Functional and Stereotactic Neurosurgery

709 Pages·1989·48.88 MB·English

by  Edward I. Kandel (auth.)

Functional and
Stereotactic
Neurosurgery
Stereotactic neurosurgery requires accuracy, a steady hand,
and sound judgment.
Functional and
Stereotactic
Neurosurgery
Edward I. Kandel
Professor, Doctor of Medical Sciences
Director, Neurosurgical Clinic
Institute of Neurology
Academy of Medical Sciences of the USSR
Moscow, USSR
Translated from Russian by
George Watts
Translation edited by
A. Earl Walker
Professor Emeritus of Neurosurgery
The Johns Hopkins University School of Medicine
Baltimore, Maryland
Adjunct Professor, Neurosurgery/Surgery
University of New Mexico School of Medicine
Albuquerque, New Mexico
Plenum Medical Book Company
New York and London
Library of Congress Cataloging in Publication Data
Kandel, E. I. (Eduard Izrailevich)
[Funktsional'naia i stereotaksicheskaia neirokhirurgiia. English)
Functional and stereotactic neurosurgery I Edward I. Kandel; translated from Rus
sian by George Watts; translation edited by A. Earl Walker.
p. cm.
Translation of rev. and updated ed. of: Funktsional'nafa stereotaksicheskafa
neiro khirurgifa. 1981.
Includes bibliographies and index.
1. Nervous system-Surgery. 2. Stereoencephalotomy. I. Walker, A. Earl (Arthur
Earl), 1907- . II, Title.
[DNLM: 1. Nervous System-surgery. WL 368 K16f]
RD593.K2613 1989
617'.48
DNLM/DLC 88-39617
for Library of Congress CIP
ISBN-l3: 978-1-4612-8040-8 e-ISBN-13: 978-1-4613-0703-7
DOl: 10.1007/978-1-4613-0703-7
Softcover reprint of the hardcover 18t edition 1989
This translation is published under an agreement with the
Copyright Agency of the USSR (V AAP).
This volume is based on Funktsional'naya i stereotaksicheskaya
neirokhirurgiya by E. I. Kandel, published in 1981 by
Meditsina, Moscow. The original Russian work has been completely
revised and updated by the author for this edition.
© 1989 Plenum Publishing Corporation
233 Spring Street, New York, N.Y. 10013
Plenum Medical Book Company is an imprint of Plenum Publishing Corporation
All rights reserved
No part of this book may be reproduced, stored in a retrieval system, or transmitted
in any form or by any means, electronic, mechanical, photocopying, microfilming,
recording, or otherwise, without written permission from the Publisher
In memory of my parents
To my wife, Helen
Foreword
Soon after neurosurgery had advanced past the stage of that older neurosurgeons will consider their cra
removing lesions on the surface of the brain, it became niotomies quite adequate for the relief of many neu
apparent that subcortical diseased tissue could not be rological disorders that Professor Kandel shows so
excised safely by the usual surgical techniques because clearly to be amenable to stereotactic intervention,
of the risk of damaging overlying normal structures. there are many lesions that undoubtedly can be reached
Various means of reaching deep-seated lesions were more easily and with less risk to life and limb by ster
devised, most of which attempted to approach the eotactic than by open procedures.
pathological tissue through "silent areas" of the brain. This book is not just a description of operative
However, these operations often resulted in serious procedures, although it does give clear accounts of
neurological deficits. Spiegel and Wycis's modifica surgical techniques. It presents the postoperative histo
tion of the Horsley-Clarke apparatus to reach targets ries of patients who have been cured or markedly re
deep in the human brain introduced a new approach to lieved of longstanding afflictions; these persons have
subcortical surgery. True, as Professor Edward Kandel been followed for 10 to 15 or more years, so that the
relates, Russian surgeons had pioneered in the field, results may be considered more or less permanent.
but it was the persistent endeavors of Spiegel and Thus, Professor Kandel has presented a chronicle of
Wycis that popularized the technique in the various the benefits or, alas, in some cases, failures that may
countries of the world. In the 1950s and 1960s, ster be expected as the result of modem refined stereotactic
eotactic surgery began to be used by many neu surgery for the relief of afflictions, particularly of the
rosurgeons for the treatment of movement disorders, deep-seated nuclei of the brain.
uncontrollable aggression, inaccessible or difficult to Certainly he has broadened the scope of stereotac
reach tumors, and vascular lesions. The subject was tic surgery and has improved the traditional techniques
sufficiently popular that a journal was founded to pub for operations on the basal ganglia and thalami. Util
lish the advances. izing stereotactic principles and his new methods for
It was at this time that Professor Kandel began his eradicating deep-seated tumors, aneurysms, and an
work with stereotactic neurosurgery. He realized that giomas with a permissible mortality, he has given
the stereotactic instrumentation then in use was either long-term benefit to patients formerly considered to be
too complicated or too simple to adjust to brains of suffering from inoperable conditions. Such novel tech
various sizes and shapes. To correct these discrepan niques have promise of further application in neurolog
cies, he devised a stereotactic instrument based on ical practice.
novel principles. With this new technique he has treat All who have to deal with patients suffering from
ed many conditions with exceptionally good results. diseases of the nervous system will find the insight that
In this book Professor Kandel gives a detailed this book gives into the treatment of some neurological
account of his experiences with stereotactic operations diseases by stereotactic surgery a very enlightening
and reviews the work of brain surgeons in different experience.
countries of the world. He has produced a unique re
cord of the advances made by neurosurgeons of inter
A. Earl Walker, M.D.
national stature. Although stereotactic surgery may not
Division of Neurosurgery
replace open operative procedures, Professor Kandel
University of New Mexico
has shown that it has an important place in the neu
School of Medicine
rosurgical armamentarium for the treatment of many Albuquerque, New Mexico
conditions previously considered inoperable. Granted
vii
Preface
Albert Einstein once said that the most amazing thing currents flowing from various branches of science. The
about this world is that it is comprehensible. It is no less merging of this trend became possible through the inte
amazing that we comprehend the human brain, which gration of the achi vements of present-day engineering
not only perceives this world but also remakes it. (stereotactic apparatuses, x-ray machines, computed
It is necessary to understand the structures and tomography, nuclear magnetic resonance equipment,
functions of the brain in order to treat its disorders. The and instruments for various methods of destruction),
modem methods of diagnosis and treatment represent a neurophysiology (stereotactic method and the study of
most powerful and effective stimulus for the develop the functions of subcortical structures), neuromorphol
ment of medicine in general and neurosurgery in par ogy (stereotactic atlases, the study of interrelation
ticular. Over the course of several decades, hardly any ships, spatial localization, and variability of subcortical
one expected that the experimental stereotactic method structures), neurology (the study of the etiology, patho
would become an effective instrument in the hands of genesis, and clinical aspects of hyperkinesias, pain
surgeons in their fight against many grave diseases of syndromes, epilepsy, vascular lesions of the brain, and
the brain. Approximately a half century was needed for other disorders), and neurosurgery (the development of
stereotaxis to emerge from the neurophysiological lab techniques and methods of surgical operations on deep
oratory and embark on a fruitful path in the neu seated cerebral structures).
rosurgical clinic. The indisputable credit for introduc Tens of thousands of stereotactic operations have
ing this method in modem neurosurgery belongs to two been performed in many countries of the world during
American scientists, neurologist Spiegel and neu these 35 years. This trend proved to be a principally
rosurgeon Wycis, who in the 1950s designed a ster new and highly effective method in the management of
eotactic apparatus for operating on the human brain many neurological diseases for which there is either no
and were the first to perform stereotactic operations on conservative treatment or the current treatment is of
subcortical structures in man. little effect. By its success, stereotactic surgery cannot
More than 35 years have gone by since the first be compared to any of the previously employed meth
stereotactic operation on deep-seated cerebral struc ods. The list of diseases in which stereotactic opera
tures was performed. Just like angiography, radioac tions are very effective today includes more than 30
tive isotopes, or microsurgery, the stereotactic method nosological forms, which is reflected in contents of this
instantly raised neurosurgery to a qualitatively new book. The' 'sphere of action" of the stereotactic meth
level of development. od is continuing to expand steadily and gradually to
This new method, which initially, as so often is embrace more and more nosological forms. One can
the case, was met with a certain distrust, has since then not but note that the "objective" of stereotaxis in
not only confirmed its right to existence but has be cludes such pathological processes so different and
come a generally acknowledged breakthrough in mod seemingly far from each other as parkinsonism and
em neurosurgery. This method brought neurosurgery pain, cerebral palsy and cerebral aneurysms, and brain
substantially closer to its coveted goal-the most ef tumors and temporal lobe epilepsy.
fective operation with the least damage to the brain. To The stereotactic method in neurosurgery is rapidly
a great extent, stereotaxis meets the main requirements and steadfastly advancing. Stereotactic operations on
for neurosurgical operations as formulated by N. N. the cerebellum and the spinal cord have appeared quite
Burdenko-"anatomically accessible, technically fea recently and are being successfully performed. New
sible, and physiologically permissible." and improved stereotactic apparatuses are being tested.
The stereotactic trend in neurosurgery was the re Cryosurgery-a turbulently developing "offspring"
sult of a synthesis of several scientific and research of stereotaxis-is being employed more extensively in
ix
x PREFACE
many branches of clinical medicine. Stereotactic biop their etiology and pathogenesis. Many operations are
sy of tumors and other deep-seated pathological pro performed under local anesthesia, making it possible to
cesses in the brain is coming in for broader application. observe various effects of stimulation and destruction
Microelectrode equipment, electronic amplifiers, com of discrete structures of the CNS as well as to obtain a
puters, and, first and foremost, computed tomography, verbal account from the patient about his sensations.
positron emission tomography, and nuclear magnetic Therefore, according to the "feedback" principle,
resonance have become important elements of the ster these operations contribute greatly to the study of the
eotactic technique. pathogenesis of many neurological diseases, and this in
The International Society for Research in Ste turn offers greater possibilities and enhances the effi
reoencephalotomy was founded in 1961, and in 1975 it cacy of new surgical techniques.
became the World Society for Stereotactic and Func During the past two decades, one other term
tional Neurosurgery. Altogether, the Society held nine "functional neurosurgery" -has acquired, as it were,
World Congresses, the last in Toronto in'1985. "citizenship rights." As far back as almost a century
ago, John Hughlings Jackson emphasized that the term
"functional" was synonymous with "physiological."
Consequently, "functional neurosurgery" is a method
in the management of physiological disorders caused
by various pathological processes. The term "func
tional surgery" was first proposed by Rene Leriche in
reference to operations on the sympathetic nervous sys
tem in pain and vascular disorders. Subsequently,
Wertheimer introduced the term "functional neu
rosurgery. " Today, this generally acknowledged term
is used for designating a trend that, over the course of
several decades, had been gradually developing within
the framework of general neurosurgery but only in re
The emblem of the World Society for Stereotactic and Functional
Neurosurgery cent years has evolved as a separate branch from that
specialty. Functional neurosurgery may be defined as
It should be stressed that all the great therapeutic an aggregate of methods for surgical action on roots,
achievements of the stereotactic method have not ex pathways, and neuronal structures of the CNS based on
hausted its significance and unique possibilities. This the anatomophysiological properties of pathological
method also plays an exceptionally important part in processes in the CNS and having as its purpose to
the advancement of human neurophysiology. The de change these processes to obtain a therapeutic effect.
velopment of stereotactic neurosurgery has primarily At this moment, it is still too early to speak about
opened up new prospects for neurophysiology. One of the total merging of the two trends-stereotactic and
the most important tasks of functional and stereotactic functional neurosurgery; this, in all likelihood, is a
neurosurgery is to study the structures and functions of matter for the future. Nevertheless, it is quite apparent
the human CNS. Undoubtedly, this task cannot be re that the concept "functional neurosurgery" is much
solved only by extrapolating the data obtained in neu broader, for it includes, as is shown in this book, a
rophysiological experiments on animals. The stereotac great number of surgical methods not directly related to
tic method, which has dovetailed with many electro stereotaxis. At the same time, there can be no doubt
physiological methods, has today become one of the that stereotactic neurosurgery represents the main com
main and most fruitful ways of understanding the func ponent of the concept of functional neurosurgery.
tions of the human brain. This method has yielded A tremendous number of publications has accu
much new information about the functional organiza mulated in literature over the past quarter of a century.
tion of subcortical structures, the interaction and func That is why the main goal of this book is to systematize
tions of which have been studied far too insufficiently. and critically analyze this huge wealth of world liter
The clinical application of stereotactic and func ature and to review the current state of the art, i.e., to
tional operations has made it possible to obtain a present the state of knowledge and development in the
wealth of new and very useful data on the pathophysio field of stereotactic and functional neurosurgery. The
logical mechanisms of many cerebral disorders and on second objective of this book is to summarize the 30
PREFACE xi
years of experience of the author and his associates in of these chapters, the main emphasis is placed on ques
the area of functional and stereotactic neurosurgery. tions of surgical treatment-indications for functional
Besides covering the experience gained from per operations, their methods and techniques, and long
forming more than 2000 operations, the book sums up term results.
the results of the scientific and research work of the The monograph is addressed, first of all, to neu
author in collaboration with representatives of many rosurgeons and neuropathologists; however, it may
theoretical and clinical SUbjects. prove interesting to representatives of other profes
This volume consists of two parts. The first part sions-neurophysiologists, electrophysiologists, x-ray
(Chapters 1-5) offers contemporary data on the ster specialists, psychiatrists, endocrinologists, and neuro
eotactic anatomy of the central nervous system, on the oncologists.
neurophysiological mechanisms of the main patholog The author expresses cordial appreciation to his
ical phenomena and processes, on the fundamentals of associates and many representatives of other medical
the stereotactic technique, on the main stages of ster and technical branches with whom joint work was done
eotactic operations, on the methods of destruction of over the course of many years and thanks to whom the
deep cerebral structures, and so on. appearance of this book became possible.
The second part (Chapters 6-20) presents descrip The author also expresses his profound apprecia
tions of various diseases of the brain and spinal cord in tion to the esteemed Professor A. Earl Walker for his
which functional and stereotactic operations are indi vital and valuable advice in the preparation of this book
cated and have been shown to be effective. On each of for print.
these nosological forms, there is brief but, in the main,
updated information on their pathogenesis, patholog- E. Kandel
ical anatomy, clinical aspects, and diagnosis. In each Moscow. USSR
Contents
Foreword .......................................................... Vll
Preface.. . . . .... . . . . ... . ... . .. . . ... . . ... . .. . . .. . . ... . . ... . . . . . . . . . . lX
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. xxv
1 Anatomy of Subcortical Structures Related to Stereotaxy ....... . 1
1. Extrapyramidal System ............................................ . 1
1.1. Thalamus ................................................... . 4
1.1. 1. Ventrolateral Nucleus ................................... . 8
1.1.2. Posterior Ventrolateral and Ventromedial Nuclei .............. . 9
1.1.3. Centrum Medianum ..................................... . 10
1.1.4. Pulvinar .............................................. . 10
1. 2. Capsula Intema .............................................. . 10
1.3. Subthalamic Region .......................................... . 10
1.4. Globus Pallidus .............................................. . 12
1.5. Striatum .................................................... . 13
1.5.1. Nucleus Caudatus ....................................... . 13
1.5.2. Putamen .............................................. . 14
1.6. Substantia Nigra ............................................. . 14
1.7. Subthalamic Nucleus .......................................... . 14
1.8. Nucleus Ruber ............................................... . 15
2. Limbic System ................................................... . 15
2.1. Amygdaloid Nucleus .......................................... . 16
2.2. Hippocampus ................................................ . 16
2.3. Hypothalamic Region ......................................... . 17
3. Cerebellum ...................................................... . 18
4. Pain Structures and Pain-Conducting Pathways of the CNS ............... . 20
2 Extrapyramidal Mechanisms ................................. . 27
1. General Remarks ................................................. . 27
1.1. Regulation of Motor Activity ................................... . 29
1.2. The Pathogenesis of Extrapyramidal Syndromes .................... . 30
xiii