Controversy in Neurosurgery: Unnecessary Spinal Surgery

By James I Ausman, MD, PhD

In May and June, Surgical Neurology International (SNI) published some controversial papers, including a prospective study by Nancy Epstein on the number of unnecessary spinal surgeries being performed in the United States. Read all the commentaries at the end of the paper from neurosurgeons around the world, then add your own comments.

Read the latest installment from the University of Chicago Journal Club – an analysis of randomized multi-center SPORT trials on spine surgery comparing medical therapy to various surgical treatments for lumbar disc, spinal stenosis, and spondylolisthesis. Are randomized surgical trials of any value?

In June, J. Chen et al wrote about a unique measure of pupillary size and reactivity as an early indicator of increased intracranial pressure. Pouratian has written a review of the use of EEG and brain signals with a computer interface to restore function in patients with limb paralysis. This is the 21st century in neurosurgery. C. Chen et al report on the successful use of third ventriculostomy as a palliative measure in patients with brain metastases as a minimally invasive option. Yilmaz et al report on an interesting study relating the degree of vasospasm in the anterior choroidal arteries with the loss of neurons in the trigeminal ganglion. I suspect we will see more relationship between the central nervous system neurons and autonomic nervous systems to explain our failure to successfully cure vasospasm and other diseases. Bari and Hauptman add to their series "From Bench to Bedside" in Translational Neuroscience, discussing a gene-based treatment to improve Parkinson’s Syndrome, the role of other hypothalamic nuclei in depression, and the role of microglial activation in causing neurological disease. SNI will publish a landmark paper on this subject in the future.

What is the diagnosis?

In May, Morina et al described their technique of preserving bone flaps subcutaneously; this is good information for surgeons who do not have the equipment to freeze and store bone flaps. Forbes et al describe how patients post-TSH can be discharged safely 2 days after surgery. Booth et al wrote how Near Infrared Spectroscopy, a transcutaneous measure of brain oxygenation, can be used to determine the proper settings for assisted ventilation. This technique will become a standard around the world. There are also a number of papers on interventional approaches to cerebral aneurysms, as well as a number of case reports of interest to neurosurgeons worldwide.

Note SNI’s introduction of the controversy surrounding the use and complications of BNP which has now hit the headlines in the press. We published on this subject first by Epstein in January 2011, then Watts in March 2011, and most recently by Rakovac in April, 2011

Other papers not to miss are preventing wrong level spinal surgery by Hsiang that appeared in April, 2011; stenting of a stenotic vein graft bypass by Maselli in April 2011; and also in April 2011, the natural history of pediatric putamenal infarcts in children with traumatic brain injuries from Pakistan. For our Spanish-speaking colleagues, be sure to read the latest edition of Neurocirugía Hoy. Also, within the next few days, we will have our first translation of the popular "From Bench to Bedside" articles into Spanish; look for it on our navigational menu under Posts -> En Español.

SNI has now reached neurosurgeons in 171 countries. Over 40,000 individual people have read SNI.

SNI welcomes the support of Elekta and Medtronic. Elekta is supporting the cost of publishing some papers from the developing world, as is SNI. In another new feature from SNI, other companies are preparing video ads to educate our readers about their products and will begin advertising in the next few months.


James I Ausman, MD, PhD
Surgical Neurology International