Functional and Stereotactic Neurosurgery

Soon after neurosurgery had advanced past the stage of that older neurosurgeons will consider their cra­ removing lesions on the surface of the brain, it became niotomies quite adequate for the relief of many neu­ apparent that subcortical diseased tissue could not be rological disorders that Professor Kandel shows so excised safely by the usual surgical techniques because clearly to be amenable to stereotactic intervention, of the risk of damaging overlying normal structures. there are many lesions that undoubtedly can be reached Various means of reaching deep-seated lesions were more easily and with less risk to life and limb by ster­ devised, most of which attempted to approach the eotactic than by open procedures. pathological tissue through "silent areas" of the brain. This book is not just a description of operative However, these operations often resulted in serious procedures, although it does give clear accounts of neurological deficits. Spiegel and Wycis's modifica­ surgical techniques. It presents the postoperative histo­ tion of the Horsley-Clarke apparatus to reach targets ries of patients who have been cured or markedly re­ deep in the human brain introduced a new approach to lieved of longstanding afflictions; these persons have subcortical surgery. True, as Professor Edward Kandel been followed for 10 to 15 or more years, so that the relates, Russian surgeons had pioneered in the field, results may be considered more or less permanent.

Foreword.- Preface.- Abbreviations.- 1 Anatomy of Subcortical Structures Related to Stereotaxy.- 1. Extrapyramidal System.- 1.1. Thalamus.- 1.1.1. Ventrolateral Nucleus.- 1.1.2. Posterior Ventrolateral and Ventromedial Nuclei.- 1.1.3. Centrum Medianum.- 1.1.4. Pulvinar.- 1.2. Capsula Interna.- 1.3. Subthalamic Region.- 1.4. Globus Pallidus.- 1.5. Striatum.- 1.5.1. Nucleus Caudatus 4.- 1.5.2. Putamen.- 1.6. Substantia Nigra.- 1.7. Subthalamic Nucleus.- 1.8. Nucleus Ruber.- 2. Limbic System.- 2.1. Amygdaloid Nucleus.- 2.2. Hippocampus.- 2.3. Hypothalamic Region.- 3. Cerebellum.- 4. Pain Structures and Pain-Conducting Pathways of the CNS.- 2 Extrapyramidal Mechanisms.- 1. General Remarks.- 1.1. Regulation of Motor Activity.- 1.2. The Pathogenesis of Extrapyramidal Syndromes.- 2. Tremor.- 2.1. Historical Note.- 2.2. The Characteristics of Tremor.- 2.3. Graphic Recording of Tremor.- 2.4. Physiological Tremor.- 2.5. Pathological Tremor.- 2.6. Action Tremor.- 2.7. Tremor and Proprioceptive Input.- 2.8. Interrelationship of Various Types of Tremor.- 2.9. Pathogenesis of Tremor.- 2.10. Generator of Rhythmic Tremor.- 2.11. Computerized Spectral Analysis of Tremor.- 2.12. Tremor and Cerebral Structures.- 3. Rigidity.- 3.1. Muscle Tone and Its Regulation.- 3.2. Pathogenesis of Extrapyramidal Rigidity.- 4. Spasticity.- 5. Akinesia.- 3 Stereotactic Method.- 1. Historical Note.- 2. General Principles.- 2.1. Cranial Reference Points.- 2.2. Intracerebral Reference Points.- 2.3. Linear Reference Points.- 3. Individual Variability.- 4. Stereotactic Atlases.- 5. Stereotactic Instruments.- 5.1. Stereotactic Frame of Spiegel and Wycis.- 5.2. Stereotactic Frame of Riechert and Mundinger.- 5.3. Stereotactic Frame of Guiot and Gillingham.- 5.4. Stereotactic Frame of Leksell.- 5.5. Stereotactic Frame of Talairach.- 5.6. Stereotactic Frame of Rand and Wells.- 5.7. Stereotactic Frame of Laitinen.- 5.8. Stereotactic Frame of Oliver-Bertrand-Tipal.- 5.9. Stereotactic Frame of Kandel.- 5.10. Other Stereotactic Instruments.- 6. Computer Techniques.- 7. Stereotaxis and Computerized Tomography.- 7.1. Brown-Roberts-Wells Stereotactic System.- 7.2. Patil Stereotactic System.- 8. Stereotaxis and Nuclear Magnetic Resonance.- 9. Stereotaxis and Digital Subtraction Angiography.- 10. Combined Visualization Techniques.- 11. Stereotaxis and Ultrasound.- 4 Principles of Stereotactic Operations on Subcortical Structures 1.- 1. General Considerations.- 2. Anesthesia.- 3. Location of the Burr Hole.- 4. Visualization of the Ventricular System.- 5. Stereotactic Coordinates.- 5.1. Anteroposterior Projection.- 5.2. Lateral Projection.- 6. X-RayControl.- 7. Functional Control.- 7.1. Electrostimulation.- 7.1.1. Ventrolateral Nucleus.- 7.1.2. Sensory Nuclei.- 7.1.3. Pulvinar.- 7.1.4. Centrum Medianum and Intralaminar Nuclei.- 7.1.5. Dorsomedial Nuclei.- 7.1.6. Anterior Nuclei.- 7.1.7. Capsular Interna.- 7.1.8. Subthalamic Region.- 7.1.9. Pallidum (Globus Pallidus).- 7.1.10. Nucleus Caudatus.- 7.1.11. Nucleus Ruber.- 7.1.12. Hypothalamic Region.- 7.1.13. Midbrain Tegmentum.- 7.1.14. Periaqueductal Gray Matter.- 7.1.15. Amygdala.- 7.1.16. Hippocampus.- 7.1.17. Cerebellar Nuclei.- 7.2. Electrosubcorticography.- 7.3. Microelectrode Recording.- 7.4. Evoked Potentials.- 7.5. Impedance Techniques.- 7.6. Other Techniques.- 7.7. Summary of Functional Controls.- 5 The Production of Lesions in Stereotactic Operations.- 1. General Principles.- 2. Local Freezing.- 2.1. Biological Effects of Freezing.- 2.2. Effect of Low Temperatures on Vessels.- 2.3. Experimental Cryoneurosurgery.- 2.4. Factors Determining the Size of the Cryogenic Lesion.- 2.5. Morphological Pathology of Cryogenic Brain Lesions.- 2.6. Cryosurgical Equipment.- 2.7. The Author’s Cryosurgical Instrument.- 2.8. Technique for Producing Cryosurgical Lesions.- 3. Electrical Methods.- 3.1. Anodal Electrolysis.- 3.2. High-Frequency Coagulation.- 3.3. Induction Heating Method.- 4. Radioactive Isotopes.- 5. Laser Techniques.- 6. Remote Control Methods.- 6.1. 7 Irradiation.- 6.2. Proton Beam.- 6.3. Ultrasound.- 7. Chemical Methods.- 8. Mechanical Methods.- 6 Parkinsonism.- 1. Historical Note.- 2. Epidemiology.- 3. Mortality.- 4. Etiology.- 5. Pathological Anatomy.- 6. Pathogenesis.- 7. Clinical Picture.- 7.1 The Beginning and Development of the Disease.- 7.2. Symptomatology.- 7.2.1. Disorders of Posture and Gait.- 7.2.2. Speech Disorders.- 7.2.3. Writing Disorders.- 7.2.4. Vegetative Disorders.- 7.2.5. Pain Syndrome.- 7.2.6. Deformities of the Hands and Feet.- 7.2.7. Mental Disorders.- 7.2.8. Vestibular Disorders.- 7.2.9. Glucose Metabolic Disorders.- 7.2.10. Respiratory Disorders.- 7.2.11. Oculogyric Crises.- 7.2.12. Sleep Disorders.- 7.3. Electroencephalography.- 7.4. Electromyography.- 7.5. Cerebral Blood How.- 7.6. Forms of Parkinsonism.- 7.6.1. Mixed Type.- 7.6.2. Tremor Type.- 7.6.3. Rigid Type.- 7.6.4. Akinetic Type.- 7.7. Stages of Parkinsonism.- 7.8. Diagnosis.- 7.9. Medical Therapy.- 7.9.1. Anticholinergic Agents.- 7.9.2. L-Dopa.- 7.9.3. Dopamine Agonists.- 7.9.4. Amantadine and Deprenyl.- 7.9.5. Postoperative Medication.- 8. Indications and Contraindications for Surgery.- 8.1. Age.- 8.2. Etiology.- 8.3. Form of the Disease.- 8.4. Duration of Disease.- 8.5. State of Internal Organs.- 8.6. Brainstem Functions.- 8.7. Mental State.- 8.8. Hydrocephalus.- 8.9. Medication.- 8.10. Stage of the Disease.- 8.11. Summary.- 8.12. Side of the Operation.- 9. Surgery.- 9.1. Historical Note.- 9.1.1. Operations on the Cerebral Cortex.- 9.1.2. Operations on Subcortical Pathways.- 9.1.3. Frontal Leukotomy.- 9.1.4. Pedunculotomy.- 9.1.5. Bulbotomy.- 9.1.6. Clipping of the Anterior Choroidal Artery.- 9.1.7. Operations on the Cerebellum.- 9.1.8. Operations on the Spinal Cord.- 9.1.9. Operations on the Sympathetic System.- 9.1.10. Operations on the Basal Ganglia.- 9.2. Summary.- 10. Stereotactic Surgery.- 10.1. Stereotactic Destruction of the Subthalamus.- 10.2. Bilateral Operations.- 10.3. Clinicoanatomic Correlations.- 11. Prevention and Treatment of Postoperative Complications.- 12. Personal Observations.- 13. Concluding Remarks.- 7 Dystonia Musculorum Deformans.- 1. Historical Note.- 2. Etiology.- 3. Pathology.- 4. Pathogenesis.- 5. Clinical Investigation.- 5.1. Westphal Phenomenon.- 5.2. Effect of Thalamotomy.- 6. Biochemical Pathogenesis.- 7. Clinical Aspects.- 7.1. Stages of the Disease.- 7.2. Diagnostic Studies.- 7.3. Differential Diagnosis.- 8. Indications and Contraindications for Surgical Treatment.- 9. Surgical Treatment.- 10. Stereotactic Operations.- 11. Personal Observations.- 8 Spasmodic Torticollis.- 1. Introduction.- 2. Etiology.- 3. Pathology.- 4. Pathogenesis.- 5. Clinical Picture.- 6. Stages of the Disorder.- 7. Other Manifestations of ST.- 8. Differential Diagnosis.- 9. Surgical Treatment.- 9.1. Cervical Rhizotomy.- 9.2. Stereotactic Operations.- 9.3. Stimulation of Spinal Cord.- 10. Personal Observations.- 11. Summary.- 9 Cerebral Palsy.- 1. Introduction.- 2. Etiology.- 3. Pathology and Pathogenesis.- 4. Clinical Aspects.- 5. Surgical Treatment.- 5.1. Stereotactic Operations.- 5.1.1. Stereotactic Thalamotomy.- 5.1.2. Stereotactic Destruction of Pulvinar (Pulvinotomy).- 5.1.3. Stereotactic Dentatotomy.- 5.1.4. Stereotactic Pallidotomy.- 5.1.5. Stereotactic Putamenotomy.- 5.1.6. Combined Operations.- 5.2. Selective Posterior Rhizotomy.- 5.3. Stimulation Methods.- 6. Personal Observations.- 10 Hemihyperkinesias.- 1. Introduction.- 2. Etiology and Pathogenesis.- 3. Clinical Features.- 4. Stereotactic Surgery.- 5. Personal Observations.- 11 Multiple Sclerosis.- 1. Introduction.- 2. Surgical Treatment.- 2.1. Stereotactic Operations.- 2.2. Operations on the Spinal Cord.- 3. Personal Observations.- 12 Hereditary Degenerative Disorders.- 1. Introduction.- 2. Hepatocerebral Dystrophy (Wilson’s Disease).- 2.1. Background.- 2.2. Surgical Treatment.- 3. Huntington’s Chorea.- 3.1. Background.- 3.2. Surgical Treatment.- 4. Essential Tremor.- 4.1. Background.- 4.2. Surgical Treatment.- 5. Hunt’s Cerebellar Dyssynergia.- 5.1. Background.- 5.2. Surgical Treatment.- 6. Myoclonus and Myoclonus Epilepsy.- 6.1. Background.- 6.2. Myoclonus.- 6.3. Myoclonus Epilepsy.- 6.4. Surgical Treatment.- 13 Pain.- 1. General Remarks.- 2. Gate Control Theory.- 3. Antinociceptive System.- 4. Pathogenesis of Chronic Pain.- 5. Surgical Management of Pain.- 5.1. General Remarks.- 5.2. Operations on the Brain.- 5.2.1. Operations on Thalamic Nuclei.- 5.2.1a. Destruction of Sensory Nuclei.- 5.2.1b. Destruction of Centromedian Nuclei.- 5.2.1c. Destruction of Th Pulvinar.- 5.2.1d. Destruction of Intralaminar, Parafascicular, and Limitans Nuclei.- 5.2.1e. Destruction of Internal Medullary Lamina.- 5.2.1f. Destruction of Dorsomedial Nuclei.- 5.2.1g. Destruction of Anterior Nuclei.- 5.2.1h. Basal Medial Thalamotomy.- 5.2.1i. Destruction of Multiple Th Nuclei.- 5.2.1j. Destruction of Thalamocortical Pathways.- 5.2.2. Destruction of GP.- 5.2.3. Destruction of Hypoth.- 5.2.4. Destruction of the Cingulate Gyrus.- 5.2.5. Operations on the Midbrain and Brainstem.- 5.2.5a. Mesencephalotomy.- 5.2.5b. Pontine Spinothalamic Tractotomy.- 5.2.6. Hypophysectomy.- 5.3. Operations on the Spinal Cord.- 5.3.1. General Remarks.- 5.3.2. Cordotomy.- 5.3.2a. Somatotopic Organization of the Spinothalamic Tract.- 5.3.2b. Open Anterolateral Cordotomy.- 5.3.2c. Stereotactic Percutaneous Cordotomy.- 5.3.2d. High Cervical Percutaneous Cordotomy by the Lateral Approach.- 5.3.2e. Bilateral High Percutaneous Cordotomy.- 5.3.2f. Low Cervical Percutaneous Cordotomy by the Anterior Approach.- 5.3.2g. Posterior Percutaneous Cordotomy.- 5.3.3. Commissural Myelotomy (Commissurotomy).- 5.3.4. Stereotactic Cervical Commissurotomy.- 5.3.5. Extralemniscal Myelotomy.- 5.3.6. Posterior Rhizotomy.- 5.3.6a. Selective Posterior Rhizotomy.- 5.3.6b. Percutaneous Posterior Rhizotomy.- 5.3.7. Destruction of Entry Zone of Posterior Roots.- 5.3.8. Administration of Opiates to the Spinal Cord.- 5.4. Stimulation Methods.- 5.4.1. Stimulation of Subcortical Structures.- 5.4.1a. Thalamic Nuclei.- 5.4.1b. Internal Capsule.- 5.4.1c. Hypothalamic Nuclei.- 5.4.1d. Septal Area.- 5.4.1e. Periaqueductal Gray Matter.- 5.4. If. Stimulation of Multiple Structures.- 5.4.2. Stimulation of Posterior Columns of the Spinal Cord.- 5.4.3. Stimulation of Peripheral Nerves.- 5.4.3a. Percutaneous Stimulation.- 5.4.3b. Direct Stimulation.- 6. Central Pain Syndromes.- 6.1. Thalamic Pain Syndrome.- 6.1.1. Stereotactic Operations.- 6.1.2. Stimulation Methods.- 6.2. Phantom Pain Syndrome.- 6.2.1. Stereotactic Operations.- 6.2.2. Stimulation Methods.- 6.3. Causalgia.- 6.3.1. Stereotactic Operations.- 6.3.2. Stimulation Methods.- 7. Trigeminal Neuralgia.- 7.1. Percutaneous Trigeminal Injection of Lytic and Other Substances.- 7.2. Percutaneous Electrothermocoagulation.- 7.3. Percutaneous Medullary Trigeminal Tractotomy.- 7.4. Stereotactic Midbrain Tractotomy.- 7.5. Destruction of Thalamic Nuclei.- 7.6. Stimulation Methods.- 7.7. Microvascular Decompression.- 7.8. Microcompression of the Gasserian Ganglion.- 7.9. Endoscopic Dissection.- 7.10. X-Ray Irradiation.- 8. Neuralgia of the Glossopharyngeal Nerve.- 9. Convulsive Tic.- 10. Occipital Neuralgia.- 11. Migrainous Neuralgia.- 12. Hemifacial Spasm.- 14 Epilepsy.- 1. General Remarks.- 2. Etiology.- 3. Pathogenesis.- 4. Epileptogenic Focus.- 5. Diagnostic Procedures.- 6. Surgical Treatment.- 6.1. General Remarks.- 6.1.1. Indications for Surgery.- 6.1.2. Types of Operative Procedures.- 6.1.3. Principles of Localization of Epileptic Foci.- 6.2. Focal Epilepsy.- 6.2.1. Surgical Procedures.- 6.2.2. Stereotactic Procedures.- 6.3. Generalized Epilepsy.- 6.3.1. Callosotomy.- 6.3.2. Stereotactic Procedures.- 6.3.3. Chronic Stimulation.- 6.4. Kojevnikoff’s Epilepsy.- 6.4.1. Surgical Treatment.- 6.4.2. Stereotactic Procedures.- 6.5. Temporal Lobe Epilepsy.- 6.5.1. Etiology and Pathogenesis.- 6.5.2. Clinical Aspects and Diagnostic Procedures.- 6.5.3. Surgical Treatment.- 6.5.3a. Temporal Lobectomy.- 6.5.3b. Stereotactic Procedures.- 6.5.3c. Stereotactic Amygdalotomy and Hippocampotomy.- 6.5.3d. Stereotactic Amygdalohippocampotomy.- 6.5.3e. Stereotactic Fornicotomy and Anterior Commissurotomy.- 6.5.3f. Stereotactic Hypothalamotomy.- 6.5.3g. Stereotactic Destruction of Anterior Thalamic Nuclei.- 6.5.3h. Combined Operations.- 15 Brain Tumors.- 1. Introduction.- 2. Stereotactic Biopsy.- 3. Stereotactic Biopsy with Computed Tomography.- 4. Stereotactic Destruction.- 4.1. Radioactive Isotopes.- 4.2. Cryodestruction.- 5. Pituitary Tumors.- 5.1. Stereotactic Operations.- 5.2. Preoperative Preparations.- 5.3. Surgical Equipment.- 5.4. Technique of Cryohypophysectomy.- 5.5. Postoperative Care.- 5.6. Personal Observations.- 6. Stereotactic Destruction of the Normal Hypophysis.- 16 Cerebral Arterial Aneurysms and Arteriovenous Malformations.- 1. Introduction.- 2. Arterial Aneurysms.- 2.1. Stereotactic Electrolytic Thrombosis.- 2.2. Stereotactic Magnetic Thrombosis.- 2.3. Balloon Catheter Thrombosis.- 2.4. Thrombosis by Coagulants and Slowing of Cerebral Blood Flow.- 3. Arteriovenous Malformations.- 3.1. Artificial Embolization.- 3.2. Combined Stereotactic and Open Operations.- 3.3. Cryogenic Thrombosis.- 3.4. Balloon Catheter Occlusion.- 4. Stereotactic Clipping of Aneurysms.- 4.1. Technical Equipment.- 4.2. Clips.- 4.3. Experimental Testing.- 4.4. Preoperative Calculations.- 4.5. Operative Technique.- 4.6. Indications and Contraindications for Stereotactic Clipping.- 4.7. Clinical Results.- 4.7.1. Arterial Aneurysms.- 4.7.2. Arteriovenous Malformations.- 17 Spontaneous Intracerebral Hematomas.- 1. Introduction.- 2. Improved Technique.- 3. Experimental Tests.- 4. Preoperative Calculations.- 5. Operative Technique.- 6. Clinical Results.- 7. Summary.- 18 Mental Disorders.- 1. Introduction.- 2. Stereotactic and Functional Operations.- 2.1. Cingulotomy.- 2.2. Basal Frontal Lobotomy.- 2.3. Dorsomedial Thalamotomy.- 2.4. Destruction of CM.- 2.5. Amygdalotomy.- 2.6. Destruction of Stria Terminalis.- 2.7. Posterior Hypothalamotomy.- 2.8. Anterior Capsulotomy.- 2.9. Callosotomy.- 2.10. Lesions of Internal Medullary Lamina.- 3. Surgical Treatment of Mental Disorders.- 3.1. Aggressive Syndrome.- 3.2. Erethic Oligophrenia.- 3.3. Depression.- 3.4. Schizophrenia.- 3.5. Obsessive-Compulsive Neuroses.- 3.6. Gilles de la Tourette’s Syndrome.- 3.7. Sexual Deviations.- 3.8. Narcotic Dependence.- 3.9. Anorexia Nervosa.- 19 Spinal Cord Disorders.- 1. Introduction.- 2. Spasticity.- 2.1. Myelotomy.- 2.1.1. Lateral Longitudinal Myelotomy.- 2.1.2. Posterior Longitudinal Myelotomy.- 2.2. Posterior Rhizotomy.- 2.3. Stimulation Methods.- 2.4. Embolization of Spinal Cord Arteries.- 3. Bladder Dysfunctions.- 3.1. Myelotomy.- 3.2. Sacral Rhizotomy.- 3.3. Stimulation Methods.- 3.4. Pudendotomy.- 4. Phrenic Nerve Stimulation.- 20 Additional Possibilities of Stereotactic Neurosurgery.- 1. Introduction.- 2. Ventriculoscopy.- 3. Removal of Foreign Bodies.- 4. Obstructive Hydrocephalus.- 5. Reconstruction of the Sylvian Aqueduct.- 6. Relief of Nystagmus.- 7 Treatment of Obesity.- 8. Relief of Writer’s Cramp.- 9. Treatment of Raynaud’s Disease.- 10. Relief of Erythromelalgia.- Epilogue.- References.