Neurosurgery
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Ethical discussions around health care reform typically focus on problems of social justice and health care equity. This review, in contrast, focuses on ethical issues of particular importance to neurosurgeons, especially with respect to potential changes in the physician-patient relationship that may occur in the context of health care reform. The Patient Protection and Affordable Care Act (ACA) of 2010 (H. ⋯ Each of these aims is complicated by a number of ethical challenges, of which 7 stand out because of their potential influence on patient care: the accountability of physicians and surgeons to individual patients; the effects of financial incentives on clinical judgment; the definition and management of conflicting interests; the duty to preserve patient autonomy in the face of protocolized care; problems in information exchange and communication; issues related to electronic health records and data security; and the appropriate use of "Big Data."Systematic social and economic reforms inevitably raise ethical concerns. While the ACA may have driven these 7 to particular prominence, they are actually generic. Nevertheless, they are immediately relevant to the practice of neurosurgery and likely to reflect the realities the profession will be obliged to confront in the pursuit of more efficient and more effective health care.
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Multicenter Study
The Safety and Feasibility of Image-Guided BrainPath-Mediated Transsulcul Hematoma Evacuation: A Multicenter Study.
Subcortical injury resulting from conventional surgical management of intracranial hemorrhage may counteract the potential benefits of hematoma evacuation. ⋯ The approach was safely performed in all patients with a relatively high rate of clot evacuation and functional independence.
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Functional recovery following supinator motor branch transfer requires further investigation. ⋯ Supinator motor branch transfer allows for faster recovery and is a more effective procedure for restoring finger extension in C7-T1 brachial plexus palsies.
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Review Case Reports
Spontaneous Bilateral Carotid-Cavernous Fistulas Secondary to Cavernous Sinus Thrombosis.
Bilateral carotid cavernous fistulas are rare entities that can cause debilitating symptoms and can lead to more severe consequences if left untreated. Therefore, the recognition and adequate treatment of these pathologies is very important. We present 2 cases of bilateral carotid cavernous fistulas that arose as a result of cavernous sinus thrombosis. ⋯ The patient in case 2 demonstrated resolution of bilateral carotid cavernous fistulas after anticoagulation therapy. Case 2 highlights the fact that certain cases of bilateral carotid cavernous fistulas due to cavernous sinus thrombosis may benefit from extensive anticoagulation therapy. If anticoagulation therapy is unsuccessful, endovascular therapy may prove beneficial in resolving the fistulous shunt.
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This workshop addressed challenges of clinical research in neurosurgery. Randomized controlled clinical trials (RCTs) have high internal validity, but often insufficiently generalize to real-world practice. ⋯ The workshop considered possible solutions, such as (1) statistical methods for demonstrating causality using observational data; (2) characteristics required of a registry supporting effectiveness research; (3) trial designs combining advantages of observational studies and RCTs; and (4) equipoise, an identified challenge for RCTs. In the future, advances in information technology potentially could lead to creation of a massive database where clinical data from all neurosurgeons are integrated and analyzed, ending the separation of clinical research and practice and leading to a new "science of practice."