The Evolution of Surgery—the Soul of Neurosurgery

The Evolution of Surgery—the Soul of Neurosurgery

Keywords: meningioma, brain tumors, skull base surgery, microneurosurgery, endoscopic surgery, transsphenoidal surgery

Edward R Laws, Jr., Ian F Dunn


Meningiomas have been present in mankind since prehistoric times. This chapter records the history of this common tumor of the nervous system, its symptoms and signs, and its diagnosis and treatment. Many factors have evolved to make meningiomas a great intellectual and technical challenge, and a pivotal factor in the development of modern neurosurgery. They are a major focus of skull base surgery, and represent for many, as they did for Harvey Cushing, the soul of neurosurgery.

2.1 Introduction: Early History

Evidence from prehistoric skulls indicates that meningiomas have been with us as long as humans have walked the earth. Descriptions in the literature of what probably were meningiomas date back as far as Plater’s case of 1614 (▶ Table 2.1). It is likely that the first documented case of surgery for an intracranial meningioma was that of Berlinghieri in 1813, documenting treatment of a “sarcoma of the dura”. Another Italian surgeon, Zenobi Pecchioli, described a similar procedure for successfully removing a “fungus of the dura mater” in 1835. Tito Vanzetti, surgeon for the Pope, exposed and removed a skull base tumor which probably was a meningioma in 1841. 1,​ 2,​ 3

Table 2.1 Early Descriptions of Meningioma


Felix Plater, Switzerland: Autopsy


Johann Salzmann, Germany: Autopsy


Laurenz Heister, Germany: Unsuccessful Rx with caustic lime


Olaf Acrel, Sweden: Unsuccessful attempt at surgery


Antoine Louis, France: Unsuccessful attempt at surgery


John Cleland, Scotland: Villous tumor of arachnoid

Traditionally, Sir William Macewen of Glasgow is credited with a successful craniotomy in 1879, for a skull base tumor arising from the roof of the left orbit, and presenting with seizures. 4 Other contributions included operations by Davide Giordano and Francesco Durante who used transfacial and trans-basal approaches, described in 1883 (▶ Fig. 2.1). 5 Durante also reported a craniotomy for the removal of a left olfactory groove meningioma in 1885. 5 In the United States, Frank Hartley of New York City described surgery for a meningioma in 1896. Robert Weir and William W. Keene described successful surgical cases in 1887, in New York City and Philadelphia, respectively. In Berlin, Fedor Krause successfully diagnosed and excised a frontal skull base meningioma in 1905. Removal of meningiomas of the posterior fossa and the cerebellopontine angle were described by Sir Charles Ballance in 1894 (London) and by Fedor Krause in 1906 (▶ Table 2.2).


Fig. 2.1 Sir William Macewen, Francesco Durante, and Tito Vanzetti—pioneers of meningioma surgery

Table 2.2 Surgical Pioneers: Meningioma


Andrea Berlingheri, Italy


Zanobi Pecchioli, Italy


William Macewen, Scotland


Francesco Durante, Italy


Robert F Weir, United States


William W Keen, United States


Charles Ballance, England


Fedor Krause, Germany

2.2 Nomenclature

Ultimately, the above accomplishments by some of the pioneer figures in neurosurgery were overshadowed by those of Dr Harvey Cushing (▶ Fig. 2.2) Many of these tumors had been given a series of descriptive names such as dural endothelioma, fibrous tumor of the dura, sarcomas, meningeal fibroblastomas, etc. It was Cushing who coined the name “meningioma” in 1922, and described this tumor as “the soul of neurosurgery”. In his monograph of 1938, Harvey Cushing thoroughly recounted the origin of meningiomas as arising from the arachnoid cap cells of the Pacchionian granulations. 6 He described the distribution of these tumors along the venous sinuses and the dura of the skull base, and recognized that they usually were benign lesions that could be surgically excised. Dr Cushing stated, “There is nothing in the whole realm of surgery more gratifying than the successful removal of a meningioma with subsequent perfect functional recovery” 6.


Fig. 2.2 Cushing and Ballance, Fedor Krause, and Krause’s meningioma

In reviewing his early meningioma cases, Cushing said that the most common were meningiomas of the anterior skull base, divided among 29 olfactory groove meningiomas, 28 suprasellar meningiomas, and a few meningiomas of the orbital roof. Second most common were meningiomas of the sphenoid ridge, which occurred either as mass lesions or en plaque. He also described the less common meningiomas involving the cavernous sinus. 7

2.3 Stages of Surgery for Meningiomas

The evolution of skull base surgery for meningiomas occurred in stages. These stages exemplified the various aspects of successful neurosurgery in general, and of successful skull base surgery in particular.

The initial challenges were those of making the diagnosis and localizing the lesion. Early cases were detected because of deformations of the skull and other external signs, including proptosis. Visual loss was an obvious sign, particularly when it was present as a bitemporal hemianopsia, or was associated with papilledema and optic atrophy, as in the Foster Kennedy syndrome, which also could include loss of olfaction. Cranial nerve deficits such as ptosis, anisocoria, diplopia, and loss of facial sensation, were identified as characteristic of meningiomas with cavernous sinus involvement. With the advent of roentgenography, tumors could be diagnosed by changes in the sellar bone and by blistering of bone and hyperostosis in the skull base, along with calcifications in some cases. Posterior fossa tumors were noted to cause tinnitus, hearing loss, and facial weakness or facial sensation disorders. Pituitary endocrinopathy was noted to occur with sellar and parasellar lesions. Seizures, and their location were also often important clues for the diagnosis of these tumors.

2.4 Initial Surgical Progress

Once diagnosed and localized, the next challenge was to expose the tumor accurately and safely. The initial exposures were transcranial, as described by the pioneers, and later by Sir Victor Horsley, Harvey Cushing, Walter Dandy with George Heuer, Charles Frazier, Herbert Olivecrona, Francesco Castellano, Beniamino Guidetti, Clovis Vincent, Pierre Wertheimer,Charles Elsberg, John Jane, and Collin McCarty (who described the essential “keyhole” placement for the frontotemporal craniotomy) 1,​ 8,​ 9,​ 10,​ 11,​ 12,​ 13,​ 14,​ 15,​ 16 (▶ Box 2.1), (▶ Fig. 2.3).

Box 2.1 Craniotomy for Meningioma

Victor Horsley

Charles Frazier

George Heuer/Walter Dandy

Harvey Cushing

Charles Elsberg

Herbert Olivecrona

Collin MacCarty

Ludwig Kempe

John Jane Sr.

Pierre Wertheimer

Patrick Derome


Fig. 2.3 Victor Horsley, and Heuer/Dandy approach

2.5 Extracranial Approaches to Skull Base Lesions

A parallel series of skull base approaches using extracranial methods developed as well. Many of the pioneers, following Durante’s lead, were the Viennese surgeons Hermann Schloffer (1907), and Anton von Eiselsberg, along with Theodor Kocher and Oscar Hirsch (▶ Fig. 2.4) Ultimately, the transnasal transsphenoidal approach became favored, and was advocated by Cushing, and by A. E. Halstead and Allen Kanavel of Chicago. They represented the first wave of transsphenoidal surgery that lapsed for some time after Dr Cushing abandoned it in 1926. The second wave began with Cushing’s trainee, Norman Dott of Edinburgh, who persisted with the transsphenoidal technique. 17 He trained Gerard Guiot of Paris, who added much to the concepts and to details of the techniques (▶ Fig. 2.5) Guiot, in turn, trained Jules Hardy of Montréal. Dr. Guiot is credited with the introduction of video fluoroscopy in this operation, and he also performed the first endoscopic approach to the pituitary in 1963. Dr Hardy introduced the use of the operating microscope for pituitary surgery, and demonstrated its effectiveness in performing hypophysectomy and also for the selective removal of pituitary microadenomas 18 (▶ Box 2.2).


Fig. 2.4 Schloffer, Oskar Hirsch, and Von Eiselsberg

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Jul 31, 2019 | Posted by in NEUROSURGERY | Comments Off on The Evolution of Surgery—the Soul of Neurosurgery
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