- Email: [email protected]
The Fringes
Editor’s Letter
The Fringes
W
e, at WORLD NEUROSURGERY, have introduced a variety of innovations in information transmission. They have ranged from the aesthetics (e.g., filler and cover art) to new sections that emphasize our global and humanitarian mission (e.g., the “Doing More with Less” section). This, my 29th Editor-in-Chief letter, focuses on our global and humanitarian mission. In the prior issue, my July 2017 Editor-in-Chief letter discussed our mission statement and the dynamic nature of truly meaningful mission statements. Hence our mission statement is under revision as we speak. Its rough draft is as follows:
-
To provide an international information, 2-way conduit for the transmission of information that is relevant to neurosurgeons worldwide including clinical and basic science information, as well as information that is of social, political, educational, economic, cultural, or societal relevance to neurosurgeons.
-
To act as a primary intellectual catalyst for the stimulation of creativity, creation of new knowledge, and enhancement of quality neurosurgical care worldwide.
-
To provide a forum for communication that enriches the lives of all neurosurgeons and, in so doing, enriches the lives of their patients.
In the deliberations regarding the philosophies, opinions, and words that make up a mission statement, we must maintain our focus on the long-term objective (i.e., global neurosurgical health and the provision of quality of neurosurgical care to all human beings). One of our relatively new sections, “Doing More with Less,” epitomizes this focus by emphasizing the fact that there exists more than 1 way to solve problems—and the less expensive way may be the best. Peter Nakaji, Section Editor, has done a marvelous job of “raising” this project from a mere concept to the publication of a large series of articles (20 published articles and 40 submitted to-date, with the first published article appearing in the July 2016 issue of WORLD NEUROSURGERY) that have truly made a difference regarding our collective long-term objective. Thank you, Peter!!!!!! It is interesting to me that “first world” concerns and standards diverge so much from “third world” concerns and standards. Please excuse the use of the terms first and third worlds. I am merely using them to illustrate a point in this letter. A better term for third world countries, perhaps, is “developing countries.” Regardless, for the sake of brevity and ease of communication, I am sticking with third world herein. Let me relate the essence of a conversation I recently had at the 2017 Nepaleze Neurosurgery Society Meeting in Kathmandu, Nepal, as well as my internal deliberation that ensued following said conversation. The conversation focused on anterior cervical diskectomy and fusion (ACDF) regarding the selection of interbody
WORLD NEUROSURGERY 104: XIX, AUGUST 2017
spacers and the use of fixation via spinal implants. As is the case currently in Nepal and many other regions of the world, patients cannot afford expensive spinal implants; hence the operation of choice may often be ACDF with the placement of an autologous iliac tricortical crest strut. It was opined by a first world surgeon that, although such is a good treatment, it is not the standard of care in first world countries. Although this may be true from a medicolegal perspective, is it really, really true? Have we truly proven that supplementing an ACDF with a costly spacer and plate is more effective? Without excessively belaboring this point, I suggest no. The literature that directly addresses this subject is meager and biased. I honestly, in my heart of hearts, believe that a spacer and plate add some modicum of benefit, but at what cost? The term cost is used here in several ways. Of course, the escalation of the cost of medical care, via the use of spinal implants, contributes at least in part to the economic health care crisis faced in many first world countries. Additional costs are involved, however. There exists a “grip” by the drug and device industry on first world surgeons’ decision-making process. This grip uses bias in the form of misleading research and “alternative forms of influence” to alter the decision-making process. I mentioned that I was not going to belabor this point, so I will now redirect the conversation to the question at hand (i.e., is ACDF with a tricortical autograft strut a standard of care in both first and third world countries?) I personally believe that it should be. This opinion is predominantly based on the notion that surgical approach and strategy is, to a significant degree, surgeon specific and surgeon unique, keeping in mind that excessive surgery and the overuse of technology is associated with unequivocal downsides including complications, additional operations, and redo surgery. Such downsides often leave in their wake a substantial financial burden on the patient and health care system, as well as a physical and psycho-social toll on the patient and his or her family. I merely ask all of us to rethink the surgical decision-making process from a global perspective. We cannot easily change the medico-legal system in first world countries—or can we? Perhaps we need to level the playing field here by decreasing unnecessary resource allocation to first world countries and working on ways to increase such allocations to third world countries. Such should, perhaps, be addressed in our new mission statement. If you have any suggestions regarding modifications of the mission statement, please share your thoughts by emailing [email protected]. Ed Benzel To whom correspondence should be addressed: Ed Benzel, M.D. [E-mail: [email protected]] 1878-8750/$ - see front matter ª 2017 Published by Elsevier Inc. http://dx.doi.org/10.1016/j.wneu.2017.06.017
www.WORLDNEUROSURGERY.org
xix
The Fringes
W
e, at WORLD NEUROSURGERY, have introduced a variety of innovations in information transmission. They have ranged from the aesthetics (e.g., filler and cover art) to new sections that emphasize our global and humanitarian mission (e.g., the “Doing More with Less” section). This, my 29th Editor-in-Chief letter, focuses on our global and humanitarian mission. In the prior issue, my July 2017 Editor-in-Chief letter discussed our mission statement and the dynamic nature of truly meaningful mission statements. Hence our mission statement is under revision as we speak. Its rough draft is as follows:
-
To provide an international information, 2-way conduit for the transmission of information that is relevant to neurosurgeons worldwide including clinical and basic science information, as well as information that is of social, political, educational, economic, cultural, or societal relevance to neurosurgeons.
-
To act as a primary intellectual catalyst for the stimulation of creativity, creation of new knowledge, and enhancement of quality neurosurgical care worldwide.
-
To provide a forum for communication that enriches the lives of all neurosurgeons and, in so doing, enriches the lives of their patients.
In the deliberations regarding the philosophies, opinions, and words that make up a mission statement, we must maintain our focus on the long-term objective (i.e., global neurosurgical health and the provision of quality of neurosurgical care to all human beings). One of our relatively new sections, “Doing More with Less,” epitomizes this focus by emphasizing the fact that there exists more than 1 way to solve problems—and the less expensive way may be the best. Peter Nakaji, Section Editor, has done a marvelous job of “raising” this project from a mere concept to the publication of a large series of articles (20 published articles and 40 submitted to-date, with the first published article appearing in the July 2016 issue of WORLD NEUROSURGERY) that have truly made a difference regarding our collective long-term objective. Thank you, Peter!!!!!! It is interesting to me that “first world” concerns and standards diverge so much from “third world” concerns and standards. Please excuse the use of the terms first and third worlds. I am merely using them to illustrate a point in this letter. A better term for third world countries, perhaps, is “developing countries.” Regardless, for the sake of brevity and ease of communication, I am sticking with third world herein. Let me relate the essence of a conversation I recently had at the 2017 Nepaleze Neurosurgery Society Meeting in Kathmandu, Nepal, as well as my internal deliberation that ensued following said conversation. The conversation focused on anterior cervical diskectomy and fusion (ACDF) regarding the selection of interbody
WORLD NEUROSURGERY 104: XIX, AUGUST 2017
spacers and the use of fixation via spinal implants. As is the case currently in Nepal and many other regions of the world, patients cannot afford expensive spinal implants; hence the operation of choice may often be ACDF with the placement of an autologous iliac tricortical crest strut. It was opined by a first world surgeon that, although such is a good treatment, it is not the standard of care in first world countries. Although this may be true from a medicolegal perspective, is it really, really true? Have we truly proven that supplementing an ACDF with a costly spacer and plate is more effective? Without excessively belaboring this point, I suggest no. The literature that directly addresses this subject is meager and biased. I honestly, in my heart of hearts, believe that a spacer and plate add some modicum of benefit, but at what cost? The term cost is used here in several ways. Of course, the escalation of the cost of medical care, via the use of spinal implants, contributes at least in part to the economic health care crisis faced in many first world countries. Additional costs are involved, however. There exists a “grip” by the drug and device industry on first world surgeons’ decision-making process. This grip uses bias in the form of misleading research and “alternative forms of influence” to alter the decision-making process. I mentioned that I was not going to belabor this point, so I will now redirect the conversation to the question at hand (i.e., is ACDF with a tricortical autograft strut a standard of care in both first and third world countries?) I personally believe that it should be. This opinion is predominantly based on the notion that surgical approach and strategy is, to a significant degree, surgeon specific and surgeon unique, keeping in mind that excessive surgery and the overuse of technology is associated with unequivocal downsides including complications, additional operations, and redo surgery. Such downsides often leave in their wake a substantial financial burden on the patient and health care system, as well as a physical and psycho-social toll on the patient and his or her family. I merely ask all of us to rethink the surgical decision-making process from a global perspective. We cannot easily change the medico-legal system in first world countries—or can we? Perhaps we need to level the playing field here by decreasing unnecessary resource allocation to first world countries and working on ways to increase such allocations to third world countries. Such should, perhaps, be addressed in our new mission statement. If you have any suggestions regarding modifications of the mission statement, please share your thoughts by emailing [email protected]. Ed Benzel To whom correspondence should be addressed: Ed Benzel, M.D. [E-mail: [email protected]] 1878-8750/$ - see front matter ª 2017 Published by Elsevier Inc. http://dx.doi.org/10.1016/j.wneu.2017.06.017
www.WORLDNEUROSURGERY.org
xix