The Supratentorial Cranial Space Microsurgical Anatomy and Surgical.pdf

EDITOR’S LETTER

P ILLARS AND I CONS

early forty years ago the operating microscope

began its emergence as a principle pillar

in the reinvention of neurosurgery. The ability

to achieve enhanced three-dimensional visualization

through intense lighting and magnification via

narrow corridors revolutionized surgical events.

Developments in medical imaging and the subsequent

creation of the broad scope of image-directed

stereotaxy completed a ÑtroikaÒ of what might be

considered ÑpillarsÒ of the platform of modern

neurosurgery.

With the introduction of the microscope and the

availability of other important technical adjuvants it

became rapidly apparent that a fourth pillar was

necessary. This was a more refined comprehension

and sophisticated appreciation of microscopically

related anatomy of the surgical targets and periphery.

Recognizing this need, Albert Rhoton embarked on a

four decade odyssey of discovery, comprehension and

documentation, defining the microscopic anatomy of

the intracranial content and cranium as it had never

before been depicted and thus enhanced the safety,

fluidity and potential for success of each and every

microoperative event in the cranial neurosurgical

catalogue. This work stands as a truly remarkable

achievement and one of the most important

contributions by a single individual during our

neurosurgical time and indeed in the entire history of

the specialty.

This work stands as a tribute to Dr. Rhoton and his

absolutely iconic status in the field of neurosurgeryÐa

position that he has attained by remarkable features of

his persona and contributions as a surgeon,

investigator, mentor, statesman and humanitarian.

N EUROSURGERY is grateful to Dr. Rhoton for his

willingness and immense effort in the development of

this epic manuscript dealing with the heart and

substance of his work on the supratentorial spaceÐthe

cerebrum, its arteries, veins, and surgical complexities

as well as associated anterior frontal and middle basal

anatomy and exposures.

We are truly indebted to Carl Zeiss Surgical and

Medtronic Midas Rex for generously supporting this

classic.

Michael L.J. Apuzzo

Los Angeles, California

N EUROSURGERY

VOLUME 51 NUMBER 5 NOVEMBER 2002

S1-i

FOREWORD

T HE S UPRATENTORIAL C RANIAL S PACE :M ICROSURGICAL A NATOMY AND

S URGICAL A PPROACHES

gery and Editor-in-Chief Michael L.J. Apuzzo on the

25th anniversary of the birth of this magnificent con-

tributor of academic and scientific information to our spe-

cialty. This journal has elevated the care of neurosurgical

patients everywhere. I am deeply appreciative to Dr. Apuzzo

and the editorial board for giving me the opportunity to work

with them on this supplement. I also salute Carl Zeiss, Inc.,

and Medtronic Midas Rex on the occasion of this publication

and thank them for the grant that made this supplement

possible. The increased safety and accuracy and improved

results obtained with the Zeiss microscope are among my

greatest professional blessings and are a great contributor to

the quality of life of my patients. Medtronic Midas Rex,

through the increased ease and delicacy of bone removal

made possible with the use of their drills, has also made a

contribution to the care of neurosurgical patients worldwide

and has allowed neurosurgeons to focus on operating accu-

rately and precisely in the delicate neural tissue that is the

basis of our specialty. Both Midas Rex and Zeiss have contin-

ued to invest in modifying and upgrading their instruments

by integrating them with modern technological advances to

aid us in our work and provide new benefits for our patients.

Both Zeiss and Midas Rex have assisted with educational

endeavors, such as this supplement, that have improved neu-

rosurgical care on every continent and have made the aca-

demic aspects of my career much more rewarding. I am grate-

ful for their support of the publication of my studies of

microsurgical anatomy and for partnering with neurosur-

geons throughout the world to improve neurosurgical care.

As stated in the Millennium issue of Neurosurgery, this work

on microsurgical anatomy has grown out of my personal

desire to improve the care of my patients. It represents a

40-plus-years’ attempt to gain an understanding of the anat-

omy and intricacies of the brain with the goal of improving the

safety, gentleness, and accuracy of my operations on my pa-

tients. In this Foreword, I share some of my thoughts about

neurosurgery, some of which were included in addresses that

I delivered as president of the AANS and the CNS (1, 2).

Neurosurgeons share a great professional gift; our lives have

yielded an opportunity to help people in a unique and exciting

way. I would like to reflect on the joy and excitement of being

allowed to participate in the miracle that we call neurosurgery .In

my early years, I never imagined that my life would hold as

exciting and delicate a challenge as that of being a physician or a

neurosurgeon. Neurosurgeons’ work is performed in response to

the idea that human life is sacred, that it makes sense to spend

years of one’s life in study to prepare to help others. Our training

brings into harmony a knowledgeable mind, a skilled set of

hands, and a well-trained eye, all of which are guided by a caring

human being. The skills that we use have been described as the

most delicate, the most fateful, and, to the layperson, the most

awesome of any profession. The Gallup Poll has reported that

neurosurgeons are among the most prestigious and highly

skilled members of American society. We share the opportunity

to serve people in this unique way, dealing surgically with the

most delicate of tissues.

Our ranking among the most highly skilled members of

society tends to lead us to forget that our work and success are

made possible by the benevolent order built into the universe

around us. That people heal and survive after surgery pro-

vides us with our work and serves as a constant reminder of

this benevolent, protective order. We are surrounded by bio-

logical and physical forces that could overcome us, outstrip-

ping our finest medical and scientific achievements. The mo-

mentous process of injured tissues’ knitting together is as

essential to the work of the surgeon as the air people breathe

is to their survival. That humanity survives and that neuro-

surgeons can play a role in the process of healing are examples

of the compassion and love that surround us. A patient who

writes a thank-you note or praises my efforts leads me to

inwardly reflect that the great gift we have been given is that

we were created to help each other.

The next gift that we share is a historical one based on the

standards set by early physicians. Hippocrates taught that

medicine is a difficult art that is inseparable from the highest

morality and love of humanity. The noble values and loyal

obedience of generations of physicians since Hippocrates have

raised the calling to the highest of all professions. Many of us

were attracted to neurosurgery by both the meticulousness of

surgical craftsmanship and the intellectual challenge posed by

modern clinical neurology and neurophysiology. All of us

have submitted ourselves to the discipline of rigorous train-

ing, possibly the most demanding in modern society, and are

capable of giving a great deal of ourselves.

Our work has grown out of the belief in absolute standards

of value and worth in humanity. These values are reflected in

the increasing importance of one man, one woman, or one

child in American society and throughout the world. An ex-

ample of the evolving importance of the individual is found in

examining great human creations such as the Egyptian pyra-

mids and the Great Wall of China. Through the decades and

the centuries, humankind has evolved to the point where the

pyramids of modern society are some of our medical centers.

N EUROSURGERY

VOLUME 51 | SUPPLEMENT 1 | OCTOBER 2002 | S1-iii

N eurosurgeons throughout the world salute Neurosur-

R HOTON

In them, society’s most highly trained teams, using human-

kind’s most advanced technology at great cost, are allowed to

work for days trying to improve the lives of individual pa-

tients without regard to whether the patients are rich or poor.

Issues related to the dignity and worth of a single man,

woman, or child are clearer now than they were a century or

two ago and provide the driving force behind our work. These

values and standards, which are inseparable from the highest

morality and love of humanity, are built into us just as the

process of healing is built into nature.

Another circumstance leading to the esteem that neurosur-

geons enjoy is the magnificent tissue with which we work. The

brain is the crown jewel of creation and evolution. It is a

source of mystery and wonder. Of all of the natural phenom-

ena to which science can draw attention, none exceeds the

fascination that greets the workings of the human brain. The

brain holds the greatest unexplored biological frontiers. It is

the most frequent site of crippling, incurable disease. The

brain, although it does not move, is the most metabolically

active of all organs, receiving 20% of cardiac output while

representing only 3% of total body weight. It is the only organ

in the body that is hidden and completely enclosed within a

fortress of bone. It is exquisitely sensitive to touch, anoxia, and

derangements of its internal environment. Its status deter-

mines whether the humanity within us lives or dies. It yields

all that we know of the world. It controls both the patient and

the surgeon.

Brain accounts for the mind, and through the mind, we are

lifted from our immediate circumstances to consciousness and

given an awareness of ourselves, our universe, our environ-

ment, and even the brain itself. Here, in two handfuls of living

tissue, we find an ordered complexity sufficient to preserve

the record of a lifetime of the richest human experience and

create computers that can store amounts of data that can be

comprehended only by the mind. Perhaps the most significant

achievement of this tissue is the ability, on the one hand, to

conceive of a universe more than a billion light-years across

and, on the other, to conceptualize a microcosmic world out of

the reach of the senses and to model words completely sepa-

rate from the reality that we can see, hear, smell, touch, and

taste. Mind and brain are the source of happiness, knowledge,

and wisdom. The brain is not the seat of the soul, but it is

through the brain and mind that we become aware of our

souls.

In my early years, never in my wildest flights of imagination

did I consider that life would yield such rewarding and chal-

lenging work as that of being a physician, and I was unaware

that neurosurgery even existed. My early life was without

exposure to physicians or to hospitals, electricity, or other

modern conveniences. My birth was aided by a midwife in

exchange for a bag of corn. As I entered college, the goal of

being a physician seemed so unattainable that I had not en-

tertained that possibility. I first pursued chemistry, but the

missing human element led me to major in social work. Social

work also failed to satisfy me because it lacked the opportu-

nity to touch and help others by working with my hands. That

I might become a physician did not enter my mind until a

psychology instructor invited me to see a brain operation

performed in his laboratory. To my amazement, a tiny lesion

improved the small animal’s behavior, but without affecting

its motor skills. That day, I sensed some of the amazement that

must have been experienced in the 1870s when Broca pre-

sented his early observations regarding the cerebral localiza-

tion of speech in his patient, Tan, and when Fritsch and Hitzig

described their experiments in the cerebral motor cortex. Be-

fore their time, interest in the brain and its function centered

on philosophical discussions of the brain as the seat of the

mind and the soul and not as a site possessing the localizing

features suitable for the application of a physician’s or sur-

geon’s skills. On that day in the psychology laboratory, I

learned that surgery based on these concepts was possible,

and I knew that I had found my calling. I know that many

neurosurgeons have had a similar meaningful experience.

In medical school, I began to work in a neuroscience labo-

ratory in my spare time. At the end of my residency, I com-

pleted a fellowship in neuroanatomy. It was during this fel-

lowship that I realized the potential for greater knowledge of

microsurgery and microneurosurgical anatomy to improve

the care of my patients. I resolved early in my career to

incorporate this new technique into my practice, because it

seemed to increase the safety with which I could delve deep

into and under the brain during surgery. One of my favorite

personal goals has been to find images of a single operation

performed perfectly, because the inner discipline of striving

toward perfection leads to improvement. Such images are the

essential building blocks for the improvement of operative

techniques. During my training and thereafter, I lay awake

many nights, as I know all neurosurgeons have, worrying

about a patient who was facing a necessary, critical, high-risk

operation the next day. With the use of this new technique, I

found that difficult operations that carried significant risk

were performed with greater accuracy and less postoperative

morbidity. During my training, I did not see a facial nerve

preserved during the surgical removal of an acoustic neu-

roma. Today, that goal is accomplished in a high percentage of

surgical patients with acoustic neuromas. In the past, in oper-

ating on patients with pituitary tumors, there was minimal

discussion of preserving the normal pituitary gland; today,

however, the combination of new diagnostic and surgical

techniques has made tumor removal with the preservation of

normal pituitary function a frequent achievement. The appli-

cation of microsurgery in neurosurgery has yielded a whole

new level of neurosurgical performance and competence, and

the microsurgical anatomy is the roadmap for applying mi-

crosurgical techniques.

As I started to work with microsurgical techniques, I real-

ized that there was a need to train many neurosurgeons in

their use. When I moved to the University of Florida, I began

trying to develop a center for teaching neurosurgeons these

techniques. Eventually, with the help of private contributions,

my institution was able to purchase the necessary microscopes

and equipment for a laboratory in which seven surgeons could

learn at one time. The next task was to find seven individuals

who were willing to come to the university for a course.

S1-iv | VOLUME 51 | SUPPLEMENT 1 | OCTOBER 2002

www.neurosurgery-online.com

F OREWORD

Finally, after much solicitation, seven surgeons joined us for a

1-week course. I was quite apprehensive about that course,

because I was not sure that we could keep seven surgeons

busy learning microvascular skills for a whole week. It was

comforting to learn that Harvey Cushing, early in his career,

had developed a similar laboratory in which surgeons could

practice and perfect their operative skills. I still remember and

am grateful to each member of the initial group of neurosur-

geons who were willing to invest 1 week of their valuable time

in our first course more than 25 years ago. During the first

afternoon of that course, I walked into the laboratory and, to

my amazement, found seven surgeons working quietly and

diligently. Nothing was said for long periods of time. In the

midst of this intense endeavor and amazing quietness, I real-

ized that we had tapped into a great force: the desire of

neurosurgeons to improve themselves. Each individual neu-

rosurgeon can acquire new skills so that a new level of per-

formance in the specialty is achieved. Microtechniques are

now being applied throughout neurosurgery, thus adding a

new level of delicacy and gentleness to our specialty. The

competence of the whole specialty has been improved, and

with this experience has come the realization that neurosur-

geons, as a group, are constantly aspiring to and achieving

higher levels of performance that are not based on advances in

diagnostic equipment and medication but are dependent on

inspired individuals striving to improve their surgical skills

and knowledge to better serve their patients. Every year pro-

vides multiple examples of modifications in microsurgery that

make operations more successful. It is interesting how the

insights gained from recent patients, even after many years of

practice, when combined with an intense desire to improve

one’s skill and competence, lead to new insights.

After years of retirement, J. Lawrence Pool, who led the neu-

rosurgical program at Columbia University, recently wrote, “As

I look back on the pattern of my life I see how fortunate it was

that I had chosen a career in neurosurgery, which I passionately

loved despite its long hours and many grueling experiences.” He

concluded with a statement about his belief that the best sur-

geons have a strong sense of compassion. It is important that we

grow in compassion as we grow in competence. Competence is

the possession of a required skill or knowledge. Compassion, on

the other hand, does not require a skill or knowledge; it requires

an innate feeling, commonly called love, toward someone else.

Both competence and compassion need to be developed simul-

taneously, just as the giant oak develops its root system along

with its leaves and branches. Competence without compassion is

worthless. Compassion without competence is meaningless. It is

a great challenge to guide patients competently and compassion-

ately through neurosurgery. Death and darkness crowd near to

our patients as we help them search for the correct path. Neuro-

surgical illness threatens not only their physical but also their

financial security, because it is so expensive and the potential for

disability is so great.

No experience draws more frequently than the performance of

neurosurgical procedures on the passage in Psalm 23, “though I

walk through the valley of the shadow of death. . . .” Neurosur-

geons’ competence should be reflected in our training, knowl-

edge, and skill; our compassion should be reflected in our kind-

ness, sincerity, and concern. The Saints and Buddhas taught that

compassion and wisdom, which lead to competence, are one.

Our patients are looking for help from someone who is knowl-

edgeable, patient, and wise and who can provide clarity, wis-

dom, and enlightenment so that they can face life after surgery

on the brain. That is the essence of integrating competence and

compassion. Neurosurgeons have the responsibility to develop

the dialogue in understandable terms to help the patient, the

patient’s family, and society understand the meaning of the

patient’s illness. One of my personal precepts is, “The best ally in

the treatment of neurosurgical illness is a well-informed patient.”

Success requires more than advancing and applying medical

knowledge. It also requires increased compassion so that we can

respond sympathetically and with the best of our knowledge to

all of our patients’ questions and provide them with timely

information that will help them understand their illness and plan

their lives. There comes a time in our work when we can make as

much of a difference in each other’s lives by sitting for 30 min-

utes, 1 hour, or longer to answer questions as we can by hours in

surgery. There is no substitute for an honest, concerned, and

sympathetic attitude. Success may not mean that every patient

survives or is cured, because some problems are insolvable and

some illnesses are incurable. Instead, success should mean giving

every patient the feeling that he or she is cared about, no matter

how desperate their situation, that their pain is felt, their anger is

understood, and that we care and will do our best. The greatest

satisfaction in life comes from offering what you have to give.

Devotion and giving to others provides purpose and meaning to

life.

This 25th anniversary issue on the supratentorial area and

the Millennium issue of Neurosurgery on the posterior fossa

represent a distillation of more than 40 years of work and

study in which 62 residents and fellows have participated,

resulting in several hundred publications. In this supplement,

we attempt not only to display the brain and the cranial base

in the best views for understanding the anatomy but also to

show the anatomy exposed in the surgical routes to the su-

pratentorial area and the anterior part of the cranial base. For

those who want even greater detail than that displayed in this

supplement, our prior work, published largely in Neurosurgery

and the Journal of Neurosurgery, can be consulted. It has been

gratifying to view the role of our fellows and trainees in

spreading this knowledge to other countries and around the

world and to see the benefits of neurosurgeons applying this

knowledge to improve their patients’ operations. Especially

gratifying have been the relationships with Toshio Matsu-

shima of Fukuoka, Japan, and Evandro de Oliveira of São

Paulo, Brazil, whose studies of microsurgical anatomy have

elevated the care of neurosurgical patients around the world.

The following are the residents and fellows who have worked

in the laboratory:

Hajime Arai, Japan

Allen S. Boyd, Jr., Tennessee

Robert Buza, Oregon

Alberto C. Cardoso, Brazil

Christopher C. Carver, California

Patrick Chaynes, France

Evandro P. de Oliveira, Brazil

W. Frank Emmons, Washington

J. Paul Ferguson, Georgia

Andrew D. Fine, Florida

N EUROSURGERY

VOLUME 51 | SUPPLEMENT 1 | OCTOBER 2002 | S1-v

Plik z chomika:

Inne pliki z tego folderu:

Inne foldery tego chomika: