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Neurosurgery is a superspecialty whose research and development is
based on the same underlying principles as those of general medical
practice on the one hand and basic sciences on the other. Indeed, some of
the work of recent Nobel laureates has greatly impacted on neurosurgery,
most notably that of Hounsfield and McCormack on the development of
computed tomography (CT). Current work in neurobiology, some of it
described in your Snapshots from the decade of the brain (1), will
certainly affect neurosurgical practice. The framework of the scientific
method lies at the foundation of the recent advances in the practice of
neurosurgery outlined by colleague Michael Powell (2).
I will attempt to bridge the science and practice of my specialty
from the point of view of innovations-- what is happening and how it is a
model for all clinicians wishing to develop their clinical practice.
Neurosurgical centres are above all clinical care providers and so
traditionally they have been organised, manned and funded to perform, not
to innovate or to develop scientifically. Technical assistance at even
academic clinics often meant maintenance more than scientific innovation.
At our own university, for example, scientific research in neurosurgery
has been reliant on external sources, such as the national research
council, various kinds of technology funding agencies and industry. Thus,
much of the clinical R&D is project based, not at all like the mass of
serious scientific inquiry in the more basic sciences. Yet one of the
most exciting results of the decade of the brain has been the awareness
that neurosurgery -- including the actual surgical part -- is not only a
clinical practice but also a scientific discipline in its own right. The
surgical neuroscientist, according to Spencer (3), works not only with
molecular biologists in disease-oriented research and with statisticians
in clinical trials, but also with engineers and biophysicists -- and
neurobiologists, I might add -- in the research and development of the
very tools and methods of operative neurosurgery. The goal of all of this
activity is to offer the finest service to our patients and referring
colleagues. Indeed, the integrated development of neurosurgery itself
must be the job of the practising clinician working together with a core
multidisciplinary team of scientists in the clinic.
The neurosurgeon stands at crossroads with myriad recent advances in
the neurosciences. His mind is confronted with increasingly complex
information and knowledge and his hands with a vast array of technology.
Here, I consider technology to be something quite fundamental, namely an
extension of human senses and of motor functions. At the bedside, the
neurosurgeon can tell his patient about many of the modern advances of
molecular biology and epidemiology. He must then proceed to describe in a
very basic Hippocratic way what he is able do for his patient in the
operating room -- today, not later. Fortunately, the limitations of doing
can be continually improved in the exciting atmosphere of developing,
applying and assessing.
This has led the present author to stress the doubly mind-oriented
innovative aspect of neurosurgical research and development, indeed the
mind operating on not only brain but also mind. Let us first consider the
mind as the object of surgery, the patient. Neurobiology teaches us that
there are really no "noneloquent regions" in the brain. The first
corollary is that surgical technique must be minimally invasive. To be
mini-invasive is to be image directed. To be mini-invasive is to have
adequate information to plan surgery and appropriate tools to perform the
operation -- thus the current stress on neuronavigation and on
intraoperative methods of control, such as electrophysiological and
imaging techniques. This is what makes intraoperative MRI such an
intuitive partner of ultrasound imaging. By simply examining the
electromagnetic spectrum one can see that no other pheonomena are
available at present for intraoperative imaging of brain.
Let us now consider the mind of the subject, of the clinician. In
the mind-oriented research setting, the hypothesis generator -- its
properties and potential -- is at the center of attention: to use the
terminology of Gregory (4), a brain operation is based on conceptual and
perceptual knowledge in the neurosurgeon´s mind, the "hypothesis
generator", resulting in step-by-step "output behaviour" that results each
time in a change in the surgical field, providing updated perceptual input
in feedback fashion. This results in a cycle of action: sensory input -
deliberation - motor output, and back again. Here is the essence of the
meaning of our varied technology and the reason why the next decade will
surely be exciting. Thus in a mind-oriented approach the sources of
perceptual knowledge and the mediators of output behaviour are integrated
in a user-friendly manner in the context of an innovative clinic (5).
This is the key to developing the technology of neurosurgery -- and really
any clinical technology. In neurosurgery, the decade of the brain will
certainly lead to one of the mind -- the mind operating on a mind.
John Koivukangas, M.D., Ph.D.
Professor of Neurosurgery,
Chairman, Finnish Neurosurgical Society
1 Martyn C. Snapshots from the decade of the brain. Editorial. BMJ
1998; 317: 1673.
3 Spencer DD. Neurological surgery and biologic science. In:
Philosophy of Neurological Surgery. Park Ridge: American Association of
Neurological Surgeons, 1995: 105-15.
4 Gregory R. Snapshots from the decade of the brain: Brainy Mind. BMJ
1998;317: 1693-5
5 Koivukangas J. The Oulu neuronavigator system – and beyond. In:
Technology transfer between research institutes and industry. Oulu:
Biomedical Engineering Program, 1996 (internet address: http://cc.oulu.fi/~emk/koivuk.htm)
Decade of the brain and neurosurgery
Neurosurgery is a superspecialty whose research and development is
based on the same underlying principles as those of general medical
practice on the one hand and basic sciences on the other. Indeed, some of
the work of recent Nobel laureates has greatly impacted on neurosurgery,
most notably that of Hounsfield and McCormack on the development of
computed tomography (CT). Current work in neurobiology, some of it
described in your Snapshots from the decade of the brain (1), will
certainly affect neurosurgical practice. The framework of the scientific
method lies at the foundation of the recent advances in the practice of
neurosurgery outlined by colleague Michael Powell (2).
I will attempt to bridge the science and practice of my specialty
from the point of view of innovations-- what is happening and how it is a
model for all clinicians wishing to develop their clinical practice.
Neurosurgical centres are above all clinical care providers and so
traditionally they have been organised, manned and funded to perform, not
to innovate or to develop scientifically. Technical assistance at even
academic clinics often meant maintenance more than scientific innovation.
At our own university, for example, scientific research in neurosurgery
has been reliant on external sources, such as the national research
council, various kinds of technology funding agencies and industry. Thus,
much of the clinical R&D is project based, not at all like the mass of
serious scientific inquiry in the more basic sciences. Yet one of the
most exciting results of the decade of the brain has been the awareness
that neurosurgery -- including the actual surgical part -- is not only a
clinical practice but also a scientific discipline in its own right. The
surgical neuroscientist, according to Spencer (3), works not only with
molecular biologists in disease-oriented research and with statisticians
in clinical trials, but also with engineers and biophysicists -- and
neurobiologists, I might add -- in the research and development of the
very tools and methods of operative neurosurgery. The goal of all of this
activity is to offer the finest service to our patients and referring
colleagues. Indeed, the integrated development of neurosurgery itself
must be the job of the practising clinician working together with a core
multidisciplinary team of scientists in the clinic.
The neurosurgeon stands at crossroads with myriad recent advances in
the neurosciences. His mind is confronted with increasingly complex
information and knowledge and his hands with a vast array of technology.
Here, I consider technology to be something quite fundamental, namely an
extension of human senses and of motor functions. At the bedside, the
neurosurgeon can tell his patient about many of the modern advances of
molecular biology and epidemiology. He must then proceed to describe in a
very basic Hippocratic way what he is able do for his patient in the
operating room -- today, not later. Fortunately, the limitations of doing
can be continually improved in the exciting atmosphere of developing,
applying and assessing.
This has led the present author to stress the doubly mind-oriented
innovative aspect of neurosurgical research and development, indeed the
mind operating on not only brain but also mind. Let us first consider the
mind as the object of surgery, the patient. Neurobiology teaches us that
there are really no "noneloquent regions" in the brain. The first
corollary is that surgical technique must be minimally invasive. To be
mini-invasive is to be image directed. To be mini-invasive is to have
adequate information to plan surgery and appropriate tools to perform the
operation -- thus the current stress on neuronavigation and on
intraoperative methods of control, such as electrophysiological and
imaging techniques. This is what makes intraoperative MRI such an
intuitive partner of ultrasound imaging. By simply examining the
electromagnetic spectrum one can see that no other pheonomena are
available at present for intraoperative imaging of brain.
Let us now consider the mind of the subject, of the clinician. In
the mind-oriented research setting, the hypothesis generator -- its
properties and potential -- is at the center of attention: to use the
terminology of Gregory (4), a brain operation is based on conceptual and
perceptual knowledge in the neurosurgeon´s mind, the "hypothesis
generator", resulting in step-by-step "output behaviour" that results each
time in a change in the surgical field, providing updated perceptual input
in feedback fashion. This results in a cycle of action: sensory input -
deliberation - motor output, and back again. Here is the essence of the
meaning of our varied technology and the reason why the next decade will
surely be exciting. Thus in a mind-oriented approach the sources of
perceptual knowledge and the mediators of output behaviour are integrated
in a user-friendly manner in the context of an innovative clinic (5).
This is the key to developing the technology of neurosurgery -- and really
any clinical technology. In neurosurgery, the decade of the brain will
certainly lead to one of the mind -- the mind operating on a mind.
John Koivukangas, M.D., Ph.D.
Professor of Neurosurgery,
Chairman, Finnish Neurosurgical Society
1 Martyn C. Snapshots from the decade of the brain. Editorial. BMJ
1998; 317: 1673.
2 Powell M. Clinical review: Recent advances: Neurosurgery. BMJ 1999;
318: 35-8.
3 Spencer DD. Neurological surgery and biologic science. In:
Philosophy of Neurological Surgery. Park Ridge: American Association of
Neurological Surgeons, 1995: 105-15.
4 Gregory R. Snapshots from the decade of the brain: Brainy Mind. BMJ
1998;317: 1693-5
5 Koivukangas J. The Oulu neuronavigator system – and beyond. In:
Technology transfer between research institutes and industry. Oulu:
Biomedical Engineering Program, 1996 (internet address:
http://cc.oulu.fi/~emk/koivuk.htm)
Competing interests: No competing interests