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Looking back 10 years and then looking forward
Editorial
Looking Back 10 Years and Then Looking Forward
his December 2004 issue of Surgical Neurology marks the 10th year I have been editor of this journal. I thought it would be appropriate for me to look back over the changes I have seen in the last 10 years and look forward to what I see coming. In my view the 21st century will see the greatest and most exciting growth in the neurosciences in human civilization. The most significant advances in medicine will be in imaging and molecular biology. For the first time in the history of science of the nervous system, we are able to learn how it works without invading it and disturbing its function. In imaging the growth of MR technology is staggering. We have witnessed not only the finer detail of the brain, spinal cord, and peripheral nerve anatomy, but we are looking at their biochemistry with MR spectroscopy. With Diffusion Tensor Imaging (DTI) we can now visualize fiber tracts and with Functional MR (fMR) we are able to stimulate the sensory input of the nervous system or use motor or cognitive skills to reveal the connections among all the fiber tracts. We are learning that in multiple areas of the brain are connected in performing a function. This work is being expanded to look at “the higher cortical functions” such as thinking, emotions and feelings. The results are dramatic, with areas of the brain we believe to be silent being involved in the processing of crucial thinking and planning. Memory circuits are being mapped out in the temporal lobes with MR. The frontal lobes are now found to be involved in information processing. We are even seeing the genetic differences in peoples’ responses to pain and to anxiety. These findings will have significant impact on the “failed back syndrome” or “chronic pain patient.” Is the patient crazy or the doctor ignorant of the complexities of the nervous system? The latter will become true. There are more advances with MRI on the way. Visualization of blood vessels of 500 microns or less will mark the end of angiography. Phase contrast MR can determine the blood flow in cerebral vessels and other organs more accurately than ever,
T
0090-3019/04/$–see front matter doi:10.1016/j.surneu.2004.09.022
and noninvasively. With higher strength magnets we will see protein structure and the actual molecular activity in cells. Imaging and imaging physics will revolutionize medicine and neuroscience. Radiology will become Molecular Imaging. During the last 10 years we saw the decoding of the genetic code for humans. This discovery will be one of the greatest scientific achievements in human history. Neurology will be transformed by genetics. A number of neurological diseases that were not understood can now be revealed as genetically caused. Molecular biological investigations have found the abnormal pathways in many neurological diseases that now await the discovery of targeted chemotherapy for those pathways or replacements of defective genetic genes. We see these discoveries in dystonias, Parkinson’s, Huntington’s, cerebellar degenerations, and many more. Neurology will undergo exciting changes in the 21st century as neurologists become basic scientists and successfully treat the diseases that in the past century they could only watch. The molecular basis of stroke is being uncovered. Multiple genetic changes occur after the ischemic event to control the behavior of the cells and attract others to the area of injury. Some of these sequential events are helpful and others harmful. Scientists are learning to distinguish between the events and develop targeted therapies for each sequence in ischemia. Similar cellular events are being uncovered in traumatic injury to the brain and spinal cord after injuries to these two anatomical sites. I expect that in the 21st century the secondary events that occur after ischemia and injury will be known and controlled. Better survivals of our patients will be seen. The neurointensivist position will become an exciting career as the dynamic minute-to-minute changes in the brain and spinal cord will be followed and treated. The field of nanotechnology is young. To be able to engineer molecular behavior at the molecular level will allow scientists and neuroscientists an enormous power to alter the functions of the cell. It © 2004 Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010 –1710
Editorial
has been stated that Nanotechnology will have a greater impact on civilization than the Internet and will be one of the greatest growth industries in the 21st century. The development of interventional approaches to aneurysms, AVMs, and ischemia is the beginning of the use of the vascular highway for the treatment of a variety of diseases everywhere. Most neurosurgeons are actively opposing these great scientific achievements to hold on to surgical approaches that will soon fade into history. More and more aneurysms are being treated endovascularly, and eventually the surgical treatment for this disease will vanish. Carotids, like coronary arteries, will be stented with stents created with new technology. New stent technology, including nanotechnologically made stents, will emerge. These changes await the training of more skilled interventionalists, and these advances should be ones in which neurosurgeons lead rather than oppose. The growth of spine surgery has been fueled by the financial incentives for increased complicated surgery and the impetus of the spine device manufacturers to take advantage of this financial opportunity and exploit the predicament of the neurosurgeon. There are no studies proving that the devices are of any value in degenerative conditions with only a few exceptions. Why? (Read this issue’s paper on the discussion of the treatment of myelopathy.) Imaging studies will reveal that the differences in pain expressed by patients may have a genetic basis and that the chronic pain patient may have a genetic problem and not a structural one. Social stresses and problems are probably the major contributor to back pain but little attention is paid to this cause except by a limited number of neurosurgeons. The trend to develop spine centers that are procedurally oriented is a testimony to this viewpoint. What is needed are comprehensive pain evaluation centers. Where is the research by neurosurgeons into the reasons for chronic pain, the biochemistry of the disc and the genesis of arthritis? Soon, there will be studies supplementing those already reported but disregarded—that cranial surgical procedures cause great harm to the cognitive and functional activity of the brain. These reports will be widely distributed in the lay press and understood by all physicians and the public. There
Surg Neurol 571 2004;62:570 –1
will be a huge reluctance for people to undergo brain surgery because it will alter their thinking and the basic aspects of their life. Noninvasive surgical approaches will then be given a great push for development. Endovascular approaches will become predominant. The stereotactic and functional neurosurgeons are in the forefront of neurosurgery for the future. They are working with minimally invasive approaches to the brain, collaborating with neurologists and other basic scientists to understand the workings of the brain biochemically and functionally. The advances in imaging and molecular biology are part of their thinking. Similar changes are affecting the neurosurgical oncologists who are embracing the molecular and genetic changes that are being discovered to influence the course of cancer. Enormous advances in the understanding of cancer biologically are being exploited to interfere with the molecular signals that cause angiogenesis and cell proliferation. Some forms of lung cancer are being cured as are some leukemias. Colon cancer and its metastases are being inhibited by targeted molecular therapy. These advances are close to being understood from meningiomas to glioblastomas. Medulloblastoma has been cured in the laboratory by interference in the genetic signals. Radiosurgery has replaced the skilled surgeons of the past 40 years who removed acoustic neuromas and meningiomas and other tumors in difficult locations. These tumors are now being treated noninvasively. Metastases are better treated by radiosurgery than surgery. Trigeminal neuralgia is now being treated with radiosurgical techniques. More advances in this field of Radiosurgery are coming. So, in the past 10 years neurosurgery has undergone tremendous changes. Yet, I see resistance to these changes by neurosurgeons from everywhere in the world. Why? The surgery we are now doing will become historical interest in the 21st century. So what. The challenge is to move on to the new and not hang on to the old. There are exciting opportunities in science and particularly in the neurosciences in the 21st century. Are neurosurgeons going to get on the train or be left at the station? James I. Ausman, M.D., Ph.D. Editor
Looking Back 10 Years and Then Looking Forward
his December 2004 issue of Surgical Neurology marks the 10th year I have been editor of this journal. I thought it would be appropriate for me to look back over the changes I have seen in the last 10 years and look forward to what I see coming. In my view the 21st century will see the greatest and most exciting growth in the neurosciences in human civilization. The most significant advances in medicine will be in imaging and molecular biology. For the first time in the history of science of the nervous system, we are able to learn how it works without invading it and disturbing its function. In imaging the growth of MR technology is staggering. We have witnessed not only the finer detail of the brain, spinal cord, and peripheral nerve anatomy, but we are looking at their biochemistry with MR spectroscopy. With Diffusion Tensor Imaging (DTI) we can now visualize fiber tracts and with Functional MR (fMR) we are able to stimulate the sensory input of the nervous system or use motor or cognitive skills to reveal the connections among all the fiber tracts. We are learning that in multiple areas of the brain are connected in performing a function. This work is being expanded to look at “the higher cortical functions” such as thinking, emotions and feelings. The results are dramatic, with areas of the brain we believe to be silent being involved in the processing of crucial thinking and planning. Memory circuits are being mapped out in the temporal lobes with MR. The frontal lobes are now found to be involved in information processing. We are even seeing the genetic differences in peoples’ responses to pain and to anxiety. These findings will have significant impact on the “failed back syndrome” or “chronic pain patient.” Is the patient crazy or the doctor ignorant of the complexities of the nervous system? The latter will become true. There are more advances with MRI on the way. Visualization of blood vessels of 500 microns or less will mark the end of angiography. Phase contrast MR can determine the blood flow in cerebral vessels and other organs more accurately than ever,
T
0090-3019/04/$–see front matter doi:10.1016/j.surneu.2004.09.022
and noninvasively. With higher strength magnets we will see protein structure and the actual molecular activity in cells. Imaging and imaging physics will revolutionize medicine and neuroscience. Radiology will become Molecular Imaging. During the last 10 years we saw the decoding of the genetic code for humans. This discovery will be one of the greatest scientific achievements in human history. Neurology will be transformed by genetics. A number of neurological diseases that were not understood can now be revealed as genetically caused. Molecular biological investigations have found the abnormal pathways in many neurological diseases that now await the discovery of targeted chemotherapy for those pathways or replacements of defective genetic genes. We see these discoveries in dystonias, Parkinson’s, Huntington’s, cerebellar degenerations, and many more. Neurology will undergo exciting changes in the 21st century as neurologists become basic scientists and successfully treat the diseases that in the past century they could only watch. The molecular basis of stroke is being uncovered. Multiple genetic changes occur after the ischemic event to control the behavior of the cells and attract others to the area of injury. Some of these sequential events are helpful and others harmful. Scientists are learning to distinguish between the events and develop targeted therapies for each sequence in ischemia. Similar cellular events are being uncovered in traumatic injury to the brain and spinal cord after injuries to these two anatomical sites. I expect that in the 21st century the secondary events that occur after ischemia and injury will be known and controlled. Better survivals of our patients will be seen. The neurointensivist position will become an exciting career as the dynamic minute-to-minute changes in the brain and spinal cord will be followed and treated. The field of nanotechnology is young. To be able to engineer molecular behavior at the molecular level will allow scientists and neuroscientists an enormous power to alter the functions of the cell. It © 2004 Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010 –1710
Editorial
has been stated that Nanotechnology will have a greater impact on civilization than the Internet and will be one of the greatest growth industries in the 21st century. The development of interventional approaches to aneurysms, AVMs, and ischemia is the beginning of the use of the vascular highway for the treatment of a variety of diseases everywhere. Most neurosurgeons are actively opposing these great scientific achievements to hold on to surgical approaches that will soon fade into history. More and more aneurysms are being treated endovascularly, and eventually the surgical treatment for this disease will vanish. Carotids, like coronary arteries, will be stented with stents created with new technology. New stent technology, including nanotechnologically made stents, will emerge. These changes await the training of more skilled interventionalists, and these advances should be ones in which neurosurgeons lead rather than oppose. The growth of spine surgery has been fueled by the financial incentives for increased complicated surgery and the impetus of the spine device manufacturers to take advantage of this financial opportunity and exploit the predicament of the neurosurgeon. There are no studies proving that the devices are of any value in degenerative conditions with only a few exceptions. Why? (Read this issue’s paper on the discussion of the treatment of myelopathy.) Imaging studies will reveal that the differences in pain expressed by patients may have a genetic basis and that the chronic pain patient may have a genetic problem and not a structural one. Social stresses and problems are probably the major contributor to back pain but little attention is paid to this cause except by a limited number of neurosurgeons. The trend to develop spine centers that are procedurally oriented is a testimony to this viewpoint. What is needed are comprehensive pain evaluation centers. Where is the research by neurosurgeons into the reasons for chronic pain, the biochemistry of the disc and the genesis of arthritis? Soon, there will be studies supplementing those already reported but disregarded—that cranial surgical procedures cause great harm to the cognitive and functional activity of the brain. These reports will be widely distributed in the lay press and understood by all physicians and the public. There
Surg Neurol 571 2004;62:570 –1
will be a huge reluctance for people to undergo brain surgery because it will alter their thinking and the basic aspects of their life. Noninvasive surgical approaches will then be given a great push for development. Endovascular approaches will become predominant. The stereotactic and functional neurosurgeons are in the forefront of neurosurgery for the future. They are working with minimally invasive approaches to the brain, collaborating with neurologists and other basic scientists to understand the workings of the brain biochemically and functionally. The advances in imaging and molecular biology are part of their thinking. Similar changes are affecting the neurosurgical oncologists who are embracing the molecular and genetic changes that are being discovered to influence the course of cancer. Enormous advances in the understanding of cancer biologically are being exploited to interfere with the molecular signals that cause angiogenesis and cell proliferation. Some forms of lung cancer are being cured as are some leukemias. Colon cancer and its metastases are being inhibited by targeted molecular therapy. These advances are close to being understood from meningiomas to glioblastomas. Medulloblastoma has been cured in the laboratory by interference in the genetic signals. Radiosurgery has replaced the skilled surgeons of the past 40 years who removed acoustic neuromas and meningiomas and other tumors in difficult locations. These tumors are now being treated noninvasively. Metastases are better treated by radiosurgery than surgery. Trigeminal neuralgia is now being treated with radiosurgical techniques. More advances in this field of Radiosurgery are coming. So, in the past 10 years neurosurgery has undergone tremendous changes. Yet, I see resistance to these changes by neurosurgeons from everywhere in the world. Why? The surgery we are now doing will become historical interest in the 21st century. So what. The challenge is to move on to the new and not hang on to the old. There are exciting opportunities in science and particularly in the neurosciences in the 21st century. Are neurosurgeons going to get on the train or be left at the station? James I. Ausman, M.D., Ph.D. Editor