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Application Of Neurosurgery, Diagnosis, Advances In Neurosurgery, Intraoperative Guidance Systems

Neurosurgery is a medical specialty concerned with the diagnosis and treatment of the central and peripheral nervous system.

The nervous system is composed of the brain, spinal cord and spinal column, as well as the nerves that travel through all parts of the body (hands, legs, arms, face). Neurosurgeons treat degenerative and congenital diseases of the spine, pain from pinched nerves in the neck, lower back pain, sciatica, carpal tunnel syndrome, epilepsy, stroke, Parkinson disease, chronic pain and sports injuries of the head and spine, in addition to brain tumors, hemorrhages and trauma, tumor of the pituitary gland, and disorders of the arteries that carry blood from the heart to the brain. The field of neurosurgery encompasses both adult and pediatric patients. Neurosurgery has one of the longest training periods of any medical specialty due to the extreme complexity of the nervous system and the advanced techniques used in neurosurgical operations.

Neurosurgery may have begun in the early stages of man's evolution. Skulls of early man show signs of incision through the bone. Some skulls have as many as five openings cut into them. Some of this ritual was probably for magical purposes and some was medicinal, performed to release the spirits that were causing excruciating headaches or making an individual show signs of insanity, or to remove bone fragments resulting from trauma. This process is called trephination (less commonly, trepanation) and was a common procedure as early as the Neolithic period. Interestingly, this procedure was done in human settlements around the world. These clans or tribes had no contact with each other, yet they devised and practiced a similar procedure as a form of spiritual or medical therapy.

Trephining was accomplished with a sharpened flint moved in rapid circular motions to cut through the bony skull. The procedure took about a half hour on a drugged patient. It is likely that early man had discovered the means to immobilize an individual so that surgery could be carried out. Trephining was practiced as late as the mid-twentieth century among isolated peoples. Even cadavers were trephined to remove bone fragments, which were then worn as amulets.

Needless to say, the survival rate of trephination was low. However, skulls have been found that show bone growth around the edges of the opening, indicating that the patient survived for a time after the procedure. More often, skulls with trephined openings show the raw, incised edges of the operative area, indicating that the patient probably died during surgery or shortly thereafter. Infection was not understood and was a high probability following surgery in such conditions.

It was not until the late nineteenth century that further progress was made in the field of neurosurgery. In November, 1884, two British surgeons, Bennett and Godlee, operated to remove a brain tumor. Shortly thereafter, in 1888, Sir Victor Horsley removed a tumor from the spinal cord of one of his patients. That same year an American surgeon, W.W. Keen of Philadelphia, removed a meningioma, a hard, slow-growing tumor that grows on one of the membranes covering the brain. In 1889, Keen tapped the ventricles of the brain, the small openings at the base of the brain where fluid collects.

The development of the x ray provided a means for neurosurgeons to find tumors growing in the brain, bone splinters, or other foreign objects. Still, it remained difficult to locate these growths precisely enough for surgical removal. The invention of stereotactic frames to provide precise guidance to underlying tumors helped revolutionize surgery on the brain.

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