 100% of the time. Read how they did it. It is an excellent answer to a clinical problem.
Ray et al from the United States report a very interesting observation in a patient with vasospasm. After the intraarterial injection of verapamil, the patient developed a hypertensive crisis and repeat angiography immediately after this event showed resolution of the vasospasm. Were some unknown biochemical or mechanical factors involved? What does this observation mean? Years ago after the 1985 EC/IC bypass study results were released, the study organizers denigrated any results that were not from a randomized study as “anecdotal,” implying that they were reports of no significance. We wrote an editorial at the time pointing out that there would be no randomized studies without the carefully documented observations from studies such as the one above. Case reports are of value if they reveal a biologic phenomenon not seen before that is also well analyzed with the knowledge at that time. Read this report. It is telling us something we do not yet understand. This is an excellent observation.
Tahir et al from Pakistan report on the clinical outcomes and comparative costs of clipping vs coiling of intracranial aneurysms in a small population of patients in Pakistan. The outcomes of each treatment were the same for coiling or clipping. However, the cost of coiling was 62% higher than that of clipping. This article has an important message for neurosurgeons in the developing world. Cost is an issue everywhere and until the costs of coiling have decreased, most of the world will use clipping of aneurysms as the preferred method of treatment. While visiting a company that makes interventional devices 15 years ago, I saw their research that, to me, was developing devices that were very complicated. I told them that the goal should be to produce a product that could be used easily by many people who could learn the technique. Then the device would be widely used. Also, the cost should be low so that many could use it. The manufacturers did not take that advice, and the results are seen in this article. A number of articles in this issue describe simple solutions to clinical problems that are successful. This article is the reason why that recommendation was important.
Mery et al from the United States present the first reported series of 10 patients using cadaver vein grafts as EC/IC bypass conduits. Their short-term patency was 100%, which was higher than that seen in the use of these grafts in the cardiac field. This is an innovative idea. We await the long-term follow-up results.
Dubey et al from the United States and Australia summarize the complications they saw in 500 patients undergoing posterior fossa surgery. The article is useful in documenting the complications and in assessing the treatment of these complications. The authors report a complication rate in these 500 cases of 32%, or 1 of every 3 patients. We do not know the complication rate in other large series. To me, this rate is high and needs to be reduced. How can we, as neurosurgeons, offer a product to patients when 1 of 3 will have a complication? What every neurosurgeon needs to do is to assess his/her complications and develop a plan to reduce those complications to 0. The CSF leak from the posterior fossa surgery is seen frequently. It can be related to poor closure, subtle hydrocephalus, complex surgery with tumor invasion of the dura and meninges, repeat surgery, and many more. From my experience, the best strategy is to PREVENT complications and to avoid them. Using a spinal or ventricular drain before surgery to reduce the underlying CSF pressure is helpful. I have found that closing with a horizontal mattress suture at each layer and in multiple layers is useful. Clean dissection minimizing necrosis is very important. Basically, one complication is enough. I do not need 100 cases to see if 1 complication becomes 13% or 32%. Statistically, the complication you first see will happen again. Avoiding cranial nerve deficits at 9 and 10 is absolutely essential even to the point of leaving the tumor, in my opinion. This cranial nerve deficit is devastating, life-changing, and terminal for the patient.
Wu et al from China report on their experience for a 14-year period with 114 patients who had a foramen magnum meningioma. This is an excellent article by obviously knowledgeable and experienced neurosurgeons. The comments by Zhou et al at the end are in agreement with the authors that for most of these tumors, a far lateral retrocondylar approach is all that is necessary to remove these tumors. With the “hype” for skull-based surgery, many young neurosurgeons are attracted to extensive skull base transcondylar approaches to these tumors because they read about it or are told about the approach from far less experienced surgeons than the authors. Extensive skull-based approaches are unnecessary in these tumors. The park bench position or sitting positions are useful in this operation.
Izci et al from the United States report on the arterial and venous anatomy of the frontal lobes and interhemispheric cortex. The article is difficult to read, but from my perspective, the key information is the location of the bridging veins in relation to the coronal suture. This anatomy is important in surgical planning particularly using neuronavigation. Large flaps in the past diminished these concerns as the anatomy could be seen and a corridor to the corpus callosum or to the anterior cerebral arteries could be chosen. With a limited exposure—that I do not favor for the above reason—the statistical location of the bridging veins anatomically becomes important.
Figaji et al from South Africa compared the pulsatility index (the difference in flow velocities taken at systolic and diastolic pressures) with the intracranial pressure and cerebral perfusion pressure measurements. Although there are reported relationships between these measurements in adults, the authors found no such correlations in children with severe traumatic brain injuries.
Muramatsu et al from Japan tested their hypothesis, which examined if peripheral muscle stimulation can be recorded in the cerebellar hemisphere in animals. The answer was yes, and it appeared that conduction for those impulses came through the inferior cerebellar peduncle via the spinocerebellar tract. This article—with some human correlates in the future—could be used to detect changes in the spinocerebellar tract during surgery on the brain stem.
Clark Watts, a neurosurgeon and a lawyer, discusses the issue of physician involvement in health care as a business. Surgical Neurology has warned about this behavior in the past, which if abused, can only damage all physicians. Our national societies were slow to adopt codes of ethics, even though this journal called for those steps years ago. Now the government wants to impose more regulations. This result is an example of physicians not being responsible or policing themselves. It is also interesting that the politicians are eager to regulate others but not themselves.
Mel Cheatham provides another editorial describing the volunteer activities of a neurosurgeon, Tom Flynn, who donated his time for many years to provide neurosurgical help to Thailand, Vietnam, and Laos.
Notice
After 15 years as Editor-in-Chief of Surgical Neurology, I will be leaving the journal at the end of 2009. I am first very honored to have been editor of this journal following in the footsteps of 2 neurosurgeons for whom I have great admiration: Dr Paul Bucy and Dr Eben Alexander. Both were terrific role models of fine human beings, physicians, and neurosurgeons. Secondly, I am most grateful to have had the chance to bring new information to thousands of neurosurgeons around the world that can be used in their practices. I appreciate the help of an excellent editorial board that was chosen for their outstanding clinical judgment. Lastly, I am deeply appreciative to the publishers at Elsevier for allowing me the opportunity to be editor of this journal. If you would like to write me about your comments on the journal or other thoughts, please send them to jamesausman@mac.com.
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