Features of the Month

Present & Future of Neurosurgery
by James Ausman

Russian Neurosurgical Journal

Brazilian Neurosurgical Journal

Dear Colleague,


This month, we launched a new Web site. It is a tribute to the readers from the 224 countries and territories in which SNI is read. It carries our purpose of "Helping People Everywhere," as SNI reaches all the neurosurgeons in the world who care for its 7 billion people.

  1. The site is simpler to navigate. Wherever you are in the Web site, just click the SNI logo to go back to the home page. For those 30%  of our readers who use mobile devices, the site has been designed to fit to your smaller screen with a Menu option that replaces the full Toolbar from the desktop size version of the site. The Search feature under articles can find scientific papers more easily and Search on the Toolbar will search the entire site for scientific papers and educational content.
  2. With each article you choose to read, you will see Tools on the side of the page that will allow you to print out the papers easily. All of the educational content can or will be able to be downloaded, for FREE.
  3. We are in the process of adding "1001 Videos" from Professor Hernesniemi and the Helsinki Group. They will appear as they are completed, and loaded continuously. In addition, the theses from the Helsinki-Kupio Centers will appear. These are excellent summaries of the literature on a subject.
  4. A new Pediatric Neurosurgery supplement is being edited by Sandi Lam, and will appear in the next few weeks. It will contain two selections each month reviewing a controversial area in pediatric neurosurgery. Other pediatric neurosurgery papers will also be in that supplement.
  5. We have additional editors for SNI: Neurooncology -- Zvi Ram and Gelareh Zadeh. This supplement will appear at least twice a year, in addition to the topic-oriented neurooncology supplements from Dan Silbergeld.
  6. New supplements on the Spine and Neurosurgical Nursing will appear in the coming month. We are enlarging our reader base with nurses, PAs and NPs in the growing field of Neuroscience Nursing.
  7. Current Concepts, edited by Zach Smith and Isaac Yang,  is adding additional reviewers to its board so that they can bring you the latest key papers that appear in other journals. This Supplement will appear at least every month or more.
  8. There will be more room for advertisers, whose support will allow SNI to bring more new changes and features.

After 5 years of publication, SNI has the largest circulation of any journal in its field; last month, 144,000 papers were downloaded by 50,000 readers. Please be patient as we add more new features to the Web site throughout this year, and fine-tune existing functionality to make the site as user-friendly as possible. E-mail me your thoughts on the Web site, and how we can continue to improve it.

Following are the papers that I think have special significance that have appeared since the last newsletter:


In a very significant paper on the use of gamma knife on cavernous malformations, Kida et al from Japan report that "a total of 298 cases collected from 23 GK centers across Japan were included. Hemorrhage was the most common manifestation, followed by seizures and neurological deficits. Most of the lesions were located in the brainstem and basal ganglia, followed by the cerebral or cerebellar hemispheres. The CMs, which had a mean diameter of 14.8 mm, were treated using GK surgery with a mean marginal dose of 14.6 Gy. The risk of hemorrhage is considerably reduced after GK treatment."

In a unique paper, Nayak et al from the USA used an endoscope to reach cavernomas in the base of the brainstem. Some were approached thru the clivus. This is an excellent approach to reach a difficult lesion with standard surgery.

Conger et al from the USA provide a review of the diagnosis and management of AVMs using all modalities. In my opinion, this paper is far superior to the ARUBA randomized controlled trial of unruptured AVMS that appeared in Lancet in 2014, (Lancet 2014; 383: 614–21). The ARUBA study is a significantly flawed RCT trial as the comments on the paper in that same issue of Lancet show.

Skrap et al from Italy describe a unique case of a giant MCA aneurysm treated first with a stent from the M1 to an M2 branch and then immediate surgical resection and clipping of the aneurysm. The stents preserved the structure of the MCA branches.

In a unique case report, Alafaci et al from Italy report a case of a cavernoma resected from the optic chiasma using a "quantum molecular resonance-based bipolar coagulation (Vesalius®). This device uses a relatively low temperature that does not exceed 45–50°C, having minimum effect on nervous tissues, nerves, and blood vessels." The cavernoma was completely excised with some improvement in the patient’s impaired vision.


Sattarov et al from the USA provide a step by step cadaveric and fluoroscopic approach to atlantalaxial surgical fixation. "The most common technique used in adults, and in certain cases in children, involves a posterior construct with C1 lateral mass screws, and C2 pars or pedicle screws. This technical note aims to provide a guide to this procedure using cadaveric and fluoroscopic images."

Yew et al from the USA in a retrospective study used CT-based measurements of atlas morphology in the general population and found that a majority of C1 lamina had sufficient dimensions to accept translaminar screw placement. "Although these screws appear to be a feasible alternative when lateral mass screws are precluded, further research is required to determine if they provide comparable fixation strength versus traditional instrumentation methods."

In a review of randomized controlled trials of saline, local anesthetics and steroids in facet joint injections for spinal pain, Manchikanti et al from various centers in the USA found "equal efficacy for local anesthetic with steroids and local anesthetic alone in multiple spinal conditions except for disc herniation where the superiority of local anesthetic with steroids was seen over local anesthetic alone."

In a retrospective record review of 500 patients, Bydon et al from the USA "found that patients experienced statistically significant improvements in back pain, neurogenic claudication, radiculopathy, motor weakness, and sensory deficit following lumbar laminectomy. Incidental durotomy rate was 10.00%. Following a first-time laminectomy, the reoperation rate was 14.4% over a mean of 3.40 years. The risk of experiencing at least one postoperative complication with a lumbar laminectomy was 5.60%."

Epstein et al in a paper on "Operative costs, waste and vendor replacement in spinal surgery" found that their "spine surgeon-education program reduced the costs/reasons for operative waste for 2012 to lower levels by 2013 and 2014. Although the major cost/reasons for operative waste were attributed to surgeon-related factors, these declined while the other eight reasons for operative waste were reduced to zero by 2014."

In another excellent review, Epstein et al found that "cervical C5 nerve root palsies may occur in between 0% and 30% of routine anterior or posterior cervical spine operations. They are largely attributed to traction injuries/increased cord migration following anterior/posterior decompressions. Of interest, almost all studies cite spontaneous resolution of these deficits without surgery within 3 to 24 postoperative months…there is no clear method for their avoidance at this time."


In a paper sure to be controversial, Maroon et al from the USA discuss the metabolic therapy of GBM. "The goal of metabolic cancer therapy is to restrict GBM cells of glucose, their main energy substrate. By recognizing the underlying energy production requirements of cancer cells, newly proposed metabolic therapy is being used as an adjunct to standard GBM therapies. This review discusses the calorie restricted ketogenic diet (CR-KD) as a promising potential adjunctive metabolic therapy for patients with GBMs. The effectiveness of the CR-KD is based on the "Warburg Effect" of cancer metabolism and the microenvironment of GBM tumors." This is a fascinating and innovative approach to a tumor for which standard therapy has not been too successful. The authors review the literature and animal models leading to this therapy.

Amirjamshidi et al from Iran, report on a new approach to the removal of sphenoid wing meningiomas in 88 patients with a long term follow up.

Roth et al report on the use of endosopy for large basal ganglia tumors. Deep basal-ganglia and large thalamic (BGT) tumors may cause secondary hydrocephalus by compressing the lateral and third ventricles. The ventricular distortion, as well as the infiltrative nature and friability of these tumors raise specific considerations and risks when treating these patients. Treatment goals may therefore focus on cerebrospinal fluid (CSF) diversion and tissue sampling, followed by nonsurgical treatment options. The authors present their experience in applying endoscopic techniques for the initial management of such patients.


In 7 year review of 100 ICU patients with severe traumatic brain injury, Siddiqui et al from Pakistan found that early tracheostomy compared with extended endotracheal intubation reduced pulmonary complications, produced a shorter ICU stay, less mortality, and was associated with fewer complications.


Menger et al from the USA describe their experience in 150 patients with pseudomeningocoele after operative decompression. "A statistically significant relationship exists between age and sealant use and the risk of developing a postoperative pseudomeningocele. Emphasis and attention must be placed on meticulous closure technique."


Graziano et al from Italy report on a new autologous fibrin selant in 77 patients that appears to be very effective.

Epstein reported that "Utilizing Tisseel to facilitate hemostasis in LamF (Laminectomy and fusion) versus Lam (laminectomy) still resulted in greater operative times, blood loss, postoperative average drainage, length of stay, and transfusion requirements for patients undergoing the non instrumented fusions. Although Tisseel decreases back bleeding within the spinal canal, it does not reduce blood loss from LamF decorticated transverse processes."

Bukhari et al from Pakistan describe the cost effectiveness of using mini titanium plates for bone flap replacement in a developing country.

In an excellent study from India, Raghava et al compared the value in using 3% saline and 20% mannitol infusions in producing brain relaxation. "3% hypertonic saline and 20% mannitol are equally effective for brain relaxation in elective supratentorial tumor surgery and compared with mannitol, hypertonic saline was associated with less diuretic effect."


Faria writes a short interesting summary of the reasons for trephination of the skull from the stone age until modern times.

We hope that you enjoy the appearance of the new Web site and its modifications. There are also new issues of HOY! and the Russian and Brazilian journals of neurosurgery. I have also included a lecture of a critical analysis of what we are doing in The Present and Future of Neurosurgery, some of which is related to money, political correctness, and lack of common sense -- and not to the benefit of the patient. Such ideas cannot be sustained in the future.

James I. Ausman, MD, PhD,
Editor in Chief,
Surgical Neurology International


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    Miguel A. Faria, M.D.

    Posted August 13, 2015, 5:43 pm

    As always an excellent panoramic summary!


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