History of Modern Neurosurgery

Nineteenth century witnessed the beginning of specialization in neurosurgery. The surgical personalities of the 19th century were varied and talented. Three important developments had contributed to the advancements:
1. Anesthesia:
                  Horace Wells, Morton, Warren and Simpson are credited for inventing anesthesia and patients freedom from pain during procedure.
2. Neurology: 
                  Fritsch, Hitzig, Paul Broca, Wernicke, Ferrier, John Hughling Jackson ( father of modern neurology), Hutchinson, William Gower, Bennet, Allen Starr had contributed immensely to neurological localization.
3. Antisepsis:
                Lord Lister introduced antisepsis in operation theater. Joseph Lister( 1872-1912) was born at Upton in the county of Essex and is considered as one of the greatest figures in  the history of surgery. He is best known for his antiseptic principles including introduction of carbolic acid sprays in the operating rooms , the result of which were published in the Lancet in 1967. The antiseptic principles described by Lister in 1867 reduced the infection rate significantly and gave a boost to the surgeons to proceed beyond the dura mater.
4. Development of Neurosurgical techniques &  Neuroradiology:
                  In 1884, Sir Rickmann Godlee operated upon a brain tumor for the first time solely on the basis of clinical localization by Hughes Bennet.
Sir William Macewen carried out his first surgery on brain abscess in 1881.
William Sharp ( 1840) : "Practical observation on injuries of the head"
Sir Charles Bell ( 1774-1842):  surgical drawings and illustrations.
Sir Victor Horsley, in 1892, invented bone wax which was initially made of bee's wax.
William W. Keen: " An American Textbook of Surgery" in 1890.
Sir Charles Ballance performed the first successful removal of an acoustic neuroma in 1894.
Fedor Krause
W.S.Halsted ( 1852-1922) was the first Professor of surgery at John Hopkins. Halsted was the first surgeon to introduce the use of gloves. Halsted's scrub nurse & wife was allergic to carbolic acid and he devised the glove primarily for her.
Harvey Cushing ( 1869-1939)- was perhaps the greatest neurosurgeon of all times.

1891 Quincke described lumbar puncture for relief of raised intracranial pressure.Heinrich Irenaeus Quincke (26 August 1842 - 19 May 1922) was a German internist and surgeon. His main contribution to internal medicine was the introduction of the lumbar puncture for diagnostic and therapeutic purposes (source: wikipedia).

                                                            Professor Heinrich Quincke (Source: wikipedia)




Roentgen discovered x-rays in 1896.
Walter Dandy described pneumoencephalography and pneumoventriculography in 1918.
In 1921, myelography was introduced when jean Sicard a French clinician and his pupil Jacques Forestier injected analgesics into the spine of a patient suffering from low back pain and subsequently found that the oil they used as a carrier for the analgesic, lipiodol, was radio-opaque.
The invention of myelography encouraged the Portuguese neurologist Egas Moniz to develop ' Arterial Encephalography'.
CT scan- 1967 Godfrey Hounsfield
MRI- Nobel Prize winning work of Block & Purcell in the 1940s, which was applied to medical imaging in 1970s.

Epilepsy Surgery or Seizure Surgery

20% of patients continue to have seizures even with anti epileptic drugs. Many of these patients may be candidate for surgical procedures to control their seizures. Largest group of surgical candidates are with mesial temporal epilepsy which is often medically refractory.

Preoperative evaluation with EEG and functional brain imaging like fMRI, MEG,PET can provide important information for treating medically refractory epilepsy . The candidates for epilepsy surgery are usually patients who are refractory to standard medical treatment and have epilepsy that is disabling. Clinical history, neurological examination, EEG, video EEG , brain MRI with M specroscopy, PET, SPECT, functional MRI, Magnetoencephalography (MEG) and neuropsychological testings help in the decision making.
WADA test or intracarotid amytal test localizes side of language function and dominant hemisphere and is required for resecting a large cortical lesion.
EEG obtained with invasive electrodes or depth electrodes for cortical mapping and is used to identify eloquent areas for planning a safe resection.

Surgical options:
1. Vagal Nerve Stimulation
2. Deep Brain Stimulation ( DBS ) of  thalamus ( for GTCS ), or hippocampus ( for partial seizures )
3. Disconnection: Callosotomy ( resection of corpus callosum ) or hemispherectomy of multiple subpial resections.
4. Resection of epileptic focus : Anterior temporal lobectomy, amygdalo- hippocampectomy, neocortical resection or resection of the lesion in secondary epilepsy ( e.g. cavernous malformation )
 

Intracranial Arteriovenous Malforations (AVMs)

AVM is a conglomerate of abnormal vessels( both arterial and venous) of variable size and number with no intermediate capillary network and there is no parenchyma among vessels.Both the feeding arteries and the draining veins are tortuous and dilated.
According to Mc Cormick's description ( Classification of vascular malformations of brain, 1978), the common vascular malformations of the brain are:
-AVM
-Cavernous angiomas
-Venous angiomas
-Capillary telangiectasia, &
-Transitional forms

The  majority of the patients present in the third decade and another peak in the pediatric age group. Only 18-20% of cerebral AVMs are diagnosed during infancy and childhood. The onset of symptoms is maximal in the second & third decades, although these lesions are present since birth. This latency in in the onset of symptoms is probably due to progressive maturation and growth of the lesion and gradual changes in the adjacent brain parenchyma ( Like hemorrhage and  gliosis causing headache, seizures, focal neurological deficit).
Intracranial hemorrhage is the most common mode of presentation of AVMs, with the majority of having bled before the age of 40 years. Seizures is the second most common manifestation followed by neurological deficits and mental changes as the result of arterial steal, venous hypertension causing hypoperfusion of the surrounding brain parenchyma and mass effect.
In a very large AVM with enlargement of the feeding vessels & increased blood flow there may be associated change in the pulse pressure giving rise to a water hammer pulse. In late stages high output cardiac failure may result.

Hemispheric AVMs are located in the middle cerebral , posterior cerebral and anterior cerebral territories in declining frequencies. Hemispheric AVMs  situated in the watershed areas are usually supplied by more than one arterial pedicle. The parietal lobe is the commonest region involved in supratentorial lesions. The majority of deep AVMs are located in the medial paratrigonal region.

In 1986, Spetzler and Martin published most practical classification  taking into account size, location and venous drainage.

Points are assigned for each factor as follows:
1. Size of AVM
Small ( less than 3 cm)               1  point
Medium ( 3-6 cm)                      2  point
Large ( more tha 6 cm)               3  point

2. Location of AVM ( Eloquence of adjacent brain)
Non-eloquent                               0 point
Eloquent                                       1 point

3. Pattern of venous drainage
Superficial only                             0 point 
Deep                                              1 point 


The grades are 1 to V and is arrived at by adding the scores.
Grade 1, i.e., a small AVM in a non-eloquent area with a superficial drainage has the best prognosis; and grade V ,i.e., a large AVM in an eloquent area with deep venous drainage has the worst prognosis.                     


The term "Eloquent" is used for areas of cortex that, if removed will result in loss of sensory processing or linguistic ability, minor paralysis, or paralysis.
The risk of post-surgical neurological deficit (difficulty with language, motor weakness, vision loss) increases with increasing Spetzler-Martin grade.


There are five options for treating AVMs:
1.Expectant behavior
2.Excisional Surgery: Total surgical excision is the gold standard treatment.
3.Endovascular therapy: Interventional radiologists can embolise the AVM nidusor the feeders as definitive treatment.
4.Radiosurgery is indicated for AVM of less than 3 cm size.
5.Combination of the above options
 

Role of Endoscopic surgery in treating intraventricular tumors

Endoscopic procedures are useful in resection of  midline intraventricular tumors, colloid cysts, suprasellar, pineal, tectal lesions,psterior fossa lesion, etc. Better illumination at the depth leads to better visualization of the intraventricular tumors. he endoscope can be used as an adjunt to the operating microscope.

Role of Endoscopic Third Ventriculostomy ( ETV) in treatment of Hydrocephalus

Now a days, the  endoscopic treatment of hydrocephalus is an established technique of treating hydrocephalus. Previous works of Lespinase , Dandy , Mixter, Fay and Grant had contributed in the evolution of this concept.
Lespinasse in 1910 was the first one to perform endoscopic choroid plexus fulgration for treating hydrocephalus.
Dandy described the open technique for third ventriculostomy for treatment of hydrocephalus.
In 1923, Mixter first  described percutaneous ventriculostomy, and Fay Grant published the visual record of endoscopic anatomy.
The aim of this surgery is to create a passage in the floor of the third ventricle and to allow the flow of CSF into the pre pontine cistern so that obstruction at the aqueduct can be avoided. The easiest example to explain is of obstructive hydrocephalus due to aqueductal stenosis. In this condition, patient presents with enlargement of the lateral ventricles and third ventricle. The obstruction at the aqueduct causes obstructive hydrocephalus and the cerebral sulci are effaced. So, an endoscope is introduced through the frontal horn of right lateral ventricle and advanced into the third ventricle through dilated Foramen of Monro. Floor of the third ventricle is visualized and an opening is made in the floor of the third ventricle allowing the CS flow to the pre-pontine cistern.

So, high success rate is seen in aqueductal stenosis and ventricular obstructions assosciated with tumors. Low success rate is expected in post tubercular  hydrocephalus due to basal exudates at the basal cisterns and thickened third ventricular floor.
A variety of endoscopic equipments with some modification are available for neuroendoscopic procedures.

Endoscope is passed from right lateral ventricle to third ventricle through Foramen of Monro

Intraoperative Endoscopic view of the structures at the Foramen of Monro

Diagrammatic depiction of the anatomical structures which are to be identified by the neurosurgeon

Intraoperative endoscopic view of the anatomical structures as seen at the floor of the third ventricle

Historical landmarks in Neurosurgery

William Clowes, a leading surgeon of the Elizabethan Age in year 1602 invokes a challenge that neurosurgeons must still overcome, even in the age of computerized imaging, microneurosurgery, and functional neurosurgery.

“Those which are Masters and Professors chosen to perform the like operation, ought to  have a Lyons heart, a Ladies hand, and a Haukes eye, for that is a worke of no small importance.”

Thomas Willis, a London physician published an important monograph " Cerebri Anatomie " in 1664. This book was the most accurate anatomic study of the brain. The eponym  " Circle of Willis " bears his name.

Percival Pott, English surgeon, described tuberculous caries of the spine in 1779. This disease is known as Pott's spine. An osteomyelitic infection of the scalp and skull in which pus collects under the pericranium is now called Pott's puffy tumor.

Paul Broca ( 1824-1880) introduced the concept that each part of the brain correspond to a particular function.

John Hughling Jackson ( 1835-1911) is considered the founder of modern neurology.

Sir Rickman Godlee removed cerebral tumor, the first to be successfully diagnosed by cerebral localization, in 1885.

Three years later, in 1888, Victor Horsley performed the first removal of spinal cord tumor.
Horsley invented the use of beewax to stop bone bleeding ( Bone Wax). Horley and Clarke designed the first useful stereotactic unit for brain surgery.( Horsley-Clarke stereotactic frame).

William Macewen, a scottish surgeon, was first surgeon to completely excised brain abscess in 1879.

Harvey William Cushing ( 1869-1939), an American neurosurgeon,  is  regarded as father of Neurosurgery and his name is associated with many contributions including Cushing reflex, Cushing disease, hemostatic forceps, electrocautery, etc.

Walter Dandy (1886-1946), an American neurosurgeon, developed the technique of ventriculogram, pneumoencephalogram, and was first to ligate and clip cerebral aneurysms.

Myelogram was invented by Jean Athanase Sicard

Cerebral angiogaphy was invented by Egas Moniz.

Source;
Youmans Neurological Surgery ( H.Richard Winn) sixth ed., Elsevier, Historical overview of Neurosurgery ( James T.Goodrich & Eugene S.Flamm)

Egas Moniz

António Caetano de Abreu Fre Egas Moniz (29 November 1874 – 13 December 1955), known as Egas Moniz was a Portuguese neurologist and the developer of cerebral angiography.  

He is regarded as one of the founders of modern psychosurgery, having developed the surgical procedure leucotomy—​known better today as lobotomy—​for which he became the first Portuguese national to receive a Nobel Prize in 1949.

He held academic positions, wrote many medical articles and also served in several legislative and diplomatic posts in the Portuguese government. In 1911 he became professor of neurology in Lisbon until his retirement in 1944. At the same time, he pursued a demanding political career.

 In 1927 Moniz developed cerebral angiography, a technique allowing blood vessels in and around the brain to be visualized; in various forms it remains a fundamental tool both in diagnosis and in the planning of surgeries on the brain. He also helped develop thorotrast for use in the procedure.

In 1936, he published his first report of performing a prefrontal leucotomy on a human patient, and subsequently devised the leucotome for use in the procedure. The procedure enjoyed a brief vogue, and in 1949 he received the Nobel Prize, "for his discovery of the therapeutic value of leucotomy in certain psychoses.” Later this procedure fell into disrepute.

Source: wikipedia