Introduction

Michael L. J. Apuzzo

1.1 Essential “Arrows” in the Technical Quiver: Fragments of Personal Memoirs

During the last generation, neurosurgery underwent a striking reinvention characterized by the phenomena specialization and subspecialization. This development was driven by need and the availability of technical adjuvants that allowed surgeries to meet the challenges afforded by neurological diseases.

One of the emerging areas of focused effort related to the discipline of cranial base surgery which engaged in problematical congenital, neoplastic, and vascular lesions in and around the skull base. Introduction of a few technical adjuvants and imaging modalities allowed the creation of capabilities for successfully approaching and dealing with these problems. This armamentarium emerged gradually over a four-decade period and laid the foundation for the new discipline. The author was fortunate to have frontline involvement in the introduction of a few of these tools.

The following paragraphs will offer fragments of the author’s experiences in what were seminal moments.

1.2 Imaging (1973)

In 1973, following the completion of author’s residency at Yale, William F. Collins (his chairman) encouraged him to travel from New Haven, Connecticut to Boston, Massachusetts to spend a week with William Sweet, a creative Harvard neurosurgeon who was engaged in transcutaneous electrocoagulation of fifth nerve structures through the foramen ovale for trigeminal neuralgia. These procedures were conducted in the Radiology Department of the Massachusetts General Hospital in a fluoroscopy room. Dr. Sweet was meticulous and rigorously controlled all the aspects of the procedure. However, the surrounding environment was unpredictable. Dr. Sweet was annoyed by the repetitive noise of activities in an adjacent area. Repeatedly, he uttered expletives regarding the “piece of junk” that was being installed next to his “sanctuary.” A bit of investigation on his part disclosed that this was a British device—(EMI) scanner. This was a tool that would produce grainy images of the skull and intracranial content. It was in fact, the first imaging device (computed tomography [CT] scanner) of its kind to be installed in North America. A year later, he was in Los Angeles, California where industrious individuals had incorporated these devices into truck trailer boxes and offered imaging in hospital parking lots.

One of these individuals was Ernie Bates, a neurosurgeon from San Francisco, California. Ernie trained with Charlie Wilson at USC and finished a year before the author. He never practiced neurosurgery, but would go on to establish a business that would be listed on the New York Stock Exchange. Their paths would cross frequently as the years passed. A year later, a EMI scanner was installed on the fifth floor of the Los Angeles County General Hospital, only a few steps from the neurosurgical operating room, neurologic intensive care unit and his office. History was being made again as rudimentary stereotactic procedures included brachytherapy were undertaken under imaging control.

During the middle 1980s, with the introduction of nuclear magnetic imaging (NMI) later—magnetic resonance imaging (MRI), it became apparent that imaging overlays in three-dimensional reconstructions of the brain and all intracranial contours would facilitate operative events. They worked with the University of Southern California Film School, filmmaker George Lucas, Steve Jobs, and Industrial Light and Magic to create early three-dimensional contours and reconstruction in what was termed the “Operating Room of the Future” in the USC University Hospital in 1991.

Setting the stage for what was to come, the concept was fueled by ideas and author’s relationships with Patrick Kelly (Rochester), John Tew (Cincinnati), Kintomo Takakura (Tokyo), Kajime Honda (Kyoto), and Kenichi Sugita (Nagoya/Matsumoto). It served as a global template.

1.2.1 The Operating Microscope (1955)

In 1921, Swedish otologists are credited with the introduction of the microscope into the surgical arena in otolaryngology. Although many ultimately defined the field, a small number of neurosurgeons were responsible for its introduction into intracranial surgery. Theodore Kurze in Los Angeles was an active member of this initial handful of pioneers. Ted was reluctantly introduced to the Zeiss OPMI I Microscope in the morgue at the Los Angeles County General Hospital by Howard House the notable otologist in the late 1950s. Ted along with Leonard Malis in New York and “Peter Donaghy”

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