Introduction
Throughout the historical course, the emergence of neurosurgery invariably involved
the narrative about different eras, marked by relevant discoveries in the field of
medical science. Prehistoric mystical and therapeutic reports document the first descriptions
of primitive cranial surgical procedures, including cranial perforation, called trepanation,
a procedure indicated for individuals with mental disorders, headaches and head injuries.
Harvey Cushing, a physician and neurosurgeon at Harvard University, marked the 20th
century with his contributions that leveraged the history of medicine and made him
one of the greatest references of all time.[1] Among his achievements are the use of radiography in the diagnosis of brain tumors,
the encouragement of studies and research on electroencephalic stimulation, and the
demonstration of the importance of knowledge and control of intracranial pressure,
contributing to the historical decrease in mortality from brain tumors, being, therefore,
the precursor of a new era, the Cushing Era.
Still in the 20th century, there was the advent of new imaging techniques, such as radiology and radiotherapy,
allowing for better surgical outcomes and enabling the consolidation of neurosurgery
as a well-defined specialty worldwide. In parallel to this, the development of new
microsurgical techniques by M. Gazi Ysargil, a Turkish neurosurgeon, ushered in a
new era in medicine. New surgical instruments were conceived, which transformed the
scenario of surgical microanatomy and resolved technical limitations that, until then,
made some patients inoperable. In 1980, there was a great advance in the history of
medical science with the first use of robotics to perform neurosurgical biopsies,
a fact of extreme importance that boosted the search for robotic systems that contributed
to microsurgery.[2]
[3]
In view of this, among prehistoric trepanations, the use of robots that respond to
commands from neurosurgeons and perform complex microsurgery, there is a time and
a space that must be understood on several aspects. In this context, the present study
seeks, through a narrative review of the literature, to synthesize and discuss the
main milestones in the evolution of neurosurgery throughout the ages, focusing on
the current scenario of microsurgery and surgical robotization.
Materials and Methods
This is a narrative review of the scientific literature, carried out by searching
the following databases: Scientific Electronic Library Online (SCIELO), Online System
for Searching and Analyzing Medical Literature (MEDLINE), Latin American Literature
and Caribbean in Health Sciences (LILACS), and Public Medical Literature Analysis
and Retrieval System Online (PubMed). The searches were carried out in two stages
in order to obtain better results in the literature. In the first analysis, the following
descriptors were used: History of neurosurgery and Neuroanatomy, together with the Boolean operator “AND”. In addition, the descriptors History
of
Neurosurgery and Robotics were used between the Boolean operator “AND”. Thus, the searches aimed to identify
studies of systematic reviews and narratives that describe the history of neurosurgery
throughout the ages and its advancement in the modern era. In this sense, in order
to establish a linearity of the presented narrative, the evolution of neurosurgery
in five eras was didactically separated: (a) medicine in the Pre-Cushing Era, (b)
medicine in the Cushing Era, (c) medicine in the Yasargil Era, (d) medicine from the
Endoscopic Era and, finally, (e) medicine from the Robotic Era.
The inclusion criteria were: articles that addressed the neurosurgery narratives,
studies, and essays on the evolution of neurosurgery throughout history and systematic
reviews that described the development of medicine according to historical periods.
The exclusion criteria were: articles that did not contemplate the theme about the
history, evolution, and development of neurosurgery in the course of history. Duplicates
were also excluded.
Discussion
Pre-Cushing Era
Since the beginning, classical philosophers like Aristotle and Descartes have attributed
important functions to the brain in cognitive control. In mythology, Egyptian society
documented the first record of a surgical intervention in the spinal cord, in which
the god Osiris was resurrected with Isis and Thoth, which reveals previous knowledge
of neuroanatomy.[1] In the real world, mysticism inspired neurosurgical and practical applications,
such as cranial trepanations and craniectomies reported in the Neolithic period.[2]
[3] Both procedures allowed the simple perforation of the skull, indicated for high-intensity
headaches, convulsions, and changes in the mental picture, and the wider opening of
the skull, called craniectomy, allowed bone regeneration over time and contributed
to the history of neurosurgery.[4]
Around 300 BC, in the Egyptian city of Alexandria, anatomists such as Hippocrates
and Erasistratus began dissecting criminals, which allowed greater anatomical knowledge
and further spreading of the teaching of these human structures in schools and museums.[5]
[6] Thus, it was possible to deepen the understanding of neuroanatomy, especially in
the particularity of the grooves, gyres, and the description of the torula responsible
for the union of venous sinuses.
In Greece, Plato and Democritus discussed the role of cognition with the human soul,
framing the brain as part of the soul located in the head, while Galen, in Rome, disagreed
with the correlation between gyrations and intellect, suggested by Erasistratus.[7]
[8] Therefore, the era called pre-Cushing was marked by a great advance in the knowledge
of neuroanatomy through dissections, mythology and philosophy that marked the history
of neurosurgery.[9]
[10]
Cushing Era
With the advent of the Middle Ages, little is known about the contribution to neurosurgical
knowledge. Although science was abolished, especially by the Catholic Church, the
first illustration of the human brain was obtained, in the 11th century, and the first human dissections were performed in Europe.[11]
[12] The scenario changed with the height of the Renaissance period, in which human dissection
became legal and contributed to new surgical and anatomical foundations, such as the
description of Sylvius groove by it. Thus, neuroanatomy has progressed in detailed
descriptions throughout the 17th, 18th and 19th centuries,[13]
[14] beginning an era that bears the name of one of the most important names in the consolidation
of neurosurgery as a medical specialty in the United States: Harvey Cushing.
At the beginning of the 20th century, the Cushing Era begins with great contributions from the neurosurgeon who
gives the name to the era, primarily due to the description of the treatment of traumatic
brain injuries and missile injuries, but finds its peak in the 1930s with cerebral
tumor surgery.[15] Cushing was also responsible for mapping motor and sensory activities in different
regions of the cerebral cortex, being one of the pioneers of cortical stimulation
in epileptic patients.
Yasargil Era
The second half of the 20th century enabled the advent of microneurosurgery with the leading role of the Turkish
neurosurgeon M. Gazi Yasargil, who initiated the Yasargil Era. At the University of
Basel, he had his first contact with microsurgery performing transpalatinal exploration
of the hypophysis in frogs for research. The neurosurgical microscope was used for
the treatment of acoustic neuromata through translabyrinthine and through the middle
fossa,[16]
[17] allowing the introduction of this equipment in the area of neurosurgery. In addition,
Yasargil was responsible for developing techniques for vascular neurosurgery that
started working on the middle cerebral arteries of dogs, transforming the prognosis
of patients who until then were considered inoperable.[18] Microsurgical instruments, retractors, floating microscope, and aneurysm clips were
conceived by her. The technique for transplantation of the superficial temporal artery
to the middle cerebral artery by end-to-side anastomosis was also developed by Yasargil.
Thus, the era of microsurgery enabled the detailed and meticulous study of brain areas,
contributing to topographic reasoning and to the further development of more improved
equipment in microsurgery. So, the neurosurgical procedures that are performed today
has been affected by the work of this neurosurgeon.
Endoscopic Era
The advent of magnetic resonance imaging (MRI), from a surgical point of view, in
addition to being an element of neuroimaging coupled to different stereotaxis systems,
its digital image storage and manipulation base allowed and allows three-dimensional
reconstructions to be easily created. With the different information obtained by the
method, which can be observed from different points of view, thus lending itself and
even simulations of accesses and surgical views.[19] The digital basis of storage and manipulation of the different modalities of neuroimaging
exams, associated with the technology of transmission of light pulses, culminated
in the development of the so-called surgical neuronavigator, as idealized initially
by Watanabe et al., in 1987, and which is characterized as being a stereotactic neuronavigation
system. Having images obtained before surgery and related to cranial repair points
in a computer station, whose position will be constantly updated during the surgical
procedure, the neuronavigation system is able to identify, in the stored images, structures
properly pointed in the surgical field, by means of a triangulation process similar
to that used by the well-known navigation instrument called global positioning system
(GPS).
With the development of optical and camera systems in the last 30 years, the endoscope
has been added to the arsenal of neurosurgery techniques. Neuroendoscopy can be classified
into: 1) pure neuroendoscopy: when the entire procedure is done under the view of
the endoscope and the instruments pass through working channels coupled to the shirt
or trocar that also contains the optics; 2) microsurgery controlled by endoscopy:
where the endoscope serves as an instrument of magnification and illumination replacing
the microscope, but the surgical instruments are the same as those used in conventional
microsurgery and penetrate the field parallel to the endoscope; 3) endoscopy-assisted
microsurgery: where the entire procedure is performed as in conventional microsurgery
and the endoscope serves as an aid to view portions of the operative field to which
the microscope does not allow access (AMATO, 2016). Currently, there is already an
endoscope model that allows the use of an ultrasonic aspirator inside, increasing
the efficiency of resection.
Robotic Era
Kwoh et al. were the pioneers in using a robotic system in surgery. They adapted an
industrial system produced by Unimation, the PUMA 200, whose function was to position
and align the trajectory of a stereotaxic biopsy cannula.[20] The development of several systems for stereotaxic surgery followed, one of them
a precursor to NeuroMate by Benabid et al. in 1987.[21] Later, due to the need for precision and the potential impact of the displacement
of intracranial structures during the surgical procedure, systems compatible with
the acquisition of intraoperative image emerged. Minerva (University of Lausanne,
Switzerland) was created with the purpose of operating inside a computed tomography
device, allowing the acquisition of intraoperative images in real time 1987.[22]
[23]
Subsequently, systems compatible with intraoperative MRI were created by the Universities
of Harvard, Tokyo and Calgary 1987.[24] More recently, in addition to new stereotactic surgery systems such as NeuroMate
and PathFinder, systems with other neurosurgical applications have also been developed,
such as microsurgery (for example, NeuRobot and neuroArm), spinal surgery (SpineAssist)
and radiosurgery (CyberKnife).[25]
Unlike stereotactic surgery, the systems used in microsurgery are passive. They are
typically controlled remotely through a console, which can present an input mode similar
to surgical instruments, which makes the task more intuitive for the surgeon.[26]
[27] This way, the surgeon will be away from the operative field during the procedure.
The console includes a monitor that transmits visual information to the surgeon, coming
from a video camera built into the system. Often, a system of visualization in three
dimensions is used, which allows a better perception of depth.
The Era of Robotics included not only transformations ([Figure 1]) in surgical procedures with greater precision, technology and effectiveness, but
brought safety to the surgeon due to systems complementary to his practice that, in
the past, were not available due to the gradual progress of a society that developed
in the field of neurosurgery from trepanations to the use of robots in surgical interventions.
In this sense, it is clear that the history of humanity over the historical eras also
reflects the evolution of a scientific field increasingly marked by the robotization
technique ([Figure 2]).
Fig. 1 Timeline with the main milestones of each era throughout the history of neurosurgery.
Fig. 2 Timeline illustrating the ages.
Conclusion
Neurosurgery, throughout history, has undergone several transformations. From trepanations,
skull perforations, to the use of robotics, there was a series of events that made
neurosurgery one of the most evolutionary and progressive sciences. Mystical accounts
during the Pre-Cushing Era boosted the execution of a historical narrative about the
beginning of neurosurgery that started from anatomical descriptions about the peculiarity
of the brain, but which is already consolidated in the Cushing Era when brain stimulation
in epileptic patients becomes real. Furthermore, this is because technology combined
with scientific knowledge was, in fact, what made it possible for us to get to where
we are.
Era after era, passing through Yasargil, the microsurgery using microscopes also allowed,
with cerebral mapping, to gain contours, definitions, names, and identifications more
and more specific and significant. Vascular structures and their ramifications, variations,
and extensions have been described, and for this reason, detailed and topographic
studies have become more accurate. In this sense, the studied ages allow the understanding
of a history that needs to be understood and valued by all scholars of the neurological
and neurosurgical sciences. From the Pre-Cushing era to the Robotic Era, many techniques,
procedures, surgery systems, and scientific knowledge were achieved.
The application of neuroimaging linked to stereotaxic procedures was an indisputably
unique advance regarding the success of neurosurgeries. The then Endoscopic Era used
a device, called a neuroendoscope, which in a safe and minimally invasive manner brought
the possibility of neurosurgeons to reach important territories such as those of the
cerebral ventricles. Soon, many pathologies began to be treated, such as obstructive
hydrocephalus, through an endoscopic third ventriculostomy. The Robotic Era, bringing
intraoperative MRI with the procedures that, this time, with the arrival of robotics,
brought not only safety to the neurosurgeon, but also better success, better chances
of success, and expansion of the necessary interventions.
The present article allows not only a time travel around all the protagonists who
have made neurosurgical science one of the most innovative and updated scientific
fields, as well as through the historical landmarks that, from age to age, have been
delimited and, gradually, led humanity to the point we have reached. The past, the
present, and the future have never been described and analyzed in such a close and
temporal way.
