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PubMed2000

The idea of stereotaxy toward minimally invasive neurosurgery.

The idea of stereotaxy in modern neurosurgery is reviewed. Stereotactic surgery has been one of the particular neurosurgical techniques mainly used for functional disorders. Nowadays, it is widely used in the field of general neurosurgery owing to the rapid development of computer-assisted 3D brain images. Functional neurosurgery itself is also changing in the sense that many alternative surgical procedures are now available due to the progress in neuroscience. The original premise of stereotaxy is exactly the same as that of minimally invasive neurosurgery today.

Cerebral Hemorrhage↗
PubMed2005

Battling blood loss in neurosurgery: Harvey Cushing's embrace of electrosurgery.

For his pioneering spirit, definitive work, and unparalleled devotion to conquering neurosurgery's toughest obstacles, Harvey Williams Cushing inarguably has earned the title, "The Father of Neurosurgery." His revolutionary incorporation of electrosurgical techniques in neurosurgery was not exceptional, but part of a pattern of recognizing, embracing, and establishing the use of medical technologies with great potential. Until 1910, Cushing had systematically reduced neurosurgery's primary complications--infection and the effects of intracranial pressure--to decrease mortality rates. Hemostasis had always been a concern of William Halsted's surgical protégé, but only after 1910 could Cushing primarily focus on it. In fact, Cushing's crucial collaboration with William T. Bovie and his electrosurgical apparatus conquered this major obstacle in 1926. The nature of their collaboration--two experts in their respective fields who were passionate about their work, working side by side in the operating room--resulted in progress that surpassed all predecessors in the field. Cushing never did learn the physics behind one of the most important advances of his career. Nonetheless, he did know that by greatly reducing blood loss, electrosurgery allowed him to operate in patients whose tumors had been previously deemed inoperable and on the entire spectrum of neurosurgical patients more safely.

Blood Loss, Surgical↗
PubMed2003

New development of functional neurorehabilitation in neurosurgery.

OBJECTIVES: Today, increasingly more patients with severe brain and spinal cord lesions mainly secondary to accidents, violence, stroke, and tumours survive their injuries, in many cases, however, suffering from severe functional impairments of functioning as described by the WHO-ICF criteria. New developments of functional neurorehabilitation in neurosurgery could significantly improve the patients' quality of life (QoL) in terms of brain and body functioning and certain health-related components of well-being (such as social activities and leisure). METHODS: Functional rehabilitation is an original task of neurosurgery from the very outset. Advances in biotechnology regarding both basic research and clinical application have opened up a new and very promising field to restore or compensate impaired or definitively lost organic functions in addition to the conservative rehabilitation methods. RESULTS: Along with the scientific progress in biotechnology and functional MRI and PET, neurosurgeons have become increasingly interested and actively involved in rehabilitation science and neurosurgical re-engineering of the damaged brain and spinal cord. Some of them have developed new specially designed institutions for early (acute) and subacute neurorehabilitation. Attached to the acute services, neurosurgeons thus become responsible for neurorehabilitation and at the same time for the management of all kinds of complications, which significantly improves the early and late functional outcome. At the same time microelectronics, biotechnology, and genetic engineering are being introduced into the field of neurosurgical rehabilitation in a step-by-step manner. DISCUSSION: Progress in the fields of microelectronics, computer technology, and genetic engineering along with rehabilitation science is opening up a new field of unknown chances to partially restore lost body functions and to help improve the quality of life of disabled patients in the sense of ICF. Functional neurosurgery plays a major role in neurosurgical rehabilitation. e.g. functional electrostimulation, brain-stem implants, pain and epilepsy control, restoration of locomotion and grasp faculties, and the use of potent substances such as botulinum toxin (Btx). This demands the capacity of time work and the realization of the necessity to draw up a detailed plan for the restoration of impaired functions prior to enacting a neurosurgical intervention in the sense of a complex neurorehabilitation, and consequently to assume the responsibility for the patient's outcome. From the beginning of neurological surgery, the preservation and restoration of impaired brain and spinal-cord functions as an original task for neurosurgeons demand their involvement with issues of functional neurorehabilitation including neurosurgical re-engineering of the damaged brain and spinal cord. In this connection the close and trusting cooperation with the clinical neuropsychologist from the very outset is an indispensible factor.

Brain Injuries↗
PubMed1991

History of pediatric neurosurgery in the United States and Canada.

Neurosurgery was sporadically practiced on children from prehistoric times until the Harvey Cushing era. The formal development and teaching of the specialty was begun by Franc Ingraham under Cushing's direction in 1929. The growth of pediatric neurosurgery at Boston Children's Hospital under the direction of Franc Ingraham and Donald Matson until the late 1960s is described, as is its subsequent spread throughout the United States and Canada. More recently, a number of societies and journals have played important roles in shaping and advancing the specialty. Currently, a proposal to require additional training for certification in pediatric neurosurgery is being considered by several organizations in North America.

Canada↗
PubMed1996

The future perspectives of pediatric neurosurgery.

Pediatric neurosurgery as a subspecialty dealing primarily with such congenital and perinatal pathology as the dysraphic state, and various clinical entities having in common ventriculomegaly, is fast disappearing from the scene of neurosurgery in the industrialized world. Pari passu with this, one observes ever closer collaborative work between pediatric neurosurgeons and specialists in other pediatric disciplines such as oncology, radiology, orthopedics, and maxillofacial surgery: truly multidisciplinary activities. In addition, paramedical and specialized nursing personnel are participating actively, even in the decision-making and treatment-delivery aspects of pediatric neurosurgical care. The pediatric neurosurgeon is no longer the sole decision-maker, nor the automatic captain of the ship. Very probably, as in the whole history of human activities, new instrumentation will change somewhat what we do and with whom we collaborate. However, for the immediate future the major changes most probably will be expressions of socioeconomic readjustments, of ethical redefinitions, and of the to-and-fro movement into and out of pediatric neurosurgery by both neurosurgeons and ancillary medical personnel.

Decision Making↗
PubMed1983

Neurosurgery in India.

This is a brief account of Neurosurgery in India. Prior to 1949, Neurosurgery was being practised by General Surgeons. With the return of Professor Jacob Chandy to the Christian Medical College, Vellore in 1949 modern neurosurgery was born and progressed, and today there are more than 180 neurosurgeons in India. Even so, the ratio works out to one neurosurgeon for every 3,600,000 individuals! Conditions commonly encountered such as hydrocephalus, craniovertebral anomalies, pyogenic, fungal and tuberculous infections of the central nervous system, and fluorosis are being discussed. Stereotaxic surgery for pain, epilepsy, behaviour disorders and involuntary movements is being practised at several centres especially at Madras. Following the workshops conducted by Professor Pia and his co-worker Professor Grote , enthusiasm for microneurosurgery has waxed.

Brain Injuries↗
PubMed1996

Experimental and clinical standards, and evolution of lasers in neurosurgery.

From initial experiments of ruby, argon and CO2 lasers on the nervous system so far, dramatic progress was made in delivery systems technology as well as in knowledge of laser-tissue interaction effects and hazards through various animal experiments and clinical experience. Most surgical effects of laser light on neural tissue and the central nervous system (CNS) are thermal lesions. Haemostasis, cutting and vaporization depend on laser emission parameters--wavelength, fluence and mode--and on the exposed tissues optical and thermal properties--water and haemoglobin content, thermal conductivity and specific heat. CO2 and Nd-YAG lasers have today a large place in the neurosurgical armamentarium, while new laser sources such as high power diode lasers will have one in the near future. Current applications of these lasers derive from their respective characteristics, and include CNS tumour and vascular malformation surgery, and stereotactic neurosurgery. Intracranial, spinal cord and intra-orbital meningiomas are the best lesions for laser use for haemostasis, dissection and tissue vaporization. Resection of acoustic neuromas, pituitary tumours, spinal cord neuromas, intracerebral gliomas and metastases may also benefit from lasers as accurate, haemostatic, non-contact instruments which reduce surgical trauma to the brain and eloquent structures such as brain stem and cranial nerves. Coagulative lasers (1.06 microns and 1.32 microns Nd-YAG, argon, or diode laser) will find an application for arteriovenous malformations and cavernomas. Any fiberoptic-guided laser will find a use during stereotactic neurosurgical procedures, including image-guided resection of tumours and vascular malformations and endoscopic tumour resection and cysts or entry into a ventricle. Besides these routine applications of lasers, laser interstitial thermotherapy (LITT) and photodynamic therapy (PDT) of brain tumours are still in the experimental stage. The choice of a laser in a neurosurgical operating room implies an evaluation of the laser use (applications, frequency), of the available budget and costs--including purchase, maintenance and staff training--, and material that will be necessary: unit, peripherals, safety devices and measures, training programme. Future applications of lasers in neurosurgery will come from technological advances and refined experimental applications. The availability of new wavelength, tunable, small sized and "smart" laser units, will enlarge the thermal and non-thermal interactions between laser energy and neural tissue leading to new surgical applications. Tissue photo-ablation, photohynamic therapy using second generation of photosensitizers, updated thermotherapy protocols, are current trends for further use of lasers in neurosurgery.

Animals↗
PubMed2003

Perspectives and limitations of image-guided neurosurgery in pediatric patients.

INTRODUCTION: Progress in image-guided neurosurgery, and specifically in computer-assisted frameless navigation techniques and the application of robotic systems, has brought about many changes in the way we approach and treat pathologies involving the adult and pediatric central nervous system (CNS). Nevertheless, children are a patient group with special demands, in whom image-guided surgical techniques have certain limitations. In this article we address the common problem of registration accuracy in image-guided neurosurgery and assess both the reliability and the potential of ultrasound-based neuronavigation and robot-assisted neuroendoscopy in pediatric patients. METHODS AND RESULTS: We present our experience with new referencing and tracking techniques adapted to the needs of the pediatric patient. In addition, advantages and limitations of a 3D real-time ultasonography-based navigation system are demonstrated. Finally, we describe our experience with robot-assisted neuroendocopy and discuss the possible implications of the technique for the future. CONCLUSION: Image-guided techniques in pediatric neurosurgery are valuable tools and may open up new perspectives in the future. From our point of view, these tools enhance both intellectual and manual surgical skills, which does not mean that they should be considered as a replacement for such skills.

Adolescent↗
PubMedDate not supplied

Thoughts on the present and future of pediatric neurosurgery. Skull base surgery, spinal instrumentation, and neuroendoscopy.

As part of a series of essays about the first 25 years of the International Society for Pediatric Neurosurgery--what we have accomplished and where we have been--I have decided to turn my attention to where we are now and where we are going. A corollary to consider, perhaps, is where we should be going. In other words, what is the appropriate relationship between pediatric neurosurgery and general neurosurgery?

Child↗
PubMed1999

Pediatric neurosurgery--a golden decade.

Pediatric neurosurgery, once an annex of general neurosurgery, has evolved into a well-defined and complex medical specialty. The last 10 years have witnessed major advances in documentation of the minute details of CNS diseases of childhood, refinement of the specific means of action and better adaptation of therapeutic efforts to the requirements of a developing organism. Pediatric neurosurgeons are now increasingly involved in beneficial cooperation within complex medical teams. This fact has by no means diminished the importance of pediatric neurosurgery; rather, in such settings it has proved to have better effects in the struggle for stable long-lasting good results of multi-modal treatments covering all pathological entities. Progress in neurological surgery for patients in the pediatric age group has emerged from the development of supranational scientific structures and from that of specific concepts exchanging channels, so that today pediatric neurosurgeons belong to an extremely specialized medical corps, working in harmony across geographical and socio-economic national features in the interests of humankind's young generation's health.

Child↗
PubMed1993

Richard A. Lende winter neurosurgery conference.

One of the most prestigious and popular winter neurosurgery conferences, the Richard Lende Conference, had its 18th meeting this last winter. It is also the oldest winter neurosurgery conference of this type in this country, and possibly in the world. It is, therefore, of interest to trace its history and to share this information with the neurosurgery community.

Congresses as Topic↗
PubMed1995

The perioperative use of ceftriaxone as infection prophylaxis in neurosurgery.

An open label study was conducted in the department of neurosurgery, Beijing Tiantan Hospital in China to determine the incidence of postoperative infections following the use of one or two doses of ceftriaxone administered perioperatively. A total of 343 patients, who required neurosurgery and had satisfied the inclusion criteria, was recruited during a 12 month study period. Of these 343 patients, there were 97 and 107 cases of malignant and benign tumours, respectively, 52 cases of aneurysm, 34 cases of arteriovenous malformation, and 53 other cases who underwent neurosurgery for drainage of sub-dural haematoma, relief of cerebral oedema and other indications. A total of 6 (1.75%) cases of postoperative infection was observed, of which 4 were found in the malignant tumour group, and 2 in the arteriovenous malformation group. All six patients were suffering from meningitis. During the 12 month period immediately prior to the present study, when postoperative penicillin and gentamicin was administered twice daily for 5-7 days as regular prophylaxis against infection, the incidence of postoperative infection was 7.2% in the same department managed by the same staff. Results of our present study suggest that one to two doses of ceftriaxone administered perioperatively are effective in reducing the rate of postoperative infections.

Adult↗
PubMed2001

[Research training in the programs of neurosurgery residency. Analysis of the situation in other developed countries and proposals to implementing the current program in Spain].

Research performed by neurosurgeons has been always linked to the progress of our specialty, and research training is included in the Neurosurgery Residency Programs in developed countries. Since the methodology of research related to the basic knowledge of the nervous system function is becoming increasingly complex, it could be proposed that neurosurgeons can not longer contribute to productive research in neurosciences, and this idea might be easily accepted in certain countries such as Spain, where research training is not contemplated in the Residency Program of Neurosurgery. However, all neurosurgeons academic or not, should exhibit a critical and inquiring mentality which enables them to evaluate scientific information and communicate their own clinical experience to the neurosurgical community. Such a critical capacity can not be acquired by a resident trained only in the art of clinical diagnosis and the surgical technique. The new medical practice is based on both basic and clinical-epidemiological research, and the new residents must be immersed into a motivating and inquisitive environment in which the scientific method is continuously applied to the clinical practice. In this paper I consider research training in Neurosurgery in developed countries with the aim of identifying a strategy for introducing a period devoted to research in the Spanish Residency Program. Thus, the methodologies, objectives, contents, duration and the moment for receiving research training in other countries are analysed and some alternatives for solving the problem in our country are pointed out.

Developed Countries↗
PubMed1998

Enoxaparin plus compression stockings compared with compression stockings alone in the prevention of venous thromboembolism after elective neurosurgery.

BACKGROUND: Compression stockings are recommended for prophylaxis against venous thromboembolism in patients undergoing neurosurgery, but anticoagulant agents have not gained wide acceptance because of concern about intracranial bleeding. METHODS: In a multicenter, randomized, double-blind trial, we assessed the efficacy and safety of enoxaparin in conjunction with the use of compression stockings in the prevention of venous thromboembolism in patients undergoing elective neurosurgery. Enoxaparin (40 mg once daily) or placebo was given subcutaneously for not less than seven days beginning within 24 hours after the completion of surgery. The primary end point was symptomatic, objectively confirmed venous thromboembolism or deep-vein thrombosis assessed by bilateral venography, which was performed in all patients on day 8+/-1. Bleeding side effects were carefully assessed. RESULTS: Among the 307 patients assigned to treatment groups, 129 of the 154 patients receiving placebo (84 percent) and 130 of the 153 patients receiving enoxaparin (85 percent) had venographic studies adequate for analysis. An additional patient in the placebo group died before venography of autopsy-confirmed pulmonary embolism. In this analysis, 42 patients given placebo (32 percent) and 22 patients given enoxaparin (17 percent) had deep-vein thrombosis (relative risk in the enoxaparin group, 0.52; 95 percent confidence interval, 0.33 to 0.82; P=0.004). The rates of proximal deep-vein thrombosis were 13 percent in patients receiving placebo and 5 percent in patients receiving enoxaparin (relative risk in the enoxaparin group, 0.41; 95 percent confidence interval, 0.17 to 0.95; P=0.04). Two patients in the placebo group died of autopsy-confirmed pulmonary embolism on days 9 and 16. Major bleeding occurred in four patients receiving placebo (intracranial bleeding in all four) and four patients (intracranial bleeding in three) receiving enoxaparin (3 percent of each group). CONCLUSIONS: Enoxaparin combined with compression stockings is more effective than compression stockings alone for the prevention of venous thromboembolism after elective neurosurgery and does not cause excessive bleeding.

Adult↗
PubMed1989

Leadership in neurosurgery.

These are challenging times for neurosurgery. Although no one can predict our future, great changes are in the wind--many of which we are powerless to prevent. We must all take on added social responsibility, above and beyond that of patient care. The leadership of your organization can only act with the support of active and concerned neurosurgeons who are willing to participate in many programs available to our profession. The individual must personally embrace the leadership standards of Sir William Osler and Harvey Cushing. One of the privileges of giving a presidential address is to pay public homage to those who have been supportive and instrumental in my long professional journey. During my residency, Dr. Dwight Parkinson was my mentor and teacher and set a wonderful standard for the ideal practice of neurosurgery. Decisions were black or white, never gray, with Dr. Parkinson, who left little doubt as to the correct way to handle clinical problems. He was, and continues to be, one of the most incisive, imaginative, innovative scientific minds in neurosurgery, and I owe him a great debt of gratitude. Two other men influenced my neurosurgical development. They are Dr. William Horsey, formerly neurosurgeon at the St. Michael's Hospital in Toronto, and Dr. Peardon Donaghy, with whom I spent a most enjoyable and productive year in Burlington at his microvascular neurosurgical laboratory. These two men demonstrated the humility, warmth, and kindness to patients that cannot be learned by formal study, but comes from observing the example of people who manifest those qualities in their own personality.(ABSTRACT TRUNCATED AT 250 WORDS)

History, 20th Century↗
PubMed1996

Yale neurosurgery program.

Organized neurosurgery at Yale began in 1918 with Dr. Sam Harvey. In 1928, Dr. William German became the first surgeon at Yale who was dedicated to neurosurgery. Both of these surgeons were trained by Harvey Cushing, and upon the arrival of Drs. Cushing and Eisenhardt in 1934, Yale developed a strong tradition in surgery of the nervous system. In 1967, Dr. William Collins established a training program for residents that integrated laboratory research and clinical experience. This tradition has continued under the guidance of Dr. Dennis Spencer since 1987. This article provides a brief overview of the history of neurosurgery at Yale, its current practice, and plans for the future.

Connecticut↗
PubMed1996

The Richard C. Schneider Lecture. New dimensions of neurosurgery in the realm of high technology: possibilities, practicalities, realities.

Fueled by a buoyant economy, popular attitudes and demands, and parallel progress in transferable technical and biological areas, neurosurgery has enjoyed a remarkable quarter of a century of progress. Developmental trends in the discipline have included the following: 1) a refinement of preoperative definition of the structural substrate, 2) miniaturization 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 treatment protocols. In particular, the computer has become a formidable ally in diagnostic and surgical events. Trends in technical development indicate that we are entering an exciting era of advanced surgery of the human cerebrum, which is heralded by the following: 1) current developments in areas of imaging, sensors, and visualization; 2) new devices for localization and navigation; 3) new capabilities for action at the target point; and 4) innovative concepts related to advanced operative venues. Imaging has provided structurally based surgical maps, which now are being given the new dimension of function in complex and integrated formats for preoperative planning and intraoperative tactical direction. Cerebral localization and navigation based on these advances promise to provide further refinement to the field of stereotactic neurosurgery, as linked systems are superseded by more flexible nonlinked methodologies in functionally defined volume-oriented navigational databases. Target point action now includes not only ablative capabilities through micro-operative methods and the use of stereotactically directed high-energy forms but also the emergence of restorative capabilities through applications of principles of genetic engineering in the areas of molecular and cellular neurosurgery. Complex, dedicated, and self-contained operative venues will be required to optimize the emergence and development of these computer-oriented micro/stereotactic capabilities, which appear to be unavoidably required as locales for the practice and development of virtual reality-based stations for operative rehearsal, simulation, training, and, ultimately, enhancement of operative events through robotic interfaces. Primary impetus for progress 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 training of individuals to properly administer these methods, defining the acceptable envelope of expertise, and maintaining suitable delivery and progress while containing spiraling costs. Advanced neurological surgery 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 from the standpoint of both economics and attitudes of the patients and health care providers, with diversion of economic resources, redistribution of funding bases, modification of patient referrals, practice styles, and service attitudes undermining progress. Economic pressures have brought high-technology methods under great scrutiny regarding their effectiveness and cost-effectiveness. Reform proposals have specifically targeted technology-oriented services, and the Office of Technology Assessment has recommended increasing the use of managed care providers who look to information on cost-effectiveness and clinical practice 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 control might be overbearing and overused, impeding appropriate delivery and progress.

Cost-Benefit Analysis↗
PubMed1996

Department of Neurosurgery, Karolinska Institute: 60 years.

The Swedish neurosurgical school was created during the 1920s by Herbert Olivecrona, who became the first professor of neurosurgery at the Karolinska Institute. He pioneered procedures for the treatment of arteriovenous malformations and acoustic neuromas. He was among the first to make direct attacks on berry aneurysms. Many outstanding neurosurgeons in Europe were trained by him. Clinical research to refine and minimize surgical interventions has continued to be the most important feature of the neurosurgery department at the Karolinska Institute. Lars Leksell, Olivecrona's successor, was a leader in stereotactic surgery and the creator of radiosurgery. His tool, the gamma knife, is in worldwide use today. Leksell and his students have defined the indications for radiosurgery and introduced stereotactic techniques into microsurgery. Today, 3000 neurosurgical procedures are performed annually in the four operating rooms of the department of neurosurgery. More than 300 of the procedures are performed with the gamma knife, and at least one-third of the patients are foreign referrals. There is a strong emphasis on clinically oriented research and development. There are research programs for radiosurgery, management of pain, neurooncology, treatment of traumatic brain injury, and treatment of vasospasm after subarachnoid hemorrhage.

Academies and Institutes↗