Our country is blessed with the highest level of health and life expectancy, which were attained by improvements in medical technology and the national health insurance system. Nevertheless, health care reform is indispensable in Japan, because we are confronted with serious issues such as the rapid increase in national health expenditure. A new health care system for the 21st century which is corresponding to the variety of needs and the rapid progress in aging society in Japan, is highly anticipated. On the other hand, it is essential to promote clinical research such as randomized controlled trials (RCT) and translational research, in order to improve the overall quality of health care. To this end, the Ministry of Health, Labour and Welfare (MHLW) has been making efforts to increase the research budget.

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The U.S. medical insurance system is divided into Medicare for elderly people and some disabled persons, Medicaid for low income earners, and various commercial insurance plans for the remainder. Commercial insurance plans are divided into indemnity plans based on fee-for-service payment and managed care type insurance plans which set their premiums at a lower level. In this paper, the diagnosis-related groups/prospective payment system(DRG/PPS), which was introduced for setting hospital fees for Medicare payment, and managed care plans, which cover the majority of American citizens, are discussed. Both are presently attracting much attention in Japan. In order to ensure better health care reform in our country, concern should be paid to the health insurance system trends of many foreign countries including the U.S.

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Ablative procedures and deep brain stimulation currently constitute a major part of functional neurosurgery for involuntary movement disorders. The target brain structures for lesion-making surgery and deep brain stimulation are comprise of the motor thalamus, the globus pallidus, and the subthalamic nucleus. With the option of either of the 2 surgical modalities that can be performed in these brain nuclei, surgical treatments for movement disorders should be tailored according to individual patients'conditions. In this review, we first summarize a proposed model of a functional neural circuit involving the basal ganglia and the motor thalamus, which provides a better understanding of the pathophysiology of movement disorders as well as a scientific rationale for determining proper stereotactic targets. We then review the present status of surgical treatments in Parkinson's disease with a special reference to thalamotomy and pallidal stimulation.

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Pain conditions in the contemporary neurosurgical practice generally belong to the category of neuropathic pain. Neuropathic pain should be recognized as a chronic neurological disorder following a certain damage to the nervous system. Accurate diagnosis of pain problems is important to decide therapeutic options, and this is only accomplished with detailed knowledge on the mechanisms of neuropathic pain and treatment strategies. Precise and detailed history taking and neurological examinations are the most basic and important way to accurate diagnosis of pain. We have to realize that many pain conditions can be controlled only by neurosurgeons.

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MRI and CT reliably visualize malalignment of the cervical spine, osteophyte, narrowed disc space, disc protrusion, hypertrophic intervertebral joint, infolding of the ligamentum flavum, nerve root compression, and deformity of the spinal cord. Cervical spondylosis may be associated with development of a narrow canal, OPLL, dynamic change in neck flexion and extension, engorged epidural veins and intramedullary degeneration (myelomalacia and/or edema). Diagnostic pitfalls include the high frequency of asymptomatic spondylosis on MRI. Caution must be taken in considering the lesion responsible for causing symptoms. Another pitfall is that disc lesions are often enhanced with gadolinium administration; mimick those undergoing inflammation, neoplasms or in particular, endplates adjacent to degenerated discs, annular tears, marginal areas of the herniated nucleus pulposus, capsules of the interventebral joints, engorged epidural veins and intramedullary degeneration are often enhanced.

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The anterior and posterior approach (combined approach) for treating cervical degenerative disorders is analyzed. During the past 18 years, combined approaches were adopted for 10 cases of cervical soft disc herniation, 11 cases of cervical OPLL and 13 cases of cervical spondylosis. The reasons why the combined approaches were performed for these lesions were ventral and dorsal compressive components, remarkable cervical instability with a dorsal compressive component, severe OPLL and for reinforcement of the anterior cervical graft bone. The order of the operation, anterior or posterior approach, and the simultaneous operations are controversial. There are also discussions about the application of the spinal instrumentation for the combined approach. In the present series, neither neurological deterioration nor systemic complications were noticed postoperatively. The patients who were treated by the combined approach showed good postoperative clinical course and good alignment of the cervical spine. The combined approach was thought to be a worthy option as a surgical procedure for treating cervical degenerative disorders.

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Five patients with 6 intracranial atherosclerotic lesions of the vertebrobasilar artery and the distal internal carotid artery underwent endovascular treatment with flexible balloon-expandable coronary stents. Stent implantation was successful in all patients, leading to significant changes in the degree of stenosis from 79% (range 70% to 89%) to 1% (range 0% to 6%). No complications occurred during the procedures. No cerebrovascular events occurred during the follow-up period (mean 12 months, range 2 to 20 months). Endovascular stenting appears to be a safe and effective treatment in selected cases of intracranial atherosclerotic stenoses.

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We present a case of a 47-year-old male who had a giant intracavernous carotid aneurysm that was increasing in size. The patient presented with severe trigeminal neuralgia and ocular nerve disturbance. This giant aneurysm was associated with other vascular lesions including contralateral internal carotid artery and vertebral artery occlusions and an ipsilateral vertebral artery aneurysm. After an evaluation of cerebral blood flow by SPECT, angiography and balloon test occlusion, we planned a two-staged operation to treat the giant aneurysm. First, a high-flow bypass using a radial artery graft (radial bypass) was installed for the reconstruction of the occluded contralateral carotid artery, and then proximal carotid ligation was carried out following the radial bypass. Postoperative angiogram demonstrated the complete disappearance of the giant aneurysm and sufficient blood supply through the bilateral patent radial bypasses without an increase in the size of the vertebral aneurysm.

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The case of a 40-year-old man with suprasellar ectopic pituitary adenoma is reported. He was referred to us with nasal hemianopia of left eye. Plain skull X-ray demonstrated saucer-like deformation of the sella turcica, but no ballooning of the tuberculum sellae. MR images revealed a suprasellar tumor under a left optic nerve and a normal pituitary gland in the pituitary fossa below the tumor. Intraoperative examination showed the tumor had not invaded the pituitary gland or pituitary stalk. However, slight attachment to the diaphragma sellae was observed. Gross total removal of the tumor was accomplished. Histologically, the tumor was identified as a pituitary adenoma. Postoperative findings on laboratory studies were normal, and follow-up MR images demonstrated the normal pituitary gland in the pituitary fossa.

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