- Email: [email protected]
In this issue…
Available online at www.sciencedirect.com
Surgical Neurology 70 (2008) 1 – 2 www.surgicalneurology-online.com
Editorial
In this issue… Mirza and Goodkin have written a very thoughtful analysis of the SPORT (Spine Patient Outcomes Research Trial). Their editorial is worth reading and provides an answer, which the trial was designed to supply. They have asked what should be done with a patient presenting with a lumbar radiculopathy and no motor deficit, which, on imaging, has a definite lumbar disc herniation that could explain the symptoms. Should an operation be performed or not? This is the question the trial proposed. Mirza and Goodkin analyze how the trial answered that question. Hernesniemi and “The Rainbow Team” from Finland have produced the “gold standard” article on the surgical treatment of anterior communicating aneurysms. This article is a must-read and is first-rate clinical science. I have written some comments at the end of the article. Chen et al from China have a superb article on the coiling of small aneurysms with a diameter of 3 mm. Of the 11 cases in their series, 10 had ruptured aneurysms. (What does this say about ISUIA (International Study of Unruptured Intracranial Aneurysms) that said the risk of ruptured aneurysms at this small size was extremely low?). Discussion of this article is outstanding and should be read to appreciate how some interventionalists understand the dynamics and pathology of aneurysms to coil them properly. Their careful technique is to be copied. Note that they advocate the “dense packing of aneurysms with coil material helps prevent the coil compaction and aneurysm recanalization.” Debrun, who advocated and used this principle in his successful series of coiled aneurysms, comments at the end. This is a terrific piece of work. Should these aneurysms be clipped or coiled? Read the editorial on this subject in this issue. Niemelä, from Finland, who specializes in molecular analysis of cerebral aneurysms and is the newest member of Surgical Neurology's Editorial Board, and his colleagues have written an outstanding, short, and readable summary of the genetic aspects of cerebral aneurysms. They have written this article as an introduction to the article by SungPil Joo et al, which specifically addresses this subject in a clinical research study in Korea. Niemelä et al's article presents an excellent view of the future of neurosurgery and neuroscience. 0090-3019/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.surneu.2008.04.018
Sung-Pil Joo et al from Korea have done an excellent genetic study on the cause of aneurysms in the Korean population. The genetic difference in the Korean population they analyzed is not found in Japanese aneurysm patients, who have a different genetic change. This article is not easy for non–genetically oriented neuroscientists to read. I suggest reading Niemelä et al's article preceding it. Their article explains the subject so that most readers will understand the topic. Then read the Introduction and Conclusion sections of Joo's article. If you are more sophisticated in the subject, try the Discussion section next —a general reading of it gets the point across. Nancy Epstein's article from the United States, on posterior spinous process fusion for patients with cervical stenosis and myelopathy, is excellent. This article is an example of how a surgeon evaluates the complications of common surgical approaches to lesions and develops a new technique with lower morbidity. Epstein performs a limited laminectomy and then a spinous process fusion to avoid the complications of pedicle screws eroding into the spinal canal or vertebral foramen. Her complication rates are lower than those found with pedicle screw fusions, and her fusion rate is 100%. This article is a fine example of what a thoughtful neurosurgeon can do to establish a low-risk treatment for a disease. The article is worth reading in its entirety, particularly the Discussion section. Fisher and Young analyzed a series of patients with spinal trauma in a private practice setting. They question whether the long-standing practice of obtaining a lateral–cervical spine film was necessary compared to a computed tomographic study of the cervical spine. Their answer was, “No.” The lateral cervical spine film missed the lesion about 20% of the time, and even if the lateral film was of good quality, it still missed one third of the lesions. Read the article that is a quick read, especially the Discussion section. They also provide arguments that cervical spine computed tomography has a lower total examination time than a regular 6 series of cervical spine radiographs. Chao et al from Taiwan report on their use of pulsed radiofrequency for cervical and lumbar radicular pain. They had sustained relief in 50% of the patients with cervical pain. In those with lumbar pain, the pulsed radiofrequency
2
Editorial / Surgical Neurology 70 (2008) 1–2
treatments were successful in 50%, but after 1 year, declined to 25%. The article is interesting to read and offers a new alternative to epidural steroids with no risk. Read the Discussion section for a good explanation of the comparison with alternative treatments and Pawl's comments at the end. A randomized study compared to sham treatment would be the next step. Zanon et al from Brazil compared direct placement of a catheter into a craniopharyngioma cyst, (with free hand placement through a burr hole), and stereoscopic placement. All cases resulted in leakage of the injected contrast medium from the cyst. What the authors do not tell us is how to fix the problem. Perhaps a catheter with an inflatable balloon at the tip may help prevent the leakage. There is an interesting case report by Hsieh et al from Taiwan in which the authors used fiber-tract imaging (diffuse tensor imaging) to reveal the location of the corticospinal tract in a patient with a spontaneous intracerebral hemorrhage. How would you have approached this case without diffuse tensor imaging? Would surgery even be done? If so, what would you do and how? Some would advocate no surgery, believing the lesion would reduce in size in time. Others might do microsurgical aspiration and still others would do stereotactic aspiration. What would be the results of any of the approaches? To me, the value in this article is that it demonstrated the decompression of the corticospinal tract. Common sense tells me that the sooner this decom-
pression is accomplished, the better, if a low-risk approach can be used to remove it. Stereotactic aspiration is such an approach. Regardless, surgical judgment states that you should avoid the sensitive nervous system areas to reach the lesion and direct your surgery to the center of the hematoma. As classic teaching tells us, you need not remove all the hematoma, since leaving the hematoma at the margins of the lesion prevents rebleeding. Those principles are validated by this article regardless of what country you live in or what technology you have. Read Catrambone et al's article on the use of a retinal tomography to determine the presence of papilledema. The case report and Discussion section of Adachi et al from Japan on the classification of cavernomas of the vestibular nerve is good if this is an area of your interest. This Discussion section is informative. This month I have written my analysis of the recent publications of the ISAT (International Subarchachnoid Aneurysm Trial) of clipping versus coiling. The questions: Are the results able to be generalized? and: Should patients less than 40 years of age be coiled? are answered. See if you agree or not.
James I. Ausman, MD, PhD (Editor) E-mail address: [email protected]
Surgical Neurology 70 (2008) 1 – 2 www.surgicalneurology-online.com
Editorial
In this issue… Mirza and Goodkin have written a very thoughtful analysis of the SPORT (Spine Patient Outcomes Research Trial). Their editorial is worth reading and provides an answer, which the trial was designed to supply. They have asked what should be done with a patient presenting with a lumbar radiculopathy and no motor deficit, which, on imaging, has a definite lumbar disc herniation that could explain the symptoms. Should an operation be performed or not? This is the question the trial proposed. Mirza and Goodkin analyze how the trial answered that question. Hernesniemi and “The Rainbow Team” from Finland have produced the “gold standard” article on the surgical treatment of anterior communicating aneurysms. This article is a must-read and is first-rate clinical science. I have written some comments at the end of the article. Chen et al from China have a superb article on the coiling of small aneurysms with a diameter of 3 mm. Of the 11 cases in their series, 10 had ruptured aneurysms. (What does this say about ISUIA (International Study of Unruptured Intracranial Aneurysms) that said the risk of ruptured aneurysms at this small size was extremely low?). Discussion of this article is outstanding and should be read to appreciate how some interventionalists understand the dynamics and pathology of aneurysms to coil them properly. Their careful technique is to be copied. Note that they advocate the “dense packing of aneurysms with coil material helps prevent the coil compaction and aneurysm recanalization.” Debrun, who advocated and used this principle in his successful series of coiled aneurysms, comments at the end. This is a terrific piece of work. Should these aneurysms be clipped or coiled? Read the editorial on this subject in this issue. Niemelä, from Finland, who specializes in molecular analysis of cerebral aneurysms and is the newest member of Surgical Neurology's Editorial Board, and his colleagues have written an outstanding, short, and readable summary of the genetic aspects of cerebral aneurysms. They have written this article as an introduction to the article by SungPil Joo et al, which specifically addresses this subject in a clinical research study in Korea. Niemelä et al's article presents an excellent view of the future of neurosurgery and neuroscience. 0090-3019/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.surneu.2008.04.018
Sung-Pil Joo et al from Korea have done an excellent genetic study on the cause of aneurysms in the Korean population. The genetic difference in the Korean population they analyzed is not found in Japanese aneurysm patients, who have a different genetic change. This article is not easy for non–genetically oriented neuroscientists to read. I suggest reading Niemelä et al's article preceding it. Their article explains the subject so that most readers will understand the topic. Then read the Introduction and Conclusion sections of Joo's article. If you are more sophisticated in the subject, try the Discussion section next —a general reading of it gets the point across. Nancy Epstein's article from the United States, on posterior spinous process fusion for patients with cervical stenosis and myelopathy, is excellent. This article is an example of how a surgeon evaluates the complications of common surgical approaches to lesions and develops a new technique with lower morbidity. Epstein performs a limited laminectomy and then a spinous process fusion to avoid the complications of pedicle screws eroding into the spinal canal or vertebral foramen. Her complication rates are lower than those found with pedicle screw fusions, and her fusion rate is 100%. This article is a fine example of what a thoughtful neurosurgeon can do to establish a low-risk treatment for a disease. The article is worth reading in its entirety, particularly the Discussion section. Fisher and Young analyzed a series of patients with spinal trauma in a private practice setting. They question whether the long-standing practice of obtaining a lateral–cervical spine film was necessary compared to a computed tomographic study of the cervical spine. Their answer was, “No.” The lateral cervical spine film missed the lesion about 20% of the time, and even if the lateral film was of good quality, it still missed one third of the lesions. Read the article that is a quick read, especially the Discussion section. They also provide arguments that cervical spine computed tomography has a lower total examination time than a regular 6 series of cervical spine radiographs. Chao et al from Taiwan report on their use of pulsed radiofrequency for cervical and lumbar radicular pain. They had sustained relief in 50% of the patients with cervical pain. In those with lumbar pain, the pulsed radiofrequency
2
Editorial / Surgical Neurology 70 (2008) 1–2
treatments were successful in 50%, but after 1 year, declined to 25%. The article is interesting to read and offers a new alternative to epidural steroids with no risk. Read the Discussion section for a good explanation of the comparison with alternative treatments and Pawl's comments at the end. A randomized study compared to sham treatment would be the next step. Zanon et al from Brazil compared direct placement of a catheter into a craniopharyngioma cyst, (with free hand placement through a burr hole), and stereoscopic placement. All cases resulted in leakage of the injected contrast medium from the cyst. What the authors do not tell us is how to fix the problem. Perhaps a catheter with an inflatable balloon at the tip may help prevent the leakage. There is an interesting case report by Hsieh et al from Taiwan in which the authors used fiber-tract imaging (diffuse tensor imaging) to reveal the location of the corticospinal tract in a patient with a spontaneous intracerebral hemorrhage. How would you have approached this case without diffuse tensor imaging? Would surgery even be done? If so, what would you do and how? Some would advocate no surgery, believing the lesion would reduce in size in time. Others might do microsurgical aspiration and still others would do stereotactic aspiration. What would be the results of any of the approaches? To me, the value in this article is that it demonstrated the decompression of the corticospinal tract. Common sense tells me that the sooner this decom-
pression is accomplished, the better, if a low-risk approach can be used to remove it. Stereotactic aspiration is such an approach. Regardless, surgical judgment states that you should avoid the sensitive nervous system areas to reach the lesion and direct your surgery to the center of the hematoma. As classic teaching tells us, you need not remove all the hematoma, since leaving the hematoma at the margins of the lesion prevents rebleeding. Those principles are validated by this article regardless of what country you live in or what technology you have. Read Catrambone et al's article on the use of a retinal tomography to determine the presence of papilledema. The case report and Discussion section of Adachi et al from Japan on the classification of cavernomas of the vestibular nerve is good if this is an area of your interest. This Discussion section is informative. This month I have written my analysis of the recent publications of the ISAT (International Subarchachnoid Aneurysm Trial) of clipping versus coiling. The questions: Are the results able to be generalized? and: Should patients less than 40 years of age be coiled? are answered. See if you agree or not.
James I. Ausman, MD, PhD (Editor) E-mail address: [email protected]