Surgery of the Human Cerebrum Part III, Medycyna, Neurochirurgia - podręczniki
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Theoretical representation of nanoscale excitable vesicles.
From Montemagno CD: Integrative technology for the twenty-first
century.
Annal New York Acad Sci
1013:38-49, 2004.
EDITOR’S LETTER
S
URGERY OF THE
H
UMAN
C
EREBRUM
III
A M
ATTER OF
M
ETHOD
his supplement to
N
EUROSURGERY
represents the last component of a
3-part compendium of perspec-
tives on the current and emerging status
of what is one of man's most sophisticat-
ed enterprises–surgery of the human
cerebrum. In total, 21 general topics
have been extensively reviewed in more than 1500 pages of
information–all in commemoration of the journal's first 30
years and a remarkable time in the history of neurosurgery.
The "matter of method" has been central in what has been
an evolving progression of specialization and subspecialization
of approaches to pathological challenges. A central theme
recounted repetitively has been increasing comprehension of
anatomical substrate, increased sophistication of action at tar-
get points of pathology, and general reduction in operative cor-
ridors of action.
These themes are reprised in the concluding original
manuscripts:
Psycho-affective Disorders and Pain
(Giovanni
Broggi),
3-D Microsurgical and Tractographic Anatomy of the
White Matter of the Human Brain
(Albert Rhoton, Jr.),
Intraventricular Tumors
(M. Gazi Yasargil),
Extra-axial Lesions
(Peter Black),
Basal Lesions
(Madjid Samii),
Giant and Other
Complex Aneurysms
(Robert Spetzler),
Revascularization
(Laligam Sekhar),
Endovascular Techniques
(L. Nelson Hopkins,)
and
Advanced Methodologies
(Michael L.J. Apuzzo). They are
augmented by important archival material and selected bibli-
ographies.
These documented refinements of method are in evolution
and are setting the stage for what is a most exciting era of cellu-
lar and molecular neurosurgery, neurorestoration, and ulti-
mately the exciting prospect of nanoneurosurgery with all of its
dramatic possibilities in the areas of imaging, diagnosis, and
therapies at the atomic level.
This material and the material presented in parts I and II
offer an impassioned manifesto of the excitement of neuro-
surgery–an excitement that is only a prelude to a remarkable
future that will, as always, set the standard in creating frontiers
for all of medicine and humanity in the future!
¸
Michael L.J. Apuzzo
Los Angeles, California
Neurosurgery 62:SHC897, 2008
DOI: 10.1227/01.NEU.0000326327.35212.EA
N
EUROSURGERY
VOLUME 62 | NUMBER 6 | JUNE 2008 SUPPLEMENT |
SHC897
T
PSYCHO-AFFECTIVE DISORDERS AND PAIN
P
AIN AND
P
SYCHO
-
AFFECTIVE
D
ISORDERS
Giovanni Broggi, M.D.
Department of Neurosurgery,
Istituto Neurologico C. Besta,
Milan, Italy
THE SUBJECT OF human pain can be subdivided into two broad categories: physical pain and
psychological pain. Since the dawn of human consciousness, each of these two forms of pain—
one clearly physical, the other having more to deal with the mind—have played a central role in
human existence. Psychological pain and suffering add dimensions that go far beyond the bound-
aries of its physical counterpart.
In the past 50 years, one of the more remarkable accomplishments of medical science has
been to increasingly enable the clinician to impact, as never before, each of these critical realms
of human existence.
Our intention is, therefore, to initially describe a few of the many exciting neuroscientific and
neurosurgical advances that have been made in the treatment of various types of pain and to
speculate on some of the emergent questions that we believe need to be addressed. After this is
accomplished, we will then use this information as a kind of two-pronged philosophical entrance
into questions of the mind, brain, and soul that we feel are necessary to bring back into the sphere
of the modern physician’s practice.
The goal of this article is two-fold: 1) to share some of our exciting research and 2) to renew
the interest in timeless questions, such as that of the mind-brain and the brain-mind, in the con-
versation of the modern neurosurgeon.
The International Association for the Study of Pain divides pain into two broad functions and
anatomical categories. In this framework, “nociceptive” pain is defined as the kind of physical
pain that results when the tissue is damaged. Given this perspective, such pain is usually consid-
ered a consequence of one’s defense against one’s environment. The other pain is the “neuro-
pathic” one resulting from a lesion or a dysfunction of the human nervous system.
As such, we will take the risk of crossing beyond the boundaries of neurosurgery and venture
into boundaries that, at another time, might seem more natural to the discipline of psychiatry for
two reasons. The first is that psychiatry seems to be so focused on the brain—its biochemistry
and pharmacology—that questions of mind and soul have become rare and almost negligible. The
second is to follow the course of the results of our own clinical investigations that have taken us
into that very human world where questions of physical pain, psychological pain, and the expe-
rience of suffering abound.
Today, however, the strategy of neuromodulation offers the advantage of being precisely tailored
in neuroanatomical terms and, even more importantly, of being altogether reversible. At both our
own Istituto Neurologico C. Besta and many other neurosurgical centers worldwide, many proce-
dures have been reported in which implant neuromodulation devices successfully treat pain.
For example, long-term stimulation of the spinal cord has been fairly effective in the treatment
of neuropathic pain, multiple sclerosis, and various other forms of pain. Good results have been
obtained in treating peripheral vascular diseases and sympathetic reflex dystrophy syndrome.
Good results have also been achieved in trigeminal nerve stimulation and peripheral nerve stim-
ulation. In the case of thalamic stimulation, there has also been an improvement of symptoms,
but a long-term degree of tolerance was noticed. Hypothalamic stimulation has also been seen to
be effective in controlling trigeminal autonomic cephalalgic pain, as well as the facial pain that
is known to occur in multiple sclerosis. Motor cortex stimulation was found to occasionally have
good results in treating neuropathic pain, whereas occipital nerve stimulation was found to achieve
good results in controlling chronic cluster headache and other chronic headaches, although with
only short-term follow-up so far. Recent reports of functional magnetic resonance imaging have
prompted us to propose exciting new neurosurgical targets that may be effective in treating psy-
choaffective disorders. Our results appear to be more than promising so far. It appears that neu-
ropathic pain and psychoaffective disorders seem to be sharing an anatomophysiological com-
mon background at the Brodmann Area 25 of the anterior cingulated gyrus. On the basis of these
exciting findings, we believe that it is reasonable to suggest that neuropathic pain and psychoaf-
fective disorders may ultimately be managed with complementary or, at least, similar, therapeu-
tic strategies, each of which lie within the domain of the neurosurgeon.
KEY WORDS:
Affective disorders, Neuropathic pain, Pain, Psyche, Psychosurgery
Reprint requests:
Giovanni Broggi, M.D.,
Department of Neurosurgery,
Istituto Neurologico C. Besta,
Via Celloria 11, 20133,
Milan, Italy.
Email: gbroggi@istituto-besta.it
Received, August 2, 2007.
Accepted, April 7, 2008.
Neurosurgery 62[SHC Suppl 3]:SHC-901–SHC-920, 2008
DOI: 10.1227/01.NEU.0000317337.51936.43
N
EUROSURGERY
VOLUME 62 | NUMBER 6 | JUNE 2008 SUPPLEMENT |
SHC901
B
ROGGI
categories: physical pain and psychological pain. Since
the dawn of human consciousness, each of these two
forms of pain—one clearly physical, the other having more to
do with the mind—has played a central role in human exis-
tence. Historically and etymologically, the word “pain” has
close ties to negative or unpleasant experiences and an unmis-
takable linkage to the concept of punishment. Not surprisingly,
however, dramatic differences emerge when we consider pain
of a more psychological or spiritual nature. Psychological pain,
in addition to suffering—pain’s closely related experiential
counterpart—although unmistakably bound to the idea of pun-
ishment and possessing a long history in human existence, has
added dimensions that go far beyond the boundaries of its
physical counterpart. Primary among these are its close linkage
with death, its historical linkage with spirituality and religion,
and not surprisingly, its connection to the subject of the human
soul. In the past 50 years, one of the more remarkable achieve-
ments of medical science has been the increasing ability of the
clinician to affect each of these critical realms of human exis-
tence as never before. Because of these dramatic therapeutic
inroads made possible by the advances of science, the modern
physician may now be closer to routinely treating what were
previously considered to be nonclinical situations related to
philosophers and intellectual discussions of the mind and the
brain. It is precisely because of these advances that we have
written this paper, with the hope of clarifying a number of
heretofore philosophical issues that we believe must now be
part of the clinician’s knowledge—not only to anticipate many
labyrinthine ethical situations, but also because we believe this
kind of metaphysical-philosophical inquiry will produce a bet-
ter physician.
O
ur intention is, therefore, first to describe some of the many
exciting neuroscientific and neurosurgical advances that have
been made in the treatment of various types of pain (many of
which have come out of our clinical investigations at the C. Besta
Neurological Institute in Milan, Italy) and to elaborate on some
of the emergent questions that we believe need to be addressed.
When this is accomplished, we will then use this information as
a kind of two-pronged philosophical entrance into the ques-
tions of mind, brain, and soul that we believe need to be brought
back into the modern physician’s sphere of practice. Doubtless,
because of medical science’s increasing tendency to apply engi-
neering principles to human existence, the physical body and life
itself have a growing tendency to be seen, almost exclusively,
from an extremely “robotic” or mechanistic perspective. With
advances in the neurosciences that provide convincing evidence
leading us to believe that the brain is a computer and the body
is a machine, we in medicine—and not the philosophers—may
be the ones responsible for shifting the balance created by cen-
turies of thought about humans and of human existence toward
this disturbing “brave new worldview” of soulless, mechanistic
extremism. Our intention is, therefore, twofold: 1) to share some
of our exciting research and 2) to renew interest in timeless ques-
tions, such as that of the mind-brain and the brain-mind, to the
forefront of conversation of the modern neurosurgeon. Our
urgency is both practical and philosophical and follows the logic
of Socrates, for whom the unexamined life was not worth living.
Following this logic that anticipates the growing importance of
human consciousness, our intention might be stated as follows:
the unexamined
clinician’s
life is not worth living.
Today’s nervous system clinician generally follows the phys-
ical-materialist guidelines that have been laid down by the
International Association for the Study of Pain (IASP), which
categorizes pain in two broad functional and anatomic cate-
gories. In this framework, nociceptive pain is defined as the
kind of physical pain that results when tissue is damaged; in
this scheme of thinking, such pain is usually perceived of as a
consequence of one’s defense against one’s environment.
Neuropathic pain is the pain that results following an injury to
or a dysfunction of the human nervous system. Often missing
from our clinical and therapeutic maps, however, are the
uniquely spiritual questions of human suffering and psycho-
logical pain. Although this form of pain and suffering often
blurs the distinctions between the normal and pathological,
and probably constitutes the vast majority of all the pain and
suffering that exists at any moment in time, we may be nearing
that moment when our profession, and specifically the neuro-
surgeon, starts to acknowledge this elephant in the room, even
if it complicates the simplicity of our materialistic scientific
paradigms. We are, therefore, consciously running the risk of
crossing beyond the boundaries of neurosurgery and venturing
onto terrain that, at another time, might have seemed more
natural to psychiatry. We are doing this for two reasons. The
first is that psychiatry seems to be so focused on the brain, its
biochemistry and pharmacology, that questions of mind and
soul have become rare, almost nonexistent. The second is to fol-
low the course that follow from the results of our own clinical
investigations, which have taken us into that very human
world where questions of pain, psychological pain, and the
experience of suffering are highly germane.
Though we enter this uniquely human metaphysical world
with a caution and recognition of the importance of staying
close to our results and our data. To evaluate the efficacy of
therapeutic interventions directed to the improvement of pain
syndromes and psycho-affective disorders, it is necessary for
the caregiver to rely heavily on the patient’s subjective report-
ing, which always creates problems when it comes to scientific
conclusions that rely heavily on so-called objectivity. Because
there is, as yet, no known “cure” for pain (or for psycho-affec-
tive disorders, for that matter), our professions have had to
rely on many strategies, most of which have been highly
experimental in nature. In neurosurgery, for example, our
efforts to improve pain symptoms have required that we resort
to strategies that interrupt abnormal neuronal activity in sen-
sory pathways in the hope of interfering with information
being transmitted to higher brain structures. Today, however,
the strategy of neuromodulation offers the advantages of being
precisely tailored in neuroanatomic terms and, even more
importantly, of being altogether reversible
.
In our own Istituto
Neurologico C. Besta and in numerous other neurosurgical cen-
ters worldwide, many procedures have been reported in which
SHC902
| VOLUME 62 | NUMBER 6 | JUNE 2008 SUPPLEMENT
www.neurosurgery-online.com
T
he subject of human pain can be divided into two broad
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