Neurosurgery clinics of North America
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The major changes in health care delivery today further cloud the perspectives of patient autonomy, participation, and justice and the ideals of the virtuous practice of medicine. A Workable Integrative Negotiation approach with COAST permeating the medical setting and health agenda, however, can help promote effective and ethical participatory communication in medicine. Clearly, instituting such change in a non-surgical decision-making procedure requires a new culture among all participants. ⋯ Instituting an outcome-based reimbursement system among government and providers can serve as a quasi-selection process based on the superseding objectives of the community at large. Finally, a participatory citizenry (from physicians to patients to society-at-large) that balances violence prevention, communication, innovation, community involvement, and appropriate treatment could advance optimal civic health. The challenge is to initiate such change with the communication principles outlined herein.
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This article reviews the preoperative evaluation of the child with intractable epilepsy. The importance of the history and the clinical manifestations of the seizures, and the results of electrophysiology, neurophysiology, and neuroimaging studies are discussed.
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Children requiring surgical treatment of epilepsy present many perioperative challenges. They demand the skills of a pediatric neuroanesthesiologist who is familiar with the physiologic and psychological needs of the pediatric patient, in addition to understanding the effects of anesthetic agents on the central nervous system. Not only is it important for the anesthesiologist to be aware of the neurosurgeon's specific operative plans, but also it is essential that the neurosurgeon understand the issues facing the anesthesiologist to avoid preventable intraoperative problems and to facilitate an optimal outcome for the patient.
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The Chiari II malformation and associated hydrosyringomyelia represent a complex spectrum of anatomic changes and clinical presentations whose management is rapidly changing as more is discovered about the natural history of these patients. Trends toward earlier operation on milder symptoms in selected patients may lead to improved neurologic outcome in these patients.
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Cervical spina bifida, either occult or overt, is relatively uncommon. These lesions tend to be associated with other abnormalities of the central nervous system and spine. For the occult dysraphic lesions, a Klippel-Feil syndrome is a particular association, especially the type I variety. ⋯ In both the occult dysraphic states and spina bifida cystica, there is underlying tethering of the cervical spinal cord, which can cause late neurologic deterioration, and surgical treatment is indicated both for cosmetic reasons and to untether the spinal cord. Children with spina bifida cystica may have neurologic dysfunction that may not be evident at birth or in the first few months of life but may be identifiable as the child grows older. One needs to be cautious about providing too optimistic a prognosis with respect to neurologic dysfunction based on a neonatal examination and to recognize that the appearance of neurologic deficits may not indicate deterioration.