|CHRONICLES OF MEDICINE
|Year : 2014 | Volume
| Issue : 1 | Page : 56-61
Ancient roots, gestational phase, and modern epoch of neurosurgery
Department of Diagnostic Radiology and Imaging, Safdarjung Hospital and Vardhman Mahavir Medical College, New Delhi, India
|Date of Web Publication||3-May-2014|
Prof. Yatish Agarwal
Department of Diagnostic Radiology and Imaging, Safdarjung Hospital and Vardhman Mahavir Medical College, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
The chronicles of modern neuroscience are filled with extraordinary romanticism. The triumphant, even if turbulent, journey is punctuated by man's abstract out-of-the-box thinking, audacity, amazing flashes of brilliance, courage, inventiveness, sagacity, and serendipity. The journey began with trepanation, or cutting holes in the skull. The first skull operations were carried out by Neolithic Peruvian Indians around 10,000 bc. Down the centuries the procedure was embraced by preliterate world all over mother earth. Even today, through the ubiquitous e-space, charlatans advocate trepanation for "enhancing consciousness"! The first musings that different types of head injury produce different symptoms stand engraved in gold in the Egyptian Edwin Smith surgical papyrus (1,600 bc). That the human brain-and not the heart-is the motherboard of all cognition and emotion, and seat of sensation, movement, and mentation came to be known only when the prince of physicians, Galen of Pergamum carried out his classical squealing hog experiments in the 2nd century. Nevertheless, it was not until the work of the great neuroanatomist Ramσn y Cajal (1852-1934) and that of the founder of modern neurophysiology Lord E. D. Adrian (1889-1977), that modern neuroscience found its terra firma. The more recent era, however, has witnessed a truly remarkable technological advancement. If the works of Sir Godfrey N. Hounsfield, Allan M. Cormack and Raymond Damadian have pried open the lid on human brain and spine through true-to-life cross-sectional anatomical and functional imaging, Leksell and Larsson's gamma knife, Russel Brown's stereotactic surgery, laparoscopes, brain suites, synthetic discs and pleuripotent stem cells have opened totally new vistas in the realm of neurosurgery. Given the diktat of space, capturing all the magical moments of this evolution is willy-nilly impossible. Yet, if this story narrates the essence of how a few men-in-white faced the rigours of their times and triumphed over the challenges, the scalpel would have found its mark.
Keywords: Trepanation, neurosurgery, ancient practices, ventriculography, pneumoencephalography, cerebral angiography, prefrontal leucotomy, Neurological Society of India, brain suite, gamma knife, stem cells
|How to cite this article:|
Agarwal Y. Ancient roots, gestational phase, and modern epoch of neurosurgery. Astrocyte 2014;1:56-61
Early Days: The Beginning of Trepanation
The oldest known neurosurgical procedure is trephination. Anthropological studies prove that this surgical procedure was performed in many parts of the world since late Paleolithic period.  The first skull operations were performed by Peruvian Indians around 10,000 BC.  Most of the exhumed trephined skulls belonging to this period carry a definite scar at both edges of the wound. This is evidence that the subjects must have lived for several years following surgery. Such trephined skulls belong to both genders and all ages. In this prehistoric era, five methods of trephination were used.  The first method used rectangular intersecting cuts, and obsidian, flint, or other hard stone knives and later metallic objects were utilized to make these cuts. The curved metal knife tumi, found in Peruvian burial sites might well have been used for the job.  The second method entailed scraping with a flint. Such trephined skulls have been found in France. This method was particularly common in Europe and persisted into the Renaissance in Italy.  The third method employed making a circular groove and lifting the disc of bone. This widespread method was in vogue until recent in Kenya. The fourth method, the use of a circular trephine or crown saw, may have developed out of the third. The trephine used was a hollow cylinder with a toothed lower edge. A retractable central pin and a transverse handle were later added to it. This contraption looked almost identical to modern trephines.  The fifth method employed drilling a circle of closely spaced holes and cutting or chiselling the bone between the holes. This method was used by the Arabs, and became a standard method in the Middle Ages. Essentially, this method is the same as the modern technique of turning a large osteoplastic flap in which a Gigli saw is used to saw between a set of small trephined or drilled holes. 
Neurosurgical Practices in Ancient Egypt
The Edwin Smith Surgical Papyrus, one of the oldest of all known medical papyri must hold a special lure for all neurosurgeons. It presents the first descriptions of cranial sutures, meninges, external surface of the brain, cerebrospinal fluid, and intracranial pulsations. ,
Containing the first accounts of surgical stitching, it describes various types of dressings for head injuries. It narrates the association of brain injuries with change in function of other parts of the body, especially lower limbs, and hemiplegic contractures. Changes in bodily functions are also described in association with cervical spine injuries. It also contains the first description of quadriplegia, urinary incontinence, priapism, and seminal emission following cervical vertebral dislocation. The symptoms and signs of head injury are portrayed in considerable detail. ,
The text has 33 systematically arranged neurosurgical case histories. Of them, 27 relate to head injuries and 6 with spinal trauma. Of the 27 head injuries, 4 are deep scalp wounds exposing the skull, and 11 are skull fractures. Among these 11 skull fractures, if modern terminology were to be used, 2 would stand classified as compound linear fractures; 4 compound depressed fractures; 4 compound comminuted fractures; and 1 a comminuted fracture without external wound. The symptoms and signs of head injury are described in extensive detail. Feeble pulse and fever are associated with hopeless injuries and deafness as well as aphasia is recognized in fractures of the temporal region. ,
600 BC-500 BC
Neurosurgical Practices in Ancient India
The principal authors of ancient Indian medical text were Sushruta, Charaka, Vagabhata, Bela and Madhava. The ancient Indian physicians, however, were a little uncertain whether hridaya (heart) or mastishka (brain) were the seat of consciousness.  The words mastishka and mastulunga (brain) appear in the texts of both Sushruta and Charaka Samhitas. An account of the central nervous system and its pathology can be found in both these texts. 
Old texts reveal that Jivaka, physician to Gautam Buddha and King Bimbisara, was well versed in trepanation and removal of intracranial mass.  The neurosurgical accomplishments of Sushruta, the master surgeon of Kashi, are well documented in the Sushruta Samhita.
Greek treatise on Management of Head Injuries
Greek physician, Hippocrates, wrote a whole treatise on the management of head injuries. He observed that while even very grave head injuries were not always hopeless, none was so trivial that it could be ignored. He recognized that the special danger in head injuries was that the skull allowed no room for expansion. A small amount of blood was enough to irritate or compress the brain. He recognized that although organic damage to the brain could not be repaired, much could be done to prevent further harm. 
Hippocrates established that a depressed fracture was to be treated by replacing the fragment. It could otherwise result in building up of pressure on the underlying brain tissue. 
First Recorded Removal of a Meningioma
A Scottish surgeon from Glasgow, William Macewen (1848-1924 AD) ventured into the new realm of modern neurosurgery. In the year 1879, he demonstrated his competence and surgical skill by removing a left frontal meningioma. His patient was a teenager, who could resume normal life subsequent to the surgery. 
The First British Neurosurgeon
Sir Victor Alexander Haden Horsley (1857-1916) became the first British surgeon to hold official appointment of a neurosurgeon at the National Hospital, Queen Square, London. In 1886, Horsley performed 10 operations to remove brain tumors and was named a Fellow of the Royal Society.  In 1887, Horsley and his former professor, Sir William Gowers, performed the first surgery to remove a spinal tumor. The surgery was successful and the patient was able to walk again. Horsley also developed the bone wax to stem hemorrhage during surgery.
Success in Debridement of Brain Abscess
William Macewen published a series of successful neurosurgical operations on 21 out of 22 brain abscesses and five out of five extradural abscesses. At that time most other surgeons had 100% mortality rates for these conditions.  His triumphs remained unequalled until the discovery of penicillin. In that era, surgeons also did not have any support of diagnostic imaging. Even X-rays had not been discovered.
The First French Neurosurgery Textbook
The first French neurosurgeon Antoine Chipault published a two-volume textbook on essential tenets of neurosurgery. This work had separate sections on skull base surgery, epilepsy surgery, synthetic cranioplasty, hydrocephalus surgery, spina bifida surgery, surgery of spinal fractures and tumors, and torticollis, trigeminal neuralgia and intractable pain. 
Perfecting the Art of Modern Neurosurgery
Harvey Williams Cushing (1869-1939), an American physician, took to surgery of the brain and made it his life's mission. He inspired several other surgeons to take up this new branch of surgery and could establish neurosurgery into a distinct specialty. He developed a series of new neurosurgical operations to advance neurosurgery.
Cushing treated tumors, epilepsy, trigeminal neuralgia, and pituitary disorders successfully. He used careful observation to diagnose tumors of the brain. By 1908, he had perfected a technique for the removal of benign brain tumors by observing the reactions in eyes of his patient. 
Birth of the Transsphenoidal Approach
American Surgeon Allen B. Kanavel (1874-1938) working with Chicago's Northwestern University was the first to take an infranasal trans-sphenoidal approach to access the pituitary. His pioneering work laid the foundation of a new neurosurgical department at Northwestern University, which became the germinating ground for several seminal neurosurgical works. 
Unveiling the Pituitary
Harvey Williams Cushing made a careful study of the pituitary gland. In 1912, he identified the Cushing's disease and recognized that it was caused by pituitary malfunction. He also found that the removal of pituitary gland leads to genital atrophy. 
Besides being a meticulous surgeon, he also passed this knowledge and skills to fellow surgeons who were quick to adopt his careful techniques. Cushing can be considered the torchbearer of modern epoch in neurosurgery.
Debut of Ventriculography
American neurosurgeon Walter Edward Dandy (1886-1946) at the Johns Hopkins Hospital, Baltimore, experimented with contrast media and introduced the new remarkable technique of ventriculography in 1918. 
Pneumoencephalography is introduced
In 1919, Walter Edward Dandy introduced pneumoencephalography for localizing tumors by injection of air into cerebral ventricles and the spinal subarachnoid space. He described the enormous diagnostic significance of pneumoencephalography, but also brought to book its lethal potential. 
The First Neurosurgical Society
The Society of Neurological Surgeons was founded in the United States. It had, at that time, a total of 19 members. 
Birth of Cerebral Angiography
Portuguese neurosurgeon Antonio Caetano de Egas Moniz, professor of neurology in Lisbon, introduced the path-breaking technique of cerebral angiography. 
Neurosurgery finds place in Ochsner's Textbook of Surgery
Allen B. Kanavel wrote a chapter on neurosurgery in the 1930 edition of Ochsner's Textbook of Surgery. It carried the title "Diagnosis and Treatment of Tumors, Inflammations and Abscesses of the Brain." The work portrayed his dense knowledge of neurological diagnosis and surgical treatment. He also described the anatomy of trigeminal nerve and the procedure of laminectomy. 
Textbook on Peripheral Nerve Injuries
Chicago surgeon, Loyal Davis at Northwestern University and neurologist Lewis J. Pollock co-authored the text Peripheral Nerve Injury, and described the various signs associated with these injuries and gave out their management. 
Nobel-prize winning Technique of Lobotomy
Portuguese neurologist, António Egas Moniz, and his colleague, Almeida Lima, pioneered the procedure of lobotomy or prefrontal leukotomy. Based on experimental studies in chimpanzees, lobotomy offered revolutionary relief in psychosis. 
The original Moniz procedure entailed making two side openings in the skull, one each above the temple, and severing the nerve fibers which connect the thalamus with frontal lobes of brain. Lobotomies are no longer performed.
Steps to Reduce the Risk of Head Injuries
During the Second World War, Loyal Davis was chosen to serve as a senior neurosurgical consultant to the European Theatre of Operations. During his tenure with the Army, he suggested several improvements in the design of helmets and military vehicles to reduce the risk of head injuries in the battlefield. 
New allies for Hemostasis in Neurosurgery
Control of bleeding is fundamental to the success of any surgery. However, traditional hemostatic tools like ligatures, metallic clips and electrical coagulation cannot be used satisfactorily in certain neurosurgery procedures since it is difficult to access the blood vessels. Sometimes, the blood vessels also retract and cannot be reached.
Various ingenious means were discovered to control bleeding under these compelling circumstances. In 1944, fibrin foam came to the fore as an effective coagulant. However, procurement of fibrin foam proved difficult. This led to production of a spongy substance from partially denatured gelatin. These sponges when dipped in bovine thrombin were found most useful. The material adheres to the bleeding surface and readily controls the bleeding with minimum tissue reaction. 
Birth of Neurological Society of India
In 1950, neurosurgeons Dr. B Ramamurthi and Dr. Mathew Chandy, neurologist Dr. Baldev Singh and neurophysiologist Dr. ST Narasimhan met in the city of Madras. This meeting led to the birth of Neurological Society of India at Hyderabad in 1951. The event was a part of the annual meeting of Association of Physicians of India. 
Focus on Movement Disorders, Extrapyramidal Pathways, and host of Other Areas
American neurosurgeon Paul C. Bucy (1904-1992) worked on movement disorders and spinal cord injury. Based on his studies of the pyramidal tract, he postulated the existence of the extrapyramidal pathways. Clinically, a surgeon par excellence, Bucy could perform a subtemporal retrogasserian rhizotomy in 18 minutes, skin to skin. 
Bucy carried out neurosurgical operations for pituitary adenomas, acoustic schwannomas and malignant gliomas. He advocated radical removal of gliomas. His knowledge of neuroanatomy was exceptional and he possessed extraordinary surgical instincts. 
Intranasal Radioisotope Implant for Pituitary
Dr. GV LeRoy and his team at the University of Chicago discovered the use of isotope yttrium-90 for extirpation of pituitary gland. The isotope was implanted intranasally, for palliating certain hormone-dependent cancers.
Evolution of Newer Concepts, Operating Microscope and Advances in Surgery
Greater understanding evolved around the pathology of lumbar spinal stenosis, central spinal cord injuries, and spondylolysis. Cloward and Robinson and Smith performed the first anterior cervical discectomies. Based on the Korean War experience, surgery for spinal injuries became more robust.
The first operating microscope was invented. This paved the way for minimally invasive discectomy. The first advances in bone fusion were made with the discovery of bone morphogenic proteins.
Major neurosurgical advances in 1960s included the introduction of instrumented lumbar fusion (with metal hardware) and development of a number of new surgical approaches for thoracic disc herniation.
Advent of Gamma Knife
Prof. Lars Leksell, a Swedish neurosurgeon, and Bjorn Larsson, a radiobiologist from Uppsala University, invented gamma knife at Karolinska Institute. The device contained 201 cobalt - 60 sources of approximately 30 curies (1.1 TBq) each, placed in a circular array in a heavily shielded assembly and aimed ablative dose of gamma radiation through a target point in the patient's brain to treat cerebral tumor.
Birth of the First Computed Tomography (CT) Scanner
British engineer Sir Godfrey Newbold Hounsfield and American physicist Allan MacLeod Cormack developed the first CT scanner. Hailed as one the most noteworthy medical advancement ever made, CT revolutionized neuroimaging. The first CT scanner required 4.5 min of scanning and 1.5 min of computer reconstruction to generate a single slice. The latest CT scanners create a slice in less than 1s.
Advancements in Minimally Invasive Surgery
The first percutaneous discectomy was performed. The use of the anterior approach was developed for making lumbar fusions. Anterior and posterior cervical fusion techniques were perfected.
First Clinical Use of Magnetic Resonance Imaging (MRI)
Based on the path-breaking work of the American researcher, Raymond Damadian, the first clinical images of the brain and spine were obtained with a nuclear MRI machine. The development of MRI has totally transformed the arena of neuroimaging. It is an excellent window to both structure and function.
CT is harnessed to guide Stereotactic Surgery
Dr. Russell A. Brown, an American physician and computer scientist, invented a simple technique to guide stereotactic surgery using CT. This technique has significantly improved surgical precision because CT permits a direct visualization of intracranial anatomic detail. The technique uses fiducials to create extracranial landmarks in each tomographic image or section. These landmarks specify the spatial orientation of that section with respect to the stereotactic device. Brown's invention stimulated intense interest in stereotaxy and radiosurgery.
Frameless Stereotaxy to Synthetic Grafts
In 1982, the first frameless stereotaxy made an advent. Percutaneous approaches for osteoporotic fractures were developed. Various biochemical graft materials were refined. This included the introduction of number of materials which could act as synthetic substitutes to bone.
Artificial Discs and Other Developments
Artificial discs entered into neurosurgical protocols. Replacement of the disc nucleus became possible. Endoscopic, laparoscopic, and thoracoscopic techniques were perfected. Bone morphogenic proteins become commercially available.
Picture: Courtesy Medanta Medicity
The Dawn of a New Horizon
Neurosurgeons may well routinely transplant dopamine-producing cell tissue into the brain to correct Parkinson disease. Current clinical trials promise favorable outcome.
Stem cell-based techniques could well become common as established treatments for degenerative conditions such as Alzheimer's disease and other forms of dementia.
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