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PubMed1996

[African neurosurgery. 2: Current status and future prospects].

A survey conducted among African neurosurgeons shows that there are nowadays 500 neurosurgeons in Africa, that is one neurosurgeon for 1,350,000 inhabitants, and 70,000 km2. The distribution of these neurosurgeons shows a striking regional disparity: North Africa has 354 neurosurgeons for 119 million inhabitants, that is one neurosurgeon for 338,000 inhabitants, and South Africa has 65 neurosurgeons for 40 million inhabitants, that is one neurosurgeon for 620,000 inhabitants. Between these two areas where neurosurgery is developing quite well, we have the majority of African countries with a scanty density of neurosurgeons (81 neurosurgeons for 515 million inhabitants, that is one neurosurgeon for 6,368,000 inhabitants). The Panafrican Association of Neurological Sciences "PAANS" brings together the African neurosurgeons. This continental African Association represents African neurosurgeons in the WFNS. In addition to this continental Association, there are national societies of neurosciences. However, there are only six Societies of Neurosurgery. Two systems of training exist in Africa: local training and training abroad. These two systems have unequal quality and specific difficulties which have already been pointed out. Among the optimistic elements which make us believe in the development of neurosurgery in Africa are the existence of a quite good level of neurosurgery at the two extremities of the continent (North Africa and South Africa), the development of neurosciences in the African universities, and the increasing interest that the international community bears to Africa in the last years. However, the real factor of optimism is the African neurosurgeons who should promote neurosurgery in their continent, at the level of their own countries by developing information and health education, setting their specialty in the education syllabus and health planning, and settling into active and performing societies. At the continental and international level, African neurosurgeons should institutionalize inter-African cooperation, expedite their continental association (PAANS), and further exchanges with the other continents through the SNCLF (Société de Neurochirurgie de Langue Francaise). The latter, together with other associations such as the EANS (European Association of Neurosurgical Societies) and WFNS (World Federation of Neurosurgical Societies) could provide help to the development of Neurosurgery in Africa as far as training, exchanges, research and organization are concerned.

Africa↗
PubMed1984

Present status of laser neurosurgery.

A three-fold approach to the status of laser neurosurgery was taken: 1) Questionnaire to Program Directors for neurosurgery training in the United States and Canada; 2) an analysis of titles in the preliminary neurosurgery program of the Fifth International Congress of Neurosurgery; 3) A literature survey covering the last 3 years of publication. The results showed increasing interest in the use of lasers in neurosurgery, especially for neoplasms in brain and spinal canal. The CO2 laser still dominates the field but Neodymium YAG is also finding wide use. The author comments on directions that laser neurosurgery may take in the future. Special emphasis is made on new applications combining advanced technologies, including CAT scanning, ultrasonography, stereotaxic techniques, and computer control.

Brain Neoplasms↗
PubMed2004

[Postoperative nausea and vomiting after neurosurgery (infratentorial and supratentorial surgery)].

OBJECTIVE: To perform a synthesis regarding postoperative nausea and vomiting (PONV) after neurosurgery. DATA EXTRACTION: A Medline search was performed to identify publications about frequency, risk factors, prevention and treatment of PONV in adults and children, after neurosurgery. DATA SYNTHESIS: After neurosurgery, the estimated frequency of nausea is around 50% and around 39% for vomiting. After neurosurgery; PONV risk factors are female sex and infratentorial surgery. Children older than two years are at higher risk for PONV. To reduce baseline risk factors, it is recommended to use propofol for induction and maintenance of anaesthesia, to avoid nitrous oxide and to use hydration (20 ml/kg of crystalloids before induction). For PONV prophylaxis, ondansetron and droperidol may be given, using one drug for a moderate risk patient and both drugs for a high-risk patient. Droperidol should not be used in children as a first choice therapy because of an increased risk of extrapyramidal symptoms. Dexamethasone has not been evaluated after neurosurgery. Metoclopramide has no clinically relevant effect for PONV. Especially in neurosurgery, after occurrence of PONV, it is recommended to rule out a possible triggering factor that should need specific treatment. A global management of PONV is proposed, based on the administration of the same drugs given at half the doses used for prophylaxis.

Adult↗
PubMed1999

Pediatric neurosurgery in the Middle East: present and future.

The Middle East is the term used for more than ten countries with populations characterized by different ethnic roots and religions and with diverse political and economic power. It is probably the most unstable part of the whole world, having spent centuries struggling for a settled situation. Reflecting this political turmoil, the health problems and priorities in these countries are very different than in western countries. Medical associations, including neurosurgical associations, in most of these countries have very little communication with international societies compared with such associations in other parts of the world. Although one or two neurosurgeons in almost every country in the region enjoy some prominence in the international neurosurgical arena, almost no society-based relationships have been established among Middle East countries. Pediatric neurosurgery has been regarded as a subspecialty in the Middle East countries for the last two decades. Although it is not well organized except in Turkey and Israel, most of the countries in this region now have neurosurgeons who give special attention to pediatric neurosurgery within their general neurosurgical practice. Practicing neurosurgeons are few and and far between; there are certainly not enough of them to allow specialization in specific fields of neurosurgery in most countries in the Middle East. Moreover, owing to political and economic problems, most countries in the region are behind the standard neurosurgical agenda. Nonetheless, the flow rate of papers submitted to Child's Nervous System from several countries in the region has been slowly but progressively increasing. Hopefully, political stabilization in the near future will activate progress in pediatric neurosurgery along with neurosurgery in this region.

Child↗
PubMed1994

Lectures by neurosurgery and neurology faculty at U.S. medical schools.

The lecture activity of neurology and neurosurgery faculty at allopathic medical schools during the academic years 1985-1986 through 1987-1988 was surveyed. Lectures were categorized into three combinations for analysis: first- and second-year basic science, first- and second-year clinical, and third- and fourth-year clinical lectures. Both faculties delivered more hours of clinical than basic science lectures, and this held true at most schools. Neurology provided lectures at more schools in each of these categories, as well as offering more hours of lecture per student (school medians: 11.5, 18.0, 13.8) than did neurosurgery (school medians: 6.0, 5.5, 8.0). However, neurology faculty number two-and-a-half times neurosurgery faculty. Lectures given per teaching neurology faculty member (12.2) averaged approximately the same as per teaching neurosurgery faculty member (11.5). Increased exposure to the lectures of neurology or neurosurgery faculty did not increase subsequent student enrollment in a first clinical clerkship in that discipline when students had a choice of clerkships.

Clinical Clerkship↗
PubMed2005

History of neurosurgery and neurosurgical applications in Turkey.

Although there is evidence of applications of cranial surgery in ancient times, it is commonly accepted that modern surgery started in the late 19th century. The advancements in anesthesiology and aseptic techniques were the main factors contributing to this process. Surgery of the nervous system, however, has a relatively shorter history than surgery of other systems. The process of surgical development in Turkey did not differ from most Western countries. Modern surgery started in 1890 in Turkey. In the beginning, neurosurgical applications were performed by general surgeons. Most of these applications included procedures for craniocerebral traumas and infections and procedures for pain relief. The first neurosurgeon, Dr. Tuner, started working in 1923, operating in some spinal cord and brain tumor and trigeminal neuralgia cases. Other neurosurgeons, Dr. Dilek, Dr. Baydur, and Dr. Kankat, were trained in France and started to work in the mid 1930s. The first neurosurgery department was established in Istanbul in 1923, and the first neurosurgery training program started in the late 1940s. Today, there are more than 50 neurosurgery training centers and more than 500 neurosurgeons in Turkey. There is an increasing number of publications by Turkish neurosurgeons, contributing to the total body of literature in neurosurgery. The current state of neurosurgery in Turkey is parallel to that of the advanced Western countries.

History, 15th Century↗
PubMed1996

Neurosurgery at the Montreal Neurological Institute and McGill University Hospitals.

For the past 60 years, the Montreal Neurological Institute and Hospital and three associated McGill University teaching hospitals have provided a broad course of instruction in neurosurgery and the related neurosciences. This integrated program offers a wealth of experience in adult and pediatric neurosurgery, based on a total of 140 beds, covering a full range of general and subspecialty neurosurgery. The institute, recognized for many years as a world center for epilepsy surgery, has traditional strengths in the treatment of brain tumors and cerebrovascular and spinal disorders; it has been at the cutting edge of brain imaging in all modalities applied to neurosurgical diagnosis and cerebral localization, including three-dimensional monitoring in the operating room. New approaches to stereotactic procedures have been developed in conjunction with imaging technology, including functional neurosurgery and the versatile McGill double rotation method for radiosurgery with a linear accelerator. Experience in managing trauma, pediatric cases, and general neurosurgical problems is gained at the Montreal General Hospital, the Montreal Children's Hospital, and the Jewish General Hospital. Well-established research units, including burgeoning groups in neurogenetics, molecular neurobiology, and neural regeneration, provide a wide variety of academic opportunities to provide trainees with a sound basis for coping with the rapidly advancing field of neurosurgery.

Academies and Institutes↗
PubMed1996

Minimally invasive neurosurgery.

BACKGROUND: The philosophy and practice of minimally invasive surgery have fundamentally altered the practice of general and gynaecological surgery, and are currently transforming the practice of neurosurgery. The goal of minimally invasive surgery is to reduce tissue disruption and thus morbidity. This is a review of the development, applications, and benefits of minimally invasive neurosurgery, and its wider surgical implications. METHODS: A synthesis of the literature is presented. RESULTS: Interactive computer imaging with frame-based and frameless stereotaxy, ultrasonographic and endoscopic techniques are increasingly being used independently and in combination in order to execute minimally invasive approaches and to navigate a safe path within the cranium or spine. Interaction using an interlinking stereotactic instrument or robot between the surgeon, a graphic interface (such as a computer workstation) and the patient, enables precise planning and execution of surgery with exact correspondence of imaging data and the living pathology. The direct influence of virtual reality, cybernetics, robotics, and telepresence will further revolutionize the practice of neurosurgery and will impact increasingly on other surgical disciplines. Safety and precision are further enhanced by intra-operative physiological monitoring techniques. Interventional neuroradiology and stereotactic radiosurgery add further dimensions to the minimally invasive approach and may not only diminish the need for open surgery, but in selected cases obviate the need altogether. CONCLUSIONS: Minimally invasive neurosurgery is a major force in contemporary neurosurgery and many of the current neurosurgical applications will have far-reaching effects on the practice of surgery in general.

Brain↗
PubMed2004

Father of neurosurgery in Hong Kong.

Neurosurgery in Hong Kong had its origins as a division of General Surgery and became a subspecialty only 46 years ago with the arrival of Hsiang-Lai Wen. For well over a decade, Wen would be the only neurosurgeon in the colony. His contributions to neurosurgery included the ventriculosuperior sagittal sinus shunt and the application of acupuncture in anesthesia, pain ablation, and drug detoxification. A pilot with the China National Aviation Corporation during World War II, he played an active part in the Allied war effort. As a diplomate of the American Board of Neurological Surgery, Wen sought to improve the standard of neurosurgery in Hong Kong and southern China with the establishment of the Hong Kong Neurosurgical Society in 1981 and the Research Institute of Neurosciences in Guangzhou in 1988. Wen was acknowledged as Hong Kong's "father of neurosurgery," and his work paved the way for the development of modern neurosurgery in the region.

Cerebrospinal Fluid Shunts↗
PubMed1989

A century of change in neurosurgery at Johns Hopkins: 1889-1989.

Neurosurgical admissions to The Johns Hopkins Hospital during the first year of its existence, the first and last years of Harvey Cushing's practice, the last years of Walter Dandy's practice, the last years of Earl Walker's tenure, and the current neurosurgical case load are reviewed. Sixteen patients with neurosurgical problems were admitted during the first year of the hospital's existence. In the first year of Harvey Cushing's staff appointment, 38 neurosurgical patients were admitted. Infection, trauma, and trigeminal neuralgia were the most common neurosurgical problems at that time. When Harvey Cushing retired in 1912, his practice had grown to 100 operations per year. By the end of Walter Dandy's tenure, the surgical volume was much larger, more than 500 major operations per year. The development of neurosurgery virtually can be mirrored in the practice of neurosurgery under Harvey Cushing and Walter Dandy. From its humble beginnings in the treatment of trauma and infection, neurosurgery has expanded to cover all forms of intracranial disease, virtually every aspect of spinal disease, vascular disease (both intracranial and extracranial), and peripheral nerve injury. The centennial celebration at Johns Hopkins may be considered a centennial for neurosurgery. As we reflect upon our foundations, it is worthwhile to ask what changes we will contribute to the further development of neurosurgery in the next century.

Academic Medical Centers↗
PubMedDate not supplied

[Training and practice of neurosurgery in USA-personal experience after two-year fellowship in University of Arizona].

Author describes his observations from two-year neurosurgical fellowship in University of Arizona, USA. During the fellowship he underwent rotations to Pediatric Neurosurgery Department at Phoenix Children's Hospital for one year, Neurosurgery Department at University Medical Center for six months, Neurosurgery Department at Veterans Affairs Hospital for three months and private neurosurgery group based on three separate hospitals for three months. Work in the particular departments is described as well as process of fellowship position obtainment and statistical data regarding fellowships and residences in neurosurgery in USA.

Arizona↗
PubMedDate not supplied

Low-molecular-weight and unfractionated heparin for prevention of venous thromboembolism in neurosurgery: a meta-analysis.

BACKGROUND: Venous thromboembolism is a common, life-threatening complication in neurosurgery, but prophylaxis with anticoagulant agents has not gained wide acceptance because of concern about intracranial bleeding. We performed a meta-analysis of controlled randomized trials on the efficacy and safety of heparin in the prophylaxis of venous thromboembolism in neurosurgery. OBJECTIVE: To review the clinical benefit of prophylaxis of venous thromboembolism with heparin in the controversial setting of neurosurgery. METHODS: Relevant trials evaluating heparin for prophylaxis of venous thromboembolism in neurosurgery were identified by a MEDLINE search, scan of meeting abstracts, and scrutiny of the references of original articles and reviews. Four controlled randomized studies, 3 of which involved low-molecular-weight heparin, were included in the analysis, and 4 uncontrolled studies are commented on in the article. The outcome measure (observed minus expected number of events) and its variance were calculated for each single trial and then summed. Two-tailed P values and 95% confidence intervals (CIs) were calculated. Efficacy was assessed per protocol and safety by intention-to-treat analysis. The homogeneity of the studies was tested with the chi(2) statistic. The results were also expressed as number needed for 1 extra event. RESULTS: A total of 187 thromboembolic events were recorded in 827 patients (22.6%). Heparin prophylaxis resulted in a 45% relative risk reduction of venous thromboembolic events (odds ratio [OR], 0.48; 95% CI, 0.35-0.66; P<. 001). Nineteen major bleedings were recorded in 1022 patients. None were fatal. Heparin treatment resulted in a 71% relative risk increase of major bleeding (OR, 1.72; 95% CI, 0.69-4.27; P =.24). The number needed to treat was 7.7 for venous thromboembolism and 16 for proximal deep vein thrombosis. The number needed to harm was 102 (115 for low-molecular-weight heparin). CONCLUSIONS: Low-molecular-weight and unfractionated heparin have been shown to be effective for prophylaxis of venous thromboembolism in elective neurosurgery without excessive bleeding risk.

Hemorrhage↗
PubMed2005

Characteristics of adult patients with growth hormone deficiency who underwent neurosurgery for functioning and non-functioning pituitary adenomas and craniopharyngiomas.

The aim of the present study was to evaluate the characteristics of GH deficiency (GHD) in adult patients after neurosurgery for pituitary adenomas and craniopharingiomas. One hundred and one GHD patients, (42 F/59 M), aged 47.58+/-14.4 yr (mean+/-SD; range 21-78), body mass index (BMI) 28.6+/-0.6, with a history of adult-onset hypothalamic-pituitary disease, were recruited for the study. The whole group included: 45 non-functioning pituitary adenomas, 23 craniopharyngiomas, 16 PRLomas, 8 GHomas, 7 ACTHomas and 2 FSHomas; in particular 51 were macroadenomas and 27 microadenomas. At study entry, GHD diagnosis was carried out by assessing GH secretion after GHRH+arginine. All patients were submitted to the study at least 12 months after neurosurgery and, where needed, subjects were replaced with an appropriate treatment. GHD was mild in 3/101 (3%) and severe in 98/101 patients (97%). Other hormone deficiencies associated with GHD were considered: TSH, ACTH, FSH/LH, ADH. The distribution of peak GH among all patients, according to the type of disease before neurosurgery, showed that patients with Cushing disease were characterized by the presence of higher peak GH. According to the number of additional hormone deficits, the distribution of peak GH among all patients was as follows: GHD was isolated in 4/101 subjects (4%; group A), while it was associated with 1 (14/101, 14%; group B), 2 (22/101, 22%; group C), 3 (44/101, 43%; group D) and 4 hormone deficits (17/101, 16%; group E). GHD was severe in all patients in the panhypopituitaric group. Total IGF-I plasma levels in the whole group of GHD patients were 95.2+/-4.2 microg/l. In all groups of patients IGF-I was lower in subjects with severe GHD than in those with mild GHD (93.6+/-4.1 vs 148.6+/-33.6 microg/l, p<0.03). In particular, according to the type of disease presented before neurosurgery, patients with Cushing disease were characterized by the presence of higher IGF-I plasma levels compared to the other. According to the number of additional deficits, the distribution of IGF-I plasma levels was characterized by higher values when GHD was isolated than when it was associated with multiple hormone deficiencies. IGF-I plasma levels were positively associated to peak GH during GHRH+arginine (r=0.4, p<0.0005). We conclude that patients after neurosurgery approach for sellar and parasellar neoplasia, within an appropriate clinical context, and both the presence of additional pituitary hormone deficiency and low levels of IGF-I can be considered a clear GHD condition, and therefore do not require provocative tests evaluating GH secretion.

Adenoma↗
PubMed2002

New-onset psychogenic seizures after intracranial neurosurgery.

BACKGROUND: Patients with physical brain abnormalities have an increased risk of developing psychogenic nonepileptic seizures (PNES). Here we describe patients who developed PNES after intracranial neurosurgery for indications other than the control of refractory epileptic seizures and explore whether neurosurgical intervention is at risk factor for PNES. METHOD: We searched the database of 372 patients diagnosed with PNES at our department over the last 10 years and identified 17 patients (4.6%) in whom PNES first started after intracranial neurosurgery. Surgical procedures included the complete or partial resection of a meningioma, AV malformation, cavernoma, plexus papilloma, neurinoma, astrocytoma, oligodendroglioma, dysontogenetic cyst, the drainage of a brain abscess and removal of a subdural hematoma. PNES were documented by ictal video-EEG, ictal EEG, or ictal observation and examination in all cases. The diagnosis of additional epileptic seizures were confirmed by ictal EEG/video-EEG, or made on the basis of a clinical assessment by an experienced epileptologist. FINDINGS: Five patients had purely psychogenic postoperative seizure disorders, twelve had epileptic and psychogenic attacks. Median age at neurosurgery was 32 years (range 5-54), median latency between surgery and onset of PNES was 1 year (range 0-17 years). INTERPRETATION: PNES may develop after intracranial neurosurgery undertaken for other indications than the control of refractory epileptic seizures. Younger patients with a history of pre-operative psychiatric problems or epileptic seizures and surgical complications may be at higher risk. A diagnosis of PNES should be considered in patients who develop refractory seizures after neurosurgery.

Adaptation, Psychological↗
PubMed1999

Vancomycin use in pediatric neurosurgery patients.

OBJECTIVE: The objective of this article is to describe a pediatric neurosurgery patient population receiving vancomycin and examine the indications for and appropriateness of vancomycin use. METHODS: A cross-sectional study was performed on the pediatric neurosurgery patients at Egleston Children's Hospital who received vancomycin from January 1 through December 31, 1996. Vancomycin use was compared with the Centers for Disease Control and Prevention Hospital Infection Control Practices Advisory Committee recommendations for vancomycin use. RESULTS: Thirty patients received 115 doses of vancomycin. The median patient age was 8.0 years, and 17 (56.7%) were male. Vancomycin was used for prophylaxis in 28 (93.3%) patients and empiric therapy in 3 (10.0%) patients; one patient received vancomycin for surgical prophylaxis followed by empiric therapy for suspected meningitis. Vancomycin prophylaxis was initiated after the incision in 6 (21.4%) patients and was continued as prophylaxis for more than one dose in 26 (92.9%) patients. CONCLUSIONS: Vancomycin was used primarily as surgical prophylaxis in pediatric neurosurgery patients, and use was not consistent with the Hospital Infection Control Practices Advisory Committee recommendations. These data suggest that for certain subpopulations, such as pediatric neurosurgery patients, there is a need for more specialized recommendations. Furthermore, prudent vancomycin use is warranted to successfully decrease the risk of further emergence of vancomycin resistance. Because vancomycin use may be prevalent in this population, assessment of vancomycin use in pediatric neurosurgery patients followed by establishment of vancomycin clinical guidelines may help improve the appropriateness of vancomycin use in this population.

Adolescent↗
PubMed1999

Initial clinical experience with a combined pulsed holmium-neodymium-YAG laser in minimally invasive neurosurgery.

Various biophysical features of the laser beam have already been utilized in clinical neurosurgery. However, the application of this therapeutic modality has by no means been overexploited. The history of laser application in neurosurgery has shown that there is no universal laser system capable of performing all surgical tasks in a suitable manner. The best results in traditional neurosurgery were achieved with instruments combining various wavelengths, such as the CO2 and neodymium-YAG lasers. A pulsed holmium-YAG and neodymium-YAG (Ho:YAG and Nd:YAG) combined laser have been recently developed to meet the special requirements of minimally invasive neurosurgery. The system consists of a compact double-crystal single-head solid-state laser system generating 2 different wavelengths (Ho:YAG 2.08 microns and Nd:YAG 1.05 microns), selected for their capabilities of efficient coagulation and ablation. The two wavelengths are coupled into a common flexible optical fiber, which allows endoscopic application. The wavelengths can act simultaneously or separately without any interchange of the instruments. The system was employed first for experimental and subsequently for clinical purposes, primarily for endoscopic operations. In this work the initial clinical experience is reported. The excellent haemostatic properties of the Nd:YAG laser and the ablative properties of the Ho:YAG laser were confirmed. It was concluded that simultaneous application of the two laser modalities within one flexible fiber offers new perspectives in tissue handling in endoscopic neurosurgery and as in open microsurgery.

Adult↗
PubMed2000

Changes of the hemostatic network in critically ill patients--is there a difference between sepsis, trauma, and neurosurgery patients?

OBJECTIVE: To study the time course of coagulation data in intensive care patients. DESIGN: Prospective, descriptive study. SETTING: Clinical investigation on a surgical and neurosurgical intensive care unit of a university hospital. PATIENTS: Fifteen patients with severe trauma (injury severity score, 15 to 25), 15 sepsis patients secondary to major surgery, and 15 neurosurgery patients (cancer surgery) were studied. INTERVENTIONS: Standardized intensive care therapy. MEASUREMENTS AND MAIN RESULTS: Standard coagulation data and molecular markers of coagulation activation and fibrinolytic activity (soluble thrombomodulin, protein C, free protein S, thrombin/antithrombin III complex, plasmin-alpha 2-antiplasmin complex, tissue plasminogen activator, platelet factor 4, beta-thromboglobulin were measured from arterial blood samples on the day of admission to the intensive care unit (trauma/neurosurgery patients) or on the day of diagnosis of sepsis (baseline value) and serially during the next 5 days. Antithrombin III, fibrinogen, and platelet counts were highest in neurosurgery patients but without significant differences between sepsis and trauma patients. Thrombin/antithrombin III complex increased in the sepsis patients (from 22.6+/-4.2 microg/L to 39.9+/-6.8 microg/L), but decreased in trauma (from 40.2+/-5.1 microg/L to 17.6+/-4.0 microg/L) and neurosurgery patients (from 28.2+/-4.2 microg/L to 16.2+/-3.8 microg/L). Tissue plasminogen activator increased in the sepsis patients (from 14.4+/-3.9 microg/L to 20.7+/-3.8 microg/mL) and remained almost unchanged in the other two groups. Soluble thrombomodulin plasma concentration increased significantly in the sepsis group (max, 131.8+/-22.5 ng/mL), while it remained elevated in the trauma (max, 75.5+/-5.9 ng/mL) and was almost normal in the neurosurgery patients. Protein C and free protein S remained decreased only in the sepsis group. CONCLUSIONS: Alterations of the hemostatic network were seen in all three groups of critically ill patients. Hemostasis normalized in the neurosurgery patients and posttraumatic hypercoagulability recovered within the study period. By contrast, monitoring of molecular markers of the coagulation process demonstrated abnormal hemostasis in the sepsis patients during the entire study period indicating ongoing coagulation disorders and abnormalities in fibrinolysis in these patients.

Adult↗
PubMed1998

Resurgence of functional neurosurgery for Parkinson's disease: a historical perspective.

The history of functional neurosurgery for the treatment of Parkinson's disease is reviewed. Two major stages may be distinguished: (1) open functional neurosurgery, which started in 1921 with bilateral cervical rhizotomy by Leriche. In 1937 Bucy performed the first motor cortectomy in a tremor patient, and subsequently introduced lesioning of the corticospinal tract at different levels. In 1939 Meyers started open transventricular surgery of the basal ganglia, which was abandoned in the 1940s because of high mortality. However, this operation drew attention to the basal ganglia and their efferent pathways as surgical targets for the relief of parkinsonian symptoms. (2) Stereotactic (closed) functional neurosurgery in patients was in 1947 for the first time performed by Spiegel and Wycis, soon followed by surgeons in various countries. Originally, the globus pallidus and the ansa lenticularis were the surgical targets but were replaced at the end of the 1950s by the ventrolateral thalamus. A few surgeons positioned their lesions in the subthalamic area. In both targets favorable results were reported for the treatment of tremor and rigidity with acceptable adverse events. In selected patients, bilateral surgery was performed. In 1969 the results of more than 37,000 stereotactic operations had been published. Criteria for the surgical technique and selection of patients were described, and various stereotaxic atlases became available. At that time, L-dopa became generally available and the number of stereotactic operations declined dramatically. However, as a result of the shortcomings of the L-dopa therapy in the long-term treatment of Parkinson's disease, the thalamotomy gradually regained its place. New developments were the reintroduction of the pallidotomy by Laitinen in 1992 and the thalamic stimulation for pharmacotherapy-resistant tremor by Benabid and collaborators in 1991. New insights in the pathophysiology of Parkinson's disease supported the revival of the functional stereotactic neurosurgery and recently caused the introduction of the subthalamic nucleus as a surgical target in the treatment of Parkinson's disease.

History, 18th Century↗