EXAMPLE #1

Tonight we did an operation. The patient was a 42-year-old male, a smoker, who presented with a left facial droop and minimal progressing left hemiparesis over 3 weeks. MR imaging showed a left anterior frontal ring enhancing mass and a similar larger right posterior frontal mass. He also had a chest mass. The proposed diagnosis was lung cancer with metastases to the brain. Before surgery to establish the diagnosis and treat the brain mass, the patient had a CT scan, and a detailed MR scan to prepare him for a neuronavigation assessment intraoperatively to localize the right frontal lesion. Also, the patient had fiber tract imaging to determine the location of the pyramidal fibers. From the sagittal cuts, we plotted out the location of the tumor using scalp landmarks, a simple method used in the past. Using the neuronavigation system, we found that we had localized the site of the tumor with a high degree of accuracy compared with the neuroimaging technology that delineated the tumor. We outlined the borders of the tumor with the neuroimaging instrumentation. We also had the potential of cortical mapping and recording sensory and motor potentials.

Before the actual surgery, we knew that the tumor was close to the motor strip from our clinical assessment and that the pyramidal tracts would be located on the posterior aspect of the mass. We knew that we would have to be careful in removing the lesion posteriorly, where it was close to the pyramidal tracts. The fiber tract imaging reinforced our clinical assessment. I talked to the patient and his family about the possibility of an increased deficit postoperatively.

The real question with all this information and technology is: Would its use change the management of the patient during surgery? Actually the answer was NO in most aspects because we would have to do the same surgery with this new information as without it in this case. The fiber tract imaging, electrocortical mapping, and motor-evoked potentials, and even intraoperative neuronavigation would have made no difference as we removed the tumor. It still had to come out regardless of that information. The surgical plan which we followed was to debulk the mass in the center and then try to separate the tumor walls from the brain tissue to avoid traction on the motor strip fibers. Now, if this tumor were located in the thalamus or would have been a less circumscribed infiltrating tumor, some or all of this information and technology might have been helpful in managing the case.

But are the only eloquent areas the motor strip or the language areas? What about the frontal lobes, which control much of our executive decision processes, or the temporal lobes that are crucial in our memory processing? We cannot measure the eloquence of these functions intraoperatively, but are they less important to the patient?

The patient did well postoperatively without any new deficit and was discharged in 3 days with improving deficits.

EXAMPLE #2

Earlier in the week, we admitted an 85-year-old woman with a ground level fall, whose CT scan showed a large scalp hematoma. Four hours later, her CT scan showed a 5-mm hematoma located near the cortical surface of the cerebellum. She underwent an MR and CT angio to rule out a vascular lesion. None was found. We have always had technology freely available in the USA and have tried to be complete and not miss any diagnosis. That is what our health system provides. But what is the cost–benefit of these decisions to use technology? Was it really likely that this woman had a vascular lesion other than a hematoma that appeared 4 h after she presented to the Emergency Room? Did she need the further imaging assessment?

EXAMPLE #3

Also, this week, I attended a neurosurgery conference in which a review of the use of CT scanning was presented. The conclusion was that many of the scans, which were ordered, were not necessary. I am sure that the same would apply to laboratory testing also.

DEVELOPMENT OF TECHNOLOGY

As I thought about this timely topic, I reviewed the history I had experienced over nearly 50 years in neurosurgery. When I started as a resident, CT scans did not exist. We relied on the neurological examination, angiography, and pneumo-encephalography which we did ourselves. Then, in 1970 CT scans and in 1980 MR scanning became available. At the same time, this technology, which revealed many things we did not know, began to take the place of the neurological examination to provide us with information on the patient. I remember carrying an ophthalmoscope to look at a patient's fundi to see if venous pulsations and changes were present. I have not seen a resident using this instrument for years.

RESIDENT DUTY HOURS

From the year 2000 onward, resident hours have been diminished. In the past, we were all on duty almost constantly, and thus we would see the changes in our patients. Now, residents only have 80 h or less to work and get much less direct patient experience and continuity. So, the reliance on scanning and technology is much more prevalent.

The older neurosurgeons complain that the younger ones do not examine the patients, while the younger neurosurgeons are now very skilled at obtaining information through the Internet and using technology on the patient. The same dilemma is faced by those in the developing world who do not have access to all of this technology compared with their colleagues in the developed world. Those in the developing world are doing a good job in taking care of their patients. Does all this new technology make a difference in the outcome of the patient's surgery? In most cases, it probably does not.

INTRAOPERATIVE MR SCANNING

In the past years, intraoperative MR scanning was developed. Has it made a difference in the outcome of the patients who had this costly technology used? Was the time expended in its use and its cost really necessary? The answer to this question is still unlikely. In contrast to CT and MR scanning, intraoperative MR is not a technology that has seen widespread acceptance. Selected neurosurgeons still use it, but it does not appear widely accepted as did CT and MR scanning. Perhaps the cost is the reason.

INFORMATION AND TECHNOLOGY OVERLOAD

These examples lead me to the challenge facing neurosurgeons young and old and to those in the developing and developed world as the times change and the economies of the countries all over the world suffer from overspending. We are now flooded with information and technology. Will it make a difference in the management of the patient? This is the question we are trying to understand worldwide. We do not have all the answers yet, but it is clear that all of the new technology and information is not helpful. It is also clear that without CT and MR scanning, we would miss many lesions in the brain and spinal cord that would alter our management of the patients. That is why, time has proved that this specific technology is valuable and why it has spread worldwide. Yet, we have to learn to select what technology and information is useful in making decisions on our patients. And still, there is the suggestion that multiple CT scans are exposing our patients to high levels of radiation, which will result in cognitive damage.

So, we are all going through the changes of the unfolding 21^st century and the Information Age. It will take a while to learn what is useful and what is not. There is value in the older methods, which are simple to use, like locating the site of a lesion using external landmarks, and in the newer technology, which can add necessary information that is helpful.

MINIMALLY INVASIVE TECHNIQUES

Obviously, some of this technology is helpful in allowing us to operate through smaller incisions and openings, called minimally invasive surgery. This even applies to doing spine surgery through tubes or endoscopic surgery. But are minimally invasive approaches necessary and cost effective? What are the learning curves for minimally invasive approaches, and are they superior to more invasive surgery? There are real advantages to both the old and new approaches. If we had tried to take out the metastasis though a small incision, it would have been difficult. We had another case earlier in the week in which we removed an occipital metastasis through a smaller linear incision and craniotomy and encountered some edema after the lesion was removed, which we would not have had with a larger craniotomy. So, minimally invasive approaches have their indications and are not useful in all cases. For example, Charlie Drake, Juha Hernisniemi, and myself have not found that skull base approaches are useful in aneurysm surgery. So, what is appropriate for the patient and his/her problem is the question.

THE DISADVANTAGE THE YOUNGER NEUROSURGEONS HAVE

Medicine is a specialty taught by the transfer of experience. It is an apprenticeship. The disadvantage the younger neurosurgeons have is that they do not know and are not taught the approaches that were used so successfully in the past. For example, few neurosurgeons have learned about the posterior approaches to cervical discs. This surgery was highly successful with far less complications than anterior cervical discectomy. It was used for laterally placed discs. Anterior cervical discectomy is taught everywhere and is the procedure of choice. Yet, it is not, if one reads the older literature and uses the posterior procedure appropriately. Younger neurosurgeons do not have the experience to compare the new with the old and to understand the value in each surgical treatment. The younger neurosurgeons are also impressed with the results of their colleagues whose presentations are often slick but may not be truthful in terms of complications.

Some years ago, a neurosurgeon in Turkey asked me, after trying a skull base approach nine times and having difficulty with it, “How do I know what it the truth?” After reading a textbook on the subject, he found that the author left out key portions necessary to do the surgery. The answer is that you have 1) to read, 2) to listen to the advice of experienced neurosurgeons, 3) to find out from others, usually older neurosurgeons, about those who are presenting work to learn if they are reliable, and 4) to use your own common sense and experience in evaluating results. When I read a paper, I first outline an ideal experiment to solve the problem in my mind and then see how closely the authors come to that ideal. If not, I discard the results.

THE KEY TO DEALING WITH THE INFORMATION AGE OF THE FUTURE IS REALLY THE PAST: COMMON SENSE, EXPERIENCE, AND GOOD JUDGMENT

There will be some challenges facing the younger generation and the neurosurgeons in the developing and the developed countries as they approach a future full of information and technology: What is important in the new media and what is not? How can one select what is important from the mass of information that is available? In an era of 24/7 information delivered by computers, television, iPads, mobile phones, with access to Tweets, Facebook, and YouTube, do we need all this information? Or does it rob us of thinking time that is more valuable in making decisions and developing our minds and character? Or are all of these opinions of value? Will this flood of information help us develop as human beings?

The key answer to all the new information is: Will it make a difference in the management of the patient? What is the quality of this information in helping us make a clinical decision? Will it make a difference in our own lives? That is the deciding factor as we move forward in the 21^st century. In the 1940s during World War II, which most no longer remember, there was rationing of gasoline so that it could be saved for the war effort. We may face the same problem again in the coming months and years with the shortage of oil. On the inside of the car windshield on the driver's side was a government-distributed message which read: “Is this trip necessary?” Today the same message would read as: “Is all of this technology and information necessary?” Just because others use it does not mean it is valuable. That is a decision you need to make for yourself.

Confronting changes in information is not a new experience in civilization. It has been occurring for thousands of years. What is basic to those who are able to manage this change is common sense, using your own experience, learning form those with experience, independent thinking, and good judgment. These factors will never change throughout time.