The expert witness. Neither Frye nor Daubert solved the problem: what can be done?

Flawed expert scientific testimony has compromised truth finding in American litigation, including in medical malpractice and in product liability cases. The Federal Rules of Evidence and the Supreme Court in Daubert and other cases have established standards for testimony that include reliability and relevance, and established judges as gatekeepers. However, because of lack of understanding of scientific issues, judges have problems with this role, and juries have difficulties with scientific evidence. Professionals and the judiciary have made some advances, but a better system involving the court's use of neutral experts and a mechanism to hold experts accountable for improprieties is needed.

Prognosis of chronic subdural hematomas.

This article considers factors that may be of prognostic value in evaluating the chronic subdural hematoma (CSH) patient. It also examines conditions that predispose the development of a CSH. Variables such as admission neurologic status and presenting symptomatology are reviewed. Radiologic parameters (i.e., CSH density and midline shift) and intraoperative findings (i.e., pressure and pulse) are discussed.

Prophylactic antibiotics with intracranial pressure monitors and external ventricular drains: a review of the evidence.

BACKGROUND: The role of prophylactic antibiotics (PABs) in preventing infections associated with intracranial pressure (ICP) monitors and external ventricular drains (EVD) is not well defined. METHODS: This study includes an analysis of published reports and a survey of current practices regarding the use of PABs with ICP monitors and EVDs. A computerized data search and a review of the abstracts from two major national neurosurgical meetings over the past decade yielded 85 related articles. Three independent investigators, blinded to the title, author(s), institution(s), results, and conclusions of the articles used predetermined inclusion criteria to select studies for meta-analysis. Thirty-six responses were returned from 98 questionnaires (37%) mailed to university neurosurgical programs. RESULTS: Among the articles reviewed, only two studies met the predetermined inclusion criteria for the meta-analysis, and they were of insufficient size to produce statistically significant results. Among the 36 programs that responded to the survey, 26 (72%) used PABs, mainly cephalosporins (46%) and semisynthetic penicillins (38%), with ICP monitors and EVDs. Twenty-two (85%) used one drug, and 4 (15%) used two drugs. Twenty-two (61%) of the total group reported intra-institutional variation in practices among individual staff neurosurgeons. Nineteen (53%) expressed interest in a retrospective study, and 27 (75%) expressed interest in a prospective study on the role of PABs in minor neurosurgical procedures. CONCLUSION: No consensus regarding the use of PABs with ICP monitors and EVDs is noted. Randomized controlled trials of sufficiently large size with appropriate blinding are needed to address this issue.

Laparoscopic-assisted distal ventriculoperitoneal shunt placement.

BACKGROUND: Intraperitoneal adhesions, obesity, and distorted abdominal anatomy in shunt-dependent hydrocephalic patients are patient characteristics that increase distal ventriculoperitoneal (VP) shunt failure rates. The use of laparoscopic-aided placement of the distal VP catheter as a technique to decrease the failure rate is evaluated in these patients. METHOD: Thirteen hydrocephalus patients considered to either have intra-abdominal adhesions, be obese, or have distorted abdominal anatomy underwent laparoscopic-aided distal VP catheter placement or revision. Two had shunts placed for the first time and eleven had revisions. Eight patients had revisions performed by both the standard minilaparotomy and laparoscopic methods, but at different times. The average surgical times for both techniques were looked at for these eight patients. Case illustrations are presented. RESULTS: In patients who had both types of abdominal approaches, the average surgical time was 81 min for the laparoscopic-aided technique versus 116 min for the minilaparotomy procedure. The only complication related directly to the laparoscopic procedure was one wound infection. CONCLUSION: In patients with intra-abdominal adhesions, obesity, or distorted abdominal anatomy, laparoscopic-aided distal shunt insertion increases the success rate by its direct visual capability and the ability to lyse abdominal adhesions and position the distal end of the catheter in a desired place.

Massive osteolysis of the skull and upper cervical spine. Case report and review of the literature.

Massive osteolysis is a type of idiopathic osteolysis in which there is spontaneous onset of bone resorption. Almost any bone in the body can be affected. The authors present the case of a 62-year-old man diagnosed with massive osteolysis of the occipital bone and the upper two cervical vertebrae. Despite extensive pneumocephalus, no neurological sign or spinal instability was evident. In this case 4000 cGy of radiation in 200-cGy fractions was administered to the diseased area while the patient was kept in a Miami-J collar. At the 2-year follow-up examination, arrest of the disease process and new bone formation was evident on radiographic studies.

Inadvertent intraoperative myelography with Hypaque: case report and discussion.

BACKGROUND: Myelography is routinely performed safely using nonionic water-soluble radiographic contrast media. However, inadvertent introduction of ionic contrast media into the thecal space can result in a syndrome of spasms and convulsions, which can lead to death if not recognized and dealt with in a timely manner. METHODS: We report a case of inadvertent use of the ionic diatrizoate meglumine, an ionic contrast agent, instead of a nonionic contrast agent during intraoperative myelography. RESULTS: The patient developed a sterotypical syndrome of ascending myoclonic spasms, resulting in rhabdomyolysis. Treatment included elevation of the head, removal of cerebrospinal fluid, administration of anticonvulsants, diuresis and sedation, and neuromuscular blockade. The patient recovered well, and there were no long-term sequelae. CONCLUSIONS: Intrathecal introduction of ionic contrast media and the resultant syndrome must be recognized promptly and treated with aggressive medical management to address rhabdomyolysis and seizures. Ionic contrast media should be stored and marked in such a way as to avoid inadvertent use in myelography.

Byron Stookey: "the old lion"--an unsung giant of neurosurgery.

BYRON POLK STOOKEY, an outstanding clinician and teacher, served as Director and Chief of Neurosurgery at the Neurological Institute of New York Columbia-Presbyterian Medical Center. Highlights of his clinical contributions include improved peripheral nerve and spine surgery and subtemporal trigeminal nerve section for tic douloureux. Through diverse activities in both the political and academic arenas of patient care, education, and research, stookey helped to build and strengthen neurosurgery between the world wars and helped to prepare the foundation for the accomplishments of recent decades.

Intraparenchymal hemorrhage.

Spontaneous hemorrhage into the cerebral parenchyma accounts for 8% to 13% of all strokes. It is more common in males, in blacks, and in the elderly. Fifty percent of cases are due to the effects of chronic hypertension on intracranial perforating arteries. The basal ganglia are the most frequent site of bleeding. Lobar hematomas tend to occur in younger patients, and may be due to specific causes such as vascular malformations. Many patients will have increased intracranial pressure and will require treatment in an intensive care unit. If surgery is necessary, stereotactic aspiration and pharmaceutical clot lysis are recent developments that may be advantageous. Prognosis is related to the patient's age and neurologic condition, and to the size, location, and rapidity of formation of the hematoma.

Patients with Glasgow Coma Scale scores 3, 4, 5 after gunshot wounds to the brain.

Even this information is only partial. To study fully the effects of treatment would require optimal care at all points from time of injury, including rapid prehospital resuscitation, rapid transport to an optimally equipped and staffed hospital, immediate evaluation and treatment of the initial injury and all complications, rapid and comprehensive rehabilitation, and supportive and flexible home and work settings for the patient on discharge. Patients would need to be stratified for premorbid characteristics, including intelligence, personal traits, and training. Prolonged follow-up, possibly for several years, would be required to determine true outcome. No current study contains sufficient numbers of patients treated optimally and studied for prolonged periods, but this should be done. One way of looking at such patients is to decide that many should be treated to salvage a few. The other way of looking at them is that so many must receive care, at great emotional and economic cost to themselves and others, that such treatment is inappropriate for any of them. Treating all such patients would be a major undertaking. If most of these patients were treated vigorously, a great proportion of them would still die but probably not for a number of days. During this period, their families would be under extreme stress. Once stabilized and receiving ongoing care, some patients would enter a permanent vegetative state and survive for prolonged periods until their prognosis was clear and care was withdrawn, again causing family stress as well as high cost. Some would likely survive although impaired. The charges and real costs of care for all these patients would be tremendous. The question therefore arises as to how to decide what to do about caring for a large group of patients whose maximal care would be costly in emotional and financial terms, particularly at a time when it is recognized that resources for medical care are going to be limited. When discussing such patients as a group with a view toward developing practice guidelines, many considerations must be brought to bear. One consideration is the certainty of the prognosis in both a quantitative and a qualitative sense in an individual case. It is not clear that one can be certain in patients except when there are overwhelmingly unfavorable features. As has been noted, even patients who have been shot through the geographic center of the brain and are posturing can make excellent recoveries. This would push toward aggressive treatment for many patients. Decision making must therefore be considered in terms of bioethics. The major principle-based systems of bioethics are deontologic, arising from accepted principles, and utilitarian, arising from effect on outcome. A virtue-based ethic for physicians arising from "the caring bond and the public trust" is being revived as a balance to analytical ethics. A similar orientation from the point of view of patients is communitarian ethics, that is asking for only what is reasonable and not so much as might harm others. Some of the issues to be considered include the sanctity of life while taking into account the criteria for life--vegetative function versus some level of mental function. One must also review each decision from the viewpoints of all the parties involved--patients, family and friends, physicians, and society--in the context of a heterogeneous society in which individual rights and tolerance enforced by law are primary features. In the patients' terms, there is a desire and right to medical care to maintain a healthy productive life. Even if impaired to some extent, patients may still have an interest in living. Balancing benefits and burdens of life is a complex problem. There is also the right, based on patients' values, to refuse care if there is the wish not to take a chance of having a significantly compromised existence. Such declaration before injury should be honored...

Care and variations in the care of patients with gunshot wounds to the brain.

A national survey revealed significant variations in a number of aspects of evaluation and surgical and nonsurgical treatment of patients with gunshot wounds to the brain. There could be many reasons for this. It would seem that there has probably not been sufficient research done to fully understand all aspects of such injuries. It also may be that different ways of caring for these patients provide equally satisfactory outcomes. Another problem that arises is that even with good information, there is difficulty in changing practice patterns that need to be understood better and made more effective. Based on the author's review and ethical considerations, certain basic and reasonable suggestions are made in this article.

Adenocarcinoma of the ethmoid sinus.

BACKGROUND: Carcinoma of the paranasal sinuses is rare. The majority of these originate in the maxillary sinus with primary ethmoid carcinomas occurring in up to 20% of cases. Adenocarcinomas comprise up to 50% of the ethmoid malignancy. The relative rarity of tumors originating in this area has led to their inclusion in series that consist mainly of maxillary antral tumors. METHODS: A retrospective chart review of all patients presenting with primary ethmoid adenocarcinoma at West Virginia University Hospitals between 1988 and 1993 was undertaken. Only patients whose epicenter was believed to be in the ethmoids were included in this analysis. CT scans, MRIs, operative notes, pathology, and final outcome were all analyzed. RESULTS: Eight patients with primary ethmoid adenocarcinoma were treated during this time span. The male to female ratio was 1:1 with a mean age of 50 years. Symptoms had been present from 3 to 18 months (mean 8 months). All patients underwent craniofacial resection with 5 patients receiving postoperative radiotherapy. Pathologically 4 patients had cribriform plate erosion, 2 had dural involvement, and 1 had extension into the sphenoid sinus. With a mean follow-up of 45 months (9-71 months) 7 patients are disease free and 1 patient has died of disease. CONCLUSIONS: Obtaining clear margins by craniofacial resection is essential to the management of adenocarcinoma of the ethmoid sinuses. Radiotherapy is reserved for positive margins, cribriform plate penetration, dural invasion, and high-grade lesions that are close to the cribriform plate. Local control was obtained in 87% of our patients.

Quadrant anatomy of the articular pillars (lateral cervical mass) of the cervical spine.

Knowledge of the relevant anatomy is important when developing a strategy for introducing screws into the lateral masses to secure internal fixation devices. This paper defines key bony landmarks and their relationship to critical neurovascular structures and identifies a location for safe placement of cervical articular pillar (lateral mass) screws. Measurements of anatomical landmarks in 10 spines from human cadavers aged 61 to 85 years were made by caliper and a metric ruler. Landmarks were the lateral facet line, rostrocaudal line, medial facet line, intrafacet line, and medial facet line-vertebral artery line. The average distances and ranges were recorded. Such great variance existed in measurements from spine to spine and within the same spine as to render averages clinically unreliable. Dissection revealed that division of the articular pillar into four quadrants leaves one, the superior lateral quadrant, under which there are no neurovascular structures; this may be considered the "safe quadrant" for placement of posterior screws and plates.

Treatment of high-dose intrathecal morphine overdose. Case report.

The case is reported of a 45-year-old woman who was being treated for chronic back and right leg pain with intrathecal morphine administered via a subcutaneous continuous-infusion device. She received an accidental 450-mg bolus injection of morphine intrathecally and developed hypertension, status epilepticus, intracerebral hemorrhage, and respiratory failure. Treatment with continuous intravenous naloxone infusion, lumbar catheter drainage of cerebrospinal fluid, and control of hypertension and status epilepticus resulted in an excellent outcome with return to neurological baseline. Care providers who refill pump reservoirs with morphine must be knowledgeable about these devices and the life-threatening consequences associated with errors in refilling them. This case describes the complications and successful treatment of high-dose intrathecal morphine overdose.

Treatment of spastic gait in cerebral palsy.

The most common presentation of cerebral palsy is spastic diplegia, which in severe cases can impede nursing care and in less severe cases can impair a child's ability to move around with facility. A procedure has been developed to decrease spasticity in which there is selective section of portions of the dorsal roots L2-S2. In a series of such operations in 19 children with spastic diplegia, we were able to decrease their spasticity significantly with resultant improvement in motor function and self care. There were no significant complications and patient and family satisfaction was high. Our experiences further confirm existing evidence that this procedure is very helpful and highly recommended for selected children with spasticity due to cerebral palsy.

Spinal epidural metastases: a common problem for the primary care physician.

Spinal metastases are a common complication of cancer that should be managed quickly and aggressively. Most often from lung or breast cancer (or due to lymphoma), they usually seed from blood into vertebrae and extend into the epidural space. The most common presentation is pain and weakness, and the evolution can be rapid with paraplegia within days. Better prognosis is related to slower onset and pretreatment motor status, so spinal metastases are an emergency. Testing includes X-rays, neuroimaging, myelogram/CT and most recently MRI. Treatment is guided by the severity of neurological deficits, whether compression is by soft tissue or bone, and the presence of instability. A soft tissue mass with only mild to moderate deficits can be treated with radiation. Surgery is required for severely affected patients who are deteriorating rapidly with instability and bone in the canal. New approaches and fusion techniques facilitate decompression and stabilization.

Intracranial pressure changes during bilateral radical neck dissections.

The management of the contralateral neck in patients with head and neck cancer who have undergone a radical neck dissection (RND) is controversial. A number of these patients will require a second RND. Sacrifice of both internal jugular veins (IJV) has been felt to lead to increased intracranial pressure (ICP) with subsequent neurologic sequelae. From 1987 to 1991 four patients had staged bilateral RNDs at the West Virginia University. In these patients a subarachnoid bolt was placed to directly monitor ICP. Jugular bulb, mean arterial, pulmonary artery, and central venous pressures were monitored. Electroencephalographic (EEG) monitoring was also performed. All patients demonstrated elevations in ICP immediately on head rotation. Further marked elevations were noted immediately after IJV ligation with a maximum peak at 30 minutes. Pressure levels of greater than 40 mm Hg were observed in three of four patients. Systemic hypertension was observed in response to elevated ICP (Cushing's reflex). All patients studied recovered from surgery without significant sequelae. Within 24 hours the ICP had returned to normal in all patients. Three patients required intraoperative intervention to lower their ICP. We demonstrate that even in a staged second RND there are significant rises in ICP. These are to a level that suggests emergency medical intervention is required. We feel that when the second IJV is sacrificed an increase in ICP should be anticipated, monitored, and treated accordingly.

Intracerebral hematoma related to thrombolysis for myocardial infarction.

The incidence of intracerebral hematomas after myocardial infarction increases after thrombolysis. As noted in the case described, clots formed after the administration of thrombolytic agents may remain liquid, and this blood can be drained by a catheter. However, in this case, the patient continued to bleed locally. This problem requires the development of methods to stop such ongoing local bleeding. It may be prevented in the future by improved thrombolytic drugs.