Pabellon 1

SPECIAL ARTICLES
THE GENESIS OF NEUROSURGERY AND THE EVOLUTION OF THE NEUROSURGICAL OPERATIVE ENVIRONMENT: PART IPREHISTORY TO 2003
Charles Y. Liu, M.D., Ph.D.
Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, and Division of Chemistry and Chemical Engineering, California Institute of Technology, Pasadena, California
Michael L.J. Apuzzo, M.D.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California Reprint requests: Michael L.J. Apuzzo, M.D., 1200 N. State Street, Suite 5046, Los Angeles, CA 90033. Received, May 31, 2002. Accepted, September 11, 2002.
DESPITE ITS SINGULAR importance, little attention has been given to the neurosurgical operative environment in the scientific and medical literature. This article focuses attention on the development of neurosurgery and the parallel emergence of its operative setting. The operative environment has, to a large extent, defined the state of the art and science of neurosurgery, which is now undergoing rapid reinvention. During the course of its initial invention, major milestones in the development of neurosurgery have included the definition of anatomy, consolidation of a scientific basis, and incorporation of the practicalities of anesthesia and antisepsis and later operative technical adjuvants for further refinement of action and minimalism. The progress, previously long and laborious in emergence, is currently undergoing rapid evolution. Throughout its evolution, the discipline has assimilated the most effective tools of modernity into the operative environment, leading eventually to the entity known as the operating room. In the decades leading to the present, progressive minimalization of manipulation and the emergence of more refined operative definition with increasing precision are evident, with concurrent miniaturization of attendant computerized support systems, sensors, robotic interfaces, and imaging devices. These developments over time have led to the invention of neurosurgery and the establishment of the current state-of-theart neurosurgical operating room as we understand it, and indeed, to a broader definition of the entity itself. To remain current, each neurosurgeon should periodically reconsider his or her personal operative environment and its functional design with reference to modernity of practice as currently defined.
KEY WORDS: History, Imaging, Microsurgery, Modernity, Neurosurgery, Operating room, Operative minimalism
Neurosurgery 52:3-19, 2003
DOI: 10.1227/01.NEU.0000038928.61329.44
www.neurosurgery-online.com
eurosurgery is an intellectual and physical exercise in an exquisitely complex three-dimensional space. Its proper execution requires a suitable environment that allows for the appropriate technical and supporting tools of modernity to be used in an optimal fashion by the intelligent, practiced, and prudent surgeon. This neurosurgical operative environment has been in various stages of evolving development over virtually thousands of years, beginning with what may be called the Neolithic ancestors of neurosurgery some 12,000 years ago (13). Over its time course, the development of neurosurgery experienced an initial period of prolonged stasis, followed by a rapid acceleration of progress to take its present form. The operative environment, to a large extent, has defined the state of the art and science and reflected the scope of the specialty, which is now undergoing rapid and
sequential reinvention (411, 75). These reinventions, initially measured in millennia, are now measured in decades. Historically, technological progress and influential trends that are the motivating forces for the invention of neurosurgery have been systematically assimilated in useful incarnations into the operative environment. To remain current, each neurosurgeon should periodically reconsider his or her personal operative environment and the functional design that is offered for optimization of actions during specific operative enterprises. Clearly, this reappraisal should take into consideration evolving progress in the field as well as historical trends. A review of some of the major developments in the genesis of neurosurgery and the evolution of the neurosurgical operative environment from prehistory to the present suggests that the development can be considered as being marked by sev-
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eral major milestones (13, 55): 1) assembly of the first tools and skills to allow survivable invasive manipulation of the cranium, 2) progressive definition of the anatomic substrate and improved specific and practical tools and methods for surgical access to and manipulation of the nervous system and its coverings, 3) emergence and acceptance of science and the concept of the functional nervous system, 4) development of anesthesia, 5) development of concepts and practicalities of antisepsis and asepsis, 6) emergence of the distinct entity known as the operating room, 7) emergence of minimalism with the introduction of magnification and the operating microscope, 8) rapid expansion of the arsenal of tools and broadening of the scope of surgical possibilities in the past generation, and 9) physical expression of the present concepts of modernity. At the most basic level, neurosurgeons functioning in their operative environment require appropriate instruments to effect informed manipulations on the physical anatomy. Furthermore, functional preservation and therapeutic benefit require considerations beyond the merely physical aspects of the nervous system. Complex surgical manipulation of the nervous system and its surroundings can hardly be considered practical without some rudimentary element of antisepsis and anesthesia. All modern surgical decisions are guided by visualization of both the exposed and hidden anatomy as delineated by magnification and penetrating imaging modalities. Furthermore, the computer can be found in all but the most primitive contemporary operating rooms, especially in those that support frame-based and frameless stereotactic capabilities. During the course of the evolution of neurosurgery, the elements that constitute a modern operating room may have developed independently at times, with discontinuity evident throughout its early history. For example, prehistoric trepanation was not known to the Western world for centuries. In addition, knowledge accrued by ancient civilizations was often hidden for prolonged periods of time, only to be rediscovered much later. Nevertheless, the practice of surgical manipulation of the nervous system and its coverings has been evident for more than 12,000 years, and the settings in which these practices were conducted have reflected the state of the art, science, and, indeed, purpose of these endeavors. The history of the development of this practice is rich in detail, events, and personalities. An encyclopedic treatment of this history can be found in the literature (55) and is beyond the scope of this work. However, a review of many of the highlights and major trends in development reveals that the everincreasing sophistication of the surgical endeavors required that the elements that constitute the modern practice of neurosurgery be progressively assimilated into a functional amalgam known as the operating room. This represents the initial invention of the discipline as we understand it. Later, new tools were continuously introduced into the operative environment as they were made available by advances in science and technology, resulting ultimately in the modern technological marvels of today.
Major objectives of the discipline are to expand its scope and capabilities and to achieve this while decreasing morbidity and improving economies of cost. These elements represent the natural progression of the field and are reflected in the evolution of the neurosurgical operative environment. Indeed, throughout the evolution of neurosurgery, the operative environment has represented the final culmination of science, theory, philosophy, and purpose into a practical setting to optimize the safe and beneficial execution of the surgical endeavors.
THE PRIMORDIUM: CRANIAL SURGERY AND THE OPERATIVE ENVIRONMENT IN PREHISTORY

Historical evidence suggests that perhaps the very first attempt at surgical manipulation by humans involved the removal of pieces of the bony coverings of the brain (14, 27, 53, 72, 93, 96, 100, 113). For literally thousands of years, cranial surgery was principally extradural. Since these very first attempts by Neolithic humans, surgery of the brain and its coverings has evolved slowly during some 12,000 years, with elements of refinement in instrumentation but with similar end results. Trepanation refers to the removal of sections of bone from the cranium (72) by use of an instrument called a trepan or trephine, a name derived from the Greek trypanon, or borer. Pierre Paul Broca (1824-1880) is generally credited as being the catalyst for the widespread acknowledgment of this practice in ancient cultures (25). At present, there is almost universal acceptance of antemortem cranial surgery in prehistory, and archeological evidence supports the contention that the practice was widespread, with skull specimens found in Europe, Asia, Africa, North, Central, and South America, and Oceania (14, 52, 72, 81, 93, 96, 100, 109, 116). In fact, the practice survives to modern times in certain East African and South American tribes (80). To date, more than 1500 specimens have been found and examined. The oldest examples of trepanation may be specimens found in North Africa, dating back to 10,000 BC. Excavations in the Jericho area in the Near East and Asia have produced specimens from approximately 8000 to 6000 BC. The earliest European examples are more than 10,000 years old, dating perhaps to the late Paleolithic period, but certainly to the Neolithic age (72, 96). Early Danubians were performing cranial surgery in 3000 BC, and ancients from the Seine-Oise-Marne area of France were similarly active in 2000 BC. On the basis of the numbers of skulls that have been found in France, it is probable that a veritable surgery center existed there between 1900 and 1500 BC. Trepanation specimens have also been found in other regions of Neolithic Europe, the Balkans, and Russia. New World specimens of trepanation are much more recent, with the oldest examples, found on the southern coast of Peru, dating to 400 BC. More trepanned skulls have been found in this region than in the rest of the world combined. It is possible that the practice spread from Peru to what is now Mexico and North America.
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During the primordial period in the evolution of neurosurgery, the operative environment reflected the state of the art and science of the discipline, a theme clearly recurrent in future developments (Fig. 1). In prehistoric times, our neurosurgical ancestors most likely had no knowledge of neurological function and very limited practical understanding of anatomy. Furthermore, the operative environment of the Neolithic neurosurgeons was marked by a distinct absence of antisepsis, an element required in even the most rudimentary functional operating room by current standards. Furthermore, although primitive analgesics may have been administered to alleviate pain, general anesthesia would not evolve for thousands of years. In most dramatic contrast to modern neurosurgery, the goals and purposes of prehistoric cranial operations are considered to have included magicoritual and religious motivations along with the practical treatment of head injury, with a considerable spiritual element being present. Despite the plethora of physical evidence of prehistoric trepanation, insight into such motivation has been much more problematical and controversial (72, 91, 96). However, in the absence of written records, scholars speculate about a combination of motives as varied as therapeutic, magicotherapeutic, and magicoritual. For example, given the tendency of Peruvian and Danish skulls to have openings in the left temporoparietal region, it follows that trepanations had principally therapeutic intentions to treat injuries from blows by a right-handed assailant. Ritual is thought to be an important motivation for the development of the trepanation center in Neolithic France. In postmortem operations, rondelles of cranial bone were presumably obtained for use as charms, amulets, or talismans.
These speculations are supported by observations of the practice of 20th-century East African tribes: the Kisii tribe performs trepanations primarily to alleviate headache after a blow, whereas the nearby Lugbara tribe desires to release evil spirits. In addition, one novel speculation proposes that operations on the head were aimed at resurrecting the dead (91). All of these considerations are in marked contrast to the modern neurosurgical enterprise, in which the goals of surgery must be justifiable purely on the grounds of medical science. However they were motivated, and despite their lack of fundamental knowledge, prehistoric surgeons assembled the first distinct set of skills and tools to allow survivable surgical manipulation of the cranium. Neolithic surgeons invoked essentially four different techniques to remove pieces of cranial bone: 1) scraping, 2) grooving, 3) boring and cutting, and 4) rectangular intersecting incisions (72, 96, 116). The earliest instruments found in the Neolithic operating environments were made of flaked stone, flint, obsidian, and bone. Later, the ancient Peruvians used curved tumi blades to incise soft tissue and to make rectangular cuts in the bony cranium. Sharp instruments were used to make grooves and holes that could then be connected. Flat scrapers were also used with good effect, whereas in Mexico, a bow and obsidian drill may have been used. Although the primitive surgical instruments have survived to the present day, there is a lack of specific evidence of anesthetic use. Scholars have speculated that alcohol, narcotics, or coca products were administered to alleviate pain. Using this very primitive first set of skills and tools, prehistoric surgeons were surprisingly successful, with many archeological specimens showing postoperative healing and a survival rate of 80% or more.
EXPANDING THE KNOWLEDGE BASE OF THE ANATOMIC SUBSTRATE AND IMPROVING THE TOOLS AND METHODS OF MANIPULATION: ANCIENT HISTORY TO THE 16TH CENTURY
Among those elements considered crucial to modern neurosurgery and its operative environment, the first to be assimilated was an understanding of the anatomic operative substrate and the refinement of tools and methods to effect appropriate and safer manipulations. In fact, essentially all the advances in neurosurgery from the earliest recorded history up to the 16th century can arguably be organized into this category. During this prolonged period of early development, despite the accumulation of an extensive knowledge base of neuroanatomy, only primitive and empirical correlations were being drawn between anatomy and observed symptoms. In fact, written documentation of the physical manifestations of neurological diseases is evident in numerous archeological records (22, 40). This is reflected in all the important movements that have shaped the field over the next several thousand years.
FIGURE 1. Trephination in a primitive setting included none of the essential elements found in modern operating rooms. Notice the absence of general anesthesia and the presence of assistants to hold the patient down while the procedure is accomplished with crude instruments. Also, the person standing in the robe could be present in a spiritual role. Painting by Robert A. Thom, 1957.
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The legacy of cranial surgery derived from our Neolithic ancestors was carried on by surgeons of the ancient world from Egypt to China to Europe. In Egypt, the Ebers (53), Hearst (53), and Edwin Smith papyri (22, 40) clearly documented the ancient Egyptians keen awareness of the importance of neurosurgery, with 48 descriptions of cases involving the brain and spine in the Edwin Smith papyrus (1700 BC) alone. In China, the legendary physician Yu Fu allegedly had the ability to expose the brain (112). However, the ancient Greeks are credited with initiating the intellectual evolution of neurological surgery by the founding of the Alexandrian School in 300 BC (53), with Hippocrates (460370 BC) providing the earliest writings from this period. Indeed, in De capitis vulneribus (Head Injury), Hippocrates delineated principles that would serve as the foundation of practice for the next 2000 years (57). The greatest contribution of the ancient Greeks and early Romans and Byzantines was the assembly of an extensive knowledge base of the anatomic substrate (53). Herophilus of Chalcedon (335280 BC) and Rufus of Ephesus (AD 98117) provided detailed descriptions of the meninges, distinguished the cerebrum from the cerebellum, and detailed the extent of the ventricular system, the pineal and pituitary glands, the fornix, and the quadrigeminal plate complex. Galen of Pergamon (AD 129210) was perhaps the most prolific medical writer of antiquity and the first neurosurgeon in the arena of sports. He served as physician to the gladiators of Pergamon in the time of emperors Antonius Pius and Marcus Aurelius and provided voluminous contributions in the areas of neuroanatomy and neurosurgery. Galens writings served as the basis of knowledge regarding the nervous system well into the 18th century, providing descriptions of the aqueduct of Sylvius, the cranial nerves, hydrocephalus, spinal cord injury, and neurotrauma. Advancements in the practical aspects of cranial surgery were also evident during this time, with refinements in instrumentation, wound care, and hemostasis (53). Aulus Aurelius Cornelius Celsus (25 BC to AD 50) made important contributions to methods of trephination, in addition to articulating the classic signs of inflammation, rubor, tumor, calor, and dolor. Paul of Aegineta (AD 625690) developed many instruments for cranial surgery and the treatment of cranial fractures and was perhaps the first ancient surgeon to take advantage of the as yet unknown concept of antisepsis, using wine in his wound dressings. After the Arabic period, marked by a dearth of original ideas, a medical school would emerge in Salerno during the medieval period. There, the practice of operating on the cranium would be rejuvenated with new ideas and tools. For example, Roger of Salerno (1170) encouraged the use of trephination for the treatment of epilepsy and described the use of the Valsalva maneuver to identify cerebrospinal fluid leaks in cranial fractures (90, 94). Furthermore, Roger promoted the use of the cruciate incision for depressed fracture management and used wool and feathers as prohemostatic agents and wormwood soaked in rose water and egg for dressings along with soporifics in the preoperative period. In the 13th century, Theodoric of Cervia (Borgognoni) (1205
1298) outlined more practical improvements in the treatment of wounds, advocating hemostasis, removal of dead space and necrotic tissue, and the use of wine in dressings. Other practical advancements during this period included the refinement of trephination techniques, using the knife for sharp dissection rather than cautery for incision by Lanfranchi of Milan (died c. 1306). In addition, Guy de Chauliac (13001368) of France stressed the need to shave the head before surgery and used egg albumin as a prohemostatic agent and wine to improve the treatment of wounds. It can be speculated that the empirical use of wine and its alcoholic contents may have had antiseptic effects; however, the formal concepts of antisepsis would not develop for centuries. Through the 16th century, surgeons continued to operate on head wounds on the basis of their physical appearance, without consideration of symptoms, much as Hippocrates had described 1000 years earlier (45). Until the description of the method of interconnecting burr holes to create a bone flap for a craniotomy by Leonardo Botallo (15301588), surgeons were limited to working through small apertures created by trephines (21). Furthermore, Giacomo Berengario da Carpi (14701530) and Andreas Vesalius (15141564) reintroduced the concept of evidence-based anatomic studies from direct observation (90). Berengarios Tractatus de fractura and Tractus perutilis, published in 1518 and 1535, respectively, provided concepts of staged surgeries, gravity drainage of intracranial abscesses, and the first detailed illustrations of surgical instruments (17, 18). Ambroise Par (15101590), surgeon to the House of Medici, made significant contributions to the surgical treatment of head injuries (45). In Fabrica, Vesalius gave an account of the corpus callosum that was superior to that of Galen, suggesting that it connected the two halves of the brain (110). Adding to the knowledge base, Thomas Willis (1621 1765) and his contemporaries made many important observations on neuroanatomy, neurophysiology, and neurology (45). Despite having at their disposal an increasing body of medical literature on neuroanatomy along with improved surgical instruments, surgeons continued to deal primarily with head trauma and its aftermath, limited by a distinct lack of understanding of neurological function and antisepsis, and the surgeries remained principally epidural (Fig. 2). This was reflected in their operative environment, which continued to bear little resemblance to the modern operating room. This theme would continue into the Renaissance period. However, a fundamental body of knowledge was being amassed that would lead to the paradigm change that would occur four centuries later.
ENTRY INTO THE SCIENTIFIC AGE: NEUROSCIENCE AND THE FUNCTIONAL NERVOUS SYSTEM
Into the 17th century, surgeons were hampered by a minimal understanding of neurophysiology and lacked the ability to localize processes. The next major milestone in the development of the specialty was marked by the development of
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FIGURE 2. Portrait of San Lucas (St. Luke) operating on a child with a brain tumor. Early 15th century (courtesy, Prado Museum, Madrid). Although the attire and instruments have changed, cranial surgeons continued to be plagued a lack of the knowledge of nervous system function as well as a lack of the practicalities of anesthesia and antisepsis.
the concept of function grounded in a scientific and anatomic basis (90). This period of development was fertilized by an explosion in the fields of neuroscience and neurophysiology that would fundamentally alter the conceptual view of the causation of disease (68). During the period leading up to the 19th century, neuroscience consisted essentially of gross anatomic studies on adult specimens, with galenic beliefs providing the dominant influence (64, 117). However, starting in the late 18th century, sophisticated techniques of brain tissue fixation and sectioning provided an important perspective on the three-dimensional anatomy of the brain. In addition, comparative anatomy was repopularized with the advent of Darwins theory of evolution. The microscopic architecture of the brain also became visible with the adaptation of the achromatic microscope in the 1800s, giving birth to the field of histology in the 1840s. In 1839, Theodor Schwann (18101882) proposed the cell theory. In 1906, the Nobel Prize in Physiology and Medicine was awarded to Camillo Golgi (18431926) and Santiago Ramn y Cajal (18521934). Finally, interest in the developing nervous system led to the birth of the field of embryology, adding another perspective to the study of neuroanatomy. Enhancing this growing body of knowledge, pioneering physiologists conducted animal vivisection experiments and electrical stimulation and ablation studies on animal brains. These studies culminated in the work of Charles Scott Sherrington (18571952), a central figure in the development of neurophysiology, whose work titled The Integrative Action of the Nervous System (1906) formed the basic framework for the rest of the 20th century (98).
Although the developments in science were critical for the progressive evolution of the field, a revelation of sorts was necessary that would lead to the shift in focus from the purely physical to the functional aspects of anatomy. This emergence of the concept of function began in France with Jean Louis Petit (16741750) and Henri Franois Le Dran (16851770), who called attention to the brain as being the source of alterations in levels of consciousness in head trauma with identification of the lucid interval (69, 89). In England, Percival Pott (17131788), Benjamin Bell (17491806), John Abernathy (17641831), Jonathan Hutchinson (18281913), and their contemporaries furthered the concepts put forth by the French, identifying basic signs of neurological compression such as pupillary changes and third nerve palsy (1, 15, 31, 62, 97). The conceptual revelation of the functional brain would eventually evolve to definitions of cerebral localization (54). The 19th century witnessed the flourishing of Paris medicine, or the process of correlation of disease state observations with findings at autopsy. Using this concept, Jean-Baptiste Bouillaud (17961881) localized language function to the frontal lobes in 1825 (54). Bouillaud also understood the dichotomy of aphasia and dysarthria in disorders of speech. Correlating autopsy findings with premortem observations, Pierre Paul Broca (18241880), a pioneering anthropologist as well as a prominent surgeon, in a series of studies from 1861 to 1865 astutely localized the language function to the third left frontal convolution (23, 24). Epilepsy and the physical manifestations of seizure disorders formed a natural model system for the study of brain function. John Hughlings Jackson (18351911) studied large numbers of patients with focal motor seizures and other unilateral disorders and described the systematic and consistent march of symptomatic involvement of the face and limbs in focal motor seizures. These studies are considered to be of landmark importance in the understanding of cerebral localization (42, 63). In addition to observations on humans, experimental studies also contributed tremendously to the understanding of cerebral localization (79). The French Marie Jean Pierre Flourens (17941867) conducted ablation and stimulation experiments to elegantly demonstrate the general localization of intelligence, volition, and sensation to the cerebral hemispheres, a concept he called the action propre (46). In Germany, physiologists Gustav Theodor Fritsch (18381891) and Eduard Hitzig (18381907) carried out studies in a canine model and provided evidence of cortical control of motor function (47). Building on the efforts of Jackson and of Fritsch and Hitzig, David Ferrier (18431928) published detailed studies of cortical localizations starting in 1873, including The Functions of the Brain in 1876 (44). He thus established stimulation mapping as an acceptable experimental method. With the revelation of the importance of function grounded in a solid basis of science, surgery on the nervous system entered a new paradigm. With these new considerations, the need to monitor the function of the nervous system before, during, and after the operative intervention began to assume
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ever-increasing importance. Furthermore, the awareness of nervous system function led to refinements of the electrophysiological techniques and methods developed by pioneering physiologists to monitor these functions. Among these, the development and popularization of techniques to study nerve conduction and electroencephalography by Sir Richard Caton (18421926) and Hans Berger (18731941) would eventually allow the intraoperative monitoring of nervous system function in the modern operating room.
DEVELOPMENT OF ANESTHESIA
As much as any other single factor, the development of anesthesia was an essential element in the evolution of the modern neurosurgical operating environment. Ancient surgeons most likely made use of the anesthetic qualities of alcohol and early narcotics (107). Opium was available in Egypt by 1500 BC. Hyoscine was also available in Egypt shortly thereafter and was known to exist in ancient Greece and Rome. The Scythians used cannabis. In China, Pien Chia Chow used anesthesia, and the famous surgeon Hua To (AD 190265) used ma-fei-san dissolved in wine (118). The first documented neurosurgical application is credited to the Hindus, who in AD 927 used samohimi in the trephination of the King of Dahr. From these developments in antiquity arose general anesthetic agents, which greatly expanded the scope and duration of surgical procedures (Fig. 3). In 1772, Joseph Priestley (1733 1804) discovered nitrous oxide, which Sir Humphry Davy (17781829) suggested might be useful in surgery. In fact, by
1831, all three of the main anesthetic agents of the 19th century had been discovered: ether, chloroform, and nitrous oxide. In 1842, Crawford W. Long (18151878), of Georgia, first applied nitrous oxide to minimize pain in a surgical patient. In 1846, John Collins Warren (17781856) and fellow dentist William T.G. Morton (18191868) gave the first public demonstration of painless surgery using sulfuric ether. By 1853, the hypodermic needle was invented by Alexander Wood (18171884), allowing the development of injectable agents. Injectable morphine was used in the American Civil War (Fig. 4). Forty years later, Oliver Wendell Holmes coined the term anesthesia. The early pioneers of neurosurgery were instrumental in applying these new techniques, with appropriate modifications, to surgery of the brain. In fact, Sir William Macewen (18481924) was the first to use an endotracheal tube for anesthesia in 1878 (77). With these initial developments, another critical element was added to the armamentarium of the neurosurgeon, and the operative environment moved closer to its modern form.
ANTISEPSIS TO ASEPSIS: SAFE PASSAGE PAST THE BARRIER OF THE DURA

Perhaps the most important barrier to operating inside the dural covering of the brain was the overwhelming infection that resulted. Indeed, it is now almost inconceivable that surgical manipulation of the nervous system would be even attempted without meticulous attention to sterility. Without adequate precautions against infection, violating the protective barrier of the dura resulted in wholly unacceptable outcomes. Before the 19th century, the dura was thought to be a prohibitive barrier, to be deliberately violated only as a last
FIGURE 3. First operation under ether. Robert C. Hinckley (18811894). Surgeon John Collins Warren was the first to use ether anesthesia in surgery, on October 16, 1846. With the advent of general anesthesia, the scope and duration of surgeries were dramatically broadened (courtesy, Boston Medical Library, Francis A. Countway Library of Medicine, Boston, MA).
FIGURE 4. Camp of Chief Ambulance Officer, 9th Army Corps. Field Hospital near Petersburg, VA. During the time of the American Civil War, surgeons operated under primitive conditions, and many patients succumbed to infection. They did, however, have the benefit of the hypodermic needle and injectable morphine. Daguerreotype taken by Matthew Brady or an assistant, 1864 (courtesy, Library of Congress).
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resort. In fact, even in cases in which the appropriate surgery was performed, patients often succumbed to surgical infections in the form of wound infection, subdural and epidural empyema, and intracerebral abscess (115). The work of Lord Joseph Lister (18271912) provided the final key to allow William Macewen, guided by the new concepts of cerebral localization, to perform successful pioneering craniotomies. By the time William Macewen entered medical school at the University of Glasgow, Lister was Professor and Head of the Department of Surgery. Lister was keenly aware of the work of Louis Pasteur (18221895) and the development of the germ theory and its implications for surgical infections. After trying numerous preparations, Lister used carbolic acid in aerosol form in 1865. Carbolic acid saw its initial application soaked into wound dressings in the American Civil War. Lister extended its use to the antiseptic treatment of surgical instruments, the surgeons hands, the patients skin, and finally as a spray over the surgical field (50, 73, 74). Listers work is recognized as a landmark achievement in the development of surgery. Concepts of antisepsis were combined with those of asepsis to dramatically reduce morbidity and mortality related to infection. Louis Pasteur himself advocated the sterilization of instruments by flaming and dressings by exposure to pressurized steam in 1878. Subsequently, surgical gowns, caps, and boots were introduced, along with sterilized linens, drapes, gauze, and sponges. Motivated by the work of Lister, William Macewen focused his considerable energies on improving and refining the antiseptic and aseptic technique, and he established one of the first steam autoclaves in England. Furthermore, guided by the advancements in the field of cerebral localization, in 1879 he performed a successful craniotomy for a subdural hematoma in a boy presenting with a seizure that initiated with left-sided symptoms that subsequently generalized to involve the right side. In the same year, he performed another successful surgery to remove an en plaque meningioma in a young woman. These represent the first modern neurosurgical operations. Building on these initial successes, Macewen continued to surgically treat primarily infectious intradural brain lesions. In 1893, he published the classic titled Pyogenic Infective Diseases of the Brain and Spinal Cord: Meningitis, Abscess of Brain, Infective Sinus Thrombosis, describing his personal surgical series of 94 patients (78). With antisepsis and precautions against infection, another crucial element was assimilated to become an indispensable feature of the neurosurgical operative environment. Indeed, much of the routine and ritual that fundamentally characterize modern neurosurgical operating rooms is founded on the concepts of antisepsis and asepsis.
environment had been established. The neurosurgeon now had a solid knowledge base of neuroanatomy, an appreciation for the function of the nervous system founded on a solid scientific basis, along with the practical enabling field of anesthesia and ways to combat the scourge of pyogenic infection. The early pioneers of modern neurosurgery assembled these elements as a functional amalgam into their operative environment, giving birth to the modern operating room as we now understand it. The operating room has its architectural origins in the anatomy teaching amphitheaters of the Renaissance period, which were circular or oval, with seating for the gallery of observers or students (Fig. 5) (114). However, those original entities represent nothing more than a physical shell into which all the elements of the neurosurgical enterprise would eventually be assembled (Figs. 610). This was accomplished by the early pioneers, such as Rickman Godlee (18491925), J.O. Hirschfelder (18541920), and Francesco Durante (18441934), who individually performed some of the very first neurosurgical operations for brain tumors (16, 39, 58, 76). In 1886, Sir Victor Horsley (18571916) performed the first craniotomy for epilepsy along with the resection of a brain tumor (60, 61). In Germany, Ernst von Bergmann (18361907) was instrumental in the transition from the clumsy antiseptic technique to the more practical aseptic technique (112). In 1888, William Williams Keen (18371932), in Philadelphia, recorded the first successful access of the ventricular system in a living patient, tapping the lateral ventricle with a hollow needle, and performed the first successful removal of a brain tumor in America. In France, Antoine M.J.N. Chipault (18661920) was probably the first surgeon to be completely dedicated to the nervous system (30). In 1898, Leonardo Gigli developed a wire saw that would make the actual process of opening the cra-
ASSEMBLING THE ELEMENTS OF A FUNCTIONAL AMALGAM: EMERGENCE OF THE OPERATING ROOM

By the late 19th century, many of the elements that characterize the modern neurosurgical enterprise and its operative
FIGURE 5. The Teatro Anatomica, an early ancestor of the modern operating room. This early dissection theater was constructed at Padua in the mid-16th century; dissections were carried out under torchlight. The circular construction with space for a gallery would serve as the architectural model for operating theaters to come, as seen in Figures 4 and 68 (courtesy, University of Padua as obtained by Dr. Norman Horwitz).
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FIGURE 6. Photograph of Sir William MacCormac, senior surgeon of St. Thomas Hospital, London, performing an excision of a diseased elbow joint in 1891. The operating theater continued to resemble the original layout of the Teatro Anatomica of the 16th century (Fig. 3). Although an anesthetist is present, the uniform attire, mask, and gowns are distinctly absent.
nium safer (49). All their efforts would culminate in the work of Harvey Cushing (18691939) and Walter Dandy (1886 1946), whose efforts would firmly establish the field of neurological surgery and organization of the neurosurgical operating room. Harvey Cushing was born in Cleveland, OH, in 1869 and educated at Yale College and Harvard Medical School (48, 56). His interest in surgery and neurology was initiated at the Massachusetts General Hospital and the Convalescent Home at Waverly and blossomed under the direction of William Halsted (18521922) at Johns Hopkins, where he completed his residency. He combined the halstedian principles with his drive and talents to advance the safe surgical treatment of neurological diseases and made singularly important contributions toward the establishment of neurological surgery as a distinct specialty. Toward the end of his residency in 1900, he began to take a special interest in trigeminal neuralgia. Despite engaging initially in a general practice, he began to focus more of his energies on the nervous system after returning from Europe in 1901, performing his first brain tumor operation the following year. In 1904, he made a presentation in Cleveland titled The Special Field of Neurological Surgery (32). He had a vision of a field practiced by surgeons specially trained in clinical neurology, neuropathology, and experimental neurophysiology, along with the technical skills of operating on the brain and central nervous system. He was instrumental in the development of methods of hemostasis in all structures of the head and brain, improved the understanding and control of intracranial pressure, and provided crucial insight into the pathology and natural history of surgically relevant lesions of the nervous system. In 1906, at the request of William W. Keen, Cushing produced a chapter on surgery of the head for
FIGURE 7. Theodor Billroth operating in the auditorium of the Allgemeine Krankenhaus, Vienna, in 1889. Anton F. Seligmanns painting shows Billroth performing a neurotomy for trigeminal neuralgia (courtesy, sterreichische Galerie, Vienna, Austria).
the encyclopedic text Surgery: Its Principles and Practice (33). This represented the first comprehensive treatise on the subject by an American author. By 1910, he had performed 250 brain tumor operations, with an operative mortality of 13%. In contrast, contemporary surgeons were reporting operative mortalities of approximately 50%. In 1912, Cushing left Baltimore and assumed the position of Chief of Surgery at the Peter Bent Brigham Hospital in Boston. There, he continued to develop techniques directed toward the surgical treatment of the entire spectrum of neurosurgical diseases, including extrinsic and intrinsic intracranial tumors, trigeminal neuralgia, and pituitary tumors. During World War I, Cushing made considerable contributions to the treatment of head trauma. These activities galvanized his position as the leading surgeon in America and lent prominence to the field of neurological surgery. As a further legacy of Cushings impact, many of his residents initiated academic programs of their own. Among these, John F. Fulton (18991960) was appointed Sterling Professor and Chairman of Physiology at Yale in 1930 (38). Fultons collaborations with Cushing continued from Boston to New Haven, where Cushing spent his final days. Fultons
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FIGURE 8. William Keens operating theater in Philadelphia, PA, circa 1900, one of a number of classic settings during the emergence of neurosurgery as a primary discipline. Keen, along with other pioneers, assembled the elements of anesthesia with antisepsis/asepsis to bring forth the entity of the operating room as we now understand it.
FIGURE 9. Drs. Howard, Frazier, and Jackson demonstrating an operation for students. City Hospital, Mobile, AL. In this setting, the surgeons and assistants appear to be attired in uniform gowns and caps with antiseptic protocols in place. Also absent is the large gallery seen in previous settings. Photograph by William E. Wilson, 1902 (courtesy, Historic Mobile Preservation Society Archives, Mobile).
department was a veritable Mecca for neurophysiology. He published the classic Physiology of the Nervous System and helped found the Journal of Neurophysiology in 1938. He was also instrumental in the founding of the Journal of Neurosurgery in 1944. Another giant in the history of neurosurgery in America is Walter E. Dandy (18861946). With Dandy and Cushing, the fundamental framework for modern neurosurgery had arrived. Dandy attended medical school at Johns Hopkins; there, he spent a year as a research assistant to Cushing. After Cushings departure to Boston, Dandy remained at Hopkins, where he contributed seminally to the developing field. For example, he developed the technique of pneumoventrilography to study ventricular anatomy as it related to hydrocephalus (34). He also developed pneumoencephalography to visualize the entire subarachnoid space (35). His studies on cerebrospinal fluid physiology are classic, defining the choroid plexus as the source of cerebrospinal fluid production. In 1937, Dandy also performed the first clip ligation of a cerebral aneurysm while preserving the parent vessel (36). His contributions are myriad and elegantly described in his book The Brain (37). His contributions to transcerebral surgeries, particularly intraventricular tumors and rudimentary endoscopic techniques, are particularly noteworthy. Cushing and Dandy were joined in their efforts by important figures such as Ernest Sachs (18791958), Charles A.
FIGURE 10. Photograph of an operating room, showing a nurse giving anesthetic by dripping it on a gauze over the patients face, circa 1919. Even at this time, the members of the operating staff, including the surgeons and nurses, are seen without a mask. Universal use of the surgical mask in the operating room would not be evident until after World War II (courtesy, National Library of Medicine, Bethesda, MD).
Elsberg (18711948), Charles H. Frazier (18701936), Antonio Egas Moniz (18741955), Fedor Krause (18571937), Wilder Penfield (18911976), Herbert Olivecrona (18911980), and Hugo Krayenbhl (19021985), among others (42, 43, 82, 85, 87, 88, 108). In contrast to the relatively standardized functional organization of modern neurosurgical operating rooms, the early
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pioneers assembled personalized combinations of antiseptic/ aseptic and anesthetic protocols in their customized operating rooms (28, 71, 121). For example, ether anesthetic was used in some operating rooms, whereas chloroform was used in others. Even the use of rubber surgical gloves was not ubiquitous, with none other than William Keen personally preferring cotton gloves (Fig. 8) (65, 92). Although common, the use of surgical masks was not universal until after World War II (29). In the United States, however, many hospitals had adopted stringent aseptic protocols by the turn of the 20th century. This transition was marked by the routine use of gowns, caps, masks, and gloves, and the wiping down of operating room equipment and furnishings with antiseptic between cases (Figs. 9 and 10) (3). Furthermore, routine protocols of hand washing were adopted. From these personalized practices would evolve a distinct set of rituals and routines that persists even to modern-day operating rooms. The state of the art and science of the field of neurosurgery had evolved to a point at which a specialized setting was necessary to accommodate its execution. The familiar entity known as the operating room was at last taking form (41, 83, 101).
MAGNIFICATION AND THE TREND TOWARD MINIMALISM: THE OPERATING MICROSCOPE

For the first half of the 20th century, the field continued to be refined and streamlined. Improved instruments and better knowledge of anatomy naturally resulted in a reduction of trauma related to surgery and better definition of the corridors of access to the target lesions. However, the ultimate limit to the precision and minimalism of the operative endeavor was the resolution of the naked human eye. The achievement of improved precision and minimalism by magnification and the operating microscope would represent the next major milestone in the evolution of neurosurgery and the operative environment (67, 119, 120). Magnification was well known to even the ancient Egyptians and Romans, and by the mid-1800s, the microscope was well established as a scientific tool. In 1848, the German machinist Carl Zeiss, in collaboration with physicist Ernst Abb, began to produce high-quality microscopes in mass quantities. Abb had derived the theoretical formulas that governed the optical properties of lenses, allowing the performance of new lenses to be predicted and systematically designed. This represented a distinct improvement over the trial-and-error techniques used at the time. At approximately the same time, surgeons had already recognized the potential benefit of magnification and had adapted single-lens magnifying loupes. During the early part of the 20th century, European otolaryngologists first adapted the microscope for surgery. By that point in time, technical advances in lighting and microscope design by manufacturers such as Zeiss had resulted in instruments more practical for the operative setting. By the 1950s, Howard and William House had established the use of the operating microscope in middle ear surgery through the tem-
poral bone. Concurrently, ophthalmologists had also assimilated the microscope into their own practice. The first use of the microscope in a neurosurgical operation took place in 1957 by Theodore Kurze (19222002) of the University of Southern California. Inspired by the efforts of William House, Kurze adapted the otological microscope for use in the neurosurgical operating room. Furthermore, he introduced contemporary neurosurgeons, such as Robert Rand (1923 ), J. Lawrence Pool (1906 ), and Charles Drake (19201998), to this new concept. By 1958, neurosurgeon R.M. Peardon Donaghy (19101991) had established the worlds first microsurgery research laboratory in Vermont. After some initial resistance, the operating microscope would become an indispensable neurosurgical tool and find a prominent place in the neurosurgical operating room. From 1958 onward, Theodore Kurze performed all his aneurysm operations with the operating microscope. Over the next few years, reports of microneurosurgery began to appear in the neurosurgical literature. In 1962, Kurze published his series of middle fossa operations. By 1965, J. Lawrence Pool had published the first series of cerebral aneurysms surgically treated with the aid of the microscope. The next year, Peter Jannetta (1932 ) and Robert Rand published their series of posterior circulation aneurysms treated with microsurgery. Building on these initial efforts, M. Gazi Yas argil (1925 ) would firmly establish the microneurosurgical revolution. With this, the trend toward progressive minimalism was well under way (119, 120).
PRELUDE TO MODERNITY: THE PAST GENERATION

The next several decades of evolution in neurosurgery witnessed the rapid expansion in the scope and focus of the specialty enabled by the incorporation of new tools into the operating room (Fig. 11). Important areas of influence in the
FIGURE 11. Photograph of Ernst Spiegel and Henry Wycis performing an early stereotactic procedure. Toward the middle part of the 20th century, new tools were rapidly assimilated into the operating room, greatly expanding the scope and focus of the discipline (courtesy, Time-Life Warner).
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development of sophistication in operative events in the past generation (9) have included 1) the introduction of the operating microscope, which has allowed magnification and preservation as well as reduction of operative corridors; 2) refinement of strict neuroanatomic comprehension secondary to elegant studies of elements of the neuroanatomic substrate throughout the entire neural and neurovascular systems; 3) the development of imaging devices that have allowed definition of the preoperative structural substrate, pathology, and anatomic distortions in the individual sense; 4) the introduction of the computer as a neurosurgical tool in stereotactic and refined-access cerebral and spinal neurosurgery (99); and 5) the use of a multiplicity of anatomic and neurophysiological monitoring modes during each operative event. These important influential forces have led to a precision of orientation and action, achieving what has been observed to be a progressive minimalism, a concept that has been dominant and has principal influences as one considers actions within the neurosurgical operative environment. The concepts would embrace the entire specialty and are fundamentally predicated on the notion of minimal invasion of anatomy but maximum beneficial impact on the disease process. It is clearly apparent in the technical enterprises of endoscopy, endovascular surgery (59, 111), and cellular/molecular neurosurgery (95, 122, 123) with restoration of function. However, it is most practically apparent in the field of imaging-guided stereotactic neurosurgery and so-called neuronavigation, which has been in evolution principally as a result of evolving developments in the penetrating imaging modalities beyond the visible within both structural and functional realms. During the past 2 decades, these developments have served as a platform for the further emergence of concepts to be applied within the stereotactic field. These have included 1) voice control, 2) holography in real time, 3) robotics, 4) virtual reality systems for simulation and training, and 5) telesurgical systems.
AN IDEAL VENUE: 1990

More than a decade ago, given these concepts and developments, we very carefully evaluated technical evolving fields and related them to our personal needs at the University of Southern California with the construction of a new University Hospital (12). At that time, certain characteristics of a modern operating environment appeared to be central in consideration of the architectural development and functional design of an advanced neurosurgical operating environment. These included 1) generous size to accommodate the space requirements of advanced support systems, 2) compartmentalization to offer work areas for both sterile and nonsterile activities related to operative events, 3) self-containment to minimize dependence on external support and intraoperative traffic, 4) appropriate systems for data acquisition, 5) appropriate systems for data processing, 6) appropriate systems for data display, and 7) design offering fluidity during complex procedures and multifactorial function involving instrumentation and personnel.
This idealized development offered the first detailed description of a dedicated, self-contained neurosurgical operating suite incorporating major surgical instrumentation and visualization technologies to provide a setting for microscopic, stereotactic, and microstereotactic procedures. It attempted to integrate advanced computer technology for visualization to augment, simulate, document, and facilitate all aspects of neurosurgery. Specific goals and objectives of the design were to provide an integrated visualization system, which could achieve the following functions: 1) stereotactic point and volume planning (simulation) and procedures; 2) microstereotactic volume planning (simulation) and procedures; 3) procedural integration of nonlinkage (frameless) stereotaxy, microscopy, and imaging; 4) graphic simulation of microscopic and stereotactic procedures; 5) surgical team integration through presentation of visual data on the operative environment (operative fields and physiological monitors); 6) retrieval and presentation of reference data from scientific and practical atlases, journals, and texts in an online library; 7) real-time presentation of complex and basic physiological monitoring parameters; 8) real-time presentation of operative structural staging with three-dimensional comparative imaging; 9) multiparameter recording of all surgical events; 10) a complete nursing catalog of individual case setup and surgeon setup, instrumentation, and idiosyncratic preferences; 11) enhancement of educational experience and databases; 12) fusion of images from computed tomography (CT), magnetic resonance imaging (MRI), digital subtraction venous angiography, positron emission tomography, magnetoencephalography, and graphic overlays, with consideration of functional imaging integration with the structural composite; 13) documentation for medicolegal and educational purposes; 14) increased safety and precision of operative procedures; and 15) initiation of progress toward a virtual-reality concept of an anatomic/surgeon interface. To realize these goals, the design of the operating suite comprised three primary areas (Fig. 12): 1) the operating room (approximately 700 square feet), 2) the observation/storage area (approximately 200 square feet), and 3) a computer visualization laboratory (approximately 400 square feet). This fundamental design was inspired by elements of interface with the operating theater concept of Theodore Kurze (at the University of Southern California), John M. Tew, Jr. (at the University of Cincinnati), Kintomo Takakura (at the University of Tokyo), and Patrick J. Kelly (at the Mayo Clinic and then at New York University) (51, 66). Over what is now a decade of use, this amalgam of design of space and function has proved to have benefits and problems, but in particular, supporting software development in a customized setting proved to be costly and impractical. In addition, certain conceptual trends and increasing miniaturization and functionality of available technology would initiate certain design departures from planning that occurred more than a decade ago. It should be stated, however, that the basic needs and goals have remained fundamentally unchanged.
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mentally, all of these relate to concepts that have been recognized but not brought into the realm of practical reality. Numerous developments in robotics have been apparent, with complex systems currently globally applied in cardiac surgery and other surgical disciplines (20, 26, 102106). Robotic devices have been introduced into stereotactic radiosurgery, with the automatic positioning system regularly used with great safety and technical efficiency with the Leksell gamma knife (Elekta Instruments, Inc., Atlanta, GA) (Fig. 13) and the Novalis (BrainLAB, Heimstetten, Germany) radiosurgical system. This implementation of the robotic concept has enhanced the fluidity and scope of application over previous generations of fixed-beam radiosurgery systems. The CyberKnife (Accuray, Inc., Sunnyvale, CA), a robotically devised rotational frameless radiosurgical system, is now ready for operation and promises to bring new dimensions to volumetrically controlled radiotherapy (Fig. 14) (2). During this decade, it has become clear that the concept of a conventional operating room needs to be expanded to radiosurgical suites as domains of neurosurgical enterprise (70).
FIGURE 12. A, diagonal view of the neurosurgical operating room at the University of Southern California (USC) University Hospital. Area with overhead microscope track offered more than 700 square feet of area and selfcontained support facility for microscopic and stereotactic procedures. B, diagonal view of the neurosurgical operating room at the USC University Hospital. Note overhead monitors and multifactorial visualization display wall to right. C, the computer visualization laboratory composed of three workstations and enclosed computer bank room to left. This served as an adjacent but integral component of the neurosurgical operating room at the USC University Hospital, Los Angeles (circa 1992) (from, Apuzzo MLJ, Weinberg RA: The architecture and functional design of advanced neurosurgical operating environments. Neurosurgery 33:663673, 1993 [12]).
THE PAST DECADE

During the past decade, there has been remarkable technical progress that has a bearing on the ultimate development for neurosurgical environments for the 21st century. Funda-
FIGURE 13. A, Leksell gamma knife, Model C. B, helmet and robotic device for migration through cartesian coordinates in the radiosurgical device (Leksell gamma knife). With the broadening scope of neurosurgery, the operative environment must now include radiosurgical and angiography suites (courtesy, University of Southern California University Hospital, Los Angeles, CA).
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FIGURE 15. An early-generation attempt at bringing MRI into the operating room. This configuration will eventually be miniaturized for improved functionality (Fig. 16) (courtesy, Brigham and Womens Hospital, Boston, MA). FIGURE 14. A robotically controlled frameless radiosurgical system (CyberKnife) (courtesy, Kenneth Norris, Jr., Hospital, University of Southern California, Los Angeles, CA).
During the past decade, imaging has developed at a dramatic pace from the standpoints of not only definitive capability but also locales of application. Within operative environments, structural data are applied through compact navigational devices for localization. These data are acquired preoperatively through CT, MRI, and angiography. More dramatically, intraoperative accrual is now practical in certain centers, with CT and MRI devices serving as surgical instrumentation within operating room settings (19, 84) (Fig. 15). Developments in functional imaging are now widely available and are used through both preoperative and intraoperative accrual. There appears to be important progress in the miniaturization of devices that provide these imaging capabilities and, importantly, a concurrent reduction in cost (Fig. 16). Refinement of visualization displays has been evident with the development of flat and compact plasma high-definition visualization screens that lend themselves to the operating room environment. Head-mounted displays have enjoyed significant refinement in stereotactic amalgam with the operating microscope and helmet systems for endoscopic application. Neurosurgery has been fundamentally reinvented, with tools of modernity being defined within the realms of microscopy, anatomic comprehension, imaging, computers, ionizing radiation, biomedical technology, and biomolecular science (10, 11, 13, 86, 95, 122, 123). Concurrently, concepts of modernity have emerged to include sophisticated comprehension of the individual, operative minimalism, navigational guidance, biomechanicalization, operative rehearsal, and structural/ functional restoration.
FIGURE 16. A miniature magnetic imaging device designed for intraoperative usage (Odin Technologies device) (from, Moshe H, Spiegelman R, Feldman Z, Berkenstadt H, Ram Z: Novel, compact, intraoperative magnetic resonance image-guided system for conventional neurosurgical operating rooms. Neurosurgery 48:799809, 2001 [84]).
STATE OF THE ART: 2003

Many of the ideas outlined in the development of the ideal neurosurgical operating room at the University of Southern California in 1990 can be found elegantly expressed in a commercially available unit (Figs. 17 and 18). The operating
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FIGURE 17. A state-of-the-art operating room in 2002. The Brainsuite contains all the elements of modernity conceptually organized in a manner similar to the design of the ideal venue at the University of Southern California in 1992. Notice the ceiling-mounted microscope, the video wall for data display, the image guidance systems, and intraoperative MRI capabilities (courtesy, BrainLAB).
trated by the assimilation of neurodiagnostic imaging modalities into neurosurgical practice. In the 1970s, that imaging was emerging as an important diagnostic tool. To take advantage of visualization of the target and instrument, neurosurgeons often performed procedures in the CT suites. In the 1980s, with the development of the widely used Brown-RobertsWells and other imaging-directed stereotactic frames, the information gained from the scanners was brought into the operating room, in which the elements of the neurosurgical enterprise were optimized and the neurosurgeon was more comfortable. In the 1990s, however, the scanners were brought into the operating room for intraoperative imaging to guide decision making, with the development coming full circle. Clearly, as new technology becomes available, it finds application in the practice of neurosurgery. Eventually, however, a form of this technology is brought into the operative environment. The expansion of the scope and capabilities of neurosurgery enabled by technology advancement and the eventual incorporation of new products into the operative environment represent the natural evolution of the field. History suggests that this theme will persist into the future.
REFERENCES
1. Abernethy J: Surgical Observations on Injuries of the Head and on Miscellaneous Subjects. London, Longman, Hurst, Rees, Orme, & Brown, 1810. 2. Adler JR Jr, Murphy MJ, Chang SD, Hancock SL: Image-guided robotic radiosurgery. Neurosurgery 44:12991306, 1999. 3. Alford DJ, Ritter MA, French ML, Hart JB: The operating room gown as a barrier to bacterial shedding. Am J Surg 125:589591, 1973. 4. Apuzzo MLJ (ed): Neurosurgery for the Third Millennium: American Association of Neurological Surgeons Neurosurgical Topics. Park Ridge, AANS, 1992. 5. Apuzzo MLJ: Schneider Lecture: New dimensions of neurosurgery in the realm of high technologyPossibilities, practicalities, realities. Neurosurgery 38:625639, 1996. 6. Apuzzo MLJ: Brave new world: Reaching for utopia. Neurosurgery 46: 1033, 2000. 7. Apuzzo MLJ: Modernity and the emerging futurism in neurosurgery: Tempora mutantur nos et mutamur in illis. J Clin Neurosci 7:8587, 2000. 8. Apuzzo MLJ: Reinventing neurosurgery: Entering the third millennium. Neurosurgery 46:12, 2000. 9. Apuzzo MLJ, Hodge CJ Jr: The metamorphosis of communication, the knowledge revolution, and the maintenance of a contemporary perspective during the 21st century. Neurosurgery 46:715, 2000. 10. Apuzzo MLJ, Liu CY: 2001: Things to come. Neurosurgery 49:765778, 2001. 11. Apuzzo MLJ, Liu CY: Quid Novi? In the realm of ideasThe neurosurgical dialectic. Clin Neurosurg 49:157185, 2002. 12. Apuzzo MLJ, Weinberg RA: The architecture and functional design of advanced neurosurgical operating environments. Neurosurgery 33:663 673, 1993. 13. Apuzzo MLJ, Liu CY, Sullivan SD, Faccio RA: Reinventing neurosurgery: Surgery of the human cerebrumA collective modernity. Clin Neurosurg 49:2789, 2002. 14. Aufderheide AC: The enigma of ancient cranial trepanation. Minn Med 68:119122, 1985. 15. Bell B: A System of Surgery. Edinburgh, C. Elliot, 17831788, vols 16. 16. Bennett AH, Godlee RJ: Case of cerebral tumour: The surgical treatment. Trans R Med Chir Soc Lond 68:243275, 1885. Reprinted in Wilkins RH (ed): Neurosurgical Classics. Park Ridge, AANS, 1992, pp 361371. 17. Berengario da Carpi J: Tractatus de fractura calue siue cranei. Bologna, H de Benedictis, 1518.
FIGURE 18. Video wall of the Brainsuite for effective display of data (courtesy, BrainLAB).
microscope is ceiling mounted for optimal ergonomic usefulness. Data are displayed on a large video wall for easy access. A 1.5-T high-field MRI system is integrated to provide intraoperative imaging capabilities. The images are then linked to an image guidance system. With the full benefits of early 21st-century technology, the Brainsuite contains almost all the elements of modernity in a self-contained environment. This kind of operating can be considered the current state of the art at this point in time.
A PERVASIVE THEME
A pervasive theme in the development of neurosurgery and the evolution of the operative environment is clearly illus-
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18. Berengario da Carpi J: Tractatus perutilis et completus de fractura cranei. Venice, Nicolinis de Sabio, 1535. 19. Black PM, Moriarty T, Alexander E III, Steig P, Woodard EJ, Gleason PL, Martin CH, Kikinis R, Schwartz RB, Jolesz FA: Development and implementation of intraoperative magnetic resonance imaging and its neurosurgical applications. Neurosurgery 41:831845, 1997. 20. Borst C: Operating on a beating heart. Sci Am 283:5863, 2000. 21. Botallo L: De curandis vulneribus sclopetorum. Lyon, G Roville, 1560. 22. Breasted JH: The Edwin Smith Surgical Papyrus: Published in Facsimile and Heirogliphic Transliteration with Translation and Commentary in Two Volumes. Chicago, University of Chicago Press, 1930. 23. Broca P: Nouvelle observation daphmie produite par une lsion de la moiti postrieure de deuxime et troisime circonvolutions frontales. Bull Mem Soc Anat Paris 6:398407, 1861. 24. Broca P: Perte de la parole, ramollissement chronique et destruction partielle du lobe antrieur gauche du cerveau. Bull Soc Anthropol 2:235 238, 1861. 25. Broca P: La trpanation chez les Incas. Bull Acad Natl Med 32:866871, 1867. 26. Cadeddu JA, Stoianovici D, Kavoussi LR: Robotic surgery in urology. Urol Clin North Am 23:7585, 1998. 27. Campanillo D: Neurosurgical pathology in prehistory. Acta Neurochir (Wien) 70:275290, 1984. 28. Cartwright FF: The Development of Modern Surgery. New York, Thomas Y. Crowell, 1968. 29. Castaneda A: Historical development of the surgical mask. Surgery 49:423 428, 1961. 30. Chipault A: Chirurgie Opratoire du Systme Nerveux. Paris, Reuff & Cie, 18941895, vols 1 and 2. 31. Cooper A: The Lectures of Sir Astley Cooper: On the Principles and Practice of Surgery. London, Thomas & George Underwood, 18241825, pp 252 352. 32. Cushing H: The special field of neurological surgery. Bull Johns Hopkins Hosp 16:7787, 1905. 33. Cushing H: Surgery of the head, in Keen WW (ed): Surgery: Its Principles and Practice. Philadelphia, W.B. Saunders Co., 1908, vol 3, pp 17276. 34. Dandy WE: Ventriculography following the injection of air into the cerebral ventricles. Ann Surg 68:511, 1918. Reprinted in Wilkins RH (ed): Neurosurgical Classics. Park Ridge, AANS, 1992, pp 244250. 35. Dandy WE: Rntgenography of the brain after the injection of air into the spinal canal. Ann Surg 70:397403, 1919. Reprinted in Wilkins RH (ed): Neurosurgical Classics. Park Ridge, AANS, 1992, pp 251256. 36. Dandy WE: Intracranial aneurysm of the internal carotid artery. Ann Surg 107:654659, 1938. Reprinted in Wilkins RH (ed): Neurosurgical Classics. Park Ridge, AANS, 1992, pp 437441. 37. Dandy WE: The Brain. New York, Harper, 1969. 38. Davey LM: John Farquhar Fulton. Neurosurgery 43:185187, 1998. 39. Durante F: Contribution to endocranial surgery. Lancet 2:654655, 1887. Reprinted in Wilkins RH (ed): Neurosurgical Classics. Park Ridge, AANS, 1992, pp 375376. 40. Elsberg CA: Edwin Smith Surgical Papyrus and the diagnosis and treatment of injuries to skull and spine 5000 years ago. Ann Med Hist 3:271 279, 1931. 41. Essex-Lopresti ME: Operating theatre design. Lancet 353:10071010, 1999. 42. Feindel W, Leblanc R, Villemure JG: History of the surgical treatment of epilepsy, in Greenblatt SH (ed): A History of Neurosurgery in Its Scientific and Professional Contexts. Park Ridge, AANS, 1997, pp 465488. 43. Feldman RP, Goodrich JT: Psychosurgery: A historical overview. Neurosurgery 48:647659, 2001. 44. Ferrier D: The Functions of the Brain. London, Smith, Elder & Co., 1876. 45. Flamm ES: From signs to symptoms: The neurosurgical management of head trauma from 15171867, in Greenblatt SH (ed): A History of Neurosurgery in its Scientific and Professional Contexts. Park Ridge, AANS, 1997, pp 6581. 46. Flourens P: Recherches Exprimentales sur les Propits et les Fonctions du Systme Nerveux dans les Animaux Vertbrs. Paris, Crevot, 1824.
47. Fritsch GT, Hitzig E: Ueber die elektrische Erregbarkeit des Grosshirns. Arch Anat Physiol Wiss Med 37:300332, 1870. Translated: On the electrical excitability of the cerebrum. Von Bonin G (trans), in Von Bonin G (ed): Some Papers on the Cerebral Cortex. Springfield, Charles C Thomas, 1960, pp 7396. Reprinted in Wilkins RH (ed): Neurosurgical Classics. Park Ridge, AANS, 1992, pp 1627. 48. Fulton JF: Harvey Cushing: A Biography. Springfield, Charles C Thomas, 1946. 49. Gigli L: Zur Technik der temporren Schdelresection mit meiner Drahtsge. Zentralbl Chir 25:425428, 1898. Reprinted in Wilkins EH (ed): Neurosurgical Classics. Park Ridge, AANS, 1992, pp 380382. 50. Godlee RJ: Lord Lister. London, Macmillan and Co., 1917. 51. Goerss S, Kelly PJ, Kall B, Alker GJ Jr: A computed tomographic stereotactic adaptation system. Neurosurgery 10:375379, 1982. 52. Gomez JG: Paleoneurosurgery in Colombia. J Neurosurg 39:585588, 1973. 53. Goodrich JT: Neurosurgery in the ancient and medieval worlds, in Greenblatt SH (ed): A History of Neurosurgery in Its Scientific and Professional Contexts. Park Ridge, AANS, 1997, pp 3764. 54. Greenblatt SH: Cerebral localization: From theory to practicePaul Broca and Hughlings Jackson to David Ferrier and William Macewen, in Greenblatt SH (ed): A History of Neurosurgery in Its Scientific and Professional Contexts. Park Ridge, AANS, 1997, pp 137152. 55. Greenblatt SH (ed): A History of Neurosurgery in Its Scientific and Professional Contexts. Park Ridge, AANS, 1997. 56. Greenblatt SH, Smith DC: The emergence of Cushings leadership: 1901 1920, in Greenblatt SH (ed): A History of Neurosurgery in Its Scientific and Professional Contexts. Park Ridge, AANS, 1997, pp 167190. 57. Hippocrates: On injuries of the head, in Medical Classics: Genuine Works of Hippocrates. Adams F (trans). Baltimore, Williams & Wilkins, 1938, vol 3, pp 145160. 58. Hirschfelder JO: Removal of a tumor of the brain. Pac Med Surg J 29:210 216, 1886. 59. Hopkins LN, Lanzino G, Guterman LR: Treating complex nervous system vascular disorders through a needle stick: Origin, evolution, future of neuroendovascular therapy. Neurosurgery 48:463475, 2001. 60. Horsley V: Brain surgery. Br Med J 2:670675, 1886. 61. Horsley V, Clarke RH: The structure and functions of the cerebellum examined by a new method. Brain 31:45124, 1908. Reprinted in Wilkins RH (ed): Neurosurgical Classics. Park Ridge, AANS, 1992, pp 162185. 62. Hutchinson J: Four lectures on compression of the brain. Clin Lectures Reports Lond Hosp 4:1055, 18671868. 63. Jackson JH: A study of convolutions. Trans St. Andrews Med Grad Assoc 3:162204, 1870. 64. Jacyna LS: The neurosciences: 18001875, in Greenblatt SH (ed): A History of Neurosurgery in Its Scientific and Professional Contexts. Park Ridge, AANS, 1997, pp 131136. 65. Keen WW: On the use of surgical gloves in surgical operations. Ann Surg 27:224227, 1898. 66. Kelly PJ, Kall BA, Goerss S: Transposition of volumetric information derived from computed tomography scanning into stereotactic space. Surg Neurol 21:465471, 1984. 67. Kriss TC, Kriss VM: History of the operating microscope: From magnifying glass to microneurosurgery. Neurosurgery 42:899908, 1998. 68. Laws ER Jr, Udvarhelyi GB: The Genesis of Neuroscience by A. Earl Walker, M.D. Park Ridge, AANS, 1998. 69. Le Dran HF: Observations de Chirurgie. Paris, C. Osmont, 1731, vols 1 and 2. 70. LeMay DR, Chen TC, Petrovich Z, Luxton G, Zelman V, Zee CS, Green J, Apuzzo MLJ: Gamma unit facility: Concept genesis, architectural design, and practical realization. Stereotact Funct Neurosurg 66:4149, 1996. 71. Leonardo RA: History of Surgery. New York, Froben Press, 1943. 72. Lisowski FP: Prehistoric and early historic trepanation, in Brothwell D, Sandison AT (eds): Diseases in Antiquity. Springfield, Charles C Thomas, 1967, pp 651672. 73. Lister J: Illustrations of the antiseptic system of treatment in surgery. Lancet 2:668669, 1867. 74. Lister J: On the antiseptic principle in the practice of surgery. Lancet 2:353356, 1867.
NEUROSURGERY
LIU
AND
APUZZO
75. Liu CY, Spicer M, Apuzzo MLJ: The genesis of neurosurgery and the evolution of the neurosurgical operative environment: Part IIConcepts for future development, 2003 and beyond. Neurosurgery 52:2035, 2003. 76. Lyon AE: The crucible years 1880 to 1900: Macewen to Cushing, in Greenblatt SH (ed): A History of Neurosurgery in Its Scientific and Professional Contexts. Park Ridge, AANS, 1997, pp 153166. 77. Macewen W: Clinical observations on the introduction of tracheal tubes by mouth instead of performing tracheostomy or laryngotomy. Br Med J 2:122124, 1880. 78. Macewen W: Pyogenic Infective Diseases of the Brain and Spinal Cord: Meningitis, Abscess of Brain, Infective Sinus Thrombosis. Glasgow, James Maclehose & Sons, 1893. 79. Magendie F: Prcis Elmentaire de Physiologie. Paris, Mquignon-Marvis, 1836. 80. Magetts EL: Trepanation of the skull by the medicine-men of primitive cultures, with particular reference to present-day native East African practice, in Brothwell D, Sandison AT (eds): Diseases in Antiquity. Springfield, Charles C Thomas, 1967, pp 673701. 81. Marino R Jr, Gonzales-Portillo M: Preconquest Peruvian neurosurgeons: A study of Inca and pre-Columbian trephination and the art of medicine in ancient Peru. Neurosurgery 47:940950, 2000. 82. Monaz E: Lencphalographie artrielle, son importance dans la localization des tumeurs crbrales. Rev Neurol 2:7289, 1927. Reprinted in Wilkins RH (ed): Neurosurgical Classics. Park Ridge, AANS, 1992, pp 265 276. 83. Morgeli C: The Surgeons Stage: A History of the Operating Room. Basel, F. Hoffmann-La Roche, 1999. 84. Moshe H, Spiegelman R, Feldman Z, Berkenstadt H, Ram Z: Novel, compact, intraoperative magnetic resonance image-guided system for conventional neurosurgical operating rooms. Neurosurgery 48:799809, 2001. 85. Olivecrona H, Ladenheim J: Congenital Arteriovenous Aneurysms of the Carotid and Vertebral Arterial Systems. Berlin, Springer-Verlag, 1957. 86. Patrick CW Jr, Mikos AG, McIntire LV (eds): Frontiers in Tissue Engineering. New York, Elsevier Science, 1998. 87. Penfield W, Boldrey E: Somatic motor and sensory representation in the cerebral cortex of man as studied by electrical stimulation. Brain 60:389 443, 1937. 88. Penfield W, Jasper H: Epilepsy and the Functional Anatomy of the Human Brain. Boston, Little Brown & Co., 1954. 89. Petit JL: Principe de Chirurgie. Paris, 1730. 90. Preul MC: A history of neuroscience from Galen to Gall, in Greenblatt SH (ed): A History of Neurosurgery in Its Scientific and Professional Contexts. Park Ridge, AANS, 1997, pp 99130. 91. Prioreschi P: Possible reasons for Neolithic skull trephining. Perspect Biol Med 34:296303, 1991. 92. Randers-Pehrson J: The Surgeons Glove. Springfield, Charles C Thomas, 1960. 93. Rifkinson-Mann S: Cranial surgery in ancient Peru. Neurosurgery 23:411 416, 1988. 94. Roger of Salerno: Practica chirugiae. de Vitalibus BV (trans), in Guy de Chauliac (ed): Cyrurgia. . .et cyrugia bruni. Teodorici. Rolandi. Lanfranci. Rogerii. Bertapalie. Noviter impressus. Venetiis, Per Bernardinum Venetum de Vitalibus, 1591. 95. Rutka JT, Taylor M, Mainprize T, Langlois A, Ivanchuk S, Mondal S, Dirks P: Molecular biology and neurosurgery in the third millennium. Neurosurgery 46:10341051, 2000. 96. Saul FP, Saul JM: Trepanation: Old world and new world, in Greenblatt SH (ed): A History of Neurosurgery in Its Scientific and Professional Contexts. Park Ridge, AANS, 1997, pp 2935. 97. Sharp W: Practical Observations on Injuries of the Head. London, Churchill, 1841. 98. Sherrington CS: The Integrative Action of the Nervous System. New Haven, Yale University Press, 1906. 99. Spiegel EA, Wycis HT, Marks M, Lee AJ: Stereotaxic apparatus for operation on the human brain. Science 106:349350, 1947. 100. Stone JL, Miles ML: Skull trepanation among the early Indians of Canada and the United States. Neurosurgery 26:10151020, 1990.
101. Stromberg BV: The operating room: A historical perspective. J S C Med Assoc 81:3133, 1985. 102. Taylor RH: Robotics in orthopaedic surgery, in Nolte LP, Ganz R (eds): Computer Assisted Orthopedic Surgery (CAOS). Seattle, Hogrefe and Huber, 1999, pp 3541. 103. Taylor RH, Funda J, Eldridge K, Gruben D, LaRose D, Gomory S, Talamini M: A telerobotic assistant for laparoscopic surgery, in Taylor RH, Lavallee S, Burdea G, Mosges R (eds): Computer-Integrated Surgery. Cambridge, MIT Press, 1996, pp 581592. 104. Taylor R, Jensen P, Whitcomb L, Barnes A, Kumar R, Stoinovici D, Gupta P, Wang Z, de Juan E, Kavoussi L: A steady-hand robotic system for microsurgical augmentation, in Taylor C, Colchester A (eds): Medical Image Computing and Computer-Assisted Intervention: MICCAI 99Second International Conference, Cambridge, UK, September 1922, 1999. London, Springer, 1999. 105. Taylor RH, Lavallee S, Burdea G, Mosges R (eds): Computer-Integrated Surgery. Cambridge, MIT Press, 1996. 106. Taylor RH, Paul HA, Kazandzides P, Mittelstadt BD, Hanson W, Zuhars JF, Williamson B, Musits BL, Glassman E, Bargar WL: An image-directed robotic system for precise orthopedic surgery. IEEE Trans Rob Autom 10:261275, 1994. 107. Tracy PT, Hanigan WC: History of neuroanesthesia, in Greenblatt SH (ed): A History of Neurosurgery in Its Scientific and Professional Contexts. Park Ridge, AANS, 1997, pp 213221. 108. Valenstein ES: History of psychosurgery, in Greenblatt SH (ed): A History of Neurosurgery in Its Scientific and Professional Contexts. Park Ridge, AANS, 1997, pp 499516. 109. Velasca-Suarez M, Martinez JB, Oliveros RG, Weinstein PR: Archeological origins of cranial surgery: Trephinations in Mexico. Neurosurgery 31:313 319, 1992. 110. Vesalius A: De humani corporis fabrica libri septem. Basel, Johannes Oporinus, 1543. 111. Viuela F, Murayama Y, Duckwiler GM, Gobin YP, Jahan R: Unreachable peaks of the neurointerventional mountaineers. Neurosurgery 48: 698699, 2001. 112. von Bergmann E: Die chirurgische Behandlung von Hirnkrankheiten: Zweitte, vermehrte und umgearbeitete Auflage. Berlin, A. Hirshwald, 1851. 113. Walker AE: Primitive trepanations: The beginning of medical history. Trans Stud Coll Physicians Phila 26:99102, 1958. 114. Wangensteen OW, Wangensteen SD: The surgical amphitheater, history of its origins, functions, and fate. Surgery 77:404418, 1975. 115. Wilkins RH: Treatment of craniocerebral infection and other common neurosurgical operations at the time of Lister and Macewen, in Greenblatt SH (ed): A History of Neurosurgery in Its Scientific and Professional Contexts. Park Ridge, AANS, 1997, pp 8396. 116. Wilkinson RG: Trephination by drilling in ancient Mexico. Bull N Y Acad Med 51:838850, 1975. 117. Willis T: Cerebri Anatome. Londini, Typis Ja. Flesher, impensis Jo. Martyn & Ja. Allestry, 1664. 118. Wong KC, Wu LT: History of Chinese Medicine: Being a Chronicle of Medical Happenings in China from Ancient to Present Period. Shanghai, National Quarantine Service, 1936, ed 2. 119. Yas argil MG: Microsurgery Applied to Neurosurgery. Stuttgart, Georg Thieme, 1969. 120. Yas argil MG: A legacy of microneurosurgery: Memoirs, lessons, and axioms. Neurosurgery 45:10251091, 1999. 121. Zimmerman LM, Veith I: Great Ideas in the History of Surgery. Baltimore, Williams & Wilkins, 1961. 122. Zlokovic BV, Apuzzo MLJ: Cellular and molecular neurosurgery: Pathways from concept to realityPart I: Target disorders and concept approaches to gene therapy of the central nervous system. Neurosurgery 40:789804, 1997. 123. Zlokovic BV, Apuzzo MLJ: Cellular and molecular neurosurgery: Pathways from concept to realityPart II: Vector systems and delivery methodologies for gene therapy of the central nervous system. Neurosurgery 40:805813, 1997.
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Acknowledgment
The authors have no financial interest in the methodology advanced by this study.
COMMENTS
s neurosurgeons, we walk into our arena of work each day: the operating room. That this room has changed over the years is clearly outlined and detailed in this article. The early neurosurgeon drilled holes into the head under a coconut tree with no anesthesia or antisepsis and carefully avoided entering the space below the dura. Some 3000 to 4000 years later, the knowledge of anatomy has been refined, physiology is better understood, and the patient can be cleansed and sedated. We can enter virtually any region of the brain. The authors clearly detail how this revolution occurred. An enormous amount of surgical history is covered here, and a modern reader is amazed to see how recently most of these changes have occurred. I trained at the end of the pneumoencephalography era, have practiced during the computed tomography and magnetic resonance imaging eras, and now enter an operating room where sophisticated computers reconstruct images to lead us where we need to proceed. How amazing it is to look at the illustrations of operating rooms in this article and read the details and then realize that the operating room, as we now define it, is less than 150 years of agethe first burr hole was made some 4000 years earlier! How grateful I am that, if I should ever need brain surgery, I will be taken into a sterile room and gently placed in a deep, painless sleep, images will show the exact location of my lesion, and, very likely, a computer-directed instrument will lead my surgeons to the exact point at which they need to be. How fortunate we are today to have these technical advances! Their development has been beautifully elucidated by the authors of this article. James T. Goodrich Bronx, New York he authors have created a succinct and yet very detailed review of the development of the concepts of surgery leading to a modern understanding of the operating room and the goals of a surgical procedure. The authors focus is on neurosurgery, but most of what they have written is equally applicable to the broad concept of surgery in general. It is always worthwhile to know where we have been so we can have a better understanding of where we need to go. Too often, changes are made in the operating room simply as a reflection of the technology of the moment without examining the reasons for altering current practices or considering what the proposed additions will accomplish in the long term. Much of the impact of technology has had little impact on the architectural and functional designs of operating room areas. Typically, operating rooms are large boxes; those built in the 1990s could just as easily have been built in the 1890s. The boxes just became bigger to accommodate the increasing number of large pieces of technology that were introduced into the operating room without any attempt at systems integration. Most
pieces of equipment were created to look impressive, not to conserve and maximize the use of space, and most were designed without any consideration of their interaction with other technologies in the operating room environment. The result has been cluttercables, wires, and tubes on the floor or suspended in the airthat generally obstructs the smooth flow of traffic and the movement of equipment (and sometimes even that of the surgeons) in the operating room area. It is time for a fundamental redesign of the operating theater concept to include diagnostic imaging, image-guided intervention, modular design, the emerging field of robotics, perioperative imaging for verification of the surgical outcomes and delineation of complications, and systems integration that allows efficient utilization of equipment. These concepts are likely to decrease the necessity for patient transport, with all its associated dangers. The size of operating rooms will probably decrease. The creation of remote stations for many activities, such as anesthesia, monitoring, and robotics, will become possible, and developing multiple uses for imaging equipment that is required only sporadically in the operating room will probably increase efficiency. All of these maneuvers have the potential to reduce construction costs and allow adjacencies that greatly increase the efficiency of treatment. The concepts of the space programwith its proven systems integration techniques in which the errors have been engineered out of the systemare important for us to emulate in the operating room. Appropriate documentation can have a major impact on malpractice. We can learn from problems to develop improvements in technique and technical support. Efficiency reduces cost. When we have the temerity to operate on the brain and spinal cord, we should do so with the greatest possible skill and with the best possible technical support. To do less would diminish our capacity as physicians. It is time for our operating environment to be developed in a way that engenders continuous improvements in the quality of support and patient services. In the future, operating room redesign should not be necessary but should follow improvements in technology in an evolutionary way in every neurosurgery operating room. Donlin M. Long Baltimore, Maryland s the title implies, this is an article of ambitious scope. The authoritative contribution it makes to the literature is contained in its final sections. After a rather rambling journey through history, Drs. Liu and Apuzzo review the current state of the art, what they have described as the progressive minimalism of manipulation. Their personal experience in helping to design an ideal neurosurgical operating suite and the recommendations that follow are particularly insightful, as is the discussion of recent and emerging developments in robotics, imaging, and other tools of modernity. Norman H. Horwitz Washington, District of Columbia
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Michael L.J. Apuzzo, M.D.

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THE PRIMORDIUM: CRANIAL SURGERY AND THE OPERATIVE ENVIRONMENT IN PREHISTORY

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NEUROSURGICAL OPERATIVE ENVIRONMENT

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NEUROSURGICAL OPERATIVE ENVIRONMENT

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ANTISEPSIS TO ASEPSIS: SAFE PASSAGE PAST THE BARRIER OF THE DURA

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ASSEMBLING THE ELEMENTS OF A FUNCTIONAL AMALGAM: EMERGENCE OF THE OPERATING ROOM

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MAGNIFICATION AND THE TREND TOWARD MINIMALISM: THE OPERATING MICROSCOPE

PRELUDE TO MODERNITY: THE PAST GENERATION

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AN IDEAL VENUE: 1990

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THE PAST DECADE

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NEUROSURGICAL OPERATIVE ENVIRONMENT

STATE OF THE ART: 2003

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