This book is based on a series of 171 patients who were managed by Fischer and Brotchi and on the cases of 1117 additional patients that were compiled from a survey of the Société de Neuro-chirurgie de Langue Française. The duration of follow-up ranged from one to twenty-nine years. Considering that fewer than 200 such lesions are reported each year in the United States, this compilation of data is impressive in terms of both size and scope.
The first section of the book describes the anatomy of the spinal cord and contains some of the best color prints of anatomical dissections that I have ever seen. The details are exquisite and extremely useful (if not essential) for anyone who is interested in the anatomical relationship between tumors and the spinal cord. The crisp, concise text is markedly enhanced by the illustrations. The section on epidemiology adequately describes the frequency of these tumors, although the abbreviations are rather tedious. A minor criticism is that Table II, in which clinical data are presented, is extremely laborious; the type is much too small and therefore is difficult to read. Although the table contains a wealth of information, it needs to be enlarged and perhaps simplified a bit. Fortunately, much of the same information is found in the text.
The section on diagnosis includes a clear description of the neuropathological characteristics of intramedullary tumors as well as a good discussion of the pitfalls of limited biopsy. Currently, it is quite rare for a surgeon to operate on a patient who has an intramedullary tumor without the benefit of intraoperative monitoring of the spinal cord; in the section on neurophysiology, the different techniques available for such monitoring, along with their advantages and disadvantages, are well described. Magnetic resonance imaging has become indispensable for both the diagnosis and the operative treatment of these tumors. The section on neuroradiology offers a remarkably broad review of techniques such as angiography and myelography, but all roads point back to magnetic resonance imaging. Although most of the illustrations are excellent, quite a few of the magnetic resonance images lack clarity.
The pearls in this book are found in the section on operative treatment, in which the various operative techniques are described in a step-by-step fashion. I was awed by the concise, clear presentation of this information. The pitfalls of operative treatment also are extremely well delineated for each type of tumor. The reproductions of color slides markedly enhance the clarity of the text and provide examples of what might be encountered in situ. The authors' extensive operative experience is well reflected here. I also was intrigued by, and fully agree with, the authors' recommendation that lasers not be used in the treatment of intramedullary tumors. I always have been puzzled by the popularity of lasers, as I have found that they provide only a darkened, charred field while eliminating any reasonable operative margins. The only time that I have found lasers to be useful is during the treatment of spinal cord lipomas because of their ability to vaporize fatty tissue.
The next section adds the frosting to the cake. Fischer and Brotchi review their remarkably large series of 171 patients according to the type of tumor and then describe the diagnostic workup, operative planning, and postoperative care. I was trained by an eminent spinal cord surgeon, Dr. Bennett M. Stein, who believed that radiation therapy rarely was indicated for spinal cord tumors, and I have continued to hold this view. Therefore, I was pleased that Fischer and Brotchi also believe that radiation therapy rarely, if ever, is indicated for intramedullary tumors, and then only for lesions that are highly malignant; even in those instances, however, it appears to have little effect on long-term survival. The long-term data presented in this section support the notion that radiation therapy, rather than helping, only increases morbidity and therefore has little role in the care of these patients.
The final sections deal with results and long-term outcomes. Here again, the strength of this book lies in its documentation of a large number of rare tumors. Of particular interest is the documentation of functional outcomes after operative treatment. This information is extremely useful when one wishes to discuss long-term outcomes with patients and their families.
In summary, anyone who has even a remote interest in tumors of the spinal cord will want to read this book. I know of no other work that describes the many vagaries of these lesions as comprehensively as this one does. Librarians, neurosurgeons, orthopaedic surgeons, and physical therapists will find this little monograph to be a jewel and a valuable addition to their libraries.
James T. Goodrich, M.D., Ph.D.
Division of Pediatric Neurosurgery
Leo Davidoff Department of Neurological Surgery
Albert Einstein College of Medicine
Bronx, New York