NEW DIMENSIONS OF NEUROSURGERY IN THE REALM OF HIGH-TECHNOLOGY - POSSIBILITIES, PRACTICALITIES, REALITIES

FUELED BY A buoyant economy, popular attitudes and demands, and parall el progress in transferable technical and biological areas, neurosurge ry has enjoyed a remarkable quarter of a century of progress. Developm ental trends in the discipline have included the following: 1) a refin ement of preoperative definition of the structural substrate, 2) minia turization of operative corridors, 3) reduction of operative trauma, 4 ) increased effectiveness at the target site, and 5) incorporation of improved technical adjuvants and physical operative tools into treatme nt protocols. In particular, the computer has become a formidable ally in diagnostic and surgical events. Trends in technical development in dicate that we are entering an exciting era of advanced surgery of the human cerebrum, which is heralded by the following: 1) current develo pments in areas of imaging, sensors, and visualization; 2) new devices for localization and navigation; 3) new capabilities for action at th e target point; and 4) innovative concepts related to advanced operati ve venues. Imaging has provided structurally based surgical maps, whic h now are being given the new dimension of function in complex and int egrated formats for preoperative planning and intraoperative tactical direction. Cerebral localization and navigation based on these advance s promise to provide further refinement to the field of stereotactic n eurosurgery, as linked systems are superseded by more flexible nonlink ed methodologies in functionally defined volume-oriented navigational databases. Target point action now includes not only ablative capabili ties through micro-operative methods and the use of stereotactically d irected high-energy forms but also the emergence of restorative capabi lities through applications of principles of genetic engineering in th e areas of molecular and cellular neurosurgery. Complex, dedicated, an d self-contained operative venues will be required to optimize the eme rgence and development of these computer-oriented micro/stereotactic c apabilities, which appear to be unavoidably required as locales for th e practice and development of virtual reality-based stations for opera tive rehearsal, simulation, training, and, ultimately, enhancement of operative events through robotic interfaces. Primary impetus for progr ess has relied upon new combinations of technologies, disciplines, and industries. Philosophical and practical problems include the spectrum of availability of these methods to the population at large, the trai ning of individuals to properly administer these methods, defining the acceptable envelope of expertise, and maintaining suitable delivery a nd progress while containing spiraling costs. Advanced neurological su rgery and the use and development of high-technology adjuvants require a robust economy that has a populace willing to invest in the luxury of such developments. The current socioeconomic situation is fragile f rom the standpoint of both economics and attitudes of the patients and health care providers, with diversion of economic resources, redistri bution of funding bases, modification of patient referrals, practice s tyles, and service attitudes undermining progress. Economic pressures have brought high-technology methods under great scrutiny regarding th eir effectiveness and cost-effectiveness. Reform proposals have specif ically targeted technology-oriented services, and the Office of Techno logy Assessment has recommended increasing the use of managed care pro viders who look to information on cost-effectiveness and clinical prac tice guidelines to establish efficient management strategies and issue ''report cards. '' Although the premise is laudable and ''gimmickry'' needs to be identified, it might be argued that such scrutiny and con trol might be overbearing and overused, impeding appropriate delivery and progress. Diverting funds from the patient, delivery, and research corridors by management organizations is deleterious to the quality o f care and progress. Such practice is clearly operational in a number of influential health care maintenance organizations, as reported by t he Wall Street journal (December 21, 1994). Such reordering is clearly harmful to the progress and delivery of high technology-related pract ices and tends to support simplistic and frequently regressive approac hes, diverting patients as well as funds from progressive methods. Hig h technology has brought with its application a myriad of ''middle men '' between the product and the provider. Some indication of this is ev idenced by the increase, during the past decade, of the number of comp any exhibits of high-technology products at the American Association o f Neurological Surgeons Annual Meeting. The number of exhibits has inc reased similar to 150%, whereas the number of company representatives has increased 600%. Regularly, more representatives than doctors atten d the Annual Meeting. Some scrutiny of the role, need, and expense rel ated to this aspect of free enterprise seems appropriate, because it i mpacts upon the costs of high-technology medicine. Academic health cen ters, the ''ground breakers'' for progress in technology-oriented neur ological surgery, are economically fragile, research fund-dependent be arers of large educational cost burdens. They, by their very nature, c ompete poorly in a managed care environment. The economic and organiza tional burden of reordering will no doubt have a seriously detrimental effect on proper training, advanced care delivery, and progress in th e area of high-technology neurosurgery. It seems that major economic a nd reorganizational trends are underway that will specifically undermi ne and reduce the pace of progress in areas of high-technology neurosu rgery. Creative action and a hardy temperament are needed to sustain t he momentum and promise for the extraordinary.