James I. Ausman

Cerebral and somatic venous oximetry in adults and infants.

Background: The development in the last decade of noninvasive, near infrared spectroscopy (NIRS) analysis of tissue hemoglobin saturation in vivo has provided a new and dramatic tool for the management of hemodynamics, allowing early detection and correction of imbalances in oxygen delivery to the brain and vital organs. Description: The theory and validation of NIRS and its clinical use are reviewed. Studies are cited documenting tissue penetration and response to various physiologic and pharmacologic mechanisms resulting in changes in oxygen delivery and blood flow to the organs and brain as reflected in the regional hemoglobin oxygen saturation (rSO2). The accuracy of rSO2 readings and the clinical use of NIRS in cardiac surgery and intensive care in adults, children and infants are discussed. Conclusions: Clinical studies have demonstrated that NIRS can improve outcome and enhance patient management, avoiding postoperative morbidities and potentially preventing catastrophic outcomes.

Gross total resection: Do we want survival statistics or quality of life measurements.

Should a gross total resection (GTR) of malignant gliomas be made? Although many around the world today believe in this practice, I have had some serious reservations about this principle given the underlying pathology of glioblastomamultiforme (GBM). Many cite the papers of Lacroix (Sawaya) (J Neurosurg 95:190-198, 2001) and Sanai (Berger) (Neurosurgery 62:753-766, 2008) that support the idea of GTR, which are based on survival rates and very short increases in survival with greater resection. As reported in Lancet Oncol 2006;7:392-401 by Stummer et al., who used 5-aminolevulinic acid (5ALA) fluorescence-guided resections in a randomized study, median survival and extent of resection was better than without this tumor edge marker: Yet, the ultimate survival was the same in both groups. Karnofsky scores postoperative had more deficits in the 5ALA group than in the controls. This difference became insignificant on long-term analysis, which makes sense. Kubben has written in SNI about the mistakes that can be made using tumor edge markers on imaging to determine residual tumor edges, which also can be applied to intraoperative marker usage. (Kubben et al. Surg. Neurol. Int, 2012, Volume 3, Issue 1 [p. 158]). Does the tumor end at the marker? The pathology studies would say no. Read Shinouraetals paper (Surg. Neurol. Int. 2013; 4:149) analyzing the patients’ deficits after awake craniotomies in patients with different tumors in the premotor, motor, and sensory areas. They used Diffusion Tensor Imaging, Functional MR, neuronavigation, and brain mapping to determine the eloquent areas. Still they had 8% morbidity that lasted even under these ideal conditions. The factors producing the deficits were technical that occurred at the time of surgery. Is it reasonable to have a 10% morbidity for a rapidly advancing disease with a 100% mortality in a years time? Survival is not quality of life (QOL). And from my understanding, there is little information on the QOL of the people who undergo GTR with modern techniques. Also, it is inconceivable that GTR is sufficient to eliminate the diffuse infiltration of the brain by GBM. As of this moment we have still not changed the survival much in 50 years with surgery, radiation, and chemotherapy. That does not mean that research on curing GBMs should cease. In fact, proper organized studies should be done. Approaches such as immune and molecular therapies seem the most promising. Given that fact, should we offer a patient a deficit for their short life or QOL with surgery? I remember a story of Dr Paul Bucy, a famous pioneer neurosurgeon and founder of Surgical Neurology, the print predecessor of SNI, who did a hemispherectomy in 1948 on a patient with a GBM to remove all the tumor he could find. When the tumor recurred on the opposite remaining hemisphere in the hemiplegic patient, Dr. Bucy wrote that the patient returned to curse him. Malignant tumors of the brain are not cured by surgery, or radiation, or chemotherapy as of this time. So, we need to ask, “What is our goal in doing this surgery?” What will be the QOL for the patient? I remember treating a farmer from rural Minnesota in whom we resected a GBM. Then, he faced daily 6 h trips to get radiation therapy for 5 weeks that would have occurred during some of the best days of his remaining life. Does this additional treatment make sense? No, and so we agreed that he would not get the radiation therapy for the short time increase in his survival. That was time better spent with his loved ones. The real question is “Are we treating the doctor or the patient?” Are we technicians or are we thoughtful, caring physicians? What would you do if the patient were in your family? There may be a different answer for every patient. That is called Judgment. A technician would do the same operation on everyone. That makes no sense to me. What happened to Common Sense?

The death of spine surgery, sequel - 2014.

Clark Watts has published an outstanding paper on the shift of the American Association of Neurological Surgeons (AANS) from an educational association to a trade association in 2003.[10] In simple terms, its effects were to change neurosurgery from an organization dedicated to the welfare of the patient to one dedicated to the benefit of the neurosurgeon as a business person and to the society that promotes the interests of the neurosurgeon. In this paper he describes what influence this change may have had on the practice of neurosurgery and the neurosurgeon–patient relationship. He cites data that spine surgery represents 70-100% of what a neurosurgeon does now. He quotes evidence that the fusions being done for spinal stenosis have increased 15× from 2002 to 2007 without an increase in disease complexity. In addition, the costs for the procedures tripled and the complications also increased. He cites that Consumer Reports rates spine surgery as the most over-used treatment in Medicine. He also reports that the reimbursement for a simple decompressive laminectomy has decreased by 33% and for complex procedures with fusions by 20%.[10] Nancy Epstein and others have reported in Surgical Neurology International (SNI) that 50% of spine surgery being done is unnecessary.[5,6,8] In addition, she reported a literature review in 2013 that indicated that the risks of epidural steroid injections for spinal stenosis and back root pain had higher risks than benefits.[4] A recent paper in the New England Journal of Medicine (NEJM) indicated that after 6 weeks, the benefit from epidural steroid injections compared with local anesthetic agents was no different.[7] There were reports of neurosurgeons receiving high compensation as consultants to industry producing spine technology[2] and misuse of products designed by some neurosurgeons or spine surgeons for their own benefit.[9] Watts wonders if these results are related to the change from Neurosurgery from a patient care to a trade organization.[10] I have seen these changes in spine surgery occurring all over the world as the desire for more compensation incentivizes neurosurgeons and spine surgeons to do more complex procedures for greater financial reward. It is not a phenomenon restricted to the USA. In 2003, I wrote an Editorial on “The Death of Spine Surgery”,[1] which was received with denial by spine surgeons and still is today. If I were the Secretary on Health in any government concerned about costs for healthcare and I was informed about the 15× increase in complex surgery, 3× higher costs with no increase in the disease process, my first question to my assistant would be, “Where is the evidence to justify these costs? The answer would be “There is no scientific justification”. In fact there is evidence that too much surgery is being done at too great a cost. The first action I would take, as would any 6th grader, would be to stop payments for the complex procedures until justification was established. With the coming economic problems of the economies worldwide because of the huge expansion in worldwide debt backed by the printing of money that is not backed by gold and thus has no value, governments will be forced to make decisions to restrict expenses. The ultimate effect on neurosurgeons, spine surgeons, pain management specialists, and hospitals will be a drastic reduction in reimbursement for spine surgery. These events will have a huge impact on spine specialists incomes. Epstein has suggested how economies can be made in widely used procedures.[3] What I have advised for years is that Multidisciplinary Spine Centers be developed that would include Psychologists, Occupational therapists, Physical Therapists, Drug Addiction Specialists, Chiropractors, and Neurosurgeons or Spine surgeons who together would diagnose and treat neck and back pain. Thus, regardless of what happens economically in your country, the patient would always be under the control of the “Back and Neck Pain Center”. With the multidisciplinary evaluation of each patient, the proper treatment could be administered and justified. Private practicing internists and general practitioners are flooded with patients from Orthopedists and Neurosurgeons who do not want to see those with continued postoperative pain or drug addiction. There should be plenty of patients for those whose Back and Neck Pain Center did a reasonable job in evaluating patients and restoring those to work. Industry is interested in this kind of assessment but cannot find places where this type of work is done. The alternative is to keep doing what you are doing and deny reality with the eventual crash of your income and specialty. Clark Watts has eloquently stated for National Associations what they must do given this impending crisis. You decide, or someone else will.

The World – Socio-economically and politically: What you need to know

The gravest challenge facing the USA and the nations of the world is the coming economic crisis of the world economies, if present policies are pursued. Few are aware or believe that this event could happen. The spread of centralized government control of the economies, the growth of the welfare state worldwide, the expenditures on entitlements beyond what any nation or even most states can afford, the cost of wars, the rapidly climbing debt of the USA and other countries and their inability to pay for these excessive expenses, the actions of many countries to print “fiat” (false) money to pay for their debts, the raising of taxes to pay for these debts, the rise in immigration to developed countries from the undeveloped world, the associated costs to their societies of this immigration, the promises made by politicians to get elected that cannot be fulfilled, and the desire of the public to have what they want, now, paid for by credit cards (debt), are all contributing to the coming economic crisis. The unfunded promised benefits to the citizens of the USA in Medicare, Medicaid, Social Security, and pensions plus the USA debt amount to about

Announcement of new journal and call for submission of papers: Surgical Neurology International

140 trillion. The total value of all the assets of all the people in the USA is

The future of medicine in the 21st century

99 trillion dollars. So, one can see that the people of the USA do not have the resources to pay their expenses. Besides, these entitlements, the rest of the expenses are paid for with borrowed or printed (fiat) money that has little chance of being repaid unless perhaps by subsequent generations or by increases in taxes. Efforts to correct this coming economic crisis by austerity and sacrifice have been rejected by the public and the politicians worldwide. The Governments and the Press have participated in deception of the public about these issues in order to maintain their positions of power, for the truth would destroy them. No solution is in sight except more spending and valueless money printing. This unchecked desire for more of everything without the responsibility to work or pay for these entitlements, has touched many countries and people with a few exceptions. This problem is the result of a worldwide breakdown of ethics and morality in society and a desire of the few for centralized control and power over the people. No country has instituted a solution to these problems that results in reducing expenditures or the growing debts. As many have stated in this paper, this policy cannot be sustained. The result of this scenario will be a worldwide economic crisis. Fundamental to this impending economic crisis is the failure of centrally controlled economies and socialistic programs. Those selected groups, who benefit from having control, are the politicians, bankers, some selected industry leaders, and socialist planners, who will stop at nothing to maintain power and control over the people. Liberty of the people is in jeopardy worldwide. Read the evidence presented and decide if this summary is correct. The troubling question is, “What will happen if the world economy collapses?” Will this crisis be a time for the few to take more control of the people through fear, crisis decisions, misinformation, prevention of the public from protecting themselves with guns, and pervasive spying technology on each citizen or will more democratic governments arise from the failure of centralized control, the welfare state, and the loss of liberty? Such crises have been repeated throughout 4000 years of recorded history. What happened in those past times? Read the quotations of Vladimir Lenin, developer of Marxism–Leninism, the foundation of Communism and judge what you have read from his statements. An alternative to this dismal scenario is little discussed also in the Press. Why not? In the past 150 years, the alternative has happened with a rapid growth in democracy, communications technology, and life expectancy from advances in science and medicine. To unleash this huge human potential, at this time, will require individual freedom to create and innovate with the opportunity for risk and reward in an environment aided by unrestrictive governments even at the community and organizational levels. History records the success of the alternatives in the great leadership and creativity of humankind. The USA and the world are at the critical choice for their futures. We are experiencing the results of centrally controlling governments worldwide that are not working. Is it time for an alternative option? Read the evidence in this paper and decide for yourself. Reading this paper will take you time, but you will not read all of this information elsewhere. It is key to your future. Decide for yourself what you should do after reading it. The URLs of many of the references are included so that you can read further about the many subjects presented yourself.

How do you know what you read or hear is the truth

I am pleased to announce the formation of Surgical Neurology International (SNI), a new OPEN ACCESS, Internet-only journal, accessible to all neurosurgeons. OPEN ACCESS means that anyone in the world with access to the Internet can visit the website, view the journal, obtain its papers, its editorials, and comments for FREE! Surgical Neurology International will serve approximately 35,000 neurosurgeons around the world. It will potentially have the largest circulation of any neurosurgical journal. SNI will have the same editorial policy and principally the same Editorial Board as I established and upheld as Editor-in-Chief of Surgical Neurology for 15 years. SNI will accept papers on clinical neurosurgery and other clinical and basic neurosciences with topics of interest to our audience. It will have editorial comments about controversies, the principles of medical and neurosurgical practice, socio-economics, politics, ethics, and science, as were expressed in the past. In addition to accepting research papers from all over the world, SNI will have an advanced educational website for residents and practicing neurosurgeons, with content provided by the UCLA Department of Neurosurgery and its guest lecturers under the direction of Nestor Gonzalez and with the cooperation of Neil Martin, the Department Chairman. This content, as well as downloads of papers, will be available at no charge. For those neurosurgeons who cannot afford a journal, cannot access one easily, or cannot go to meetings, Surgical Neurology International will be their source of information. Surgical Neurology International wants to involve neurosurgeons, particularly the young neurosurgeons who have a difficult time for gaining recognition in many countries around the world. SNI will have new and innovative Clinical Decision Support sites for real time use by neurosurgeons in clinical cases they see every day. SNI will also have the latest social networking sites and individual communication options so everyone can access the journal anywhere, any time. It will be twenty-first century education. For those who are interested, they can receive notices of new papers being published each month. When papers are accepted, they will be published within days rather than weeks or months. All papers will be searchable through PubMed Central, a division of PubMed, and will be searchable on PubMed and other commonly-used databases. The only cost will be to authors of accepted papers. This fee will be US

A tribute to atos de sousa, MD.

400 to publish a paper after it is accepted. For short communications and case reports, the cost will be US

Editor's thoughts: The greatest opportunity of your life.

180. We are working on ways to eliminate that fee by obtaining advertising or grants. There is no additional charge for color pictures or videos. For those who cannot afford this authors cost, it can be waived by decision of the Editor. Our publisher is Medknow Publishers in Mumbai, India. We thank Atul Goel for directing us to this organization that publishes many OPEN ACCESS medical journals. I also want to thank Bob Goodkin, Pat Kelly, Ben Roitberg, Konstantin Slavin, Neil Martin, and Nestor Gonzales for their support in bringing this new journal to all neurosurgeons in the world. You can access our new Web site at www.surgicalneurologyint.com. This site includes a link for authors to submit their new manuscripts, and is also the Web site to use to access the educational content, which will be operational soon. This Web site will have other features we are developing to help you exchange information with your colleagues about challenging cases, an imaging site for interesting cases, chat rooms, etc. If you would like to receive Table of Contents through e-mails or RSS alerts, please access the Web site and follow the instructions under “Staying in touch with the journal.” If you are interested in becoming involved with the journal, SNI, in any of its aspects, please let me know at jamesausman@mac.com. We hope that neurosurgeons everywhere will enjoy this new publication. This is your journal, and we are open to any ideas you have to make it beneficial to you and to your practice. We would be delighted if you would share this information with your colleagues.

What are the three major changes/challenges in your life?

According to futurists Alvin and Heidi Toffler, waves of change are occurring all over the world.[7,17] Some people are still living in the primitive hunter–gatherer civilizations, while others are going through the agricultural wave of change and still some others are in their industrial age, with a few moving into the knowledge age or the information age. In some countries, several of these waves of change are occurring simultaneously, making communication and understanding among the people in these different waves of change difficult. The different waves of change sweeping the world in which people exist under different philosophical and governing systems explain why there will be conflicts and wars for generations to come.