Книги по МРТ КТ на английском языке / Neurosurgery Fundamentals Agarval 1 ed 2019

with a CT scanner, which was put in 1981 here at UPMC. In 1987, we brought in the first 201 source gamma knife (fifth unit ever built) for brain surgery. Over the last 30 years, we have updated the various gamma knife devices five times and now radiosurgery has become a major component of what is done in neurosurgery, both in the brain and spine. Currently in our program, which is probably one of the busiest in the US, we do about 9,000 operations per year. Radiosurgery techniques, using things like gamma knife and spine radiosurgery devices, accounts for somewhere around 12% of the total neurosurgery practice. It has become a major component of what the field is and it is a major component of what current residents in training need to learn while they are in training. My other interests have been related to proving that new technology has value. One of the crazy things about US healthcare is that sometimes industry develops tools that are expensive but are not always shown to have sustained value over the course of time. What we have done in working with tools like gamma knife is to maintain comprehensive patient databases that allow us to do long-term outcomes research. We have published somewhere around 650 peer-­reviewed articles in the scientific literature plus 12 books related to technology, a large number of them related to gamma knife. Patient care, teaching, and academic publishing in clinical research is what I have been doing for 40 years or so that I have been in practice.”

Mentorship

“When I was in childhood and through high school, I studied piano for many years, and I had a 90-year-old piano teacher who was a concert pianist. She had a significant impact on me in terms of the need to study and apply myself. I was a never a natural talent in piano, but I was someone who was able to work hard to meet her demanding nature. Similarly, I do not think that people

who go into neurosurgery should be rocket scientists in the sense of being 200-level IQs. I think those people are brilliant theoreticians but they cannot deal with the reality of taking care of a patient sitting in the emergency room with a blood clot in their head. You have to be able to focus and apply yourself. Certainly when I decided to come to Pittsburgh for training, Peter Jannetta, who was the first truly academic chair of this department, was a major influence on me because of his somewhat demanding nature, but also his requirement that you provide skillful surgical care of patients. After that, I had experience working with two Swedish neurosurgeons Eric Olof Backlund­ at the Karolinska institute, and Lars Leksell, who was the originator of Gamma Knife. He was no longer clinically active, but was very much active in terms of his continued research interests and how to do this type of noninvasive surgery.”

Nathan Zwagerman, MD

Assistant Professor

Department of Neurosurgery

Medical College of Wisconsin

“I grew up on a small farm in Michigan. My parents are hog farmers and I am the oldest of four boys. In rural west Michigan, the plan was that I would continue the farming line. However, early on, I realized that I did not want to be on a farm. Farming just was not for me. I did not mind the work, but I just did not like it. So I was looking for every opportunity I could get to leave. It was clear from an early age that I enjoyed learning about the biology of the hogs and when I was in high school, I took Advanced Placement biology.

During medical school, I enjoyed anatomy and doing dissections in the cadaver lab. I realized very quickly that I could not sit in class anymore. I was very tired of lectures and lecture halls and all the lectures were available online at twice the speed. To get me out of the house, I ended up

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going to different grand rounds, depending on what subject we were studying. During neuroanatomy, I interacted with a couple of neurologists in the beginning of my third year and they told me about neurosurgery grand rounds.

I was leaning towards surgery at that point. I went to neurosurgery grand rounds midway through my third year. They were presenting at Morbidity and mortality (M&M), it was an aneurysm case, which was initially nonruptured. The video was up and as they were about to clip the aneurysm and the aneurysm ruptured. I remember the intensity of the room changed. The entire atmosphere was something that I had never experienced before. I thought this is something I must know more about. As a result, during my third year, I learned more about it, spent more time going to grand rounds, meeting the residents, picking their brains, just kind of hanging out around the department, while doing my rotations. I did a month of research with Dr. Ding, who also helped guide me further toward neurosurgery. I did a couple of rotations at Wayne State, Northwestern, and the University of Vermont, and was totally secured that neurosurgery was where I wanted to be. That is how I got into neurosurgery, I was a late bloomer, so to speak. Ten years ago, I would have never pictured myself as a skullbased surgeon in Milwaukee, but it is funny how life takes you on a ride.”

Shelly D Timmons, MD, PhD, FACS, FAANS

Professor of Neurosurgery Vice Chair for Administration Director of Neurotrauma Department of Neurosurgery

Penn State University Milton S. Hershey Medical Center

Hershey, Pennsylvania

“From the time I was a little girl, I had a keen interest in all things medical and anatomical, and I knew that I wanted to be a doctor at a very early age. When I was

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about 16, I read an article about brain surgery and from that moment on, there was nothing else I ever wanted or planned to do. The brain as the arbiter of our interactions with others and the world had always fascinated me, and the opportunity to work with my hands (as is so prevalent amongst surgeons) was a driving factor, as well as the chance to study and understand the most complicated organ in existence! That interest also led me to pursue my PhD in neurophysiology when the opportunity arose at the end of my residency training.”

Robert F Heary, MD, FAANS

Professor

Department of Neurological Surgery Director, Center for Spine Surgery and

Mobility

Rutgers New Jersey Medical School Newark, New Jersey

“I began my career as a general surgery resident. Midway through my third year of residency, I rotated on the neurosurgery service and had a great time. It became apparent that neurosurgeons had the opportunity to use their minds to think through complex decisions and help many people in the process. The thrill of taking care of debilitated and injured patients was fabulous. After my rotation on neurosurgery was completed, the Chief of the Section of Neurological Surgery (part of the Department of Surgery in those days) asked me to leave General Surgery and become a neurosurgery resident. It took me less than an hour to realize that this was the chance of a lifetime. Between the various spine surgeries and brain operations that I had the good fortune of participating in, I was thoroughly convinced that the correct career path for me was being handed to me and I accepted the position. I then began five more years of residency in neurological surgery and I have never regretted this decision for an instant. Later in my neurosurgical training, I decided to specialize in spinal surgery and I took an offer at a prestigious orthopaedic spine program to become a

spine fellow. Once again, I was very fortunate to make an excellent decision. Having spent the past 2+ decades performing complex surgery, and training a large number of superb neurosurgery residents during this time, has been the best decision I have ever made. I would not trade the career in neurosurgery for any other job in this world. I am also completely confident that our wonderful profession will continue to attract the “best and brightest” to enter into the rapidly expanding field of medicine that enables us to do more positive things for our patients than any other field in medicine.”

M Sean Grady, MD

Charles Harrison Frazier Professor of

Neurosurgery

Chairman, Department of Neurosurgery

Perelman School of Medicine

University of Pennsylvania

Philadelphia, Pennsylvania

“Entering medical school at Georgetown, I was unsure of what specialty I might ultimately choose. I was fascinated by Anatomy and challenged by Neurosciences so felt, upon starting clinical rotations that somewhere in the field of surgery would lie my future. A 2-week rotation on the Neurosurgery service set my career for the next 35 years. Unlike other services, I would enthusiastically spend all day and night taking care of the patients, being in the operating room and reading and learning nonstop. It was phenomenally exciting and I now realize that level of commitment is the hallmark for someone interested in a career in Neurosurgery. It is an enormously rewarding and at the same time incredibly humbling career in which I thought then and know now that I would be an eternal student. In my training at the University of Virginia from 1981 to 1987, I never saw a MRI; there was no endovascular neurosurgery, endoscopic neurosurgery, major spine instrumentation, or deep brain stimulation, to name just a few advances in the field. I am most certain that

much of what our trainees learn today will be abandoned for new approaches or whole new areas will open for surgical intervention. So, if you like continuous learning and change, neurosurgery is the specialty for you. Finally, what we do as neurosurgeons has huge implications for our patients and their families, both positive and negative. There is no higher high nor lower low than the surgical results in Neurosurgery—a neurosurgeon must possess equanimities. Always remember: do no harm.”

Pearls

•It is important to prepare early during medical school to build a competitive neurosurgery residency application.

•IMG applicants should focus on expanding their research portfolio and developing relationships with senior neurosurgery faculty in order to enhance their chances for matching.

•Sub-interns should always exhibit Affability, Availability, and Accountability towards patients and colleagues.

•USMLE Step 1 scores, research accomplishments, and letters of recommendation will help to secure interviews.

•Letters of recommendation and interpersonal skills influence applicant rank order.

References

[1]The American Board of Neurological Surgeons. 2017. [online] Available from: http://www.abns. org/. Accessed April, 2017

[2]Accreditation Council for Graduate Medical Education. 2018. [online] Available from: https://www. acgme.org/. Accessed July, 2018

[3]National Resident Matching Program. Charting Outcomes in the Match for U.S. Allopathic Seniors, 2018. National Resident Matching Program.­ Washington,­ DC; 2018

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[4]National Resident Matching Program. Results and Data: 2018 Main Residency Match®. National Resident Matching Program, Washington, DC; 2018

[5]National Resident Matching Program. Charting Outcomes in the Match for International Medical Graduates, 2018. National Resident Matching Program. Washington, DC; 2018

[6]National Resident Matching Program, Data Release and Research Committee. Results of the 2018 NRMP Program Director Survey. National Resident Matching Program, Washington, DC; 2018

[7]Neurosurgery Match. 2017. [online] Available from: http://www.neurosurgerymatch.org/. Accessed April, 2017

[8]Kashkoush A, Prabhu AV, Tonetti D, Agarwal N. The neurosurgery match: a bibliometric analysis of

206 first-year residents. World Neurosurg. 2017;

105:341–347

[9]Agarwal N, Norrmén-Smith IO, Tomei KL, Prestigiacomo CJ, Gandhi CD. Improving medical student recruitment into neurological surgery: a single institution’s experience. World Neurosurg. 2013; 80(6):745–750

[10]Grants and Fellowships. 2017; http://www.aans. org/Grants and Fellowships.aspx. Accessed March, 2018

[11]Student Research Fellowships. 2017. [online] Available from: http://alphaomegaalpha.org/student_ research.html. Accessed March, 2018

[12]Fellowships & Awards. 2017. [online] Available from: http://www.csnsonline.org/fellowship_goals. php. Accessed March, 2017

[13]Medical Research Scholars Program. 2017. [online] Availablefrom:https://clinicalcenter.nih.gov/training/ mrsp/. Accessed March, 2018

[14]Medical Research Fellows Program. 2017. [online] Available from: https://www.hhmi.org/developing- scientists/medical-research-fellows-program. Accessed­ March, 2017

[15]Visitor Visa. [online] Available from: https: //travel.state.gov/content/visas/en/visit/visitor. html. Accessed­ March, 2018

[16]Cousteau V. How to swim with sharks: a primer. Perspect Biol Med. 1987; 30:486–489

[17]Hubbard E. A message to Garcia. 1899

[18]Agarwal N, Choi PA, Okonkwo DO, Barrow DL, Friedlander RM. Financial burden associated with the residency match in neurological surgery. J Neurosurg. 2017; 126(1):184–190

[19]How the Matching Algorithm Works. 2017. [online] Available from: http://www.nrmp.org/match-­process/ match-algorithm/. Accessed March, 2017

Edward G Andrews, Chandranath Sen

2.1  Introduction

Before the dawn of the 20th century, the tools available to medical practitioners, in particular surgeons, made operating on the central nervous system virtually impossible except in the most rudimentary of applications. Advances developed slowly, with the techniques and instruments changing little from the incipient

civilizations of the Inca and Egyptians to the medical world of 19th-century Europe and United States. It was not until the late 19th century with the advent of anesthesia, antisepsis, and the ability to localize lesions in the brain successfully that neurosurgery could blossom. This chapter provides a historical timeline of advancements in the field of neurological surgery ( Fig. 2.1).

2.2  The Pre-Cushing Era

2.2.1  Paleolithic

Neolithic skulls with round or ovoid perforations recovered from prehistoric settlements in France date back as early as 8000 BC. These perforations were initially thought to be a product of trauma, but the lack of any classical signs of trauma, such as associated fractures, argued that these they were in fact intentional. There is proof that Neolithic man, inspired by magical or religious beliefs, made postmortem “diskettes” from cadaver skulls to wear as amulets.1 Nevertheless, there are also data that suggest some of these openings were made while the patient was still living. The scarred margins at the wound edges indicate healing had occurred before the death of the patient, and therefore, the perforations could have indeed been practical attempts at surgical intervention. Regardless of his motivation, Neolithic man made holes in the skull by tedious scraping with flint or obsidian to create a gradual depression or to carve intersecting lines that formed a rudimentary rectangular bone flap.2

2.2.2  Ancient

Archaeologists have found skulls with ­craniotomies similar to those of their prehistoric predecessors in burial sites of the ancient Incans and Egyptians as well. The Egyptians in particular documented extensively their medical practices, outlined best in the Edwin Smith papyrus, the world’s oldest known surgical treatise dating back to the 17th century BC. Its author, Imhotep, discusses treatments of cranial wounds and fractures with a twist drill wrapped in a bowstring, with the backward and forward motion of the bow spinning the drill.3 It was not until the age of the Greeks and the arrival of Hippocrates, however, that craniotomy was first codified as a surgical treatment in the Hippocratic­ works Corpus Hippocraticum and On Wounds in the Head.

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Fig. 2.2  Surgeon’s trephining kit from the mid-1700s. (Image has been provided courtesy of Science Museum, London.)

At this stage, the prehistoric technique of shaving bone evolved into a technique that involved cutting a circular­ groove and lifting the bone flap off, which then metamorphosed into the more efficient circular crown saw, or “trupanon” drill, referenced by Hippocrates.1,​2 This was the trephining­ drill in its simplest form ( Fig. 2.2).

2.2.3  Classical

While these ancient civilizations all eventually faded into the background, the ­trephine remained as the prime fixture in the neurosurgical armamentarium. There were modifications made to this design that allowed accessing the intracranial space quicker and more efficient, but little progress beyond this tool occurred over the centuries as this surgical option was often avoided at all costs due to significant rates of infectious complications.1,​4 This changed in the mid-to-late 1800s with the advent of antisepsis and aseptic technique. Trephination was suddenly back in vogue

and, as a result, rapid innovation in neurological surgery would ensue.

The Pre-Cushing Generation

For neurological surgery to emerge as a specialty in the 20th century, a handful of physicians needed to lay the foundation for its arrival with three important medical discoveries: general anesthesia, antisepsis, and cerebral localization.

•Anesthesia: William T.G. Morton, a dentist, introduced ether in 1842 and James Y. Simpson, an obstetrician, introduced chloroform in 1857.

•Antiseptic: Ignaz Semmelweiz, a Hungarian­ physician and obstetrician, demonstrated that handwashing with chlorinated lime before delivery reduced postpartum fever in the mother. Joseph Lister, in 1867, designed an antiseptic treatment of wounds that involved carbolic acid.5

•Cerebral localization: Gustav Fritsch and Eduard Hetzig used electrical stimulation on the precentral gyrus to define function in wounded soldiers with traumatic brain injuries in 1870. Pierre Paul Broca, who was one of the first to trephine for removal of a cerebral abscess, identified the left pars opercularis and pars triangularis in 1861 as the source of expressive aphasia. Carl Wernicke mapped receptive aphasia to the posterior aspect of the left superior temporal gyrus almost a decade later in 1874. Additional­ notable contributions came from neurologists Hughlings Jackson, David Ferrier, Gowers, and Charcot.

A new era of experimentation and invention dawned once neurosurgery could occur at the leisure of the surgeon with the above perquisites­ in place. Quickly, the list of “firsts” grew. Sir Victor Horsley was among the preeminent­ neurosurgeons prior to Cushing. One of his most notable achievements was the successful resection of a spinal cord tumor in 1888 in association

with Sir William Gowers, who himself was known for the successful evacuation of an intracerebral abscess in 1886. Horsley was one of the primary early influences on the treatment of trigeminal neuralgia,­ for which he achieved pain relief by sectioning the posterior root of the trigeminal nerve. Last but not least of his accomplishments, he was the first to operate on the pituitary gland in 1889, although Schloffer was the first to clearly document the successful removal of a pituitary tumor in 1907.5,​6 William Macewen was a contemporary of Horsley’s based in Glasgow. While he was a latecomer to neurosurgery with his first case recorded in 1876, he was no less impactful as he is among the earliest to document successful removal of a brain tumor (meningioma) in 1879.1,​5,​7,​8 He was followed by Franceso Durante, who had striking success removing an orbital groove meningioma in 1885. To wit, the patient was still alive 10 years after surgery­ unlike Macewan’s patient who succumbed to his disease and surgical wounds shortly after his operation. Other notable surgeons of the pre-Cushing era included the following:

•William Detmold: the first to open the lateral ventricle to evacuate a cerebral abscess in 1850.

•Richman Godlee and Hughes Bennett: first resection of glial neoplasm in 1884. While considered a success, the patient died from intracranial infection 28 days after surgery.4

•William W. Keen: Philadelphia-based surgeon who was the first to successfully resect a brain tumor in the United States in 1891.

•Charles Ballance: performed one of the earliest reported cases of acoustic neuroma removal.

2.3  The Cushing Era

Harvey Cushing is arguably the most influential neurosurgeon to date, which has earned him the reverent moniker of the

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“Father of Neurosurgery.” He was famous for his rigorously perfected technique. One of his critical inventions was epoch making by addressing the problem of hemorrhage. Cushing’s silver clip, which he introduced in 1911, made hemostasis possible ( Fig. 2.3). Similarly, his solution to increased intracranial pressure during surgery was groundbreaking when he first described the use of lumbar puncture to relax the brain intraoperatively in 1908. Prior to his arrival, the mortality associated with neurosurgery was estimated around 50% or higher despite antisepsis.9 Cushing’s mortality rate, however, was unprecedented: 8.4% for brain tumor surgeries and around 10% for pituitary surgeries, at a time when mortality for the latter was almost 75%.10

Some additional examples highlighting his contributions to neurosurgery include

Fig. 2.3  Cushing’s silver clip with applicator kit. (Reproduced, with permission, from Horrax G, Some of Harvey Cushing’s contributions to neurological surgery,­ J Neurosurg. 1981;54(4): 436–447.)

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his temporal and suboccipital decompression for relief of high intracranial pressure, which he used for palliation in the event of a nonresectable­ tumor. After the First World War, he outlined the management of penetrating head trauma based on his experiences as a surgeon for the army. In 1927, Cushing adapted Bovie’s electrocoagulator to neurosurgery, initially using it for piecemeal removal of brain tumors ( Fig. 2.4).10 He removed his first pituitary for acromegaly­

Fig. 2.4  Bovie electrocoagulator.

(Reproduced from Vender J, Effect of hemostasis and electrosurgery on the development and evolution of brain tumor surgery in the late 19th and early 20th centuries, Neurosurg Focus. 2005;18(4):1–7.)

in 1909 using Schoffler’s transsphenoidal approach. Oscar Hirsch, a Viennese otolaryngologist, subsequently modified this technique in 1910 to the classic and now commonly used endonasal transsphenoidal approach.5

Other significant members of the neurosurgical field at this time included Charles Frazier, known for his treatment of trigeminal neuralgia by division of the sensory root instead of entire extirpation of the gasserian ganglion as Cushing proposed, and Emil T. Kocher, a large figure in the operative treatment of epilepsy as well as spinal and cranial trauma.11 Walter Dandy, a prolific contemporary of ­Cushing’s, is credited with discovering the function of choroid plexus in 1914, the third ventriculostomy in 1920, and the first cerebral aneurysm clipping in 1937.12

2.4  Spinal Neurosurgery

Similar to its cranial counterpart, spinal surgery was hamstrung by infection until the advent of antisepsis in the closing decades of the 1800s. With effective antisepsis, the neurosurgeons of the preCushing and Cushing eras developed durable solutions to spine pathologies that had been difficult to address previously. Macewen performed the first recorded laminectomy in 1886 and Menard performed the first costotransversectomy in the opening years of the 20th century.13 Fritz Lang was the first to fix the spine posteriorly in 1909 by tethering celluloid rods with silk thread and steel wires adjacent to the spinous processes. Spinal fixation, however, did not further progress until Paul Harrington developed his eponymous rod system in 1953, which became a means to stabilize the spine in multiple pathologic contexts such as traumatic injury, degenerative disease, and deterioration from neoplastic ­processes ( Fig. 2.5).14,​15 It was ultimately short-lived, however, due

Fig. 2.5  Harrington’s rod system. (Reproduced from Vialle L, Berven S, de Kleuver M, AOSpine Master Series, Vol. 9: Pediatric Spinal Deformities, ©2017, Thieme Publishers, New York.)

to its myriad complications like dural compromise and need for an concomitant external brace. Eduardo Luque modified Harrington’s approach in 1976 with his own Luque rod system, which used long contoured rods affixed with sublaminar wires.15 This signaled the arrival of three-column fixation with the transpedicular screw, a significant step toward modern techniques. Michele and Krueger first described pedicle screw fixation in 1949, but it was not until the 1960s that this fixation technique established its dominance as the main approach for posterior fixation.15 The surgeons responsible for its rise in popularity and codification were Roy-­Camille in 1970, followed by Arthur D. Steffee in the United States with the development of his variable plating system and the Steffee screw ( Fig. 2.6 andFig. 2.7).16,​17

2.5  Instrumentation

The accomplishments of the above surgeons­ would not have been possible without the long history of invention not only from their compatriots, but also from the innovative thinking of other pioneers of surgery

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Fig. 2.6  Pedicle screw plate fixation system designed by Roy-Camille made from cobalt-chromium. (Reproduced from Kabins MB, Weinstein JN, The history of vertebral screw and pedicle screw fixation, Iowa Orthop J.

1991;11:127–136.)

Fig. 2.7  Steffee, or variable screw placement, system.

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and even visionaries outside of medicine. A summary of these remarkable achievements is catalogued chronologically below.

•1851: Hermann von Helmholtz invented the ophthalmoscope, introducing the fundoscopic examination and a helpful tool in diagnosing intracranial mass lesions.

•1876: Saemisch, a German surgeon, was the first to wear loupes while operating.

•1885: James L. Corning performed the first lumbar puncture, but it was not used in practice as a diagnostic and therapeutic tool until 1891 by Heinrich Quincke.

•1892: Sir Victor Horsley introduced an antiseptic wax in 1892 to control diploic bleeding and to achieve hemostasis, although there is evidence that Henri Dolbeau,­ a Parisian surgeon, first used bone wax in 1864 during extirpation of a frontal osteoma.18

•1895: Wilhelm Röentgen invented X-ray- based radiography, which subsequently bears his name (roentgenography). Craniography and spondylography were created once Röentgen’s idea was adapted to the needs of neurological surgery.

•1898: Leonardo Gigli adapted his famous saw for cranial surgery by creating a curved wire that would not damage the dura during formation of the bone flap.19

•1908: The electric drill replaced hand-powered trephining after Thierry de Martel’s improvement upon the design of the foot-powered drills that dentists were using. That same year, German neurosurgeon Fedor Krause introduced an electrical suction for use in surgery, which Cushing improved upon in 1920.20

•1911: Cushing introduces silver clips for hemostatic control ( Fig. 2.3).

•1918: Walter Dandy invented pneumoventriculography, and pneumoencephalography the following year in 1919. In these studies, he injected air into the patient’s cerebrospinal fluid (CSF) spaces before shooting a craniograph, outlining the ventricular system and subarachnoid territories ( Fig. 2.8).