Neurosurgical Literature Research Articles

Case-control studies in neurosurgery

Observational studies, such as cohort and case-control studies, are valuable instruments in evidence-based medicine. Case-control studies, in particular, are becoming increasingly popular in the neurosurgical literature due to their low cost and relative ease of execution; however, no one has yet systematically assessed these types of studies for quality in methodology and reporting. The authors performed a literature search using PubMed/MEDLINE to identify all studies that explicitly identified themselves as "case-control" and were published in the JNS Publishing Group journals (Journal of Neurosurgery, Journal of Neurosurgery: Pediatrics, Journal of Neurosurgery: Spine, and Neurosurgical Focus) or Neurosurgery. Each paper was evaluated for 22 descriptive variables and then categorized as having either met or missed the basic definition of a case-control study. All studies that evaluated risk factors for a well-defined outcome were considered true case-control studies. The authors sought to identify key features or phrases that were or were not predictive of a true case-control study. Those papers that satisfied the definition were further evaluated using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. The search detected 67 papers that met the inclusion criteria, of which 32 (48%) represented true case-control studies. The frequency of true case-control studies has not changed with time. Use of odds ratios (ORs) and logistic regression (LR) analysis were strong positive predictors of true case-control studies (for odds ratios, OR 15.33 and 95% CI 4.52-51.97; for logistic regression analysis, OR 8.77 and 95% CI 2.69-28.56). Conversely, negative predictors included focus on a procedure/intervention (OR 0.35, 95% CI 0.13-0.998) and use of the word "outcome" in the Results section (OR 0.23, 95% CI 0.082-0.65). After exclusion of nested case-control studies, the negative correlation between focus on a procedure/intervention and true case-control studies was strengthened (OR 0.053, 95% CI 0.0064-0.44). There was a trend toward a negative association between the use of survival analysis or Kaplan-Meier curves and true case-control studies (OR 0.13, 95% CI 0.015-1.12). True case-control studies were no more likely than their counterparts to use a potential study design "expert" (OR 1.50, 95% CI 0.57-3.95). The overall average STROBE score was 72% (range 50-86%). Examples of reporting deficiencies were reporting of bias (28%), missing data (55%), and funding (44%). The results of this analysis show that the majority of studies in the neurosurgical literature that identify themselves as "case-control" studies are, in fact, labeled incorrectly. Positive and negative predictors were identified. The authors provide several recommendations that may reverse the incorrect and inappropriate use of the term "case-control" and improve the quality of design and reporting of true case-control studies in neurosurgery.

The Impact of Telemedicine in the Postoperative Care of the Neurosurgery Patient in an Outpatient Clinic: A Unique Perspective of this Valuable Resource in the Developing World—An Experience of More Than 3000 Teleconsultations

Telemedicine has always been used as a teleconsultation tool in neurological emergencies (e.g., triage in head injuries, stroke, and cerebrovascular accidents). At Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India, we have been operating two teleconsultation sessions per week for the postoperative patient population, addressing routine follow-up and semiemergent conditions in this cohort of patients. At our center more than 80% of the neurosurgical procedures are conducted in patients traveling more than 1500 km. Telemedicine as a routine tool in clinical medicine has significant financial and psychosocial benefits versus routine outpatient clinics. There are very few reports of telemedicine use in routine outpatient teleconsultations in the available neurosurgical literature; those that are present do not differentiate or analyze the use in routine versus emergency neurosurgery. We discuss the role of this underused resource in the developing countries and retrospectively analyze the clinical data in more than 1500 patients and 3000 teleconsultations during a period of 6 years. We address the financial implications, psychosocial factors, and several other factors that could make this relatively modest technology an indispensible tool in current neurosurgical practice, especially in a developing country like India.

Complete resolution of large intracranial aneurysm and cranial nerve deficits after endovascular treatment in an infant with tuberous sclerosis

Abstract Pediatric intracranial aneurysms are a rare entity, with an often reported prevalence ranging from 0.5% to 4.6%. Their etiology is poorly understood; however, their association with other congenital disorders, such as polycystic kidney disease and Marfan syndrome, has been widely documented in the pediatric neurosurgical literature. We present a case of a 9-month-old boy with tuberous sclerosis with a giant cavernous internal carotid artery aneurysm presenting with third nerve palsy.

Erratum: Editorial. Methodology and reporting of meta-analyses in the neurosurgical literature

Erratum: Editorial. Methodology and reporting of meta-analyses in the neurosurgical literature

The Science of Medical Decision Making: Neurosurgery, Errors, and Personal Cognitive Strategies for Improving Quality of Care

During the last 2 decades, there has been a shift in the U.S. health care system towards improving the quality of health care provided by enhancing patient safety and reducing medical errors. Unfortunately, surgical complications, patient harm events, and malpractice claims remain common in the field of neurosurgery. Many of these events are potentially avoidable. There are an increasing number of publications in the medical literature in which authors address cognitive errors in diagnosis and treatment and strategies for reducing such errors, but these are for the most part absent in the neurosurgical literature. The purpose of this article is to highlight the complexities of medical decision making to a neurosurgical audience, with the hope of providing insight into the biases that lead us towards error and strategies to overcome our innate cognitive deficiencies. To accomplish this goal, we review the current literature on medical errors and just culture, explain the dual process theory of cognition, identify common cognitive errors affecting neurosurgeons in practice, review cognitive debiasing strategies, and finally provide simple methods that can be easily assimilated into neurosurgical practice to improve clinical decision making.

Comparing the Cost-Effectiveness of Endoscopic and Microscopic Approaches to Transphenoidal Pituitary Surgery

Introduction: Endoscopic endonasal approach (EEA) has become increasingly popular for resection of pituitary tumors. However, microscopic transphenoidal surgery (MTS) remains a commonly utilized approach across the USA. The economic sustainability of new techniques and technologies is rarely evaluated in the neurosurgical skull base literature, and so, the aim of this study was to determine the cost-effectiveness of EEA compared with MTS.

Methodology and reporting of meta-analyses in the neurosurgical literature

Neurosurgeons are inundated with vast amounts of new clinical research on a daily basis, making it difficult and time-consuming to keep up with the latest literature. Meta-analysis is an extension of a systematic review that employs statistical techniques to pool the data from the literature in order to calculate a cumulative effect size. This is done to answer a clearly defined a priori question. Despite their increasing popularity in the neurosurgery literature, meta-analyses have not been scrutinized in terms of reporting and methodology. The authors performed a literature search using PubMed/MEDLINE to locate all meta-analyses that have been published in the JNS Publishing Group journals (Journal of Neurosurgery, Journal of Neurosurgery: Pediatrics, Journal of Neurosurgery: Spine, and Neurosurgical Focus) or Neurosurgery. Accepted checklists for reporting (PRISMA) and methodology (AMSTAR) were applied to each meta-analysis, and the number of items within each checklist that were satisfactorily fulfilled was recorded. The authors sought to answer 4 specific questions: Are meta-analyses improving 1) with time; 2) when the study met their definition of a meta-analysis; 3) when clinicians collaborated with a potential expert in meta-analysis; and 4) when the meta-analysis was the only focus of the paper? Seventy-two meta-analyses were published in the JNS Publishing Group journals and Neurosurgery between 1990 and 2012. The number of published meta-analyses has increased dramatically in the last several years. The most common topics were vascular, and most were based on observational studies. Only 11 papers were prepared using an established checklist. The average AMSTAR and PRISMA scores (proportion of items satisfactorily fulfilled divided by the total number of eligible items in the respective instrument) were 31% and 55%, respectively. Major deficiencies were identified, including the lack of a comprehensive search strategy, study selection and data extraction, assessment of heterogeneity, publication bias, and study quality. Almost one-third of the papers did not meet our basic definition of a meta-analysis. The quality of reporting and methodology was better 1) when the study met our definition of a meta-analysis; 2) when one or more of the authors had experience or expertise in conducting a meta-analysis; 3) when the meta-analysis was not conducted alongside an evaluation of the authors' own data; and 4) in more recent studies. Reporting and methodology of meta-analyses in the neurosurgery literature is excessively variable and overall poor. As these papers are being published with increasing frequency, neurosurgical journals need to adopt a clear definition of a meta-analysis and insist that they be created using checklists for both reporting and methodology. Standardization will ensure high-quality publications.

Editorial: Methodology and reporting of meta-analyses in the neurosurgical literature

Editorial: Methodology and reporting of meta-analyses in the neurosurgical literature

Medical errors in neurosurgery.

Background:Medical errors cause nearly 100,000 deaths per year and cost billions of dollars annually. In order to rationally develop and institute programs to mitigate errors, the relative frequency and costs of different errors must be documented. This analysis will permit the judicious allocation of scarce healthcare resources to address the most costly errors as they are identified.Methods:Here, we provide a systematic review of the neurosurgical literature describing medical errors at the departmental level. Eligible articles were identified from the PubMed database, and restricted to reports of recognizable errors across neurosurgical practices. We limited this analysis to cross-sectional studies of errors in order to better match systems-level concerns, rather than reviewing the literature for individually selected errors like wrong-sided or wrong-level surgery.Results:Only a small number of articles met these criteria, highlighting the paucity of data on this topic. From these studies, errors were documented in anywhere from 12% to 88.7% of cases. These errors had many sources, of which only 23.7-27.8% were technical, related to the execution of the surgery itself, highlighting the importance of systems-level approaches to protecting patients and reducing errors.Conclusions:Overall, the magnitude of medical errors in neurosurgery and the lack of focused research emphasize the need for prospective categorization of morbidity with judicious attribution. Ultimately, we must raise awareness of the impact of medical errors in neurosurgery, reduce the occurrence of medical errors, and mitigate their detrimental effects.

Primary Spontaneous Cerebrospinal Fluid Leaks and Idiopathic Intracranial Hypertension

Idiopathic intracranial hypertension (IIH) is increasingly recognized as a cause of spontaneous cerebrospinal fluid (CSF) leak in the otolarnygological and neurosurgical literature. The diagnosis of IIH in patients with spontaneous CSF leaks typically is made a few weeks after surgical repair of the leak when symptoms and signs of elevated intracranial pressure (ICP) appear. Case reports and literature review. Two young obese women developed spontaneous CSF rhinorrhea related to an empty sella in one and a cribriform plate encephalocele in the other. Both patients underwent surgical repair of the CSF leak. A few weeks later, they developed chronic headaches and bilateral papilledema. Lumbar punctures showed elevated CSF opening pressures with normal CSF contents, with temporary improvement of headaches. A man with a 3-year history of untreated IIH developed spontaneous CSF rhinorrhea. He experienced improvement of his headaches and papilledema after a CSF shunting procedure, and the rhinorrhea resolved after endoscopic repair of the leak. These cases and the literature review confirm a definite association between IIH and spontaneous CSF leak based on: 1) similar demographics; 2) increased ICP in some patients with spontaneous CSF leak after leak repair; 3) higher rate of leak recurrence in patients with raised ICP; 4) patients with intracranial hypertension secondary to tumors may develop CSF leak, confirming that raised ICP from other causes than IIH can cause CSF leak. CSF leak occasionally may keep IIH patients symptom-free; however, classic symptoms and signs of intracranial hypertension may develop after a CSF leak is repaired, exposing these patients to a high risk of recurrence of the leak unless an ICP-lowering intervention is performed.

Fulminant post.craniotomy wound infection and meningitis with pneumocephalus caused by Acinetobacter baumannii: An unusual presentation

Sir, Acinetobacter baumannii (AB) is being increasingly recognized as an important cause of multi-drug-resistant nosocomial infections.[1] In neurosurgical literature it has been associated with secondary intracranial infections (post-traumatic/post-surgical meningitis and abscess formation).[2,3,4,5] Recently, AB has been implicated in necrotizing soft-tissue infections.[6,7,8] A similar type of fulminant wound infection after craniotomy has not been described. We report an unusual case where we had a combination of such wound infection with meningitis and pneumocephalus. A 45-year-old male presented with a one-month history of progressively increasing left-sided focal motor seizures and features of raised intracranial pressure. He had undergone surgery and radiotherapy for a right frontotemporal astrocytoma (Grade 2) three years back. The magnetic resonance imaging (MRI) brain revealed a right frontal enhancing mass [Figure 1]. He reported high-grade intermittent fever with chills since a week and at the time of admission had anemia, thrombocytopenia and pre-renal azotemia. The peripheral smear was positive for schizonts and merozoites of Plasmodium vivax. After appropriate antimalarial and supportive medical management he was operated eight days after his admission. On the sixth postoperative day he developed craniotomy flap swelling which in an hour's time had markedly progressed to involve the entire scalp. He also became confused and incoherent. A computed tomography (CT) scan revealed significant scalp edema with air pockets in the subcutaneous and subgaleal regions [Figures ​[Figures22 and ​and3].3]. There were postoperative changes in the operated site and diffuse pneumocephalus which had not been present in the immediate postoperative scan obtained a few days earlier [Figure 2]. Suspecting a fulminant necrotizing wound infection with associated meningitis, broad-spectrum antibiotics were started empirically and emergency re-exploration of the wound was performed. At surgery there was soft-tissue edema with crepitus. No tissue necrosis or pus was encountered. The dura appeared intact. A thorough wound wash was given after collecting a swab. The swab grew Acinetobacter baumannii sensitive to colistin, netilmicin, tigecycline and ceftazidime, as well as methicillin-resistant Staphylococcus aureus and Escherichia coli. With appropriate antibiotics (colistin, vancomycin and imepenem) he improved neurologically over a period of two weeks and was discharged for further adjuvant therapy. Figure 1 Preoperative magnetic resonance imaging (T1, T2 and post-contrast T1 images) showing a right frontal recurrent tumor Figure 2 Immediate postoperative computed tomography scan showing only minimal air in the resection cavity Figure 3 Subsequent computed tomography scan showing significant soft tissue and intracranial pneumocephalus AB has been reported to cause necrotizing soft-tissue infections,[7] especially with war-related injuries.[8] The wound infection in our case mimicked a necrotizing soft-tissue infection which has not been earlier described in a postoperative setting. Pneumocephalus was also a very unusual occurrence. Though pneumocephalus can occur in the postoperative setting, an earlier scan (immediate postoperative scan a few days earlier) in the same patient did not show any pneumocephalus. Besides, there was no dural leak noted at resurgery (which could also have accounted for the pneumocephalus). Moreover, presence of air in the soft tissue as well as intracranial compartments supports our contention that it was a case of necrotizing wound infection with meningitis producing pneumocephalus caused by AB. Spontaneous pneumocephalus due to meningitis has been reported with gas-forming as well as non gas-forming organisms.[9,10] Though AB is not gas-forming, it still causes necrotizing soft-tissue infections, and hence can even cause pneumocephalus by similar pathogenic mechanisms. Following successful treatment of the infection and improvement in clinical features, this pneumocephalus also resolved, reinforcing the association of the infection by AB and the spectrum of clinico-radiological findings.

Benign extracerebral fluid collection in infancy as a risk factor for the development of de novo intracranial arachnoid cysts

Intracranial arachnoid cysts are a relatively common benign intracranial pathology, accounting for as many as 0.75%-1% of nontraumatic CNS lesions. Although it has already been demonstrated that rupture of arachnoid cysts may lead to subdural hematomas/hygromas, no study to date has investigated benign extracerebral collection in infancy as a possible predisposing factor for further development of arachnoid cysts. The authors performed a retrospective imaging and chart review of macrocephalic infants 12 months old or younger who were referred to neurosurgical care at OSF St. Francis Medical Center from 2003 to 2010, and who were diagnosed with benign extracerebral fluid collection in infancy on thin-slice (1-mm) head CT scans. Special attention was given to the investigation of risk factors for further development of de novo arachnoid cysts. Several epidemiological factors in the infants and mothers were analyzed, including gestational age at delivery, mode of delivery, mother's age at delivery, delivery complications, birth weight, age of macrocephaly development, degree of macrocephaly, family history of macrocephaly, prenatal and postnatal history of infection, fontanel status, presence of papilledema, previous history of head trauma, and smoking status. Imaging characteristics of the initial scans, such as location of subdural collection (frontal vs frontoparietal and frontotemporal) and presence of ventriculomegaly, were also evaluated. For those patients in whom arachnoid cysts were identified on subsequent CT scans, the size and location of the cysts were also analyzed. The authors identified 44 children with benign extracerebral fluid collection in infancy. From this group, over a mean follow-up of 13 months (range 6-13 months), 18 children developed intracranial arachnoid cysts (a 40.9% incidence of de novo development of arachnoid cysts), with 27.8% presenting with bilateral cysts. In the multiple logistic regression analysis, infants who presented with an extracerebral collection restricted to the bilateral frontal region were more likely to develop intracranial arachnoid cysts (p = 0.035) than those with collections involving the frontotemporal and frontoparietal regions (odds ratio [OR] = 5.73). Additionally, children with benign extracerebral fluid collections and plagiocephaly were more likely to develop intracranial arachnoid cysts (p = 0.043) than those without plagiocephaly (OR = 4.96). This is the first report in the neurosurgical literature demonstrating that benign extracerebral fluid collections in infancy may constitute a significant risk factor for development of de novo arachnoid cysts. These findings support a 2-hit hypothesis for the development of arachnoid cysts, in which the combination of an embryological defect in arachnoid development followed by a second event leading to impairment of CSF fluid absorption in early childhood could lead to abnormal CSF dynamics and the consequent expansion of fluid collections in the intraarachnoid spaces.

Multifocal lymphangioendotheliomatosis with devastating intracranial hemorrhage

An in utero female was found to have a small hemorrhage at the foramen of Monro, hydrocephalus, and what was originally interpreted as a Dandy-Walker variant. At birth she had macrocephaly and numerous cutaneous, multifocal, red-pink blanchable macules. Postnatal MRI demonstrated a hemorrhagic soft-tissue mass involving the upper brainstem, thalamus, and basal ganglia most consistent with in utero complex multifocal intracranial hemorrhage. The skin lesions were thought to be consistent with multifocal lymphangioendotheliomatosis with thrombocytopenia (MLT). The size and location of the hemorrhage precluded operative intervention, although the hydrocephalus was treated with a ventricular shunt. The child continues to have severe developmental delays. Multifocal lymphangioendotheliomatosis with thrombocytopenia is a multifocal vascular disorder most commonly involving the skin and gastrointestinal tract. Intracranial hemorrhages are rare in this context. This case is the third reported instance of MLT with associated intracranial hemorrhage and the only case described in the neurosurgical literature. The authors review the presenting features and pathophysiology of this condition.

A technique to identify core journals for neurosurgery using citation scatter analysis and the Bradford distribution across neurosurgery journals

The volume of scientific literature doubles approximately every 7 years. The coverage of this literature provided by online compendia is variable and incomplete. It would hence be useful to identify "core" journals in any field and validate whether the h index and impact factor truly identify the core journals in every subject. The core journals in every medical specialty would be those that provide a current and comprehensive coverage of the science in that specialty. Identifying these journals would make it possible for individual physicians to keep abreast of research and clinical progress. The top 10 neurosurgical journals (on the basis of impact factor and h index) were selected. A database of all articles cited in the reference lists of papers published in issues of these journals published in the first quarter of 2012 was generated. The journals were ranked based on the number of papers cited from each. This citation rank list was compared with the h index and impact factor rank lists. The rank list was also examined to see if the concept of core journals could be validated for neurosurgical literature using Bradford's law. A total of 22,850 papers spread across 2522 journals were cited in neurosurgical literature over 3 months. Although the top 10 journals were the same, irrespective of ranking criterion (h index, impact factor, citation ranking), the 3 rank lists were not congruent. The top 25% of cited articles obeyed the Bradford distribution; beyond this, there was a zone of increased scatter. Six core journals were identified for neurosurgery. The core journals for neurosurgery were identified to be Journal of Neurosurgery, Neurosurgery, Spine, Acta Neurochirurgica, Stroke, and Journal of Neurotrauma. A list of core journals could similarly be generated for every subject. This would facilitate a focused reading to keep abreast of current knowledge. Collated across specialties, these journals could depict the current status of medical science.

Editorial: Proposed Surgical Trigeminal Neuralgia Score checklist

The authors merit congratulations for their ambitious efforts to assess the quality of surgical literature regarding the management of trigeminal neuralgia (TN).1 In the presented literature review and in the Surgical Trigeminal Neuralgia Score (STNS)–based evaluation of study rigor they attempt to 1) provide a checklist to guide future journal editorial decisions; 2) standardize patient-centered outcome measures in the TN literature; and 3) guide clinical practitioners in the application of study results to patient care situations. The authors’ creation and use of the proposed STNS scale falls short of their presented methodological standard. A single author scored most TN manuscripts; only 10% were randomly subjected to multiple reviewers to assess interobserver variability of the STNS checklist. The authors do not disclose their rate of scoring discordance, and they only note that scoring differences were reconciled by discussion. This method fails to account for potential bias in the overwhelming majority of papers that only benefited from a single STNS review. The STNS elements presented in Table 1 of this paper arbitrarily weigh clinical factors surrounding diagnosis, treatment, and complications comparably to manuscript organization, methods presentation, and Kaplan-Meier curve construction. More beta testing of the individual components of the list will be needed to be able to rank in order the elements of manuscript format and clinical data points in terms of their contribution to the model. As yet, the STNS checklist itself is not a validated tool, and great care must be taken in the introduction of any method that may shape the literature on a grand scale and carry unintended reporting bias. Naturally, use of the checklist by editorial boards in publication decisions would prompt publication of manuscripts that score higher by the STNS checklist standard. This self-fulfilling prophecy notwithstanding, the authors presume that a higher STNS corresponds with a greater ascertainment of clinical reality, and that subjective STNS checklist application will improve our understanding of TN treatment. This premise is tantalizingly intuitive, but remains unproven. As is common to many neurosurgical procedures, patient selection based on clinical presentation, past treatment, and imaging findings remains crucial to clinical success. Few randomized trials exist for surgical modalities because technical equipoise rarely exists. We would argue that this is clearly the case with microvascular decompression versus the nerve-injuring methodologies. The high STNSs reported by the authors for studies in the neurosurgical literature probably correspond with strong performance of these manuscripts in the clinical elements of the STNS scale; that is, treating neurosurgeons ask the right clinical questions. Conversely, journals with a high impact factor that emphasize aspects of the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) formula may perform well on the STNS methodological elements, but fail to capture the TN population of interest. From this perspective, which set of papers carries greater clinical application? Despite admirable efforts toward meta-analysis, there remains a clear role for surgical expertise and discretion in the selection of patients with TN; study data further this process by offering clear-eyed understanding of benefit durability and complication profiles in the relevant study population. Although we dispute the authors’ contention that the existing literature fails to offer surgeons this information, we remain mindful of opportunities for ongoing improvements in methodological studies in the neurosurgical literature. Overall, we stand in full agreement that the standardization of outcomes assessment in TN, be it the Brief Pain Inventory–Facial favored by the authors or another metric such as the 36-Item Short Form Health Survey, offers broad benefits for the field and should be carried forward. We further agree about the benefits of standard outcome tools for disease states to foster improved metaanalysis. We applaud the authors for empirically demonstrating the greater detail in the selection of patients with TN that is evident in the neurosurgical literature, and the correspondingly strong STNS for these manuscripts. Checklists such as the STNS may evolve as guides for future editorial decisions, and the resulting literature may inform but not dictate the application of study data to an individual patient care situation. (http://thejns.org/doi/abs/10.3171/2013.7.FOCUS13276)

Neural Sheath Tumors of the Brachial Plexus

Peripheral tumors of the brachial plexus, although rare, provide an opportunity for the plastic surgeon to coordinate a multidisciplinary team and achieve excellent outcomes. Most of the case series are reported from the neurosurgical literature. We report on the experience of the Kaiser Permanente Brachial Plexus Clinic over a recent 2-year period. A retrospective review was conducted to examine the medical records, radiographic images, operative reports, and pathologic findings of 13 consecutive patients with peripheral nerve sheath tumors of brachial plexus origin. Of the 10 patients requiring surgical exploration, 90% had significant improvement or resolution of pain, with sensory and motor recovery showing mixed results. Average follow-up consisted of 2 years with occupational therapy beginning shortly after operative intervention. Our results are similar to or better than those published in the literature. The plastic surgeon with subspecialty training can safely and successfully treat tumors of the brachial plexus by implementing a multidisciplinary approach.

RARE CASE OF FRONTAL BONE HEMATOGENIC OSTEOMYELITIS, COMPLICATED BY FOREHEAD PART BRAIN ABSCESS

Osteomyelitis of skull belongs to the rare necrotic infections of bones. Its distribution is about1.5% from osteomyelitis of the flat bones. During last 10 years in Russian neuro-surgical literature are no data covering this issue. Foreign publications review observations about single cases. This work describes clinical case of successful surgical treatment of frontal bone osteomyelitis, complicated by abscess in forehead part of brain.

Syringomyelia: A review of the biomechanics

Syringomyelia is a neurological disorder caused by the development of one or more macroscopic fluid-filled cavities in the spinal cord. While the aetiology remains uncertain, hydrodynamics appear to play a role. This has led to the involvement of engineers, who have modelled the system in silico and on the bench. In the process, hypotheses from the neurosurgical literature have been tested, and others generated, while aspects of the system mechanics have been clarified. The spinal cord is surrounded by cerebrospinal fluid (CSF) which is subject both to the periodic excitation of CSF expelled from the head with each heartbeat, and to intermittent larger transients from cough, sneeze, etc., via vertebral veins. The resulting pulsatile flow and pressure wave propagation, and their possible effects on cord cavities and cord stresses, have been elucidated. These engineering contributions are here reviewed for the first time.

Editorial: Maintaining journal independence

The membership of the American Association of Neurological Surgeons (AANS) should be aware of a disagreement between myself and the AANS Executive Committee. In my view, the matter is straightforward and should not be controversial. The Editorial Board is the ruling body of the Journal of Neurosurgery and each Editor since 1944 has served at their pleasure. I had anticipated that the Editorial Board could feasibly elect a new Editor at the April meeting of the AANS. To this end, a search committee carefully identified four candidates (a pediatric neurosurgeon, spine surgeon, and two general neurosurgeons) and these candidates subsequently visited the Journal offices in Charlottesville. Each candidate has proposed detailed but quite different plans for the future direction and administration of the Journals. They and their proposals will be presented to the 32 member Editorial Board of the Journals at the annual afternoon Journals’ meeting at the AANS. At this two and one half hour meeting, the Editorial Board will listen to the presentations, ask questions, and discuss who should be elected the next Editor. I felt that this was insufficient time for the Board members to carefully consider each candidate’s interview and to evaluate these very different proposals for the future of the Journals. I also thought that forcing a vote at the April meeting would likely result in factions, not consensus. Although the candidates and their proposals should be presented at the Editorial Board Meeting, I suggested that putting off the final vote until June 8 at the Senior Society meeting would give our Advisory Board and our Editorial Board time to thoughtfully assess the interviews, to review the proposals, and to reach a wellreasoned and measured consensus regarding the future of the Journals. It is not possible to do this in one afternoon. After I made this recommendation, I received from the Executive Committee a reply which flatly rejected my effort to afford the Editorial Board a few weeks to reach consensus on the new Editor in Chief (EIC). Instead, the Executive Committee asserted that if the Editorial Board fails to elect a new EIC and submit that individual’s name to the AANS by May 1, the Executive Committee will, on May 2, unilaterally terminate the current EIC, assume the role of EIC, assume control of all operations of the JNS offices in Charlottesville, and dictate the process of selecting the next EIC. Specifically, the Executive Committee asserts that it will send a letter to all members of the Editorial Board on May 2 for a vote, and declare the candidate with the largest number of votes to immediately assume the role of EIC, apparently regardless of whether that candidate receives less than majority approval and regardless of the response rate from this mailing. The scholarly and executive independence of the Journal has often been challenged in the past but always without success. This attempt by the AANS to take on the role held by the Journals’ Board members, those most familiar with the Journals and the neurosurgical literature, represents a sea change for JNS publishing. This assertion of control endangers the future well-being of the journals, compromises the independence of the Editorial Board, improperly assumes that the Executive Committee has authority to terminate, without cause, the duly elected EIC and fundamentally denies the Editorial Board the opportunity to reach consensus on the future leadership of the Journals of Neurosurgery. If the AANS Executive Committee forces a vote at the meeting or takes over the Journals of Neurosurgery Board’s responsibilities—neither action being justified— every subsequent Editor will be beholden to the AANS Executive Committee, the critical importance of independence will be lost. The Journal will become the political voice of the AANS not the scholarly voice of the world neurosurgical community. (http://thejns.org/doi/abs/10.3171/2013.3.JNS13610)

Measuring outcome after severe TBI

Objectives: To review current scales for measuring outcome following traumatic brain injury (TBI) and discuss changes in the types and use of these scales for the purposes of facilitating comparative effectiveness research. Methods: Functional, psychosocial/neurocognitive, and quality of life (QOL) scales used for assessing outcome following TBI are presented, along with the limitations of each. Core common data element scales are noted, and parametric, preference-based scales for performing comparative effectiveness research are discussed. Results: Many of the common outcome scales used in TBI research, including the Glasgow outcome scale (GOS), are functional measures. The emotional, cognitive, and psychosocial aspects of recovery are increasingly recognised, and metrics assessing these domains are becoming more common. Quality of life scales, which can be either directly used or translated into parametric preference-based indices for comparative effectiveness research are important for assessing patient-oriented outcomes, and in the upcoming years may yield information that improves medical decision-making, and ultimately outcomes following TBI. Discussion: Traumatic brain injury disrupts normal physical, cognitive, emotional, and social processes. Despite the dominance of functional scales like the GOS in the neurosurgical and neurocritical care literature, the use of other outcome modalities, including emotional, cognitive, psychosocial, and health-related QOL domains will be essential to improve patient care in the future.