Historical Landmarks

It is interesting to reflect that even 'high-tech' neurosurgery has its origins in the versatile skills and open minds of the earliest neurosurgeons in the first two decades of the last millennium, and that more recent technological advances have enabled latter day pioneers of voyages into the intracranial compartments to venture further and more effectively, creating a renaissance in this elegant therapeutic modality. The history of neuroendoscopy has been described elsewhere [1], and is seen to be a study in miniature of the ways in which techniques wax and wane in surgery, more often riding on the ebb and flow of fashion than on the hard facts of evidence-based science.

In 1910, Lespinasse reported to a Chicago medical society that he had employed rigid cystoscopes to perform choroid plexus ablation on two hydrocephalic infants; one child died post-operatively but the other survived for 5 years. Eighty-four years later, the phrase "minimally invasive endoscopic neurosurgery" was coined.

In 1920, at Massachusetts General Hospital, Mixter performed the first endoscopic third ventriculostomy on a 10-month-old baby, using a urethroscope and a sound. Although follow-up was for less than 1 year, he takes credit for obtaining manometric and dye injection proof of patency of the ventriculostomy. Amongst the few neurosurgeons who persisted with endoscopic neurosurgery, the most notable were Putnam, who persevered with endoscopic choroid plexectomy, and Scarff, who also employed endoscopic third ventriculostomy.

The 1950s saw the advent of the first implantable valved shunting systems for the treatment of hydrocephalus, and inevitably the interest in neuroendoscopy waned. However, even before widespread disenchantment with the fickle nature of hydrocephalus shunts had set in, this first era of neuroendoscopy was marked by important papers by Scarff [2], the results of which are summarized in Table 6.1. An interesting observation was that, whereas when 618 patients treated surgically by choroid plexectomy or third ventriculostomy, without an implanted device, were compared with 1,087 patients treated by a shunt, there were equivalent operative mortalities of about 15% and early success of about 65%, the late complication rates were 3-5% without a shunt but 35-100% with a shunt. This early experience still holds true as, although the early mortality of both types of surgery has fallen, it serves to emphasize that, in discussing the optimum treatment for any particular patient with hydrocephalus, one has to consider not only the acute efficacy and hazard, but also the late morbidity.

Major improvements in visibility came with the solid glass rod endoscope and the cohesive fiberoptic bundle. Vries in the USA, followed by Jones in Australia, Sainte-Rose in France, and the present author in the UK, saw the potential for a return to a neuroendoscopic approach to the treatment of hydrocephalus, while Griffith in the UK also perceived a wider application of neuroendoscopy both within and outside of the ventricular system, coining along the way the term "endoneurosurgery" [1].

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