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SPECIAL ARTICLES

THE GENESIS OF NEUROSURGERY AND THE EVOLUTION

OF THE NEUROSURGICAL OPERATIVE ENVIRONMENT:PART IPREHISTORY TO 2003

Charles Y. Liu, M.D.,Ph.D.

Department of NeurologicalSurgery, Keck School of Medicine,University of Southern California,

Los Angeles, California, andDivision of Chemistry and

Chemical Engineering, CaliforniaInstitute of Technology, Pasadena,California

Michael L.J. Apuzzo, M.D.

Department of Neurological

Surgery, Keck School of Medicine,University of Southern California,

Los Angeles, California

Reprint requests:Michael L.J. Apuzzo, M.D., 1200

N. State Street, Suite 5046, LosAngeles, CA 90033.

Received, May 31, 2002.

Accepted, September 11, 2002.

DESPITE ITS SINGULAR importance, little attention has been given to the neurosur-gical operative environment in the scientific and medical literature. This article focusesattention on the development of neurosurgery and the parallel emergence of itsoperative setting. The operative environment has, to a large extent, defined the stateof the art and science of neurosurgery, which is now undergoing rapid reinvention.During the course of its initial invention, major milestones in the development ofneurosurgery have included the definition of anatomy, consolidation of a scientificbasis, and incorporation of the practicalities of anesthesia and antisepsis and later

operative technical adjuvants for further refinement of action and minimalism. Theprogress, previously long and laborious in emergence, is currently undergoing rapidevolution. Throughout its evolution, the discipline has assimilated the most effectivetools of modernity into the operative environment, leading eventually to the entityknown as the operating room.

In the decades leading to the present, progressive minimalization of manipulationand the emergence of more refined operative definition with increasing precision areevident, with concurrent miniaturization of attendant computerized support systems,sensors, robotic interfaces, and imaging devices. These developments over time haveled to the invention of neurosurgery and the establishment of the current state-of-the-art neurosurgical operating room as we understand it, and indeed, to a broaderdefinition of the entity itself. To remain current, each neurosurgeon should periodically

reconsider his or her personal operative environment and its functional design withreference to modernity of practice as currently defined.

KEY WORDS: History, Imaging, Microsurgery, Modernity, Neurosurgery, Operating room, Operativeminimalism

Neurosurgery 52:3-19, 2003 DOI: 10.1227/01.NEU.0000038928.61329.44 www.neurosurgery-online.com

Neurosurgery is an intellectual and physical exercise inan exquisitely complex three-dimensional space. Itsproper execution requires a suitable environment that

allows for the appropriate technical and supporting tools ofmodernity to be used in an optimal fashion by the intelligent,practiced, and prudent surgeon. This neurosurgical operativeenvironment has been in various stages of evolving develop-ment over virtually thousands of years, beginning with whatmay be called the Neolithic ancestors of neurosurgery some12,000 years ago (13). Over its time course, the development ofneurosurgery experienced an initial period of prolonged sta-sis, followed by a rapid acceleration of progress to take itspresent form. The operative environment, to a large extent,has defined the state of the art and science and reflected thescope of the specialty, which is now undergoing rapid and

sequential reinvention (411, 75). These reinventions, initiallymeasured in millennia, are now measured in decades. Histor-ically, technological progress and influential trends that arethe motivating forces for the invention of neurosurgery havebeen systematically assimilated in useful incarnations into theoperative environment. To remain current, each neurosurgeonshould periodically reconsider his or her personal operativeenvironment and the functional design that is offered foroptimization of actions during specific operative enterprises.Clearly, this reappraisal should take into consideration evolv-ing progress in the field as well as historical trends.

A review of some of the major developments in the genesisof neurosurgery and the evolution of the neurosurgical oper-ative environment from prehistory to the present suggests thatthe development can be considered as being marked by sev-

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eral major milestones (13, 55): 1) assembly of the first tools andskills to allow survivable invasive manipulation of the cra-nium, 2) progressive definition of the anatomic substrate andimproved specific and practical tools and methods for surgicalaccess to and manipulation of the nervous system and its

coverings, 3) emergence and acceptance of science and theconcept of the functional nervous system, 4) development ofanesthesia, 5) development of concepts and practicalities ofantisepsis and asepsis, 6) emergence of the distinct entityknown as the operating room, 7) emergence of minimalismwith the introduction of magnification and the operating mi-croscope, 8) rapid expansion of the arsenal of tools and broad-ening of the scope of surgical possibilities in the past genera-tion, and 9) physical expression of the present concepts ofmodernity.

At the most basic level, neurosurgeons functioning in theiroperative environment require appropriate instruments to ef-fect informed manipulations on the physical anatomy. Fur-

thermore, functional preservation and therapeutic benefit re-quire considerations beyond the merely physical aspects of thenervous system. Complex surgical manipulation of the ner-vous system and its surroundings can hardly be consideredpractical without some rudimentary element of antisepsis andanesthesia. All modern surgical decisions are guided by visu-alization of both the exposed and hidden anatomy as delin-eated by magnification and penetrating imaging modalities.Furthermore, the computer can be found in all but the mostprimitive contemporary operating rooms, especially in thosethat support frame-based and frameless stereotacticcapabilities.

During the course of the evolution of neurosurgery, the

elements that constitute a modern operating room may havedeveloped independently at times, with discontinuity evidentthroughout its early history. For example, prehistoric trepana-tion was not known to the Western world for centuries. Inaddition, knowledge accrued by ancient civilizations was of-ten hidden for prolonged periods of time, only to be rediscov-ered much later. Nevertheless, the practice of surgical manip-ulation of the nervous system and its coverings has beenevident for more than 12,000 years, and the settings in whichthese practices were conducted have reflected the state of theart, science, and, indeed, purpose of these endeavors. Thehistory of the development of this practice is rich in detail,events, and personalities. An encyclopedic treatment of thishistory can be found in the literature (55) and is beyond thescope of this work. However, a review of many of the high-lights and major trends in development reveals that the ever-increasing sophistication of the surgical endeavors requiredthat the elements that constitute the modern practice of neu-rosurgery be progressively assimilated into a functional amal-gam known as the operating room. This represents the initialinvention of the discipline as we understand it. Later, newtools were continuously introduced into the operative envi-ronment as they were made available by advances in scienceand technology, resulting ultimately in the modern technolog-ical marvels of today.

Major objectives of the discipline are to expand its scope andcapabilities and to achieve this while decreasing morbidityand improving economies of cost. These elements representthe natural progression of the field and are reflected in theevolution of the neurosurgical operative environment. Indeed,

throughout the evolution of neurosurgery, the operative en-vironment has represented the final culmination of science,theory, philosophy, and purpose into a practical setting tooptimize the safe and beneficial execution of the surgicalendeavors.

THE PRIMORDIUM: CRANIAL SURGERYAND THE OPERATIVE ENVIRONMENT

IN PREHISTORY

Historical evidence suggests that perhaps the very firstattempt at surgical manipulation by humans involved theremoval of pieces of the bony coverings of the brain (14, 27, 53,

72, 93, 96, 100, 113). For literally thousands of years, cranialsurgery was principally extradural. Since these very first at-tempts by Neolithic humans, surgery of the brain and itscoverings has evolved slowly during some 12,000 years, withelements of refinement in instrumentation but with similarend results.

Trepanation refers to the removal of sections of bone fromthe cranium (72) by use of an instrument called a trepan ortrephine, a name derived from the Greek trypanon, or borer.Pierre Paul Broca (1824-1880) is generally credited as being thecatalyst for the widespread acknowledgment of this practicein ancient cultures (25). At present, there is almost universalacceptance of antemortem cranial surgery in prehistory, and

archeological evidence supports the contention that the prac-tice was widespread, with skull specimens found in Europe,Asia, Africa, North, Central, and South America, and Oceania(14, 52, 72, 81, 93, 96, 100, 109, 116). In fact, the practicesurvives to modern times in certain East African and SouthAmerican tribes (80). To date, more than 1500 specimens havebeen found and examined. The oldest examples of trepanationmay be specimens found in North Africa, dating back to10,000 BC. Excavations in the Jericho area in the Near East andAsia have produced specimens from approximately 8000 to6000 BC. The earliest European examples are more than 10,000years old, dating perhaps to the late Paleolithic period, butcertainly to the Neolithic age (72, 96). Early Danubians were

performing cranial surgery in 3000 BC, and ancients from theSeine-Oise-Marne area of France were similarly active in 2000BC. On the basis of the numbers of skulls that have been foundin France, it is probable that a veritable surgery centerexisted there between 1900 and 1500 BC. Trepanation speci-mens have also been found in other regions of NeolithicEurope, the Balkans, and Russia. New World specimens oftrepanation are much more recent, with the oldest examples,found on the southern coast of Peru, dating to 400 BC. Moretrepanned skulls have been found in this region than in therest of the world combined. It is possible that the practicespread from Peru to what is now Mexico and North America.

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During the primordial period in the evolution of neurosur-gery, the operative environment reflected the state of the artand science of the discipline, a theme clearly recurrent infuture developments (Fig. 1). In prehistoric times, our neuro-surgical ancestors most likely had no knowledge of neurolog-

ical function and very limited practical understanding of anat-omy. Furthermore, the operative environment of the Neolithicneurosurgeons was marked by a distinct absence of antisepsis,an element required in even the most rudimentary functionaloperating room by current standards. Furthermore, althoughprimitive analgesics may have been administered to alleviatepain, general anesthesia would not evolve for thousands ofyears.

In most dramatic contrast to modern neurosurgery, thegoals and purposes of prehistoric cranial operations are con-sidered to have included magicoritual and religious motiva-tions along with the practical treatment of head injury, with aconsiderable spiritual element being present. Despite the

plethora of physical evidence of prehistoric trepanation, in-sight into such motivation has been much more problematicaland controversial (72, 91, 96). However, in the absence ofwritten records, scholars speculate about a combination ofmotives as varied as therapeutic, magicotherapeutic, andmagicoritual. For example, given the tendency of Peruvianand Danish skulls to have openings in the left temporoparietalregion, it follows that trepanations had principally therapeuticintentions to treat injuries from blows by a right-handed as-sailant. Ritual is thought to be an important motivation for thedevelopment of the trepanation center in Neolithic France.In postmortem operations, rondelles of cranial bone werepresumably obtained for use as charms, amulets, or talismans.

These speculations are supported by observations of the prac-tice of 20th-century East African tribes: the Kisii tribe performstrepanations primarily to alleviate headache after a blow,whereas the nearby Lugbara tribe desires to release evil spir-its. In addition, one novel speculation proposes that opera-

tions on the head were aimed at resurrecting the dead (91). Allof these considerations are in marked contrast to the modernneurosurgical enterprise, in which the goals of surgery mustbe justifiable purely on the grounds of medical science.

However they were motivated, and despite their lack offundamental knowledge, prehistoric surgeons assembled thefirst distinct set of skills and tools to allow survivable surgicalmanipulation of the cranium. Neolithic surgeons invoked es-sentially four different techniques to remove pieces of cranialbone: 1) scraping, 2) grooving, 3) boring and cutting, and 4)rectangular intersecting incisions (72, 96, 116). The earliestinstruments found in the Neolithic operating environmentswere made of flaked stone, flint, obsidian, and bone. Later, the

ancient Peruvians used curved tumi blades to incise soft tissueand to make rectangular cuts in the bony cranium. Sharpinstruments were used to make grooves and holes that couldthen be connected. Flat scrapers were also used with goodeffect, whereas in Mexico, a bow and obsidian drill may havebeen used. Although the primitive surgical instruments havesurvived to the present day, there is a lack of specific evidenceof anesthetic use. Scholars have speculated that alcohol, nar-cotics, or coca products were administered to alleviate pain.Using this very primitive first set of skills and tools, prehis-toric surgeons were surprisingly successful, with many arche-ological specimens showing postoperative healing and a sur-vival rate of 80% or more.

EXPANDING THE KNOWLEDGE BASE OFTHE ANATOMIC SUBSTRATE AND

IMPROVING THE TOOLS AND METHODSOF MANIPULATION: ANCIENT HISTORY

TO THE 16TH CENTURY

Among those elements considered crucial to modern neu-rosurgery and its operative environment, the first to be assim-ilated was an understanding of the anatomic operative sub-strate and the refinement of tools and methods to effect

appropriate and safer manipulations. In fact, essentially all theadvances in neurosurgery from the earliest recorded historyup to the 16th century can arguably be organized into thiscategory. During this prolonged period of early development,despite the accumulation of an extensive knowledge base ofneuroanatomy, only primitive and empirical correlations werebeing drawn between anatomy and observed symptoms. Infact, written documentation of the physical manifestations ofneurological diseases is evident in numerous archeologicalrecords (22, 40). This is reflected in all the important move-ments that have shaped the field over the next several thou-sand years.

FIGURE 1. Trephination in a primitive setting included none of theessential elements found in modern operating rooms. Notice the absence of

general anesthesia and the presence of assistants to hold the patient downwhile the procedure is accomplished with crude instruments. Also, the per-son standing in the robe could be present in a spiritual role. Painting byRobert A. Thom, 1957.

EVOLUTION OF THE NEUROSURGICAL OPERATIVE ENVIRONMENT



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The legacy of cranial surgery derived from our Neolithicancestors was carried on by surgeons of the ancient worldfrom Egypt to China to Europe. In Egypt, the Ebers (53), Hearst(53), and Edwin Smith papyri (22, 40) clearly documented theancient Egyptians keen awareness of the importance of neu-

rosurgery, with 48 descriptions of cases involving the brainand spine in the Edwin Smith papyrus (1700 BC) alone. InChina, the legendary physician Yu Fu allegedly had the abilityto expose the brain (112). However, the ancient Greeks arecredited with initiating the intellectual evolution of neurolog-ical surgery by the founding of the Alexandrian School in 300BC (53), with Hippocrates (460370 BC) providing the earliestwritings from this period. Indeed, in De capitis vulneribus(Head Injury), Hippocrates delineated principles that wouldserve as the foundation of practice for the next 2000 years (57).

The greatest contribution of the ancient Greeks and earlyRomans and Byzantines was the assembly of an extensiveknowledge base of the anatomic substrate (53). Herophilus of

Chalcedon (335280 BC) and Rufus of Ephesus (AD 98117)provided detailed descriptions of the meninges, distinguishedthe cerebrum from the cerebellum, and detailed the extent ofthe ventricular system, the pineal and pituitary glands, thefornix, and the quadrigeminal plate complex. Galen ofPergamon (AD 129210) was perhaps the most prolific medi-cal writer of antiquity and the first neurosurgeon in the arenaof sports. He served as physician to the gladiators of Perga-mon in the time of emperors Antonius Pius and MarcusAurelius and provided voluminous contributions in the areasof neuroanatomy and neurosurgery. Galens writings servedas the basis of knowledge regarding the nervous system wellinto the 18th century, providing descriptions of the aqueduct

of Sylvius, the cranial nerves, hydrocephalus, spinal cord in-jury, and neurotrauma.Advancements in the practical aspects of cranial surgery

were also evident during this time, with refinements in instru-mentation, wound care, and hemostasis (53). Aulus AureliusCornelius Celsus (25 BC to AD 50) made important contribu-tions to methods of trephination, in addition to articulating theclassic signs of inflammation, rubor, tumor, calor, and dolor.Paul of Aegineta (AD 625690) developed many instrumentsfor cranial surgery and the treatment of cranial fractures andwas perhaps the first ancient surgeon to take advantage of theas yet unknown concept of antisepsis, using wine in hiswound dressings. After the Arabic period, marked by a dearthof original ideas, a medical school would emerge in Salernoduring the medieval period. There, the practice of operatingon the cranium would be rejuvenated with new ideas andtools. For example, Roger of Salerno (1170) encouraged the useof trephination for the treatment of epilepsy and described theuse of the Valsalva maneuver to identify cerebrospinal fluidleaks in cranial fractures (90, 94). Furthermore, Roger pro-moted the use of the cruciate incision for depressed fracturemanagement and used wool and feathers as prohemostaticagents and wormwood soaked in rose water and egg fordressings along with soporifics in the preoperative period. Inthe 13th century, Theodoric of Cervia (Borgognoni) (1205

1298) outlined more practical improvements in the treatmentof wounds, advocating hemostasis, removal of dead space andnecrotic tissue, and the use of wine in dressings. Other prac-tical advancements during this period included the refinementof trephination techniques, using the knife for sharp dissection

rather than cautery for incision by Lanfranchi of Milan (died c.1306). In addition, Guy de Chauliac (13001368) of Francestressed the need to shave the head before surgery and usedegg albumin as a prohemostatic agent and wine to improvethe treatment of wounds. It can be speculated that the empir-ical use of wine and its alcoholic contents may have hadantiseptic effects; however, the formal concepts of antisepsiswould not develop for centuries.

Through the 16th century, surgeons continued to operate onhead wounds on the basis of their physical appearance, with-out consideration of symptoms, much as Hippocrates haddescribed 1000 years earlier (45). Until the description of themethod of interconnecting burr holes to create a bone flap for

a craniotomy by Leonardo Botallo (15301588), surgeons werelimited to working through small apertures created by tre-phines (21). Furthermore, Giacomo Berengario da Carpi(14701530) and Andreas Vesalius (15141564) reintroducedthe concept of evidence-based anatomic studies from directobservation (90). Berengarios Tractatus de fractura and Tractus

perutilis, published in 1518 and 1535, respectively, providedconcepts of staged surgeries, gravity drainage of intracranialabscesses, and the first detailed illustrations of surgical instru-ments (17, 18). Ambroise Par (15101590), surgeon to theHouse of Medici, made significant contributions to the surgi-cal treatment of head injuries (45). In Fabrica, Vesalius gave anaccount of the corpus callosum that was superior to that ofGalen, suggesting that it connected the two halves of the brain(110). Adding to the knowledge base, Thomas Willis (16211765) and his contemporaries made many important observa-tions on neuroanatomy, neurophysiology, and neurology (45).Despite having at their disposal an increasing body of medicalliterature on neuroanatomy along with improved surgical in-struments, surgeons continued to deal primarily with headtrauma and its aftermath, limited by a distinct lack of under-standing of neurological function and antisepsis, and the sur-geries remained principally epidural (Fig. 2). This was re-flected in their operative environment, which continued tobear little resemblance to the modern operating room. Thistheme would continue into the Renaissance period. However,a fundamental body of knowledge was being amassed that

would lead to the paradigm change that would occur fourcenturies later.

ENTRY INTO THE SCIENTIFIC AGE:NEUROSCIENCE AND THE FUNCTIONAL

NERVOUS SYSTEM

Into the 17th century, surgeons were hampered by a mini-mal understanding of neurophysiology and lacked the abilityto localize processes. The next major milestone in the devel-opment of the specialty was marked by the development of

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the concept of function grounded in a scientific and anatomicbasis (90). This period of development was fertilized by anexplosion in the fields of neuroscience and neurophysiologythat would fundamentally alter the conceptual view of the

causation of disease (68). During the period leading up to the19th century, neuroscience consisted essentially of gross ana-tomic studies on adult specimens, with galenic beliefs provid-ing the dominant influence (64, 117). However, starting in thelate 18th century, sophisticated techniques of brain tissue fix-ation and sectioning provided an important perspective on thethree-dimensional anatomy of the brain. In addition, compar-ative anatomy was repopularized with the advent of Darwinstheory of evolution. The microscopic architecture of the brainalso became visible with the adaptation of the achromaticmicroscope in the 1800s, giving birth to the field of histologyin the 1840s. In 1839, Theodor Schwann (18101882) proposedthe cell theory. In 1906, the Nobel Prize in Physiology and

Medicine was awarded to Camillo Golgi (18431926) andSantiago Ramn y Cajal (18521934). Finally, interest in thedeveloping nervous system led to the birth of the field ofembryology, adding another perspective to the study of neu-roanatomy. Enhancing this growing body of knowledge, pio-neering physiologists conducted animal vivisection experi-ments and electrical stimulation and ablation studies onanimal brains. These studies culminated in the work ofCharles Scott Sherrington (18571952), a central figure in thedevelopment of neurophysiology, whose work titled The Inte-

grative Action of the Nervous System (1906) formed the basicframework for the rest of the 20th century (98).

Although the developments in science were critical for theprogressive evolution of the field, a revelation of sorts wasnecessary that would lead to the shift in focus from the purelyphysical to the functional aspects of anatomy. This emergenceof the concept of function began in France with Jean Louis

Petit (16741750) and Henri Franois Le Dran (16851770),who called attention to the brain as being the source of alter-ations in levels of consciousness in head trauma with identi-fication of the lucid interval (69, 89). In England, Percival Pott(17131788), Benjamin Bell (17491806), John Abernathy(17641831), Jonathan Hutchinson (18281913), and their con-temporaries furthered the concepts put forth by the French,identifying basic signs of neurological compression such aspupillary changes and third nerve palsy (1, 15, 31, 62, 97).

The conceptual revelation of the functional brain wouldeventually evolve to definitions of cerebral localization (54).The 19th century witnessed the flourishing of Paris medicine,or the process of correlation of disease state observations with

findings at autopsy. Using this concept, Jean-BaptisteBouillaud (17961881) localized language function to the fron-tal lobes in 1825 (54). Bouillaud also understood the dichot-omy of aphasia and dysarthria in disorders of speech. Corre-lating autopsy findings with premortem observations, PierrePaul Broca (18241880), a pioneering anthropologist as well asa prominent surgeon, in a series of studies from 1861 to 1865astutely localized the language function to the third left frontalconvolution (23, 24).

Epilepsy and the physical manifestations of seizure disor-ders formed a natural model system for the study of brainfunction. John Hughlings Jackson (18351911) studied largenumbers of patients with focal motor seizures and other uni-

lateral disorders and described the systematic and consistentmarch of symptomatic involvement of the face and limbs infocal motor seizures. These studies are considered to be oflandmark importance in the understanding of cerebral local-ization (42, 63).

In addition to observations on humans, experimental stud-ies also contributed tremendously to the understanding ofcerebral localization (79). The French Marie Jean PierreFlourens (17941867) conducted ablation and stimulation ex-periments to elegantly demonstrate the general localization ofintelligence, volition, and sensation to the cerebral hemi-spheres, a concept he called the action propre (46). In Germany,physiologists Gustav Theodor Fritsch (18381891) and EduardHitzig (18381907) carried out studies in a canine model andprovided evidence of cortical control of motor function (47).Building on the efforts of Jackson and of Fritsch and Hitzig,David Ferrier (18431928) published detailed studies of corti-cal localizations starting in 1873, including The Functions of theBrain in 1876 (44). He thus established stimulation mapping asan acceptable experimental method.

With the revelation of the importance of function groundedin a solid basis of science, surgery on the nervous systementered a new paradigm. With these new considerations, theneed to monitor the function of the nervous system before,during, and after the operative intervention began to assume

FIGURE 2. Portrait of San Lucas (St. Luke) operating on a child with abrain tumor. Early 15th century (courtesy, Prado Museum, Madrid).

Although the attire and instruments have changed, cranial surgeons con-tinued to be plagued a lack of the knowledge of nervous system function aswell as a lack of the practicalities of anesthesia and antisepsis.




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ever-increasing importance. Furthermore, the awareness ofnervous system function led to refinements of the electrophys-iological techniques and methods developed by pioneeringphysiologists to monitor these functions. Among these, thedevelopment and popularization of techniques to study nerve

conduction and electroencephalography by Sir Richard Caton(18421926) and Hans Berger (18731941) would eventuallyallow the intraoperative monitoring of nervous system func-tion in the modern operating room.

DEVELOPMENT OF ANESTHESIA

As much as any other single factor, the development ofanesthesia was an essential element in the evolution of themodern neurosurgical operating environment. Ancient sur-geons most likely made use of the anesthetic qualities ofalcohol and early narcotics (107). Opium was available inEgypt by 1500 BC. Hyoscine was also available in Egypt

shortly thereafter and was known to exist in ancient Greeceand Rome. The Scythians used cannabis. In China, Pien ChiaChow used anesthesia, and the famous surgeon Hua To (AD190265) used ma-fei-san dissolved in wine (118). The firstdocumented neurosurgical application is credited to the Hin-dus, who in AD 927 used samohimi in the trephination of theKing of Dahr.

From these developments in antiquity arose general anes-thetic agents, which greatly expanded the scope and durationof surgical procedures (Fig. 3). In 1772, Joseph Priestley (17331804) discovered nitrous oxide, which Sir Humphry Davy(17781829) suggested might be useful in surgery. In fact, by

1831, all three of the main anesthetic agents of the 19th centuryhad been discovered: ether, chloroform, and nitrous oxide. In1842, Crawford W. Long (18151878), of Georgia, first appliednitrous oxide to minimize pain in a surgical patient. In 1846,John Collins Warren (17781856) and fellow dentist William

T.G. Morton (18191868) gave the first public demonstrationof painless surgery using sulfuric ether. By 1853, the hypoder-mic needle was invented by Alexander Wood (18171884),allowing the development of injectable agents. Injectable mor-phine was used in the American Civil War (Fig. 4). Forty yearslater, Oliver Wendell Holmes coined the term anesthesia. Theearly pioneers of neurosurgery were instrumental in applyingthese new techniques, with appropriate modifications, to sur-gery of the brain. In fact, Sir William Macewen (18481924)was the first to use an endotracheal tube for anesthesia in 1878(77). With these initial developments, another critical elementwas added to the armamentarium of the neurosurgeon, andthe operative environment moved closer to its modern form.

ANTISEPSIS TO ASEPSIS: SAFE PASSAGEPAST THE BARRIER OF THE DURA

Perhaps the most important barrier to operating inside thedural covering of the brain was the overwhelming infectionthat resulted. Indeed, it is now almost inconceivable that sur-gical manipulation of the nervous system would be evenattempted without meticulous attention to sterility. Withoutadequate precautions against infection, violating the protec-tive barrier of the dura resulted in wholly unacceptableoutcomes.

Before the 19th century, the dura was thought to be a

prohibitive barrier, to be deliberately violated only as a last

FIGURE 3. First operation under ether. Robert C. Hinckley (18811894).Surgeon John Collins Warren was the first to use ether anesthesia in sur-

gery, on October 16, 1846. With the advent of general anesthesia, thescope and duration of surgeries were dramatically broadened (courtesy,Boston Medical Library, Francis A. Countway Library of Medicine, Bos-ton, MA).

FIGURE 4. Camp of Chief Ambulance Officer, 9th Army Corps. FieldHospital near Petersburg, VA. During the time of the American CivilWar, surgeons operated under primitive conditions, and many patientssuccumbed to infection. They did, however, have the benefit of the hypo-dermic needle and injectable morphine. Daguerreotype taken by MatthewBrady or an assistant, 1864 (courtesy, Library of Congress).

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resort. In fact, even in cases in which the appropriate surgerywas performed, patients often succumbed to surgical infec-tions in the form of wound infection, subdural and epiduralempyema, and intracerebral abscess (115). The work of LordJoseph Lister (18271912) provided the final key to allow

William Macewen, guided by the new concepts of cerebrallocalization, to perform successful pioneering craniotomies.

By the time William Macewen entered medical school at theUniversity of Glasgow, Lister was Professor and Head of theDepartment of Surgery. Lister was keenly aware of the work ofLouis Pasteur (18221895) and the development of the germtheory and its implications for surgical infections. After tryingnumerous preparations, Lister used carbolic acid in aerosol formin 1865. Carbolic acid saw its initial application soaked intowound dressings in the American Civil War. Lister extended itsuse to the antiseptic treatment of surgical instruments, the sur-geons hands, the patients skin, and finally as a spray over thesurgical field (50, 73, 74). Listers work is recognized as a land-

mark achievement in the development of surgery.Concepts of antisepsis were combined with those of asepsisto dramatically reduce morbidity and mortality related toinfection. Louis Pasteur himself advocated the sterilization ofinstruments by flaming and dressings by exposure to pressur-ized steam in 1878. Subsequently, surgical gowns, caps, andboots were introduced, along with sterilized linens, drapes,gauze, and sponges.

Motivated by the work of Lister, William Macewen focusedhis considerable energies on improving and refining the anti-septic and aseptic technique, and he established one of the firststeam autoclaves in England. Furthermore, guided by theadvancements in the field of cerebral localization, in 1879 heperformed a successful craniotomy for a subdural hematomain a boy presenting with a seizure that initiated with left-sidedsymptoms that subsequently generalized to involve the rightside. In the same year, he performed another successful sur-gery to remove an en plaque meningioma in a young woman.These represent the first modern neurosurgical operations.Building on these initial successes, Macewen continued tosurgically treat primarily infectious intradural brain lesions. In1893, he published the classic titled Pyogenic Infective Diseasesof the Brain and Spinal Cord: Meningitis, Abscess of Brain, InfectiveSinus Thrombosis, describing his personal surgical series of 94patients (78).

With antisepsis and precautions against infection, anothercrucial element was assimilated to become an indispensable

feature of the neurosurgical operative environment. Indeed,much of the routine and ritual that fundamentally characterizemodern neurosurgical operating rooms is founded on theconcepts of antisepsis and asepsis.

ASSEMBLING THE ELEMENTS OF AFUNCTIONAL AMALGAM: EMERGENCE OF

THE OPERATING ROOM

By the late 19th century, many of the elements that charac-terize the modern neurosurgical enterprise and its operative

environment had been established. The neurosurgeon nowhad a solid knowledge base of neuroanatomy, an appreciationfor the function of the nervous system founded on a solidscientific basis, along with the practical enabling field of an-esthesia and ways to combat the scourge of pyogenic infection.

The early pioneers of modern neurosurgery assembled theseelements as a functional amalgam into their operative envi-ronment, giving birth to the modern operating room as wenow understand it.

The operating room has its architectural origins in the anat-omy teaching amphitheaters of the Renaissance period, whichwere circular or oval, with seating for the gallery of observersor students (Fig. 5) (114). However, those original entitiesrepresent nothing more than a physical shell into which all theelements of the neurosurgical enterprise would eventually beassembled (Figs. 610). This was accomplished by the earlypioneers, such as Rickman Godlee (18491925), J.O.Hirschfelder (18541920), and Francesco Durante (18441934),

who individually performed some of the very first neurosur-gical operations for brain tumors (16, 39, 58, 76). In 1886, SirVictor Horsley (18571916) performed the first craniotomy forepilepsy along with the resection of a brain tumor (60, 61). InGermany, Ernst von Bergmann (18361907) was instrumentalin the transition from the clumsy antiseptic technique to themore practical aseptic technique (112). In 1888, WilliamWilliams Keen (18371932), in Philadelphia, recorded the firstsuccessful access of the ventricular system in a living patient,tapping the lateral ventricle with a hollow needle, and per-formed the first successful removal of a brain tumor in Amer-ica. In France, Antoine M.J.N. Chipault (18661920) was prob-ably the first surgeon to be completely dedicated to thenervous system (30). In 1898, Leonardo Gigli developed a wiresaw that would make the actual process of opening the cra-

FIGURE 5. The Teatro Anatomica, an early ancestor of the modern oper-ating room. This early dissection theater was constructed at Padua in themid-16th century; dissections were carried out under torchlight. The circu-lar construction with space for a gallery would serve as the architecturalmodel for operating theaters to come, as seen in Figures 4 and 68 (cour-tesy, University of Padua as obtained by Dr. Norman Horwitz).




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nium safer (49). All their efforts would culminate in the workof Harvey Cushing (18691939) and Walter Dandy (18861946), whose efforts would firmly establish the field of neu-rological surgery and organization of the neurosurgical oper-ating room.

Harvey Cushing was born in Cleveland, OH, in 1869 andeducated at Yale College and Harvard Medical School (48, 56).

His interest in surgery and neurology was initiated at theMassachusetts General Hospital and the Convalescent Homeat Waverly and blossomed under the direction of WilliamHalsted (18521922) at Johns Hopkins, where he completedhis residency. He combined the halstedian principles with hisdrive and talents to advance the safe surgical treatment ofneurological diseases and made singularly important contri-butions toward the establishment of neurological surgery as adistinct specialty. Toward the end of his residency in 1900, hebegan to take a special interest in trigeminal neuralgia. Despiteengaging initially in a general practice, he began to focus moreof his energies on the nervous system after returning fromEurope in 1901, performing his first brain tumor operation the

following year. In 1904, he made a presentation in Clevelandtitled The Special Field of Neurological Surgery (32). He hada vision of a field practiced by surgeons specially trained inclinical neurology, neuropathology, and experimental neuro-physiology, along with the technical skills of operating on thebrain and central nervous system. He was instrumental in thedevelopment of methods of hemostasis in all structures of thehead and brain, improved the understanding and control ofintracranial pressure, and provided crucial insight into thepathology and natural history of surgically relevant lesions ofthe nervous system. In 1906, at the request of William W.Keen, Cushing produced a chapter on surgery of the head for

the encyclopedic text Surgery: Its Principles and Practice (33).This represented the first comprehensive treatise on the sub-ject by an American author. By 1910, he had performed 250brain tumor operations, with an operative mortality of 13%. Incontrast, contemporary surgeons were reporting operativemortalities of approximately 50%. In 1912, Cushing left Balti-more and assumed the position of Chief of Surgery at the PeterBent Brigham Hospital in Boston. There, he continued to de-velop techniques directed toward the surgical treatment of the

entire spectrum of neurosurgical diseases, including extrinsicand intrinsic intracranial tumors, trigeminal neuralgia, andpituitary tumors. During World War I, Cushing made consid-erable contributions to the treatment of head trauma. Theseactivities galvanized his position as the leading surgeon inAmerica and lent prominence to the field of neurologicalsurgery. As a further legacy of Cushings impact, many of hisresidents initiated academic programs of their own. Amongthese, John F. Fulton (18991960) was appointed Sterling Pro-fessor and Chairman of Physiology at Yale in 1930 (38).Fultons collaborations with Cushing continued from Bostonto New Haven, where Cushing spent his final days. Fultons

FIGURE 6. Photograph of Sir William MacCormac, senior surgeon of St.Thomas Hospital, London, performing an excision of a diseased elbow

joint in 1891. The operating theater continued to resemble the originallayout of the Teatro Anatomica of the 16th century (Fig. 3). Although ananesthetist is present, the uniform attire, mask, and gowns are distinctlyabsent.

FIGURE 7. Theodor Billroth operating in the auditorium of the Allge-meine Krankenhaus, Vienna, in 1889. Anton F. Seligmanns paintingshows Billroth performing a neurotomy for trigeminal neuralgia (courtesy,sterreichische Galerie, Vienna, Austria).

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department was a veritable Mecca for neurophysiology. He

published the classic Physiology of the Nervous System andhelped found the Journal of Neurophysiology in 1938. He wasalso instrumental in the founding of the Journal of Neurosurgeryin 1944.

Another giant in the history of neurosurgery in America isWalter E. Dandy (18861946). With Dandy and Cushing, thefundamental framework for modern neurosurgery had ar-rived. Dandy attended medical school at Johns Hopkins; there,he spent a year as a research assistant to Cushing. AfterCushings departure to Boston, Dandy remained at Hopkins,where he contributed seminally to the developing field. Forexample, he developed the technique of pneumoventrilogra-phy to study ventricular anatomy as it related to hydroceph-

alus (34). He also developed pneumoencephalography to vi-sualize the entire subarachnoid space (35). His studies oncerebrospinal fluid physiology are classic, defining the cho-roid plexus as the source of cerebrospinal fluid production. In1937, Dandy also performed the first clip ligation of a cerebralaneurysm while preserving the parent vessel (36). His contri-butions are myriad and elegantly described in his book TheBrain (37). His contributions to transcerebral surgeries, partic-ularly intraventricular tumors and rudimentary endoscopictechniques, are particularly noteworthy.

Cushing and Dandy were joined in their efforts by impor-tant figures such as Ernest Sachs (18791958), Charles A.

Elsberg (18711948), Charles H. Frazier (18701936), AntonioEgas Moniz (18741955), Fedor Krause (18571937), WilderPenfield (18911976), Herbert Olivecrona (18911980), andHugo Krayenbhl (19021985), among others (42, 43, 82, 85,87, 88, 108).

In contrast to the relatively standardized functional organi-zation of modern neurosurgical operating rooms, the early

FIGURE 8. William Keens operating theater in Philadelphia, PA, circa1900, one of a number of classic settings during the emergence of neuro-surgery as a primary discipline. Keen, along with other pioneers, assem-bled the elements of anesthesia with antisepsis/asepsis to bring forth theentity of the operating room as we now understand it.

FIGURE 9. Drs. Howard, Frazier, and Jackson demonstrating an opera-tion for students. City Hospital, Mobile, AL. In this setting, the surgeonsand assistants appear to be attired in uniform gowns and caps with anti-septic protocols in place. Also absent is the large gallery seen in previoussettings. Photograph by William E. Wilson, 1902 (courtesy, Historic

Mobile Preservation Society Archives, Mobile).

FIGURE 10. Photograph of an operating room, showing a nurse givinganesthetic by dripping it on a gauze over the patients face, circa 1919.

Even at this time, the members of the operating staff, including the sur-geons and nurses, are seen without a mask. Universal use of the surgicalmask in the operating room would not be evident until after World War II(courtesy, National Library of Medicine, Bethesda, MD).




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pioneers assembled personalized combinations of antiseptic/aseptic and anesthetic protocols in their customized operatingrooms (28, 71, 121). For example, ether anesthetic was used insome operating rooms, whereas chloroform was used in oth-ers. Even the use of rubber surgical gloves was not ubiquitous,

with none other than William Keen personally preferring cot-ton gloves (Fig. 8) (65, 92). Although common, the use ofsurgical masks was not universal until after World War II (29).In the United States, however, many hospitals had adoptedstringent aseptic protocols by the turn of the 20th century. Thistransition was marked by the routine use of gowns, caps,masks, and gloves, and the wiping down of operating roomequipment and furnishings with antiseptic between cases(Figs. 9 and 10) (3). Furthermore, routine protocols of handwashing were adopted. From these personalized practiceswould evolve a distinct set of rituals and routines that persistseven to modern-day operating rooms. The state of the art andscience of the field of neurosurgery had evolved to a point at

which a specialized setting was necessary to accommodate itsexecution. The familiar entity known as the operating roomwas at last taking form (41, 83, 101).

MAGNIFICATION AND THE TRENDTOWARD MINIMALISM:

THE OPERATING MICROSCOPE

For the first half of the 20th century, the field continued tobe refined and streamlined. Improved instruments and betterknowledge of anatomy naturally resulted in a reduction oftrauma related to surgery and better definition of the corridorsof access to the target lesions. However, the ultimate limit to

the precision and minimalism of the operative endeavor wasthe resolution of the naked human eye. The achievement ofimproved precision and minimalism by magnification and theoperating microscope would represent the next major mile-stone in the evolution of neurosurgery and the operativeenvironment (67, 119, 120).

Magnification was well known to even the ancient Egyp-tians and Romans, and by the mid-1800s, the microscope waswell established as a scientific tool. In 1848, the German ma-chinist Carl Zeiss, in collaboration with physicist Ernst Abb,began to produce high-quality microscopes in mass quantities.Abb had derived the theoretical formulas that governed theoptical properties of lenses, allowing the performance of new

lenses to be predicted and systematically designed. This rep-resented a distinct improvement over the trial-and-error tech-niques used at the time. At approximately the same time,surgeons had already recognized the potential benefit of mag-nification and had adapted single-lens magnifying loupes.During the early part of the 20th century, European otolaryn-gologists first adapted the microscope for surgery. By thatpoint in time, technical advances in lighting and microscopedesign by manufacturers such as Zeiss had resulted in instru-ments more practical for the operative setting. By the 1950s,Howard and William House had established the use of theoperating microscope in middle ear surgery through the tem-

poral bone. Concurrently, ophthalmologists had also assimi-lated the microscope into their own practice.

The first use of the microscope in a neurosurgical operationtook place in 1957 by Theodore Kurze (19222002) of theUniversity of Southern California. Inspired by the efforts of

William House, Kurze adapted the otological microscope foruse in the neurosurgical operating room. Furthermore, heintroduced contemporary neurosurgeons, such as RobertRand (1923 ), J. Lawrence Pool (1906 ), and Charles Drake(19201998), to this new concept. By 1958, neurosurgeon R.M.Peardon Donaghy (19101991) had established the worldsfirst microsurgery research laboratory in Vermont. After someinitial resistance, the operating microscope would become anindispensable neurosurgical tool and find a prominent placein the neurosurgical operating room. From 1958 onward,Theodore Kurze performed all his aneurysm operations withthe operating microscope. Over the next few years, reports ofmicroneurosurgery began to appear in the neurosurgical lit-

erature. In 1962, Kurze published his series of middle fossaoperations. By 1965, J. Lawrence Pool had published the firstseries of cerebral aneurysms surgically treated with the aid ofthe microscope. The next year, Peter Jannetta (1932 ) andRobert Rand published their series of posterior circulationaneurysms treated with microsurgery. Building on these ini-tial efforts, M. Gazi Yasargil (1925 ) would firmly establishthe microneurosurgical revolution. With this, the trend to-ward progressive minimalism was well under way (119, 120).

PRELUDE TO MODERNITY:THE PAST GENERATION

The next several decades of evolution in neurosurgery wit-nessed the rapid expansion in the scope and focus of thespecialty enabled by the incorporation of new tools into theoperating room (Fig. 11). Important areas of influence in the

FIGURE 11. Photograph of Ernst Spiegel and Henry Wycis performing anearly stereotactic procedure. Toward the middle part of the 20th century, newtools were rapidly assimilated into the operating room, greatly expanding thescope and focus of the discipline (courtesy, Time-Life Warner).

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development of sophistication in operative events in the pastgeneration (9) have included 1) the introduction of the oper-ating microscope, which has allowed magnification and pres-ervation as well as reduction of operative corridors; 2) refine-ment of strict neuroanatomic comprehension secondary to

elegant studies of elements of the neuroanatomic substratethroughout the entire neural and neurovascular systems; 3)the development of imaging devices that have allowed defi-nition of the preoperative structural substrate, pathology, andanatomic distortions in the individual sense; 4) the introduc-tion of the computer as a neurosurgical tool in stereotactic andrefined-access cerebral and spinal neurosurgery (99); and 5)the use of a multiplicity of anatomic and neurophysiologicalmonitoring modes during each operative event. These impor-tant influential forces have led to a precision of orientation andaction, achieving what has been observed to be a progressiveminimalism, a concept that has been dominant and has prin-cipal influences as one considers actions within the neurosur-

gical operative environment. The concepts would embrace theentire specialty and are fundamentally predicated on the no-tion of minimal invasion of anatomy but maximum beneficialimpact on the disease process. It is clearly apparent in thetechnical enterprises of endoscopy, endovascular surgery (59,111), and cellular/molecular neurosurgery (95, 122, 123) withrestoration of function. However, it is most practically appar-ent in the field of imaging-guided stereotactic neurosurgeryand so-called neuronavigation, which has been in evolutionprincipally as a result of evolving developments in the pen-etrating imaging modalities beyond the visible within bothstructural and functional realms. During the past 2 decades,these developments have served as a platform for the furtheremergence of concepts to be applied within the stereotacticfield. These have included 1) voice control, 2) holography inreal time, 3) robotics, 4) virtual reality systems for simulationand training, and 5) telesurgical systems.

AN IDEAL VENUE: 1990

More than a decade ago, given these concepts and devel-opments, we very carefully evaluated technical evolving fieldsand related them to our personal needs at the University ofSouthern California with the construction of a new UniversityHospital (12). At that time, certain characteristics of a modernoperating environment appeared to be central in consideration

of the architectural development and functional design of anadvanced neurosurgical operating environment. These in-cluded 1) generous size to accommodate the space require-ments of advanced support systems, 2) compartmentalizationto offer work areas for both sterile and nonsterile activitiesrelated to operative events, 3) self-containment to minimizedependence on external support and intraoperative traffic, 4)appropriate systems for data acquisition, 5) appropriate sys-tems for data processing, 6) appropriate systems for datadisplay, and 7) design offering fluidity during complex pro-cedures and multifactorial function involving instrumentationand personnel.

This idealized development offered the first detailed de-scription of a dedicated, self-contained neurosurgical operat-ing suite incorporating major surgical instrumentation andvisualization technologies to provide a setting for microscopic,stereotactic, and microstereotactic procedures. It attempted to

integrate advanced computer technology for visualization toaugment, simulate, document, and facilitate all aspects ofneurosurgery.

Specific goals and objectives of the design were to providean integrated visualization system, which could achieve thefollowing functions: 1) stereotactic point and volume planning(simulation) and procedures; 2) microstereotactic volumeplanning (simulation) and procedures; 3) procedural integra-tion of nonlinkage (frameless) stereotaxy, microscopy, andimaging; 4) graphic simulation of microscopic and stereotacticprocedures; 5) surgical team integration through presentationof visual data on the operative environment (operative fieldsand physiological monitors); 6) retrieval and presentation of

reference data from scientific and practical atlases, journals,and texts in an online library; 7) real-time presentation ofcomplex and basic physiological monitoring parameters; 8)real-time presentation of operative structural staging withthree-dimensional comparative imaging; 9) multiparameterrecording of all surgical events; 10) a complete nursing catalogof individual case setup and surgeon setup, instrumentation,and idiosyncratic preferences; 11) enhancement of educationalexperience and databases; 12) fusion of images from com-puted tomography (CT), magnetic resonance imaging (MRI),digital subtraction venous angiography, positron emission to-mography, magnetoencephalography, and graphic overlays,with consideration of functional imaging integration with the

structural composite; 13) documentation for medicolegal andeducational purposes; 14) increased safety and precision ofoperative procedures; and 15) initiation of progress toward avirtual-reality concept of an anatomic/surgeon interface.

To realize these goals, the design of the operating suitecomprised three primary areas (Fig. 12): 1) the operating room(approximately 700 square feet), 2) the observation/storagearea (approximately 200 square feet), and 3) a computer visu-alization laboratory (approximately 400 square feet). This fun-damental design was inspired by elements of interface withthe operating theater concept of Theodore Kurze (at the Uni-versity of Southern California), John M. Tew, Jr. (at the Uni-versity of Cincinnati), Kintomo Takakura (at the University ofTokyo), and Patrick J. Kelly (at the Mayo Clinic and then atNew York University) (51, 66).

Over what is now a decade of use, this amalgam of designof space and function has proved to have benefits and prob-lems, but in particular, supporting software development in acustomized setting proved to be costly and impractical. Inaddition, certain conceptual trends and increasing miniatur-ization and functionality of available technology would initi-ate certain design departures from planning that occurredmore than a decade ago. It should be stated, however, that thebasic needs and goals have remained fundamentallyunchanged.




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THE PAST DECADE

During the past decade, there has been remarkable techni-cal progress that has a bearing on the ultimate developmentfor neurosurgical environments for the 21st century. Funda-

mentally, all of these relate to concepts that have been recog-nized but not brought into the realm of practical reality. Nu-merous developments in robotics have been apparent, withcomplex systems currently globally applied in cardiac surgeryand other surgical disciplines (20, 26, 102106). Robotic de-

vices have been introduced into stereotactic radiosurgery,with the automatic positioning system regularly used withgreat safety and technical efficiency with the Leksell gammaknife (Elekta Instruments, Inc., Atlanta, GA) (Fig. 13) and theNovalis (BrainLAB, Heimstetten, Germany) radiosurgical sys-tem. This implementation of the robotic concept has enhancedthe fluidity and scope of application over previous genera-tions of fixed-beam radiosurgery systems. The CyberKnife(Accuray, Inc., Sunnyvale, CA), a robotically devised rota-tional frameless radiosurgical system, is now ready for oper-ation and promises to bring new dimensions to volumetricallycontrolled radiotherapy (Fig. 14) (2). During this decade, it hasbecome clear that the concept of a conventional operating

room needs to be expanded to radiosurgical suites as domainsof neurosurgical enterprise (70).

FIGURE 12. A, diagonal view of the neurosurgical operating room at theUniversity of Southern California (USC) University Hospital. Area withoverhead microscope track offered more than 700 square feet of area and self-contained support facility for microscopic and stereotactic procedures. B, diag-onal view of the neurosurgical operating room at the USC University Hospi-tal. Note overhead monitors and multifactorial visualization display wall to

right. C, the computer visualization laboratory composed of three workstationsand enclosed computer bank room to left. This served as an adjacent but inte-

gral component of the neurosurgical operating room at the USC UniversityHospital, Los Angeles (circa 1992) (from, Apuzzo MLJ, Weinberg RA: Thearchitecture and functional design of advanced neurosurgical operating envi-ronments. Neurosurgery 33:663673, 1993 [12]).

FIGURE 13. A, Leksell gamma knife, Model C. B, helmet and roboticdevice for migration through cartesian coordinates in the radiosurgicaldevice (Leksell gamma knife). With the broadening scope of neurosurgery,the operative environment must now include radiosurgical and angiogra-

phy suites (courtesy, University of Southern California University Hospi-tal, Los Angeles, CA).

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During the past decade, imaging has developed at a dra-matic pace from the standpoints of not only definitive capa-bility but also locales of application. Within operative envi-ronments, structural data are applied through compact

navigational devices for localization. These data are acquiredpreoperatively through CT, MRI, and angiography. More dra-matically, intraoperative accrual is now practical in certaincenters, with CT and MRI devices serving as surgical instru-mentation within operating room settings (19, 84) (Fig. 15).

Developments in functional imaging are now widely availableand are used through both preoperative and intraoperative ac-crual. There appears to be important progress in the miniatur-ization of devices that provide these imaging capabilities and,importantly, a concurrent reduction in cost (Fig. 16).

Refinement of visualization displays has been evident withthe development of flat and compact plasma high-definitionvisualization screens that lend themselves to the operating

room environment. Head-mounted displays have enjoyed sig-nificant refinement in stereotactic amalgam with the operatingmicroscope and helmet systems for endoscopic application.

Neurosurgery has been fundamentally reinvented, withtools of modernity being defined within the realms of micros-copy, anatomic comprehension, imaging, computers, ionizingradiation, biomedical technology, and biomolecular science(10, 11, 13, 86, 95, 122, 123). Concurrently, concepts of moder-nity have emerged to include sophisticated comprehension ofthe individual, operative minimalism, navigational guidance,biomechanicalization, operative rehearsal, and structural/functional restoration.

STATE OF THE ART: 2003

Many of the ideas outlined in the development of the ide-al neurosurgical operating room at the University of South-ern California in 1990 can be found elegantly expressed in acommercially available unit (Figs. 17 and 18). The operating

FIGURE 14. A robotically controlled frameless radiosurgical system(CyberKnife) (courtesy, Kenneth Norris, Jr., Hospital, University ofSouthern California, Los Angeles, CA).

FIGURE 15. An early-generation attempt at bringing MRI into the oper-ating room. This configuration will eventually be miniaturized forimproved functionality (Fig. 16) (courtesy, Brigham and Womens Hospi-tal, Boston, MA).

FIGURE 16. A miniature magnetic imaging device designed for intraop-

erative usage (Odin Technologies device) (from, Moshe H, Spiegelman R,Feldman Z, Berkenstadt H, Ram Z: Novel, compact, intraoperative mag-netic resonance image-guided system for conventional neurosurgical oper-ating rooms. Neurosurgery 48:799809, 2001 [84]).




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microscope is ceiling mounted for optimal ergonomic useful-ness. Data are displayed on a large video wall for easy access.

A 1.5-T high-field MRI system is integrated to provide intra-operative imaging capabilities. The images are then linked toan image guidance system. With the full benefits of early21st-century technology, the Brainsuite contains almost all theelements of modernity in a self-contained environment. Thiskind of operating can be considered the current state of the artat this point in time.

A PERVASIVE THEME

A pervasive theme in the development of neurosurgery andthe evolution of the operative environment is clearly illus-

trated by the assimilation of neurodiagnostic imaging modal-ities into neurosurgical practice. In the 1970s, that imaging wasemerging as an important diagnostic tool. To take advantageof visualization of the target and instrument, neurosurgeonsoften performed procedures in the CT suites. In the 1980s,

with the development of the widely used Brown-Roberts-Wells and other imaging-directed stereotactic frames, the in-formation gained from the scanners was brought into theoperating room, in which the elements of the neurosurgicalenterprise were optimized and the neurosurgeon was morecomfortable. In the 1990s, however, the scanners were broughtinto the operating room for intraoperative imaging to guidedecision making, with the development coming full circle.

Clearly, as new technology becomes available, it finds ap-plication in the practice of neurosurgery. Eventually, however,a form of this technology is brought into the operative envi-ronment. The expansion of the scope and capabilities of neu-rosurgery enabled by technology advancement and the even-

tual incorporation of new products into the operativeenvironment represent the natural evolution of the field. His-tory suggests that this theme will persist into the future.

REFERENCES

1. Abernethy J: Surgical Observations on Injuries of the Head and on Miscellaneous

Subjects. London, Longman, Hurst, Rees, Orme, & Brown, 1810.

2. Adler JR Jr, Murphy MJ, Chang SD, Hancock SL: Image-guided robotic

radiosurgery. Neurosurgery 44:12991306, 1999.

3. Alford DJ, Ritter MA, French ML, Hart JB: The operating room gown as a

barrier to bacterial shedding. Am J Surg 125:589591, 1973.

4. Apuzzo MLJ (ed): Neurosurgery for the Third Millennium: American Associa-

tion of Neurological Surgeons Neurosurgical Topics. Park Ridge, AANS, 1992.

5. Apuzzo MLJ: Schneider Lecture: New dimensions of neurosurgery in therealm of high technologyPossibilities, practicalities, realities. Neuro-

surgery 38:625639, 1996.

6. Apuzzo MLJ: Brave new world: Reaching for utopia. Neurosurgery 46:

1033, 2000.

7. Apuzzo MLJ: Modernity and the emerging futurism in neurosurgery:

Tempora mutantur nos et mutamur in illis. J Clin Neurosci 7:8587, 2000.

8. Apuzzo MLJ: Reinventing neurosurgery: Entering the third millennium.

Neurosurgery 46:12, 2000.

9. Apuzzo MLJ, Hodge CJ Jr: The metamorphosis of communication, the

knowledge revolution, and the maintenance of a contemporary perspective

during the 21st century. Neurosurgery 46:715, 2000.

10. Apuzzo MLJ, Liu CY: 2001: Things to come. Neurosurgery 49:765778,

2001.

11. Apuzzo MLJ, Liu CY: Quid Novi? In the realm of ideasThe neurosurgical

dialectic. Clin Neurosurg 49:157185, 2002.

12. Apuzzo MLJ, Weinberg RA: The architecture and functional design ofadvanced neurosurgical operating environments. Neurosurgery 33:663

673, 1993.

13. Apuzzo MLJ, Liu CY, Sullivan SD, Faccio RA: Reinventing neurosurgery:

Surgery of the human cerebrumA collective modernity. Clin Neurosurg

49:2789, 2002.

14. Aufderheide AC: The enigma of ancient cranial trepanation. Minn Med

68:119122, 1985.

15. Bell B: A System of Surgery. Edinburgh, C. Elliot, 17831788, vols 16.

16. Bennett AH, Godlee RJ: Case of cerebral tumour: The surgical treatment.Trans R Med Chir Soc Lond 68:243275, 1885. Reprinted in Wilkins RH

(ed): Neurosurgical Classics. Park Ridge, AANS, 1992, pp 361371.

17. Berengario da Carpi J: Tractatus de fractura calue siue cranei. Bologna, H de

Benedictis, 1518.

FIGURE 17. A state-of-the-art operating room in 2002. The Brainsuitecontains all the elements of modernity conceptually organized in a mannersimilar to the design of the ideal venue at the University of SouthernCalifornia in 1992. Notice the ceiling-mounted microscope, the video wall

for data display, the image guidance systems, and intraoperative MRIcapabilities (courtesy, BrainLAB).

FIGURE 18. Video wall of the Brainsuite for effective display of data(courtesy, BrainLAB).

LIU AND APUZZO



15/17

18. Berengario da Carpi J: Tractatus perutilis et completus de fractura cranei.

Venice, Nicolinis de Sabio, 1535.

19. Black PM, Moriarty T, Alexander E III, Steig P, Woodard EJ, Gleason PL,

Martin CH, Kikinis R, Schwartz RB, Jolesz FA: Development and imple-

mentation of intraoperative magnetic resonance imaging and its neurosur-

gical applications. Neurosurgery 41:831845, 1997.

20. Borst C: Operating on a beating heart. Sci Am 283:5863, 2000.21. Botallo L: De curandis vulneribus sclopetorum. Lyon, G Roville, 1560.

22. Breasted JH: The Edwin Smith Surgical Papyrus: Published in Facsimile and

Heirogliphic Transliteration with Translation and Commentary in Two Volumes.

Chicago, University of Chicago Press, 1930.

23. Broca P: Nouvelle observation daphmie produite par une lsion de la

moiti postrieure de deuxime et troisime circonvolutions frontales. Bull

Mem Soc Anat Paris 6:398407, 1861.

24. Broca P: Perte de la parole, ramollissement chronique et destruction

partielle du lobe antrieur gauche du cerveau. Bull Soc Anthropol 2:235

238, 1861.

25. Broca P: La trpanation chez les Incas. Bull Acad Natl Med 32:866871,

1867.

26. Cadeddu JA, Stoianovici D, Kavoussi LR: Robotic surgery in urology. Urol

Clin North Am 23:7585, 1998.

27. Campanillo D: Neurosurgical pathology in prehistory. Acta Neurochir(Wien) 70:275290, 1984.

28. Cartwright FF: The Development of Modern Surgery. New York, Thomas Y.

Crowell, 1968.

29. Castaneda A: Historical development of the surgical mask. Surgery 49:423

428, 1961.

30. Chipault A: Chirurgie Opratoire du Systme Nerveux. Paris, Reuff & Cie,18941895, vols 1 and 2.

31. Cooper A: The Lectures of Sir Astley Cooper: On the Principles and Practice

of Surgery. London, Thomas & George Underwood, 18241825, pp 252

352.

32. Cushing H: The special field of neurological surgery. Bull Johns Hopkins

Hosp 16:7787, 1905.

33. Cushing H: Surgery of the head, in Keen WW (ed): Surgery: Its Principles

and Practice. Philadelphia, W.B. Saunders Co., 1908, vol 3, pp 17276.

34. Dandy WE:Ventriculography followingthe injectionof airinto thecerebral

ventricles. Ann Surg 68:511, 1918. Reprinted in Wilkins RH (ed): Neuro-surgical Classics. Park Ridge, AANS, 1992, pp 244250.

35. Dandy WE: Rntgenography of the brain after the injection of air into the

spinal canal. Ann Surg 70:397403, 1919. Reprinted in Wilkins RH (ed):

Neurosurgical Classics. Park Ridge, AANS, 1992, pp 251256.

36. Dandy WE: Intracranial aneurysm of the internal carotid artery. Ann Surg

107:654659, 1938. Reprinted in Wilkins RH (ed): Neurosurgical Classics.

Park Ridge, AANS, 1992, pp 437441.

37. Dandy WE: The Brain. New York, Harper, 1969.

38. Davey LM: John Farquhar Fulton. Neurosurgery 43:185187, 1998.

39. Durante F: Contribution to endocranial surgery. Lancet 2:654655, 1887.

Reprinted in Wilkins RH (ed): Neurosurgical Classics. Park Ridge, AANS,

1992, pp 375376.

40. Elsberg CA: Edwin Smith Surgical Papyrus and the diagnosis and treat-

ment of injuries to skull and spine 5000 years ago. Ann Med Hist 3:271

279, 1931.

41. Essex-Lopresti ME: Operating theatre design. Lancet 353:10071010, 1999.

42. Feindel W, Leblanc R, Villemure JG: History of the surgical treatment of

epilepsy, in Greenblatt SH (ed): A History of Neurosurgery in Its Scientific and

Professional Contexts. Park Ridge, AANS, 1997, pp 465488.

43. Feldman RP, Goodrich JT: Psychosurgery: A historical overview. Neuro-

surgery 48:647659, 2001.

44. Ferrier D: The Functions of the Brain. London, Smith, Elder & Co., 1876.

45. Flamm ES: From signs to symptoms: The neurosurgical management of

head trauma from 15171867, in Greenblatt SH (ed): A History of Neurosur-

gery in its Scientific and Professional Contexts. Park Ridge, AANS, 1997, pp

6581.

46. Flourens P: Recherches Exprimentales sur les Propits et les Fonctions duSystme Nerveux dans les Animaux Vertbrs. Paris, Crevot, 1824.

47. Fritsch GT, Hitzig E: Ueber die elektrische Erregbarkeit des Grosshirns.

Arch Anat Physiol Wiss Med 37:300332, 1870. Translated: On the electri-

cal excitability of the cerebrum. Von Bonin G (trans), in Von Bonin G (ed):

Some Papers on the Cerebral Cortex. Springfield, Charles C Thomas, 1960, pp

7396. Reprinted in Wilkins RH (ed): Neurosurgical Classics. Park Ridge,

AANS, 1992, pp 1627.

48. Fulton JF: Harvey Cushing: A Biography. Springfield, Charles C Thomas,1946.

49. Gigli L: Zur Technik der temporren Schdelresection mit meiner

Drahtsge. Zentralbl Chir 25:425428, 1898. Reprinted in Wilkins EH (ed):

Neurosurgical Classics. Park Ridge, AANS, 1992, pp 380382.

50. Godlee RJ: Lord Lister. London, Macmillan and Co., 1917.

51. Goerss S, Kelly PJ, Kall B, Alker GJ Jr: A computed tomographic stereo-

tactic adaptation system. Neurosurgery 10:375379, 1982.

52. Gomez JG: Paleoneurosurgery in Colombia. J Neurosurg 39:585588, 1973.

53. Goodrich JT: Neurosurgery in the ancient and medieval worlds, in

Greenblatt SH (ed): A History of Neurosurgery in Its Scientific and Professional

Contexts. Park Ridge, AANS, 1997, pp 3764.

54. Greenblatt SH: Cerebral localization: From theory to practicePaul Broca

and Hughlings Jackson to David Ferrier and William Macewen, in



55. Greenblatt SH (ed): A History of Neurosurgery in Its Scientific and ProfessionalContexts. Park Ridge, AANS, 1997.

56. Greenblatt SH, Smith DC: The emergence of Cushings leadership: 1901

1920, in Greenblatt SH (ed): A History of Neurosurgery in Its Scientific and

Professional Contexts. Park Ridge, AANS, 1997, pp 167190.

57. Hippocrates: On injuries of the head, in Medical Classics: Genuine Works of

Hippocrates. Adams F (trans). Baltimore, Williams & Wilkins, 1938, vol 3, pp

145160.

58. Hirschfelder JO: Removal of a tumor of the brain. Pac Med Surg J 29:210

216, 1886.

59. Hopkins LN, Lanzino G, Guterman LR: Treating complex nervous system

vascular disorders through a needle stick: Origin, evolution, future of

neuroendovascular therapy. Neurosurgery 48:463475, 2001.

60. Horsley V: Brain surgery. Br Med J 2:670675, 1886.

61. Horsley V, Clarke RH: The structure and functions of the cerebellum

examined by a new method. Brain 31:45124, 1908. Reprinted in Wilkins

RH (ed): Neurosurgical Classics. Park Ridge, AANS, 1992, pp 162185.

62. Hutchinson J: Four lectures on compression of the brain. Clin Lectures

Reports Lond Hosp 4:1055, 18671868.

63. Jackson JH: A study of convolutions. Trans St. Andrews Med Grad Assoc

3:162204, 1870.

64. Jacyna LS: The neurosciences: 18001875, in Greenblatt SH (ed): A History

of Neurosurgery in Its Scientific and Professional Contexts . Park Ridge, AANS,

1997, pp 131136.

65. Keen WW: On the use of surgical gloves in surgical operations. Ann Surg

27:224227, 1898.

66. Kelly PJ, Kall BA, Goerss S: Transposition of volumetric information de-

rived from computed tomography scanning into stereotactic space. Surg

Neurol 21:465471, 1984.

67. Kriss TC, Kriss VM: History of the operating microscope: From magnifying

glass to microneurosurgery. Neurosurgery 42:899908, 1998.

68. Laws ER Jr, Udvarhelyi GB: The Genesis of Neuroscience by A. Earl Walker,M.D. Park Ridge, AANS, 1998.

69. Le Dran HF: Observations de Chirurgie. Paris, C. Osmont, 1731, vols 1 and 2.

70. LeMay DR, Chen TC, Petrovich Z, Luxton G, Zelman V, Zee CS, Green J,

Apuzzo MLJ: Gamma unit facility: Concept genesis, architectural design,

and practical realization. Stereotact Funct Neurosurg 66:4149, 1996.

71. Leonardo RA: History of Surgery. New York, Froben Press, 1943.

72. Lisowski FP: Prehistoric and early historic trepanation, in Brothwell D,

Sandison AT (eds): Diseases in Antiquity. Springfield, Charles C Thomas,

1967, pp 651672.

73. Lister J: Illustrations of the antiseptic system of treatment in surgery.

Lancet 2:668669, 1867.

74. Lister J: On the antiseptic principle in the practice of surgery. Lancet

2:353356, 1867.




16/17

75. Liu CY, Spicer M, Apuzzo MLJ: The genesis of neurosurgery and the

evolution of the neurosurgical operative environment: Part IIConcepts

for future development, 2003 and beyond. Neurosurgery 52:2035, 2003.

76. Lyon AE: The crucible years 1880 to 1900: Macewen to Cushing, in



77. Macewen W: Clinical observations on the introduction of tracheal tubes bymouth instead of performing tracheostomy or laryngotomy. Br Med J

2:122124, 1880.

78. Macewen W: Pyogenic Infective Diseases of the Brain and Spinal Cord: Menin-

gitis, Abscess of Brain, Infective Sinus Thrombosis. Glasgow, James Maclehose

& Sons, 1893.

79. Magendie F: Prcis Elmentaire de Physiologie. Paris, Mquignon-Marvis,1836.

80. Magetts EL: Trepanation of the skull by the medicine-men of primitive

cultures, with particular reference to present-day native East African prac-

tice, in Brothwell D, Sandison AT (eds): Diseases in Antiquity. Springfield,

Charles C Thomas, 1967, pp 673701.

81. Marino R Jr, Gonzales-Portillo M: Preconquest Peruvian neurosurgeons: A

study of Inca and pre-Columbian trephination and the art of medicine in

ancient Peru. Neurosurgery 47:940950, 2000.

82. Monaz E: Lencphalographie artrielle, son importance dans la localiza-

tion des tumeurs crbrales. Rev Neurol 2:7289, 1927. Reprinted inWilkins RH (ed): Neurosurgical Classics. Park Ridge, AANS, 1992, pp 265

276.

83. Morgeli C: The Surgeons Stage: A History of the Operating Room. Basel, F.Hoffmann-La Roche, 1999.

84. Moshe H, Spiegelman R, Feldman Z, Berkenstadt H, Ram Z: Novel, com-

pact, intraoperative magnetic resonance image-guided system for conven-

tional neurosurgical operating rooms. Neurosurgery 48:799809, 2001.

85. Olivecrona H, Ladenheim J: Congenital Arteriovenous Aneurysms of the Ca-

rotid and Vertebral Arterial Systems. Berlin, Springer-Verlag, 1957.

86. Patrick CW Jr, Mikos AG, McIntire LV (eds): Frontiers in Tissue Engineering.

New York, Elsevier Science, 1998.

87. Penfield W, Boldrey E: Somatic motor and sensory representation in the

cerebral cortex of man as studied by electrical stimulation. Brain 60:389

443, 1937.

88. Penfield W, Jasper H: Epilepsy and the Functional Anatomy of the Human

Brain. Boston, Little Brown & Co., 1954.

89. Petit JL: Principe de Chirurgie. Paris, 1730.

90. Preul MC: A history of neuroscience from Galen to Gall, in Greenblatt SH

(ed): A History of Neurosurgery in Its Scientific and Professional Contexts. Park

Ridge, AANS, 1997, pp 99130.

91. Prioreschi P: Possible reasons for Neolithic skull trephining. Perspect Biol

Med 34:296303, 1991.

92. Randers-Pehrson J: The Surgeons Glove. Springfield, Charles C Thomas,1960.

93. Rifkinson-Mann S: Cranial surgery in ancient Peru. Neurosurgery 23:411

416, 1988.

94. Roger of Salerno: Practica chirugiae. de Vitalibus BV (trans), in Guy de

Chauliac (ed): Cyrurgia. . .et cyrugia bruni. Teodorici. Rolandi. Lanfranci.

Rogerii. Bertapalie. Noviter impressus. Venetiis, Per Bernardinum Venetum de

Vitalibus, 1591.

95. Rutka JT, Taylor M, Mainprize T, Langlois A, Ivanchuk S, Mondal S, DirksP: Molecular biology and neurosurgery in the third millennium. Neuro-

surgery 46:10341051, 2000.

96. Saul FP, Saul JM: Trepanation: Old world and new world, in Greenblatt SH

(ed): A History of Neurosurgery in Its Scientific and Professional Contexts. Park

Ridge, AANS, 1997, pp 2935.

97. Sharp W: Practical Observations on Injuries of the Head. London, Churchill,

1841.

98. Sherrington CS: The Integrative Action of the Nervous System. New Haven,

Yale University Press, 1906.

99. Spiegel EA, Wycis HT, Marks M, Lee AJ: Stereotaxic apparatus for opera-

tion on the human brain. Science 106:349350, 1947.

100. Stone JL, Miles ML: Skull trepanation among the early Indians of Canada

and the United States. Neurosurgery 26:10151020, 1990.

101. Stromberg BV: The operating room: A historical perspective. J S C Med

Assoc 81:3133, 1985.

102. Taylor RH: Robotics in orthopaedic surgery, in Nolte LP, Ganz R (eds):

Computer Assisted Orthopedic Surgery (CAOS). Seattle, Hogrefe and Huber,

1999, pp 3541.

103. Taylor RH, Funda J, Eldridge K, Gruben D, LaRose D, Gomory S, Talamini

M: A telerobotic assistant for laparoscopic surgery, in Taylor RH, LavalleeS, Burdea G, Mosges R (eds): Computer-Integrated Surgery. Cambridge, MIT

Press, 1996, pp 581592.

104. Taylor R, Jensen P, Whitcomb L, Barnes A, Kumar R, Stoinovici D, Gupta

P, Wang Z, de Juan E, Kavoussi L: A steady-hand robotic system for

microsurgical augmentation, in Taylor C, Colchester A (eds): Medical Image

Computing and Computer-Assisted Intervention: MICCAI 99Second Interna-tional Conference, Cambridge, UK, September 1922, 1999. London, Springer,1999.

105. Taylor RH, Lavallee S, Burdea G, Mosges R (eds): Computer-Integrated

Surgery. Cambridge, MIT Press, 1996.

106. Taylor RH, Paul HA, Kazandzides P, Mittelstadt BD, Hanson W, Zuhars JF,

Williamson B, Musits BL, Glassman E, Bargar WL: An image-directed

robotic system for precise orthopedic surgery. IEEE Trans Rob Autom

10:261275, 1994.

107. Tracy PT, Hanigan WC: History of neuroanesthesia, in Greenblatt SH (ed):A History of Neurosurgery in Its Scientific and Professional Contexts. Park

Ridge, AANS, 1997, pp 213221.

108. Valenstein ES: History of psychosurgery, in Greenblatt SH (ed): A History

of Neurosurgery in Its Scientific and Professional Contexts . Park Ridge, AANS,

1997, pp 499516.

109. Velasca-Suarez M, Martinez JB, Oliveros RG, Weinstein PR: Archeological

origins of cranial surgery: Trephinations in Mexico. Neurosurgery 31:313

319, 1992.

110. Vesalius A: De humani corporis fabrica libri septem. Basel, Johannes Oporinus,

1543.

111. Viuela F, Murayama Y, Duckwiler GM, Gobin YP, Jahan R: Unreach-

able peaks of the neurointerventional mountaineers. Neurosurgery 48:

698699, 2001.

112. von Bergmann E: Die chirurgische Behandlung von Hirnkrankheiten: Zweitte,

vermehrte und umgearbeitete Auflage. Berlin, A. Hirshwald, 1851.

113. Walker AE: Primitive trepanations: The beginning of medical history.Trans Stud Coll Physicians Phila 26:99102, 1958.

114. Wangensteen OW, Wangensteen SD: The surgical amphitheater, history of

its origins, functions, and fate. Surgery 77:404418, 1975.

115. Wilkins RH: Treatment of craniocerebral infection and other common

neurosurgical operations at the time of Lister and Macewen, in Greenblatt

SH (ed): A History of Neurosurgery in Its Scientific and Professional Contexts .

Park Ridge, AANS, 1997, pp 8396.

116. Wilkinson RG: Trephination by drilling in ancient Mexico. Bull N Y Acad

Med 51:838850, 1975.

117. Willis T: Cerebri Anatome. Londini, Typis Ja. Flesher, impensis Jo. Martyn &

Ja. Allestry, 1664.

118. Wong KC, Wu LT: History of Chinese Medicine: Being a Chronicle of Medical

Happenings in China from Ancient to Present Period. Shanghai, National

Quarantine Service, 1936, ed 2.

119. Yasargil MG: Microsurgery Applied to Neurosurgery. Stuttgart, Georg

Thieme, 1969.

120. Yasargil MG: A legacy of microneurosurgery: Memoirs, lessons, and axi-

oms. Neurosurgery 45:10251091, 1999.

121. Zimmerman LM, Veith I: Great Ideas in the History of Surgery. Baltimore,

Williams & Wilkins, 1961.

122. Zlokovic BV, Apuzzo MLJ: Cellular and molecular neurosurgery: Path-

ways from concept to realityPart I: Target disorders and concept ap-

proaches to gene therapy of the central nervous system. Neurosurgery

40:789804, 1997.

123. Zlokovic BV, Apuzzo MLJ: Cellular and molecular neurosurgery: Path-

ways from concept to realityPart II: Vector systems and delivery meth-

odologies for gene therapy of the central nervous system. Neurosurgery

40:805813, 1997.

LIU AND APUZZO



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Acknowledgment

The authors have no financial interest in the methodology advanced by this

study.

COMMENTS

As neurosurgeons, we walk into our arena of work each day:the operating room. That this room has changed over theyears is clearly outlined and detailed in this article. The earlyneurosurgeon drilled holes into the head under a coconut treewith no anesthesia or antisepsis and carefully avoided enteringthe space below the dura. Some 3000 to 4000 years later, theknowledge of anatomy has been refined, physiology is betterunderstood, and the patient can be cleansed and sedated. We canenter virtually any region of the brain. The authors clearly detailhow this revolution occurred. An enormous amount of surgicalhistory is covered here, and a modern reader is amazed to seehow recently most of these changes have occurred. I trained at

the end of the pneumoencephalography era, have practiced dur-ing the computed tomography and magnetic resonance imagingeras, and now enter an operating room where sophisticatedcomputers reconstruct images to lead us where we need toproceed. How amazing it is to look at the illustrations of oper-ating rooms in this article and read the details and then realizethat the operating room, as we now define it, is less than 150years of agethe first burr hole was made some 4000 yearsearlier! How grateful I am that, if I should ever need brainsurgery, I will be taken into a sterile room and gently placed in adeep, painless sleep, images will show the exact location of mylesion, and, very likely, a computer-directed instrument will leadmy surgeons to the exact point at which they need to be. How

fortunate we are today to have these technical advances! Theirdevelopment has been beautifully elucidated by the authors ofthis article.

James T. GoodrichBronx, New York

The authors have created a succinct and yet very detailedreview of the development of the concepts of surgeryleading to a modern understanding of the operating room andthe goals of a surgical procedure. The authors focus is onneurosurgery, but most of what they have written is equallyapplicable to the broad concept of surgery in general. It isalways worthwhile to know where we have been so we canhave a better understanding of where we need to go. Toooften, changes are made in the operating room simply as areflection of the technology of the moment without examiningthe reasons for altering current practices or considering whatthe proposed additions will accomplish in the long term.

Much of the impact of technology has had little impact on thearchitectural and functional designs of operating room areas.Typically, operating rooms are large boxes; those built in the1990s could just as easily have been built in the 1890s. The boxesjust became bigger to accommodate the increasing number oflarge pieces of technology that were introduced into the operat-ing room without any attempt at systems integration. Most

pieces of equipment were created to look impressive, not toconserve and maximize the use of space, and most were de-signed without any consideration of their interaction with othertechnologies in the operating room environment. The result hasbeen cluttercables, wires, and tubes on the floor or suspended

in the airthat generally obstructs the smooth flow of traffic andthe movement of equipment (and sometimes even that of thesurgeons) in the operating room area.

It is time for a fundamental redesign of the operating theaterconcept to include diagnostic imaging, image-guided inter-vention, modular design, the emerging field of robotics, peri-operative imaging for verification of the surgical outcomesand delineation of complications, and systems integration thatallows efficient utilization of equipment. These concepts arelikely to decrease the necessity for patient transport, with allits associated dangers. The size of operating rooms will prob-ably decrease. The creation of remote stations for many activ-ities, such as anesthesia, monitoring, and robotics, will becomepossible, and developing multiple uses for imaging equip-ment that is required only sporadically in the operating roomwill probably increase eff

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