Distribution of Psychological Instability Among Surgeons.

BACKGROUND: High emotional instability (i.e., neuroticism) is associated with poor mental health. Conversely, traumatic experiences may increase neuroticism. Stressful experiences such as complications are common in the surgical profession, with neurosurgeons being particularly affected. We compared the personality trait neuroticism between physicians in a prospective cross-sectional study. METHODS: We used an online survey using the Ten-Item Personality Inventory, an internationally validated measure of the 5-factor model of personality dimensions. It was distributed to board-certified physicians, residents, and medical students in several European countries and Canada (n = 5148). Multivariate linear regression was used to model differences between surgeons, nonsurgeons, and specialties with occasional surgical interventions with respect to neuroticism, adjusting for sex, age, age squared, and their interactions, then testing equality of parameters of adjusted predictions separately and jointly using Wald tests. RESULTS: With an expected variability within disciplines, average levels of neuroticism are lower in surgeons than nonsurgeons, especially in the first part of their career. However, the course of neuroticism across age follows a quadratic pattern, that is, an increase after the initial decrease. The acceleration of neuroticism with age is specifically significant in surgeons. Levels of neuroticism are lowest towards mid-career, but exhibit a strong secondary increase towards the end of the surgeon's career. This pattern seems driven by neurosurgeons. CONCLUSIONS: Despite initially lower levels of neuroticism, surgeons suffer a stronger increase of neuroticism together with age. Because, beyond well-being, neuroticism influences professional performance and health care systems costs, explanatory studies are mandatory to enlighten causes of this burden.

Predictors of outcomes after surgery for medically intractable insular epilepsy: A systematic review and individual participant data meta-analysis.

Insular epilepsy (IE) is an increasingly recognized cause of drug-resistant epilepsy amenable to surgery. However, concerns of suboptimal seizure control and permanent neurological morbidity hamper widespread adoption of surgery for IE. We performed a systematic review and individual participant data meta-analysis to determine the efficacy and safety profile of surgery for IE and identify predictors of outcomes. Of 2483 unique citations, 24 retrospective studies reporting on 312 participants were eligible for inclusion. The median follow-up duration was 2.58 years (range, 0-17 years), and 206 (66.7%) patients were seizure-free at last follow-up. Younger age at surgery (≤18 years; HR = 1.70, 95% CI = 1.09-2.66, P = .022) and invasive EEG monitoring (HR = 1.97, 95% CI = 1.04-3.74, P = .039) were significantly associated with shorter time to seizure recurrence. Performing MR-guided laser ablation or radiofrequency ablation instead of open resection (OR = 2.05, 95% CI = 1.08-3.89, P = .028) was independently associated with suboptimal or poor seizure outcome (Engel II-IV) at last follow-up. Postoperative neurological complications occurred in 42.5% of patients, most commonly motor deficits (29.9%). Permanent neurological complications occurred in 7.8% of surgeries, including 5% and 1.4% rate of permanent motor deficits and dysphasia, respectively. Resection of the frontal operculum was independently associated with greater odds of motor deficits (OR = 2.75, 95% CI = 1.46-5.15, P = .002). Dominant-hemisphere resections were independently associated with dysphasia (OR = 13.09, 95% CI = 2.22-77.14, P = .005) albeit none of the observed language deficits were permanent. Surgery for IE is associated with a good efficacy/safety profile. Most patients experience seizure freedom, and neurological deficits are predominantly transient. Pediatric patients and those requiring invasive monitoring or undergoing stereotactic ablation procedures experience lower rates of seizure freedom. Transgression of the frontal operculum should be avoided if it is not deemed part of the epileptogenic zone. Well-selected candidates undergoing dominant-hemisphere resection are more likely to exhibit transient language deficits; however, the risk of permanent deficit is very low.

A case of aphasia due to temporobasal edema: Contemporary models of language anatomy are clinically relevant.

BACKGROUND: Understanding the anatomy of language in the human brain is crucial for neurosurgical decision making and complication avoidance. The traditional anatomical models of human language, relying on relatively simple and rigid concepts of brain connectivity, cannot explain all clinical observations. The clinical case reported here illustrates the relevance of more recent concepts of language networks involving white matter tracts and their connections. CASE DESCRIPTION: Postoperative edema of the ventral occipitotemporal cortex, where modern network models locate a crucial language hub, resulted in transient severe aphasia after a subtemporal approach. Both verbal comprehension and expression were lost. The resolution of edema was associated with complete recovery from phonetic and semantic dysfunction. CONCLUSION: Complete aphasia due to a functional disturbance remote from the areas of Broca and Wernicke could be explained by contemporary neuroanatomical concepts of white matter connectivity. Knowledge of network-based models is relevant in brain surgery complication avoidance.

Conscious Experience and Psychological Consequences of Awake Craniotomy.

BACKGROUND: Experiencing cranial surgery under awake conditions may expose patients to considerable psychological strain. METHODS: This study aimed to investigate the occurrence and course of psychological sequelae following awake craniotomy (AC) for brain tumors in a series of 20 patients using a broad, validated psychological assessment preoperatively, intraoperatively, postoperatively and a standardized follow-up of 3 months. In addition, the association of the preoperative psychological condition (including, but not limited to, anxiety and fear) with perioperative pain perception and interference was assessed. RESULTS: AC did not induce any shift in the median levels of anxiety, depression, and stress symptoms already present prior to the procedure. Furthermore, anxiety and depression were all moderately to strongly associated over time (all P < 0.05). Stress symptoms also correlated positively over all times of measurement. Stress 3 days after surgery was strongly associated with stress 3 months after surgery (P < 0.001), whereas the correlation between preoperative and immediate postoperative stress showed a statistical trend (P = 0.07). Preoperative fear was not related to intraoperative pain, but to pain and its interference with daily activity on the third postoperative day (P < 0.001 and P < 0.01, respectively). CONCLUSIONS: Postoperative psychological symptoms clearly correlated with their corresponding preoperative symptoms. Thus, mental health was not negatively affected by the AC experience in our series. Intraoperative fear and pain were not related to the preoperative psychological condition. However, preoperative fear and anxiety were positively related with pain and its interference with daily activity in the immediate postoperative period.

Intrarectal Anesthesia in Neurosurgery.

In the early days of modern neurologic surgery, the inconveniences and potential dangers of general anesthesia by chloroform and ether using the so-called "open-drop technique" led to the quest for alternative methods of anesthesia. This became all the more necessary, since patient positioning and the surgical arrangements often hindered the use of a drop bottle. One approach to solve this problem was intrarectal ether application. The present article aims to shed light on this original, less well-known anesthesia technique in the neurosurgical field.

The influence of lunar phases and zodiac sign 'Leo' on perioperative complications and outcome in elective spine surgery.

BACKGROUND: Many people believe that the moon has an influence on daily life, and some even request elective surgery dates depending on the moon calendar. The aim of this study was to assess the influence of 'unfavorable' lunar or zodiac constellations on perioperative complications and outcome in elective surgery for degenerative disc disease. METHODS: Retrospective database analysis including 924 patients. Using uni- and multivariate logistic regression, the likelihood for intraoperative complications and re-do surgeries as well as the clinical outcomes at 4 weeks was analyzed for surgeries performed during the waxing moon, full moon, and dates when the moon passed through the zodiac sign 'Leo.' RESULTS: In multivariate analysis, patients operated on during the waxing moon were 1.54 times as likely as patients who were operated on during the waning moon to suffer from an intraoperative complication (OR 1.54, 95 % CI 1.07-2.21, p = 0.019). In contrast, there was a trend toward fewer re-do surgeries for surgery during the waxing moon (OR 0.51, 95 % CI 0.23-1.16, p = 0.109), while the 4-week responder status was similar (OR 0.73, 95 % CI 0.47-1.14, p = 0.169). A full moon and the zodiac sign Leo did not increase the likelihood for complications, re-do surgeries or unfavorable outcomes. CONCLUSIONS: We found no influence of 'unfavorable' lunar or zodiac constellations on the 4-week responder status or the revision rate that would justify a moon calendar-based selection approach to elective spine surgery dates. However, the fact that patients undergoing surgery during the waxing moon were more likely to suffer from an intraoperative complication is a surprising curiosity and defies our ability to find a rational explanation.

[Meningioma: management of the most common brain tumour]. / Das Meningeom: Management des häufigsten hirneigenen Tumors.

Meningiomas are the most common primary brain tumours in adults and are therefore relevant for general practitioners. Most meningiomas are benign and neurosurgical resection offers the best chance of cure. However, complete resection is not achievable in many patients. This accounts for a relevant rate of tumour recurrences within 15 years of follow up. In atypical and anaplastic meningiomas of WHO grade II and III time to recurrence is dramatically shorter and these tumours need multimodal treatment strategies including postoperative radiotherapy. Various systemic treatments have occasionally been used as salvage therapy, but were essentially not effective. Only recently, Sunitinib, a small thyrosine kinase inhibitor as well as bevacizumab, a therapeutic antibody, have shown more promising results in highly pretreated, refractory meningioma patients.

Awake Craniotomy: First-Year Experiences and Patient Perception.

BACKGROUND: Awake craniotomy for brain lesions in or near eloquent brain regions enables neurosurgeons to assess neurologic functions of patients intraoperatively, reducing the risk of permanent neurologic deficits and increasing the extent of resection. METHODS: A retrospective review was performed of a consecutive series of patients with awake craniotomies in the first year of their introduction to our tertiary non-university-affiliated neurosurgery department. Operation time, complications, and neurologic outcome were assessed, and patient perception of awake craniotomy was surveyed using a mailed questionnaire. RESULTS: There were 24 awake craniotomies performed in 22 patients for low-grade/high-grade gliomas, cavernomas, and metastases (average 2 cases per month). Mean operation time was 205 minutes. Failure of awake craniotomy because of intraoperative seizures with subsequent postictal impaired testing or limited cooperation occurred in 2 patients. Transient neurologic deficits occurred in 29% of patients; 1 patient sustained a permanent neurologic deficit. Of the 18 patients (82%) who returned the questionnaire, only 2 patients recalled significant fear during surgery. CONCLUSIONS: Introducing awake craniotomy to a tertiary non-university-affiliated neurosurgery department is feasible and resulted in reasonable operation times and complication rates and high patient satisfaction.

Reversible pure word deafness due to inferior colliculi compression by a pineal germinoma in a young adult.

We report a clinical case of a 19-year-old male patient who developed pure word deafness due to the local compressive effect of a pineal germinoma on the inferior colliculi of the quadrigeminal plate. After percutaneous radiation therapy the size of the tumor decreased significantly, while audiometry demonstrated a complete regression of the auditory deficit. Since pure word deafness is commonly attributed to temporal lesions, the inferior colliculi represent an exceptional site for these symptoms. The pathophysiological background and the scarce literature on pure word deafness, especially the one related to neoplasms of the tectal region, are briefly discussed.

Sexuality after surgery for diffuse low-grade glioma.

BACKGROUND: Although neurological and neurocognitive outcomes have previously been studied after resection of diffuse low-grade glioma (DLGG), the impact of surgery on sexual life has not been investigated. Our aim was to assess whether DLGG surgery could have consequences on sexual experience. METHODS: Anonymous standardized questionnaires concerning sexual functioning, including the Arizona Sexual Experiences Scale (ASEX) and a subjective statement, were completed by 32 patients who underwent surgery for DLGG. All patients returned to a normal social and professional life following resection, with neither neurological deficits nor depression. No radiotherapy was administered, and patients who received chemotherapy were without treatment for at least 1 year. RESULTS: Seventeen patients (53%) reported a postoperative sexual change, with subjective deterioration in 15 (88%) and improvement in 2 (12%). Sexual dysfunction according to ASEX affected 9 of 15 women (60%) and 5 of 17 men (29%). Right-sided resections were associated with more difficulties in reaching orgasm than left-sided resections (P < .02). Men with temporal lobe resection displayed more reduction in sexual drive (P < .003) and sexual arousal (P < .004) than women, resulting in significant higher overall ASEX scores for temporal lobe resections in men (P = .01). Men remaining on antiepileptic drugs who underwent right-sided resection displayed higher overall ASEX scores than women (P = .031). CONCLUSIONS: This first evaluation of sexual life after surgery for DLGG suggests that sexual dysfunction is common in this population. Therefore, we suggest that sexual health should consistently be addressed during routine pre- and postoperative examination of patients with DLGG.

The evolution of brain surgery on awake patients.

In the early days of modern neurological surgery, the inconveniences and potential dangers of general anesthesia by chloroform and ether using the so-called "open-drop technique" led to the quest for alternative methods of anesthesia. Besides preventing the feared side effects, the introduction of regional anesthesia revealed another decisive advantage over general anesthesia in neurosurgery: While intraoperative direct cortical stimulation under general anesthesia could only delineate the motor area (by evocation of contralateral muscular contraction), now, the awake patients were able to report sensations elicited by this method. These properties advanced regional anesthesia to the regimen of choice for cranial surgeries in the first half of the 20th century. While technical advances and new drugs led to a progressive return to general anesthesia for neurosurgical procedures, the use of regional anesthesia for epilepsy surgery has only decreased in recent decades. Meanwhile, awake craniotomies regained popularity in oncologically motivated surgeries, especially in craniotomies for diffuse low-grade gliomas. Intraoperative mapping of brain functions using electrical stimulation in awake patients enables not only for increased tumor removal while preserving the functional status of the patients but also opens a window to cognitive neuroscience. Observations during such interventions and their correlation with both pre - and postoperative neuropsychological examinations and functional neuroimaging is progressively leading to new insights into the complex functional anatomy of the human brain. Furthermore, it broadens our knowledge on cerebral network reorganization in the presence of disease-with implications for all disciplines of clinical neuroscience.

Hans Brun: a Swiss pioneer in the surgery of the spinal cord, brain and herniated lumbar disc.

INTRODUCTION: Toward the end of the nineteenth century, it was Gowers, Horsley and Macewen who first reported successful surgical procedures for the treatment of subdural extramedullary tumors. Following this, Church and Eisendrath as well as Putnam and Warren reported unsuccessful attempts to treat subpial spinal pathologies in their patients. Only at the beginning of the twentieth century did reports of successful interventions of this type accumulate. In the analysis of these case reports, the authors noticed a certain lack of accuracy about the anatomical allocations and descriptions of intra- and extramedullary spinal lesions. From this, the question of who actually carried out the pioneering works in the early twentieth century in the field of surgery of intramedullary pathologies arose. METHODS: Analysis of the relevant original publications of Hans Brun and research on the poorly documented information about his life history by personally contacting contemporary relatives. RESULTS: The literature analysis showed that the Swiss neurologist Otto Veraguth and surgeon Hans Brun made fundamental contributions to subpial spinal cord surgery at the very beginning of the last century that remain valid today. According to our research, Hans Brun should be remembered as the third surgeon (after von Eiselsberg and Elsberg) who successfully removed an intramedullary lesion in a patient. CONCLUSION: Brun should be remembered as an early and successful surgeon in this specialized field. His operative work is described in detail in this article. At the same time, his achievements in the fields of brain and disc herniation surgery are presented.

Little-known Swiss contributions to the description, diagnosis, and surgery of lumbar disc disease before the Mixter and Barr era.

The understanding of lumbar spine pathologies made substantial progress at the turn of the twentieth century. The authors review the original publication of Otto Veraguth in 1929 reporting on the successful resection of a herniated lumbar disc, published exclusively in the German language. His early report is put into the historical context, and its impact on the understanding of pathologies of the intervertebral disc (IVD) is estimated. The Swiss surgeon and Nobel Prize laureate Emil Theodor Kocher was among the first physicians to describe the traumatic rupture of the IVD in 1896. As early as 1909 Oppenheim and Krause published 2 case reports on surgery for a herniated lumbar disc. Goldthwait was the first physician to delineate the etiopathogenes is between annulus rupture, symptoms of sciatica, and neurological signs in his publication of 1911. Further publications by Middleton and Teacher in 1911 and Schmorl in 1929 added to the understanding of lumbar spinal pathologies. In 1929, the Swiss neurologist Veraguth (surgery performed by Hans Brun) and the American neurosurgeon Walter Edward Dandy both published their early experiences with the surgical therapy of a herniated lumbar disc. Veraguth's contribution, however, has not been appreciated internationally to date. The causal relationship between lumbar disc pathology and sciatica remained uncertain for some years to come. The causal relationship was not confirmed until Mixter and Barr's landmark paper in 1934 describing the association of sciatica and lumbar disc herniation, after which the surgical treatment became increasingly popular. Veraguth was among the first physicians to report on the clinical course of a patient with successful resection of a herniated lumbar disc. His observations should be acknowledged in view of the limited experience and literature on this ailment at that time.

Somatosensory and pharyngolaryngeal auras in temporal lobe epilepsy surgeries.

Purpose. Somatosensory (SSA) and pharyngolaryngeal auras (PLA) may suggest an extratemporal onset (e.g., insula, second somatosensory area). We sought to determine the prognostic significance of SSA and PLA in temporal lobe epilepsy (TLE) patients undergoing epilepsy surgery. Methods. Retrospective review of all patients operated for refractory TLE at our institution between January 1980 and July 2007 comparing outcome between patients with SSA/PLA to those without. Results. 158 patients underwent surgery for pharmacoresistant TLE in our institution. Eleven (7%) experienced SSA/PLA as part of their seizures. All but one had lesional (including hippocampal atrophy/sclerosis) TLE. Compared to patients without SSA or PLA, these patients were older (P = 0.049), had a higher prevalence of early ictal motor symptoms (P = 0.022) and prior CNS infection (P = 0.022), and were less likely to have a localizing SPECT study (P = 0.025). A favorable outcome was achieved in 81.8% of patients with SSA and/or PLA and 90.4% of those without SSA or PLA (P > 0.05). Conclusion. Most patients with pharmacoresistant lesional TLE appear to have a favorable outcome following temporal lobectomy, even in the presence of SSA and PLA.

Von Bergmann, Kocher, and Krönlein--a triumvirate of pioneers with a common neurosurgical concept.

BACKGROUND: The rise of a neurosurgical subspecialisation in general surgery was strongly influenced by some key surgeons. In the German-speaking regions of Europe, Ernst von Bergmann, Emil Theodor Kocher and Rudolf Ulrich Krönlein have to be especially highlighted. METHODS: This article describes their contributions to the neurosurgical field and their personal interactions. For this, the numerous publications on cranial neurosurgery of von Bergmann were reviewed. They are presented in chronological order. Kocher's and Krönlein's contributions to early neurosurgery have been valued recently by the authors and are briefly summarized. RESULTS: All three developed early interest in the neurosurgical field and conducted clinical and experimental research at the turn of the twentieth century. It becomes evident that von Bergmann, Kocher and Krönlein provided a basis for a transnational neurosurgical school. CONCLUSION: This triumvirate developed a common neurosurgical concept that was grounded in the physiological experiments and scientific evidence.

Emil Theodor Kocher--valve surgery for epilepsy.

Emil Theodor Kocher (1841-1917) was a pioneering and versatile Swiss surgeon who played a decisive role in the surgical evolution on the threshold to the 20th century. Apart from conducting intense research and fostering the development of the surgical treatment of thyroid gland diseases (honored with a Nobel Prize in 1909), he remained a generalist and was active in orthopedic, genitourinary, and neurologic surgery. Even today, many surgical techniques and instruments are still named after him, thus providing evidence of his great impact. His neurosurgical ambitions included, in particular, cerebral and spinal trauma, the pathophysiology of elevated intracranial pressure, as well as etiological considerations and the operative treatment of epilepsy. This article aims to shed light on Kocher's work on epilepsy, published exclusively in German, and illustrates the development of his idea on valve surgery for recurrent general convulsions.

Emil Theodor Kocher: the first Swiss neurosurgeon.

BACKGROUND: Emil Theodor Kocher (1841-1917) was elected as head of the university clinic for surgery in Berne, Switzerland at the age of 31 years. During the 45 years of his professorship he became one of the outstanding surgeons of Europe by using surgical techniques based predominately on physiological and biological ideas. The aim of this article was to highlight his neurosurgical achievements published in the German language. METHODS: The illustrations of Kocher's works in the field of neurosurgery are exclusively based on his publications and works published by his co-workers. RESULTS: Kocher received the Nobel Prize in Physiology or Medicine in 1909 because he devoted himself to intense research and development in the pathophysiology and surgical treatment of diseases of the thyroid gland. His particular neurosurgical interests were in cerebral and spinal trauma, operative treatment of epilepsy and the pathophysiology of elevated intracranial pressure. CONCLUSION: Studies of Kocher's contributions, published exclusively in the German language, lead to the conclusion that Kocher must be designated as the first Swiss neurosurgeon.