Like other neurosurgeons, I strive to provide my patients with the best and most up-to-date care. While neurosurgery itself is a challenging profession, an additional challenge is staying current with the constant changes in how we practice. I do things in my practice now that I did not learn in my residency during the 1980s. There are many reasons for these changes, including research and development of new and innovative treatment protocols, better surgical tools and techniques, and better understanding of disease processes. In this era of evidence-based medical practice, quality research is necessary to demonstrate efficacy and update practice patterns.
Reviewing Neurosurgical Literature
There are numerous sources of research information available to the practicing neurosurgeon. Peer-reviewed neurosurgery and spine surgery journals are my primary sources of information. The Journal of Neurosurgery; the Journal of Neurosurgery: Spine; Neurosurgery; Spine; and The Spine Journal are my primary references. While these publications contain both clinical research and basic science research studies, I find that the clinical studies are most beneficial to my practice.
It is common for me to read an article that either causes me to change some aspect of my practice or validates what I already do. Consider surgical treatment of atlanto-axial instability. When I finished training, posterior wiring techniques with halo stabilization were the options. Transarticular lateral mass screw fixation was introduced, but it was technically challenging. Then I read a study reporting atlanto-axial fixation with lateral mass screws in the atlas, and pars interarticularis screws in the axis. I began using this technique with good success, and subsequently further studies were reported demonstrating efficacy in a large clinical trial, as well as biomechanical strength comparable to transarticular fixation.
Comprehensive topic review articles are available from a number of sources, and I find that these are extremely valuable. Currently I read: Contemporary Neurosurgery; Contemporary Spine Surgery; Techniques in Neurosurgery; Neurosurgery Quarterly; Neurosurgery Clinics; and Seminars in Neurosurgery. While a journal article may report research on one aspect of a problem, the review article can summarize available literature on multiple aspects of a given topic, direct one to specific references on the subject, and provide expert commentary and opinion. I find myself consulting review articles particularly when I am confronted with an uncommon problem. In addition, some of these publications, for example Contemporary Neurosurgery and Contemporary Spine Surgery, offer an opportunity to earn continuing medical education credits, which I find valuable in my busy practice.
Participating in Annual Meetings and Courses
Specialty meetings such as the annual meetings of the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons provide a forum for the dissemination of research information. Although presentations are relatively brief and are not peer-reviewed, the material presented at meetings is likely to be the most current information available, and it is possible to learn a great deal about current trends in neurosurgical practice.
Specialty courses offered at the annual meetings give the participant an opportunity to learn new information and obtain hands-on experience with surgical techniques. I participated in a practical clinic offered at an AANS annual meeting to learn both posterior cervical spine lateral mass screw fixation and anterior cervical spine plate fixation. When I finished residency training, the Caspar anterior plate was just starting to be used for anterior cervical spine stabilization. Over several years other anterior cervical plates were developed using unicortical screws making placement less difficult and dangerous. Soon, lab studies were reporting biomechanical strength of convverging unicortical screws equivalent to the bicortical screw placement used with the Caspar plate. Also, clinical studies demonstrated that anterior cervical fusion with allograft and plating was as successful as fusion with autografts, but without graft site morbidity or external bracing. A specialty course provided me with the education and experience I needed to be able to incorporate anterior plate fixation into my practice.
As new techniques and devices are developed and described in the literature, I try to analyze them critically. Some are clever or ingenious solutions to a problem, yet I think it is prudent to carefully evaluate the research literature before changing my practice. In the early 1990s there were reports describing a new posterior cervical fixation device that was simpler and safer to use than sublaminar wiring. Halifax clamps were marketed and were at least temporarily popular. Then clinical studies began to appear identifying a problem with the clamps loosening and failing to maintain fixation of the spine. About this time, laboratory biomechanical studies as well as clinical studies reported the advantages and successes of lateral mass plating for posterior cervical fusions. The advent of lateral mass plating has relegated Halifax clamps to the museum. After extensive literature documented the safety and efficacy of lateral mass plates, I learned the surgical techniques by first consulting many review articles and then attending a hands-on course at an AANS annual meeting.
Research is indispensable in my practice. As I tackle increasingly complex problems, it is the experience of other surgeons, reported in the form of clinical and basic science research, that helps me do the best for my patients. Comprehensive topic review publications are my most efficient educational tool because they cover multiple aspects of a problem, refer to appropriate literature and many offer continuing medical education credits.
Brett A. Scott, MD, is in private practice with Neurosurgical Associates PSC in Lexington, Ky.