The contributions of Arthur Elvidge (1899-1985), Wilder Penfield's first neurosurgical recruit, to the development of neurosurgery have been relatively neglected, although his work in brain tumors extended the previous work of Percival Bailey and Harvey Cushing. He published rigorous correlations of clinical and histological information and formulated a revised, modern nosology for neuroepithelial tumors, including a modern histological definition of glioblastoma multiforme. Well ahead of his time, he believed that glioblastoma was not strictly localized and was the first to comment that the tumor frequently showed "satellitosis." He was the first neurosurgeon in North America to use angiography as a radiographic aid in the diagnosis of cerebrovascular disease. Having studied with Egas Moniz, he was the first to detail the use of angiographic examinations specifically for demonstrating cerebrovascular disorders, believing that it would make possible routine surgery of the intracranial blood vessels. Seeking to visualize all phases of angiography, he was the impetus behind the design of one of the first semi-automatic film changers. Elvidge and Egas Moniz made the first observations on thrombosis of the carotid vessels independently of each other. Elvidge elucidated the significance of embolic stroke and commented on the ischemic sequelae of subarachnoid hemorrhage. Besides his contributions to neurosurgery, he codiscovered the mode of transmission of poliomyelitis. Elvidge's soft-spoken manner, his dry wit and candor, mastery of the understatement, love of exotic travel, and consummate dedication to neurosurgery made him a favorite of patients, neurosurgery residents, nurses, and other hospital staff. His accomplishments and example as teacher and physician have become part of neurosurgery's growing legacy.
Newly qualified surgeons, as well as their referring physicians, are understandably anxious when dangerous surgery is contemplated. Carotid endarterectomy (CEA), which requires a low morbidity/mortality rate to be successful, is especially problematic in this realm. There is a paucity of literature indicating the results that can be expected when a less-experienced surgeon is asked to perform this procedure. As the volume of CEA surgery is expected to decrease in the future with improvements in endovascular techniques, there will be fewer highly experienced CEA surgeons around.
We studied the first consecutive, prospectively recorded 100 CEAs performed by each of two newly qualified surgeons (200 total) between January 1993 and May 1998. Standard technique was used and all cases were done under general anesthesia. The only difference in technique was the more liberal use of shunting and protamine by one individual.
There were no significant differences in the patient demographics between the two surgeons. Seventy-five percent of the cases harbored symptomatic stenoses. An overall combined stroke/mortality rate of 5.5% was observed. The rate in those operated on for symptomatic stenosis (n = 150) was 6% while it was 4% for those with asymptomatic pathology. There were no significant differences in outcome between the two surgeons. The average stroke/mortality rate in the first 50 cases for each surgeon was 7%, as opposed to 4% for the second 50 cases.
These data indicate that less-experienced individuals can perform this procedure with good results.
When Harvey Cushing announced his full-time commitment to neurological surgery in 1904, it was a discouraging and discouraged enterprise. Other surgeons' mortality rates for patients with brain tumors were 30 to 50%. By 1910 Cushing had operated on 180 tumors; he had a thriving practice, with a patient mortality rate of less than 13%. The three essential ingredients of his success were: 1) a new surgical conceptualization of intracranial pressure (ICP); 2) technical innovations for controlling ICP; and 3) establishment of a large referral base. In the years 1901 through 1905, the implications of his research on the "Cushing reflex" were quickly translated into surgical techniques for controlling ICP. In the period between 1906 and 1910, Cushing built up his referral practice by publishing widely, and especially by lecturing to medical audiences throughout the United States and Canada. His scientific work on ICP was essential to his clinical success, but without his professional and social ability to build a thriving practice, there would have been insufficient material for him to use to improve his approaches.
The interface design of a Chiari malformation hypermedia document was tested with formative evaluation, a type of usability testing. The evaluation tested six common interactive design features essential for the design of user-friendly interfaces: image, size, label highlighting, text presentation (scrolling vs. hyperlinks), color (text, visual material, and background), and button behavior. Six neurosurgical residents answered a questionnaire focusing on these interactive design features during the development of the hypermedia document. Over a period of two months, the responses to the questions and suggestions made by the volunteers were used to improve the six interactive design features for the specific target audience of Toronto Hospital, Western Division neurosurgical residents.
The neurosurgical population consists of professors, consultants, specialised senior registrars, and doctors in training (senior registrars, trainees and young doctors to be educated as neurosurgeons). Knowing number and size of the neurosurgical departments in each European country, the number of staff members, the politics of retirement (age, educational level) and the age of every neurosurgeon it is possible to calculate the exact number of trainees needed per year to maintain a state of balance in every single European country. With Denmark as a model we based our assessments partly on a simple calculation model of the exact annual number of neurosurgical trainees or senior registrars and partly used an actuary flow model for calculation. In Denmark with 5 neurosurgical departments, 5.2 mill. population and a retirement age of 70, we have an average of 1-2 newcomers per year and maintain a bulk of 10 senior registrars in education. Thus there will be a balance between intake of newcomers and retirement, of course with some unknown factors as unforeseen dismissal or resignation, death rate among neurosurgeons and transfer to private practice.
PURPOSE: To analyse the intraoperative complications of a single neurosurgeon, with emphasis on devastating intraoperative incidents, and how they possibly could have been avoided. METHODS: All the patients operated upon by the author between 1986 and 2002, i.e. 252 patients with 270 craniotomies for 294 aneurysms, were included. All intraoperative events that possibly could have influenced the clinical outcome were recorded prospectively. RESULTS: A total of 16 cases (6.3% of all the patients) with serious intraoperative incidents were identified. In 11 cases (3.6% of all aneurysms), an intraoperative rupture occurred that was judged to have had mild to severe consequences for the patient. In another four patients (1.6% of all patients), all with unruptured, large aneurysms (>15 mm) of the carotid or middle cerebral arteries, a major vessel occlusion occurred inadvertently. In one patient with a large, unruptured MCA aneurysm, a clip slipped after the closure of the wound, causing a fatal intracerebral haemorrhage. These events had a severe impact on the clinical outcome. In retrospect, most of these incidents could, and should have, been avoided. CONCLUSIONS: It is recommended to start the training of new aneurysm surgeons on patients with small, supratentorial, unruptured aneurysms, followed by ruptured aneurysms in all other supratentorial locations than the anterior communicating artery (ACOM), which is the supratentorial location that should be the last step in the training of independent aneurysm surgeons.