✓ The authors report their experience with nine cases of acute pituitary apoplexy; eight had proven chromophobe adenomas, and two of these patients had the clinical stigmata of Cushing's syndrome. One patient who displayed acromegalic features was treated with x-ray, and no pathological specimen was obtained. The outstanding clinical features of acute pituitary apoplexy were sudden headache, depressed consciousness, ophthalmoplegia, meningismus, and signs of compression of the optic nerve or chiasma. Clinical or laboratory evidence of severe hypopituitarism was rare. The apoplectic syndrome was the first indication of the presence of a pituitary tumor in all nine cases. In one case anticoagulant therapy (for an acute myocardial infarction) appeared to have precipitated hemorrhage in an unrecognized chromophobe adenoma. The authors suggest that acute pituitary apoplexy is a surgical emergency resulting from sudden ischemia, necrosis, and hemorrhage when an expanding pituitary neoplasm has become impacted at the diaphragmatic notch.

A neurosurgeon's chances of being sued for malpractice are not necessarily related to the medical complexity of a particular case but rather to the types of cases with which the physician is involved. Elective spinal surgery cases constitute the majority of litigation. Neurosurgeons can take steps to reduce their vulnerability to potential litigation and to increase the odds of a successful defense.

Dr. Irving Cooper (1922–1985) was a pioneer in the field of functional neurosurgery. After years of treating patients with tremor by creating deep lesions with either anterior choroidal artery ligation or cryogenic thalamotomy, he began to utilize methods of electrical cerebral stimulation as treatment for a variety of disorders. Chronic cerebellar stimulation was employed for patients with epilepsy, cerebral palsy, and dystonia. While Dr. Cooper believed his results to be significant, there still remain many challenges to his claims. Later in his career, he placed deep brain electrodes in the internal capsule and thalamus for epilepsy and dystonia. His encouraging results from this small series were often overlooked. This paper reviews the science behind Dr. Cooper’s work, his case series, and the controversies surrounding his results.

The indications, advantages, complications, and benefits of peripheral neurectomy in patients with trigeminal neuralgia were studied in detail in 40 patients treated between 1982 and 1991. Twenty-eight patients had previously received radiofrequency thermocoagulation: peripheral neurectomy was performed for pain recurrence. These patients had excellent or good pain relief for at least 5 years postsurgery. Of the 12 patients who had peripheral neurectomy as their only procedure, seven had an excellent result and five had a good result. Five of the patients had recurrence of pain after 2 years but responded well to a second neurectomy. Elderly patients who experienced pain in the first and second divisions of the trigeminal distributions were the best candidates. Peripheral neurectomy is an effective, safe procedure for elderly patients who suffer from trigeminal neuralgia and have a limited life span.

Neurosurgery has designed a rigid curriculum that must be followed precisely by those who wish to enter the specialty. A similar process at the other end of the practice cycle has never been formalized except for mandatory retirement from certain administrative positions at a particular age. Basic considerations for strategic decision making about voluntary retirement from neurosurgery, especially operative neurosurgery, are investigated. Statistical data from the US Census Bureau and sources in the medical literature were reviewed regarding life expectancy and retirement ages. Age-related differences in verbal and performance intelligence quotients, attention span, verbal memory recall, and visuospatial facility were surveyed. A questionnaire was sent to 29 recently retired academic neurosurgeons about their age and reasons for retirement along with postretirement activities; 22 responses were received. Analysis of the data indicates that surgeons are now retiring at the age of approximately 60 years, whereas life expectancy is approximately 80 years. An individual thus may have 15 to 20 productive years after leaving active neurosurgical practice. Reasons for retirement among the 22 responding neurosurgeons included decreasing personal satisfaction and financial rewards, a desire to pursue other activities, local ground rules mandating age-specific retirement, the general sense that enough is enough, and, overall, a strong desire to stop performing surgery while at the top of one's game. The process of age-related competence assessment of commercial airline pilots is outlined, and a similar process of assessment of practicing surgeons may be warranted, with consideration for mandatory retirement from operative neurosurgery.

Irving S. Cooper (1922-1985), the son of a salesman, worked his way through high school, college, and medical school to become one of the pioneers in functional neurosurgery. He developed several novel techniques for the surgical management of Parkinson's disease and other crippling movement disorders. A keen interest in the physiology of movement disorders was kindled by his doctoral research and continued during his neurosurgical training. He began to apply this knowledge to surgical practice in 1952 when he began his faculty career as Assistant Professor of Surgery at New York University. At the time, surgical treatment of parkinsonian tremor focused on various techniques used to interrupt the pyramidal tract. During a subtemporal approach for a cerebral pedunculotomy, he inadvertently injured and, subsequently, was forced to occlude the anterior choroidal artery. Much to Cooper's surprise, following emergence from anesthesia the patient's tremor and rigidity were abolished without any residual hemiparesis. This serendipitous observation, together with Meyer's earlier work on the role of the basal ganglia in motor control, helped focus surgical efforts on targets within the basal ganglia and, subsequently, within the thalamus to alleviate the movement disorders associated with Parkinson's disease. While at New York University, Cooper developed chemopallidectomy and, later at St. Barnabas Hospital in the Bronx (1954-1977), he used cryothalamectomy as a surgical technique for primary control of tremor in patients with Parkinson's disease. Cooper authored many original papers on surgical techniques and several textbooks on the lives of patients afflicted with Parkinson's disease and other crippling movement disorders. Although considered controversial, this fascinating and complex neurosurgeon made significant contributions to this field.

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