Neurosurgery
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The concept of futility has been a source of discussion for many years. Even though it is tempting to propose that an action or clinical intervention should be deemed futile if it does not achieve the goals of that action, further clarification is needed in terms of the nature of the likely outcomes of an intervention and the probabilities of various outcomes being achieved. ⋯ This is especially the case when considering outcome following decompressive craniectomy for severe traumatic brain injury, in which certain outcomes are likely to be severely impaired states that the patient would consider unacceptable. In this article, we use some key ethical concepts such as substantial benefit and the risk of unbearable badness to explore the concept of futility in severe traumatic brain injury and, by linking that to recent advances in neurosurgical science, propose a pragmatic patient-centered approach to deal with the concept of futility.
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In small series, endoscopic third ventriculostomy (ETV) has been shown to potentially have efficacy similar to that of ventriculoperitoneal shunting (VPS) for idiopathic normal-pressure hydrocephalus (iNPH). Therefore, some clinicians have advocated for ETV to avoid the potential long-term complications associated with VPS. Complication rates for these procedures vary widely based on limited small series data. ⋯ This is the first study that robustly assesses the perioperative complications and safety outcomes of ETV for iNPH. Compared with VPS, ETV is associated with higher perioperative mortality and complication rates. This consideration is important to weigh against the potential benefit of ETV: avoiding long-term shunt dependence. Prospective, randomized studies are needed.
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Instrumentation of the spine depends on choosing the correct insertion angles to implant screws. Although modern image guidance facilitates precise instrumentation of the spine, the equipment is costly and availability is limited. Although most surgeons use lateral fluoroscopy to guide instrumentation in the sagittal plane, the lateromedial angulation is often chosen by estimation. To overcome the associated uncertainty, iPod touch-based applications for measuring angles can be used to assist with screw implantation. ⋯ iPod touch-assisted instrumentation of the spine is a very simple technique, which, in combination with a lateral fluoroscopy, may guide placement of pedicle screws in the lumbar spine.