Book Review

Brain Surgery: Complication Avoidance and Management

N Engl J Med 1994; 330:228January 20, 1994

Article

Brain Surgery: Complication Avoidance and Management
Edited by Michael L.J. Apuzzo. 2365 pp. in two volumes, illustrated. New York, Churchill Livingstone, 1993. $475. ISBN: 0-443-08709-1

Medical and surgical therapies are increasingly subject to formal risk-benefit analysis; surgical complications remain substantial causes of morbidity that often weigh heavily in discussions of the relative merits of medical and surgical alternatives. Techniques of avoiding complications have rarely been formalized; most programs of surgical or neurosurgical training continue to follow the apprenticeship model, in which one learns by emulating the practice of a senior mentor “because it works.” Apuzzo's new textbook, Brain Surgery, attempts to provide such formalization. He has asked his stellar contributing senior neurosurgeons to describe not only how they perform a procedure, but also why, and what to do when things go wrong. Although most of the contributors have written extensively on their topics in the past, this approach puts much old material in an interesting new light without becoming idiosyncratic. The emphasis is on judgment as much as technique; as Apuzzo says in the preface, the goal is “maximal technical and intellectual neurosurgical competence.” In the chapter on arteriovenous malformations Heros writes, “Faulty judgment has been the largest single source of operative morbidity.”

The chapters provide an extensive discussion of operative techniques and potential complications, a description of the surgical maneuvers used to avoid them, and a general discussion of complications as described in the literature. For instance, the chapters on acoustic neuroma describe the details of alternative procedures (i.e., the suboccipital, translabyrinthine, and middle fossa approaches), present a useful algorithm for surgical decision making, discuss the important complications (seventh-nerve palsy and cerebrospinal fluid leak) in the light of the pertinent literature, and present techniques of managing these complications. The relevant questions asked throughout are these: What techniques are available to treat this problem? How are these techniques used? What are the relative risks? How do we individualize the approach to apply to a given patient?

Although there are extensive discussions of surgical technique and potential complications, the book does not attempt to be encyclopedic in the manner of other textbooks in the field. There is limited discussion of pathology itself and no formal discussion of radiology, although photographs obtained by magnetic resonance imaging and computed tomography are profuse, and operative techniques are well illustrated. The book's usefulness as an introductory textbook for non-neurosurgeons is therefore limited. The book is organized under three main headings: supratentorial procedures, infratentorial procedures, and “special” procedures (skull-base surgery). This division is useful to those familiar with the anatomy of neurosurgical approaches, but it also means, for example, that the general topic of “infections” is covered in a number of different places, though this difficulty is ameliorated by the comprehensive 140-page index. Finally, it is unfortunate that as the title indicates, Brain Surgery does not discuss surgery of the spine or the peripheral nervous system; both topics, commonly encountered in neurosurgical practice, could clearly benefit from the careful analysis of alternative surgical techniques, decision making, and potential complications characteristic of this book.

Brain Surgery is a welcome and important addition to the neurosurgical literature and is highly recommended to practicing neurosurgeons and residents. Not only does it contribute to the analysis of the risks and benefits of surgical procedures, but also it contains a wealth of eminently practical advice on minimizing morbidity, provided in the context of a detailed presentation of operative techniques.

Brooke Swearingen, M.D.
Massachusetts General Hospital, Boston, MA 02114