Neurosurgery

historical collection of more than 2,000 cases of verified brain tumors, was thus founded. Through the study of this collection, a classification of brain tumors based on histogenesis was made by Bailey and Cushing [1, 2] - the forerunner of many subsequent and continuously revised classifications of brain tumors.

Cushing and his associates were fortunate because the basic histological techniques were already well developed and the repertoire of neuropathological lesions was limited in those days to expanding lesions, such as tumors and abscesses in the central nervous system (CNS). Thus, neurosurgeons were able to undertake pathological studies of the specimens they dug out between their busy clinical and surgical schedules. However, the extensive developments of new techniques in neurosurgery, neuroradiology and neuropathology over the past few decades make it extremely difficult today for neurosurgeons to assume such studies. The new histological tools include immunocytochemistry and molecular biology, as well as numerous tinctorial staining techniques, and require an expensive set-up for laboratories and lengthy specialized training for neuropathologists. Furthermore, the new diagnostic imaging techniques enable clinicians today to discover and locate numerous lesions other than tumors and abscesses. As a result, the repertoire for neuropathologists has expanded enormously to include many exotic lesions that were hitherto unknown in surgical pathology. The ability to visualize small millimeter-size lesions under sophisticated diagnostic imaging and by stereotactic biopsy now forces neuropathologists to make more and more diagnoses from smaller and smaller specimens, including those that look much larger to the neurosurgeon, who removes them under open microscopic control!

Cushing was able to follow up his patients by requesting them to write to him every year on the anniversary of their operation. By this system he was able to collect data concerning the end results of his operations, ultimately to learn the probable life expectancy of patients with any particular type of tumor. Today, serial imagings give an advantage to the clinician, enabling them to follow the patients post-operatively, to visualize the subsequent evolution of the lesion, to disclose signs of recurrence at an early stage, and even to calculate the growth rate of tumors. The data collected by Cushing and his followers concerning the life expectancy of brain tumors prior to CT-MRI (computed tomography/magnetic resonance imaging) days, however, should be readjusted for today's statistics. The neurosurgeons then were operating on brain tumors that had become so large as to produce papilledema and other signs that increased the morbidity and mortality of those patients. Today's patients are typically operated on after their first seizure, the lesion visualized via CT-MRI. The tumors now are relatively small, sometimes even found incidentally after a head injury, and one would expect the life expectancy of each particular patient to be much longer than that suggested by the data collected in the early days. The fact that the survival period of the patients can be improved by finding diseases earlier is well known as the "Will Rogers' effect": the "Okies" who left Oklahoma for California increased the IQ in both states! And all of this ignores the very valuable contributions of the anesthesiologists, nurses, rehabilitation and other personnel comprising today's neurosurgical team.

As a side-product of CT-MRI, contemporary neuropathologists are given many opportunities to observe the histological sequences in the evolution of tumors and the effects of radiation and chemotherapy. Similarly, many non-neoplastic lesions are seen, such as various stages of inflammatory processes, the early stages of active demyelinating processes, embolized tumors and vascular malformations, and numerous other conditions, which used to be seen only at autopsy and were never considered in the practice of surgical neuropathology.

Thus, the history of neuropathology is inseparable from that of neurosurgery, as if the shadow follows the form. Neuropathology, especially of tumors, was born within Cushing's neurosurgical kingdom by neurosurgeons. It was fortunate for the future of neuropathology that it was founded as a subspecialty of pathology at the same time that neurosurgery was established as a subspecialty of surgery. It has become a tradition in the USA to require trainees in neurosurgery to spend some months in a neuropathology lab in order to learn the elements of diagnostic neuropathology. As it is not possible for neurosurgical trainees to learn all aspects of neuropathology during their short rotation, we have tried to design some limited

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