Don't let the phrase “Fuzzy Logic” discourage you from reading the article by Shamin et al from Pakistan and Qatar on the subject. The concept makes common sense. Here is the story: we have all grown up and learned a statistical system, the Aristotelian system, in which the world is black or white; the event either happened or it did not happen. Either a patient has cancer or he or she does not; either they have diabetes or they do not. In this system there is no room for mild diabetes. Either you have it or you don't. On that basis the statistics are calculated. That is Aristotelian logic. But the world we live in is not black or white, it is gray. You can have a limited form of cancer or mild diabetes. A grading system can be applied to the degree of presence of such diseases to make statistical calculations. This is “Fuzzy Logic.” It is used in most branches of science except medicine. The authors apply Fuzzy Logic to predict those who will have a good or poor result from surgery of the lumbar disk. They found a highly predictive relationship using Fuzzy Logic among some of the variables they chose to predict outcome and the final result. This is a terrific article. We wrote about Fuzzy Logic in this journal 8 years ago. Fuzzy Logic will become common in medical practice because it makes sense. Randomized studies will also disappear because the data of the future will be based on each individual's parameters from his or her imaging and biology. Read the Discussion first. The Abstract is too confusing to read first. Then, read the article for more information.
Possover and Chiantera from Switzerland present a terrific idea of using a stimulator on the superior hypogastric plexus to activate an atonic bladder.
Bell et al from Canada have written a superb paper on the ethical, economic, patient selection, and informed consent issues for deep brain stimulation in the future. Neurosurgery, neurology, and psychiatry are all specialties looking at different manifestations of the same brain. More applications for deep brain stimulation in treating functional disorders will emerge. The multidisciplinary approach to these problems will become essential. Read Slavin's good comments at the end. This article will be quoted widely.
Guangming et al from China studied the psychiatric symptoms in patients before and after temporal lobectomy. Those who were seizure-free had improved psychiatric symptoms. Read Mathern's excellent analysis at the end. In the future I believe we will learn that psychiatric (behavioral) performance of patients is not separate from neural or structural disease. This is an integrated functioning brain with motor, visual, sensory, and complex integrative functions. Surgery alone may not alter long-standing pathways that are established in patients with epilepsy, dendritic, and synaptic connections and neural network changes associated with the epilepsy.
Otawara et al from Japan continue a series of fine publications from their institution. In this study, the authors analyzed the cognitive decline in patients with aneurysmal SAH compared with patients who had unruptured aneurysms. The authors assume by comparing patients after surgery has occurred that the effect of surgery on cognitive function will be eliminated. I do not agree with that premise. Regardless, the patients with SAH versus those without SAH had more neuropsychiatric dysfunction than the controls. What they found was that the impairment in cognitive function was related to the Hunt-Hess grade on admission. This is important work. It is obvious that surgery itself will introduce cognitive changes. More studies examining the neuropsychiatric outcome of patients with treatment will be key to determining treatment choices in medicine.
Alexander and Riina from the United States report on Riina's experience in treating 413 aneurysms over a 6-year period with clipping or coiling. Riina's experience is the same or better than that found in larger series, either coiling or clipping. The authors suggest that one vascular neurosurgeon can perform both clipping and coiling well. Read Levy and Hopkins' comments at the end and the Discussion of the article indicating how other specialists are making inroads into cerebral vascular patient treatments. The other option in having a team of people who treat the patient is also very acceptable. It is hard to think one neurosurgeon will be available at all times for all treatments. Ultimately, a team is necessary.
Zhao et al from China report on their experience treating intracranial stenoses, which are prevalent in China, with angioplasty and stents. The authors had excellent results using the Gateway-Wingspan system. Read Gobin's comments at the end. Long-term follow-up is critical in these patients with intracranial stenoses to ensure that restenosis does not take place.
Wajnberg et al from Brazil report on their successful experience using Neuroform stents for wide-necked intracranial aneurysms. The authors reported successful treatment, with poor outcomes in 8% of their patients. The authors had technical difficulty deploying the stents in one-third of their cases. I know of complaints about deploying a stent that was used by the interventionalist, but the neurosurgeon was not present or called to evaluate continuing the intervention as opposed to resorting to clipping. To me this treatment is a joint and continuing decision between the interventionalist and the neurosurgeon. At each stage of the treatment whether it be surgical or interventional, the risks of pursuing a specific treatment must be evaluated as they may change as the treatment evolves. And the new risks may not be the ones to which the patient agreed when the treatment was proposed. I do not like the blanket consents that are obtained before coiling that places all the decisions in the hands of the treating physician. The patients must have the right to decide what they want as the risks change. Would you want that if you were the patient?
Ibrahim Sbeih from Jordan has written an important letter (it was intended as an Editorial) on dishonesty in neurosurgery. I commend him for presenting this subject and his recommendations to eliminate this problem. If we do not police ourselves, others will do it for us on the demands of the public. I remember attending my first Cushing Society meeting (before it became the AANS) in 1964. I was struck by the statements of the people who commented on the presented papers. Everyone was complimentary when it was obvious that there were criticisms of the work. Was being politically correct more important than the truth? Sbeih's paper should be discussed in every organization and steps should be taken to implement the recommendations. Of course, at meetings, it is the responsibility of the moderator and the audience to ask critical questions of the presenter, if indicated, to make sure that the truth is being told. “The patient comes first” is the principle.
Read Nancy Epstein's article on the use of a wound peritoneal shunt to treat CSF leaks in complex spine surgery. Nancy's work is consistently outstanding.
I have written a final series of editorials for this issue you may enjoy reading.
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