Patton: death of a soldier. Historical vignette.

General George S. Patton Jr. died as the result of quadriplegia sustained in a car crash in Germany in 1945. His x-ray films revealed a fractured C-3 vertebra and a posterior dislocation of C-4 on C-5. The likely cause of death was a pulmonary embolus. Details of his medical treatment are reviewed and compared with therapies that a patient with a similar injury would receive today.

Autonomic failure: observations of a physician-patient.

Here I describe the clinical symptoms of autonomic failure that I began experiencing when I turned 80, a treatment combination that has been remarkably effective, and the recent finding of high titers of antibodies against the ganglionic nicotinic receptor.

Neurosurgical experience with malpractice litigation: an analysis of closed claims against neurosurgeons in New York State, 1999 through 2003.

OBJECT: Neurosurgeons are a high-risk group for allegations of malpractice. To determine the kinds of cases and the neurosurgical practice patterns associated with the highest proportion of litigation, the authors examined the experience over a 5-year period of a major physician-owned and -administered insurance company dealing with this issue, the Medical Liability Mutual Insurance Company (MLMIC) of New York. With the MLMIC cases as a basis, the authors also analyzed areas of physician vulnerability and determined the steps neurosurgeons can take to reduce potential litigation. METHODS: All cases closed against MLMIC-insured neurosurgeons from January 1, 1999, through December 30, 2003, were reviewed. Variables examined included allegation, anatomical site, and the ultimate resolution of the case. Of the 280 cases against neurosurgeons that were closed during the study period, 156 (56%) involved the spine, 109 (39%) involved the head and/or brain, and 15 (5%) reflected miscellaneous allegations. These proportions are relatively similar to the 1999 procedural statistics for neurosurgical practices. Of the cases examined, 98 were closed with a total loss indemnity of approximately $50 million, and 182 resulted in no indemnity payment. CONCLUSIONS: A neurosurgeon's chances of being sued for malpractice are not necessarily related to the medical complexity of a particular case but rather to the types of cases with which the physician is involved. Elective spinal surgery cases constitute the majority of litigation. Neurosurgeons can take steps to reduce their vulnerability to potential litigation and to increase the odds of a successful defense.

Neurosurgical workforce trends in the United States.

OBJECT: The purpose of this study was to evaluate the US neurosurgery workforce by reviewing journal recruitment advertisements published during the past 10 years. METHODS: The number of available academic and private neurosurgical staff positions was determined based on recruitment advertisements in the Journal of Neurosurgery and Neurosurgery for the 10-year period from 1994 to 2003. Advertisements were evaluated for practice venue, subspecialization, and location. The numbers of active neurosurgeons and graduating residents also were reviewed. The number of advertised neurosurgical positions increased from 141.6 +/- 38.2 per year from 1994 through 1998 to 282.4 +/- 13.6 per year from 1999 through 2003 (mean +/- standard deviation, p < 0.05). The mean number of academic positions increased from 50.6 +/- 11.1 to 95 +/- 17.5 (p < 0.05), and the mean number of private positions rose from 91 +/- 30.4 to 187.4 +/- 6.8 (p < 0.05). Subspecialty positions represented a mean of only 15.6 +/- 5% per year during the first time period and 18.8 +/- 3% per year in the second period (p = 0.22), and therefore the majority of positions advertised continued to be those for generalists. The number of practicing neurosurgeons declined after 1998, and by 2002 it was less than it had been in 1991. The numbers of incoming and matriculating residents during the study period were static. CONCLUSIONS: The number of recruitment advertisements for neurosurgeons during the last 5 years has increased significantly, concomitant with a severe decline in the number of active neurosurgeons and a static supply of residents.

William Osler at Mcgill University: the Baby Professor and his early contributions to neurosurgery.

Between 1870 and 1884, as both a medical student and a member of the faculty, Sir William Osler performed approximately 1000 postmortem examinations at McGill University in Montreal. He conducted 786 of these examinations during his 7 years (1877--1884) of service as a pathologist at the Montreal General Hospital. The results of these were carefully recorded and catalogued either by him or by those who compiled the Pathological Report of the Hospital. Included in this material are many early descriptions of neurosurgical disease. Osler used this information for subsequent teaching in both Philadelphia and Baltimore. Osler's early and lifelong special interest in diseases of the nervous system not only led him to make seminal observations but also served to initiate his influence and relationships with the emerging leaders in neurology and neurosurgery.

To everything there is a season and a time to every purpose: retirement and the neurosurgeon.

Neurosurgery has designed a rigid curriculum that must be followed precisely by those who wish to enter the specialty. A similar process at the other end of the practice cycle has never been formalized except for mandatory retirement from certain administrative positions at a particular age. Basic considerations for strategic decision making about voluntary retirement from neurosurgery, especially operative neurosurgery, are investigated. Statistical data from the US Census Bureau and sources in the medical literature were reviewed regarding life expectancy and retirement ages. Age-related differences in verbal and performance intelligence quotients, attention span, verbal memory recall, and visuospatial facility were surveyed. A questionnaire was sent to 29 recently retired academic neurosurgeons about their age and reasons for retirement along with postretirement activities; 22 responses were received. Analysis of the data indicates that surgeons are now retiring at the age of approximately 60 years, whereas life expectancy is approximately 80 years. An individual thus may have 15 to 20 productive years after leaving active neurosurgical practice. Reasons for retirement among the 22 responding neurosurgeons included decreasing personal satisfaction and financial rewards, a desire to pursue other activities, local ground rules mandating age-specific retirement, the general sense that enough is enough, and, overall, a strong desire to stop performing surgery while at the top of one's game. The process of age-related competence assessment of commercial airline pilots is outlined, and a similar process of assessment of practicing surgeons may be warranted, with consideration for mandatory retirement from operative neurosurgery.

Role of surgery in the treatment of microprolactinomas.

Prolactinomas are a common cause of reproductive and sexual dysfunction and account for a large proportion of pituitary adenomas. The objectives for treatment of hyperprolactinemia due to microprolactinomas are to suppress excessive hormone secretion, preserve residual pituitary function, and prevent disease recurrence. These objectives may be achieved in most patients harboring microprolactinomas by medical treatment with effective dopamine agonists or microsurgical or endoscopic adenomectomy by an experienced surgeon. The choice of pituitary surgery should be made in consideration of the volume and location of the adenoma, age of the patient, the desire for restoration of fertility, and the efficacy and tolerability of dopamine agonists. The presence of a symptomatic microprolactinoma, especially in a young patient, should remain an indication for micro- or endoscopic tumor removal. This article reviews the emergence of radiosurgery as a treatment for microprolactinomas.

A man for all seasons: W.W. Keen.

William Williams Keen was the catalyst for the advent of neurosurgery in the United States. He served in the Civil War and collaborated with Silas Weir Mitchell in studying injuries sustained to the nervous system. These studies culminated in the publication in 1864 of "Gunshot Wounds and Other Injuries of the Nerves and Reflex Paralysis," which first described causalgia, reflex sympathetic dystrophy, and secondary paralysis. His most monumental accomplishment undoubtedly was being the first surgeon in the United States to successfully remove a primary brain tumor (1887) and have the patient survive for more than 30 years. As the editor of "Surgery, Its Principles and Practice," Keen invited Harvey Cushing to write the section on surgery of the head, which propelled Cushing to international recognition and provided a foothold for the new specialty of neurosurgery. Multiple sources were reviewed to prepare this comprehensive biographical account of Keen's contributions. Emphasis is placed on those achievements that furthered the discipline of neurosurgery. Although a general surgeon, Keen had a special interest in the nervous system. He treated patients with trigeminal neuralgia, performed cortical excisions for patients with epilepsy, and devised the procedure of posterior upper cervical root sections for spasmodic torticollis. He was the first surgeon to perform and advocate ventricular punctures. He served as a consultant and surgeon to both Grover Cleveland and Franklin Delano Roosevelt.

Hypophysopexy technique for radiosurgical treatment of cavernous sinus pituitary adenoma.

Stereotactic radiosurgery is being used with increased frequency in the treatment of residual or recurrent pituitary adenomas. The major risk associated with radiosurgical treatment of residual or recurrent pituitary tumor adjacent to normal functional pituitary gland is radiation of the pituitary, which frequently leads to the development of hypopituitarism. The authors describe a technique of pituitary transposition to reduce the radiation dose to the normal pituitary gland in cases of planned radiosurgical treatment of residual pituitary adenoma within the cavernous sinus. A sellar exploration for tumor resection is performed, the pituitary gland is transposed from the region of the cavernous sinus, and a fat and fascia graft is interposed between the normal pituitary gland and the residual tumor in the cavernous sinus. The residual tumor may then be treated with stereotactic radiosurgery. The increased distance between the normal pituitary gland and the residual tumor facilitates treatment of the tumor with radiosurgery and reduces the radiation to the normal pituitary gland. An illustrative case of a young female with recurrent acromegaly and a pituitary adenoma invading the cavernous sinus is described.

Rethinking neurosurgical subspecialization.

In this article, the authors trace the evolution of subspecialty development in the relatively young specialty of neurosurgery. The current categorization of neurosurgical subspecialties represents an incongruent group of "areas of interest" whose origins are historical in their development and whose boundaries are indistinct, artificial, and often fail to share a common theme. While subspecialty development has undoubtedly improved the quality of care of patients with neurosurgical disease in these respective areas, the authors present important questions invoked by the artificial boundaries. The current move towards formalization of subspecialty training and accreditation, with ultimate certification, poses both intended and unintended consequences. The implications of these trends in neurosurgery are discussed.

Irving S. Cooper and his role in intracranial stimulation for movement disorders and epilepsy.

Dr. Irving Cooper (1922-1985) was a pioneer in the field of functional neurosurgery. After years of treating patients with tremor by creating deep lesions with either anterior choroidal artery ligation or cryogenic thalamotomy, he began to utilize methods of electrical cerebral stimulation as treatment for a variety of disorders. Chronic cerebellar stimulation was employed for patients with epilepsy, cerebral palsy, and dystonia. While Dr. Cooper believed his results to be significant, there still remain many challenges to his claims. Later in his career, he placed deep brain electrodes in the internal capsule and thalamus for epilepsy and dystonia. His encouraging results from this small series were often overlooked. This paper reviews the science behind Dr. Cooper's work, his case series, and the controversies surrounding his results.