Fifty Years of Neurosurgery

2011 Neurosurgeon of the Year

Fifty Years of Neurosurgery

Albert L. Rhoton, Jr.

N eurosurgeons everywhere saluteWORLD NEUROSURGERY and Edi-tor Michael Apuzzo for world-class

academic and scientific contributions toour specialty. WORLD NEUROSURGERY isproviding a needed international perspec-tive that will elevate the care of neurosur-

gical patients in all corners of the globe. I am deeply appreciativeof Dr. Apuzzo and the leadership of WORLD NEUROSURGERY givingme the opportunity to work with them on this issue, and I thankDr. William Friedman, who succeeded me as Chairman ofNeurosurgery at the University of Florida, for his preparation ofthe introduction to this issue (Figure 1).

A personally wondrous and rewarding aspect of my career hasbeen the opportunity to see the world through the eyes of neu-rosurgeons on every continent. My early life was in an isolatedarea where there was little knowledge of life on the other side ofthe next mountain and almost none of the surrounding world. Inmy early years, I never in my wildest flights of imagination con-sidered that life would yield such rewarding and challenging workas being a physician, and I was unaware that neurosurgery evenexisted.

I was born, delivered by a midwife in a log cabin, in exchangefor a bag of corn, in Parvin, Kentucky, a remote and poor areawithout doctors or hospitals. Hardened mud filled in the spacebetween the logs of our cabin to keep the cold outside. Therewas no camera for baby pictures, no electricity, no plumbing,no telephone, and no car. Water was carried from a nearbyspring. Heating was from a fireplace and chopped wood.Travel was usually by foot or mule-drawn wagon on a dirt roador trail. Clothing was homemade from corn or flour sacs. Thebest clothes were donated by the charities in the big cities. Myearly schooling in one- or two-room school houses wasfocused on elementary reading and simple arithmetic. Myparents, who had not completed high school (there were nohigh schools in the area), passed a test that allowed them tobe teachers in my school, which was attended by a fewstudents only when their parents did not need them forwork in the surrounding fields. When we moved to the cityduring World War II, the teachers wanted to put me back ayear in school, but my mother would not allow that so theteacher flunked me and I had to take the fifth grade twice. Imay be one of the few neurosurgeons who flunked the fifthgrade but graduated at the academic top of their medicalschool class.

After moving to the city, my parents insisted, up to the time Ientered college, that I hold a job before and after school
selling newspapers on a street corner or delivering them to
WORLD NEUROSURGERY 75 [2]: 163-173, FEBRUARY 2011

homes in our area. My father had eventually earned a collegedegree in chemistry, and I planned to pursue a degree inchemistry when I entered The Ohio State University, where Ihad to continue part-time work including washing dishes inthe faculty club and local restaurants supplemented by wash-ing cars and mowing lawns on the weekends. During my 3rdyear of college, I found a part-time job that I loved, workingwith clubs for disadvantaged children. That job prompted meto switch my college major to social work, in which I receiveda degree. One of the last courses in the social work curricu-lum, physiological psychology, activated my interest in thebrain.

Being a physician did not enter my mind until the instructor inphysiological psychology invited me to see an operation on thebrain in his laboratory. To my amazement, a tiny lesion improvedthe small animal’s behavior. On that day, I learned that brainsurgery, based on the localizing features of the brain, was pos-sible, and I knew that I had found my life’s work. I know thatmany of you share a similar meaningful experience. The instruc-tor in that course in physiological psychology had a powerfulimpact on my life. I returned to that university years later as avisiting professor and tried to find that physiological psychologyprofessor to let him know how he had changed my life, but hehad died. I regret that I had not let him know what an importantrole he had in my life.

After graduating from The Ohio State University in social work,I entered their premedical curriculum, which I found verydifficult, but I achieved excellent grades and was accepted intoThe Ohio State College of Medicine. However, I had met theregistrar from Washington University in St. Louis at a summercamp, and he sent me a medical school application, which Icompleted, knowing and writing that I wanted to be a neuro-surgeon. I hitchhiked from Ohio to St. Louis for the interviewat Washington University and accepted their invitation tomedical school. My goal to be a neurosurgeon remained intactduring medical school, and I entered neurosurgical training 51years ago. I found in medical school that I learned a subjectbest by teaching it. My willingness to teach led to my beingnoted as the classmate to whom other students most oftenwent to for help in dealing with a difficult subject. I wasteaching fetal circulation to a group of occupational therapystudents when I met Joyce, my wife of 53 years. Aftercompleting my residency in 1964, I entered a research fellow-ship in neuroanatomy, and it was during the use of themicroscope in that fellowship that I developed a stronginterest in microsurgical anatomy as a way of making whatwas a delicate, fateful, and awesome experience for my
patients more accurate, gentle, and safe.
www.WORLDNEUROSURGERY.org 163

2011 NEUROSURGEON OF THE YEAR

My first opportunity tocross an ocean to visitanother country was atthe end of my residency.Since then, my work withneurosurgeons around theworld has been one of themost rewarding aspectsof my life and a sourceof many treasured friend-ships. The relationshipswith the many young menand women and their fam-ilies from around the worldwho have attended ourcourses and studied micro-surgical anatomy with ushave been especially grat-ifying (Figure 2). It wastruly exciting nearly 40years ago to receive thefirst request of a youngneurosurgeon from an-

other country wanting to study with us. He and many of our othertrainees have become leaders in their part of the world. Thenumber of department chairmen in the group total several dozen,and there are many in the early stages of their careers.

Being the guest of neurosurgical societies around the worldhas made me aware that neurosurgeons share a commonsense of joy and excitement about being allowed to participatein the miracle we call neurosurgery using the skills embodiedin our specialty (3, 4). Participating in meetings and courses onevery continent has yielded many treasured friends and hasmade me aware that neurosurgeons share a magnificentprofessional gift; our lives have yielded an opportunity to helpmankind in a unique and exciting way (Figure 3). Our work isdone in response to the ideas that human life is sacred andthat it makes sense to spend years of one’s life in study to beable to help others. Our training brings into harmony aknowledgeable mind, a skilled set of hands, and a well-trainedeye, all guided by a caring human being. The skills we use areamong the most delicate, the most fateful, and to the laymanthe most awesome of any profession. This work has placed usamong the most prestigious and highly skilled members of ournations. We share the opportunity to serve our fellow humansin a unique way, dealing surgically with the most delicate oftissues.

Our ranking among the most highly skilled members of societytends to make us forget that our work and success are madepossible by the benevolent order built into the universe aroundus. The fact that humans heal and survive after surgery providesus with our work and serves as a constant reminder of thisbenevolent protecting order. We are surrounded by biologic andphysical forces that could overcome us, outstripping our finestmedical and scientific achievements, and yet we survive. Themomentous process of injured tissues knitting together is asessential to the neurosurgeon’s work as the air we breathe is to

Figure 1. Professor William A. Friedman,the Albert L. Rhoton, Jr., Professor andChairman of Neurosurgery at theUniversity of Florida.

the survival of humanity. The fact that humanity survives and that

164 www.SCIENCEDIRECT.com WO

we can play a role in the process of healing are examples of thecompassion and love that surrounds us. A patient writing a“thank you” or praising my efforts leads to the inward recall thatone of our greatest gifts is that we are constituted so that we canhelp each other.

Our work has grown out of the fact that there are absolutestandards of value and worth built into humanity. These valuesare reflected in the growing importance of one man, woman, orchild throughout the world. An example of the evolving impor-tance of one person is found in examining humanity’s greatcreations, such as the pyramids and the Great Wall of China.Over the decades and centuries, humankind has evolved to thepoint that the “pyramids” of modern society are the modernmedical centers found in many parts of the world. In them,society’s most highly trained teams, using the most advancedtechnology, often at great cost, are allowed to work for daystrying to improve the life of one man, woman, or child withoutregard to whether they are rich or poor.

Pool, who led the neurosurgery program at Columbia University,wrote, “As I look back on the pattern of my life I see howfortunate it was that I had chosen a career in neurosurgery, whichI passionately loved despite its long hours and many gruelingexperiences” (2). He concluded with a statement about his beliefthat the best surgeons have a strong sense of compassion. It isimportant that we grow in compassion just as we grow incompetence. Competence is the possession of a required skill orknowledge. Compassion does not require a skill or knowledge; itrequires an innate feeling, commonly called love, toward some-one else. Competence and compassion need to be developedsimultaneously, just as the giant oak develops its root systemalong with its leaves and branches.

It is a great challenge to guide one’s patient competently andcompassionately through neurosurgery. Death and darknesscrowd near our patients as we help them search for the correctpath. Neurosurgical illness threatens not only their physical butalso their financial security because it is so expensive and thepotential for disability is so great. No experience draws morefrequently on the phrase from the Book of Psalms (23:4), “. . .though I walk through the valley of the shadow of death. . . .” Ourcompetence should be reflected in our training, knowledge, andskill; our compassion should be reflected in kindness, sincerity,and concern. Our patients are looking for help from someonewho is knowledgeable, patient, and wise and who can giveclarity, wisdom, and enlightenment to facing life after neuro-surgery. That is the essence of integrating competence andcompassion.

We have the responsibility to develop the dialogue in understand-able terms to help the patient, the patient’s family, and societyunderstand the meaning of neurosurgical illness. I believe thatour best ally in the treatment of neurosurgical illness is awell-informed patient. Success requires more than advancingand applying medical knowledge. It also requires growing com-passion that allows us to respond sympathetically and to the bestof our knowledge to all of our patients’ questions and to providethem with timely information that will help them understand their
illness and plan their lives. Sometimes in our work we can make
RLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.01.025

l tech


as much of a difference in the life of a patient by sitting for 30minutes or 1 hour or longer answering questions as we can by

Figure 2. (A) Former fellows at the 2010 “Rhoton Seminar” in Japan. Nearlystudied microsurgical and endoscopic anatomy in the Florida laboratory havefellows in the front row have been or are currently serving as department cSaeki, Tooru Inoue, Shigeaki Kobayashi, Erdener Timurkaynak (Turkey), AlbeYamamoto, Kiyotaka Fujii, and Kazunari Oka. Many of the former fellows inof their academic career and will likely become chairmen. (B) With some ofmicrosurgical anatomy fellows from Brazil at a surgical anatomy course at thright are Antonio Mussi, Paulo Kadri, Alvaro Campero (Argentina), GuilhermeMartins, Evandro de Oliveira, Hung Tzu Wen, and Helder Tedeschi. FormerAlencastro, Alexandra Yasuda, and Alberto Cardoso. Professor Oliveira stud1983 and has developed an outstanding laboratory for teaching microsurgica

hours in surgery. There is no substitute for an honest, concerned,


and sympathetic attitude.Success may not mean thatevery patient survives or iscured because some prob-lems are unsolvable andsome illnesses are incurable.Instead, success shouldmean giving every patientthe feeling that he or she iscared about no matter howdesperate their situation,that their pain is felt, thattheir anger is understood,and that we care and will doour best. The greatest satis-faction in life comes fromoffering what you have togive. Devotion and giving toothers provide purpose andmeaning to life.

I am pleased to see thatWORLD NEUROSURGERY plansto present not only scientificand academic issues but alsotimely information about so-cioeconomic issues importantto the practice of neurosur-gery in different parts of theworld. The many socioeco-nomic environs in which worldneurosurgeons must practicerange from practices sup-ported by some of mankind’sbest technology to practices inthe midst of chronic war, fam-ine, and strife where criticalsurgical decisions are madeon the basis of only physicalexamination and skull x-rays. Icongratulate the Foundationof the World Federation ofNeurosurgical Societies formaking basic sets of neurosur-gical instruments available forneurosurgical practices in eco-nomically disadvantaged andremote parts of the world.Some see our involvement insocioeconomics as self-serv-ing, rather than as an effortto preserve the resourcesneeded to provide our type ofcare. The delivery of neurosur-gical care is expensive. Rela-tive or absolute caps havebeen placed on private andgovernmentally financed med-

ical programs in all parts of the world. There is competition amongthe multiple specialties for fiscal resources. It is only through an

the almost 100 fellows who havefrom Japan. Nearly all of the

en. From left to right are Naokatsuhoton, Toshio Matsushima, Isao

ack two rows are in the early stagesormer University of Florida0 Brazilian Congress. From left to

s, Albert L. Rhoton, Carolinaian fellows not shown are Felipethe University of Florida from 1981-niques in Sao Paulo, Brazil.

30 ofbeen

hairmrt L. Rthe bthe fe 201Riba

Brazilied at

understanding of and involvement in socioeconomic issues that



needed resources will be made available for the delivery of neuro-surgical care and for the research needed to expand our frontiers.As we work toward our goal, each of us must share in the provisionof care for poor and less fortunate patients.

It is important that we plan our personal financial affairs so thatour private financial condition does not influence our surgicaljudgment. This separation of the physician’s need for income andthe needs of the patient can be achieved only through a well-planned program of financial security, saving, and selection of alifestyle so that one’s day-to-day living needs are met and notinfluenced by day-to-day income. We are not here to get all thatwe can out of life for ourselves but to try to make the lives ofothers happier. This is the essence of the admonition from theGospel According to Matthew (10:39), “He that findeth his lifeshall lose it, and he that loseth his life for my sake shall find it.”

Figure 3. (A) Dissection course in Japan with Takeshi Kawase (to left of RhoKanpalot (seated to right of Rhoton). (Continues)

Osler commented, “Throw away, in the first place, all ambition


beyond that of doing theday’s work well. Find yourway into work in which thereis an enjoyment of it and allshadows of annoyance seemto flee away. Let each day’swork absorb your energy andsatisfy your wildest ambition.Success in the long run de-pends on endurance and per-severance. All things cometo him who has learned tolabor and wait whose talentsdevelop in the still and quietyears of unselfish work” (1).

Another aspect leading tothe esteem we enjoy is themagnificent tissue with whichwe work. The brain is thecrown jewel of creation andevolution. It is a source ofmystery and wonder. Of allthe natural phenomena towhich science can turn itsattention, none exceeds thefascination with the work-ings of the human brain. Thebrain holds our greatest un-explored biologic frontiers. Itis the most frequent site ofcrippling incurable disease. Itis the only organ to be hiddenand completely enclosedwithin a fortress of bone. Al-though the brain does notmove, it is the most metabol-ically active of all organs, re-ceiving 20% of the cardiacoutput while representingonly 3% of the total bodyweight. The brain is exqui-sitely sensitive to touch, an-oxia, and derangements ofits internal environment. Its

status determines whether the humanity within us lives or dies.It yields all we know of the world. It controls both the patient andthe surgeon.

The brain accounts for the mind and through the mind we arelifted out of our immediate circumstances and are given anawareness of ourselves, our universe, our environment, andeven of the brain itself. Here, in two hands’ full of living tissue,we find an ordered complexity sufficient to preserve the recordof a lifetime of the richest human experience and create com-puters that can store amounts of data that can be comprehendedonly by the mind. Perhaps the most significant achievement ofthis tissue is the ability on the one hand to conceive of a universemore than a billion light-years across and on the other toconceptualize a microcosmic world out of reach of our senses

(B) Course in Turkey with Yucel
ton).
and to model words completely separate from the reality we can


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see, hear, and feel. The mind and brain are the source ofhappiness, knowledge, and wisdom. The brain is not the seat ofthe soul, but it is through the brain and mind that we becomeaware of our own essence, our own soul.

MICROSURGICAL ANATOMY

Our work on surgical anatomy has grown out of my personaldesire to improve the care of my patients (Figure 4). It representsa 50-year attempt to gain an understanding of the intricacies ofthe brain that would improve the safety, precision, gentleness,and accuracy of surgery in my patients, and it has been mostrewarding to see the interest and support neurosurgeons around

Figure 3. (Continued) (C) Course in Bogota, Colombia, with the 2009 Congr(D) Course participants in 3D glasses at 3D course at Beijing Neurosurgicalto the left of Rhoton).

the world have focused on this work (5-7). During medical school, c


I began to work in a neuro-science laboratory in myspare time. At the end of myresidency, I completed a fel-lowship in neuroanatomy.During this fellowship, I be-gan to use the operating mi-croscope in the laboratory,and I realized the potentialfor greater knowledge of mi-croneurosurgical anatomy toimprove the life of my pa-tients. The operating micro-scope and knowledge ofmicrosurgical anatomy haveproven to be one of my great-est professional blessings anda great contributor to the qual-ity of life of my patients.

I resolved early in my careerto incorporate microsurgicaltechnique into my practicebecause it appeared to in-crease the safety with whichwe could delve deep into andunder the brain. During mytraining and thereafter, I layawake many nights, as Iknow you have, worryingabout a patient who faced anecessary, critical, and high-risk operation the next day.With this new technique, Ifound that difficult opera-tions carrying significant riskwere done with greater accu-racy and less postoperativemorbidity. During my trainingin the early 1960s, I did notsee a facial nerve preservedduring removal of an acousticneuroma. Today, that goal isaccomplished in a high per-centage of acoustic neuromacases. During my early ca-reer, in dealing surgically

ith pituitary tumors, there was minimal discussion of preservinghe normal pituitary gland, but today newer diagnostic andurgical techniques have made tumor removal with preservationf normal pituitary function a frequent achievement. The applica-ion of anatomy in neurosurgery has yielded a whole new level ofeurosurgical performance and competence.

s I began to use microsurgical techniques, I realized that there wasneed to train many neurosurgeons in their use. When I moved to

he University of Florida, I began trying to develop a center foreaching neurosurgeons these techniques. Eventually, with the helpf private contributions, we were able to purchase the necessaryicroscopes and equipment for a laboratory where seven surgeons

the Latin Neurosurgical Societies.te with Qing Liang Liu (seated third

ess ofInstitu

ould learn at one time. The next task was to find seven individuals



Figure 4. Areas examined in prior studies. From left to right and top to bottom:cerebral hemispheres, third ventricle, lateral ventricles, pineal region, basal

superficial temporal artery bypass, high-flow bypass, venous system, insula,fiber tracts, middle fossa, cavernous sinus, temporal bone, cerebellopontine

cisterns, perforating arteries important in aneurysm surgery, low-flow angle, internal acoustic meatus, sellar region, and sphenoid sinus.

168 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.01.025


who were willing to come for a course (Figure 5). Finally, after muchsolicitation, seven surgeons joined us for a 1-week course. I wasquite apprehensive about that course because I was unsure that wecould keep seven surgeons busy learning microsurgical skills for awhole week. It was comforting to learn that Harvey Cushing, earlyin his career, had developed a laboratory where surgeons couldpractice and perfect their operative skills.

I still remember and am grateful to each member of the initialgroup of neurosurgeons who was willing to invest 1 week of theirvaluable time in our first course more than 35 years ago. Duringthe first afternoon of that course, I walked into the laboratory and,to my amazement, found seven surgeons working quietly anddiligently. Nothing was said for long periods of time. In the midstof their intense effort and amazing quietness, I realized that wehad tapped into the great desire of neurosurgeons to improve

Figure 5. (A) First course held in the microsurgery teaching laboratoryat the University of Florida in 1975 attended by only neurosurgeonsfrom Florida. Over the years, more than 1000 neurosurgeons fromaround the world have visited the laboratory to learn microvascularanastomoses and approaches to the brain and skull base. Thislaboratory had six workstations for trainees and one for the instructorleading the course. (B) Microsurgery course in the current laboratory atthe McKnight Brain Institute of the University of Florida, which has 16workstations that can accommodate 32 neurosurgeons. (C) Participantsin 3D glasses at a University of Florida course. Carolina Martins (Brazil),Yoshi Natori (Japan), Eduardo Seoane (Argentina), and NecmettinTanriover (Turkey) assisted with the course. (D) Rhoton in teachinglaboratory at the McKnight Brain Institute. (Photo by Ray Carson.)

themselves. Over the years, more than 1000 neurosurgeons


have attended courses in our microneurosurgery laboratories.Microsurgical techniques have added a new level of accuracy andgentleness to neurosurgery. It is rewarding to see that manyresidency training programs now provide a laboratory for study-ing microsurgical anatomy and perfecting microsurgical tech-niques and that articles on microsurgical anatomy are publishedregularly in neurosurgery journals.

Creating the precise images that have the potential to make theawesome, delicate, and fateful experience of our patients moreaccurate, gentle, and safe has been a challenging experience(Figure 4). When we began our studies of microsurgical anatomymore than 45 years ago, our dissections, even with the operatingmicroscopes, were crude by current standards with photographsneeding to be retouched to bring out the facets of anatomyimportant in achieving a satisfactory outcome. As we learned
over the years to expose fine neural structures, the display of


microsurgical and endoscopic anatomy has become more vividlyaccurate and beautiful than we had imagined at the onset, andthe experience of creating these images has enhanced theaccuracy and safety of our surgery. A recent step has been tocapture the outstanding images in three-dimensional (3D) formatand to make them available on smart phones, laptops, and 3Dtelevision and for 3D projection for large groups (Figure 5C) (9).

It was rewarding to learn that Michelangelo and Leonardo DaVinci had gone through the discipline of cadaveric dissection as away of achieving perfect art and beauty in their work just as greatsurgeons have done in an effort to improve the lives of theirpatients. We hope that our previous writing will play some role inimproving the lives of neurosurgery patients. The 25th Anniver-sary Issue of Neurosurgery, with 1100 color illustrations, on thesupratentorial area and the Millennium Issue on the posteriorfossa, with nearly 800 illustrations done with the encouragementof Dr. Apuzzo, editor, represent a distillation of more than 45years of work and study in which nearly 100 neurosurgeryresidents and fellows have participated resulting in severalhundred publications. I am deeply appreciative of Dr. Apuzzocombining the Millennium Issue and 25th Anniversary Issue ofNeurosurgery into the book, Cranial Anatomy and Surgical Ap-proaches, which was introduced at the 2003 Meeting of theCongress of Neurological Surgeons, translated into Portuguesein 2009 by the Brazilian neurosurgeons, and translated intoChinese in 2010 with translations into other languages in prog-ress (Figure 6). For readers wanting even greater detail thanprovided in Cranial Anatomy and Surgical Approaches, our manyarticles published largely in Neurosurgery and the Journal ofNeurosurgery can be consulted.

In our work, we have attempted not only to display the brain andskull base in the best views for understanding the anatomy butalso to show the anatomy as exposed in the surgical routes to thesupratentorial and infratemporal areas and skull base. Areasexamined include the cerebrum; cerebellum; lateral, third, andfourth ventricles; cranial nerves; skull base; orbit; cavernoussinus; temporal bone; cerebellopontine angle; foramen magnum;and numerous others (Figure 4). Our work is not complete in anyarea. There is no finish line for this effort. Future anatomicstudies will continue to yield new insights in neurosurgery.Insights gained from the other medical sciences and new tech-nologies, when combined with our increasing knowledge ofmicrosurgical anatomy, will create new surgical possibilities,therapies, and cures.

Surgical anatomy will continue to be the most fundamentalscience to neurosurgery in the future. It will always occupy amajor role in the training of neurosurgeons. The study anddissection of anatomic specimens improve surgical skill. Thestudy of microsurgical anatomy continues to be important inimproving and adapting old techniques to new situations. Itsstudy will lead to numerous new and more accurate operativeapproaches and provide the basis for applying new neurosurgicaltechnologies in the future. It provides the basis for understandingthe constantly improving imaging studies and yields insights intothe safest and most effective surgical pathway for visualizing anddealing with neurosurgical pathology.

The combination of the knowledge of microsurgical anatomy and
the use of the operating microscope has improved the technical

performance of many standard neurosurgical procedures (eg,brain, spine, and skull base tumor removal; aneurysm obliteration;neurorrhaphy; lumbar and cervical discectomy) and has opened newdimensions previously unattainable to the neurosurgeon. Knowl-

Figure 6. (A) Speaking at the Chinese Academic Congress of NeurosurgicalSciences in Chengdu, China, at which the Chinese translation of CranialAnatomy and Surgical Approaches was introduced. (B) Cranial Anatomy andSurgical Approaches has also been translated into Portuguese by Brazilianneurosurgeons and into Chinese by Qing Liang Liu of the Beijing NeurosurgicalInstitute. (C) Book signing for neurosurgeons in Chengdu, China.

edge of microsurgical anatomy has improved operative results by



permitting neural and vascular structures to be approached anddelineated with greater accuracy, deep areas to be reached by saferroutes with less brain retraction and smaller cortical incisions,bleeding to be controlled with less damage to adjacent neural andvascular structures, and nerves and perforating arteries to bepreserved with greater frequency. When combined with the knowl-edge of surgical anatomy, the use of the microscope has resulted insmaller wounds, less postoperative neural and vascular damage,better hemostasis, more accurate nerve and vascular repairs, andsurgical treatment for some previously inoperable lesions. Themicroscopic study of surgical anatomy has introduced a whole newera in surgical education by permitting the recording of minuteanatomic detail not visible to the eye for later study and discussion.

A friend recently asked me what normal microsurgical anatomyhas to do with dealing with neurosurgical pathology. The discus-sion of the role of surgical anatomy in dealing with neurosurgicalpathology is divided into the three parts into which all operativeprocedures are divided: (i) approach, (ii) dealing with the pathol-ogy at the target site, and (iii) reconstruction and closure (8). Theapproach usually involves dissection of normal anatomy. Someroutes to pathology, such as routes directed to or through thetemporal bone, basal cisterns, pineal region, and ventricles, areso complex that they are often best learned through hands-onpractice in the anatomy laboratory. Closure and reconstructionare essentially efforts to preserve and restore normal anatomy.

Once the target pathology has been reached, a precise under-standing of anatomy is fundamental to dealing with the pathol-ogy. Numerous operations involve dissections of predominatelynormal anatomy. Examples include operations to remove colloidcysts at the foramen of Monro, procedures to address smallschwannomas and meningiomas, microvascular decompressionoperations for trigeminal neuralgia and hemifacial spasm, andclipping of most aneurysms. An understanding of normal micro-surgical anatomy increases the accuracy and safety of all opera-tions involving dissections of nearly normal anatomy.

Larger lesions also commonly create characteristic displace-ments of normal anatomy. The position of the displaced nervesand vessels around tumors and other lesions commonly can bepredicted from the knowledge of the site of origin of the tumorand the normal microsurgical anatomy of the area. This isespecially true in aneurysm surgery in which the perforatingarteries at each aneurysm site usually have a characteristic originand relationship to the neck of the aneurysm. Another example isan acoustic neuroma in which the facial nerve, although possiblydisplaced in multiple directions around the tumor, would consis-tently be found at the anterior-superior quadrant of the lateral endof the internal acoustic meatus and on the brainstem side at thelateral end of the pontomedullary sulcus just above the linedrawn along the brainstem junction with cranial nerves IX, X, andXI and in front of the flocculus and choroid plexus protruding fromthe foramen of Luschka. Achieving an optimal result not onlyrequires that the structures passing through or involved in thepathology be preserved, but also that the normal structures alongthe periphery of the pathology, whose location can be predictedfrom the knowledge of normal surgical anatomy, are preserved.

Microsurgical anatomy provided the basis for our entry into skullbase surgery and has provided the road map for reaching every
site in the skull base through carefully placed windows. The joint

development of microsurgery and endoscopic surgery, in combi-nation with imaging guidance, has made it possible to work inlong narrow exposures to reach multiple deep sites within thebrain and skull base. In recent years, more of our studies havefocused on endoscopic anatomy and approaches. The endo-scope has proven especially helpful in reaching anterior midlinelesions between the planum above and C2 below. Microsurgicalapproaches, such as retrosigmoid, translabyrinthine, anteriorpetrosectomy, and far lateral, all predominantly lateral ap-proaches, have the disadvantage that they must cross cranialnerves III to XII from lateral to medial to reach medially situated

Figure 7. (A) Demonstrating microsurgical anatomy to three formerfellows in the laboratory. From left are Hiroshi Muratani (Japan), AlbertoCardoso (Brazil), and Eduardo Seoane (Argentina). (Photo by Russ Lante.)(B) The graduation party for the fellows and their spouses is held at theRhoton’s home. This party was at the graduation of Dr. Xiaoguang Tong(upper row center) of Tianjin, China. Other fellows in picture are HatemEl Khouly (Egypt), Juan Carlos Fernandez Miranda (Spain), YutakaFukushima (Japan), Hiroshima Abe (Japan), Satoshi Tsutsumi (Japan).

target areas, placing these nerves at risk. Endoscopic approaches


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have the advantage of being able to enter these areas fromanteriorly between the cranial nerves; however, entry into thebasal cisterns presents special problems related to closure,cerebrospinal fluid leak, and infection. It seems likely that morefocal exposures and techniques of closure, based on studies ofendoscopic anatomy, would aid in overcoming the problemsrelated to closure in the expanded endoscopic approaches.

MICROSURGICAL TRAINEES

It has been gratifying to view the role of our fellows and traineesin spreading this knowledge to other countries and around theworld and to see the benefits of neurosurgeons applying thisknowledge to improve surgery in their patients (Figure 7). Espe-cially gratifying have been the relationships with Dr. ToshioMatsushima of Fukuoka, Japan; Dr. Evandro de Oliveira of SaoPaulo, Brazil; and Dr. Erdener Timurkaynak of Ankara, Turkey; thestudies, career, and teaching of microsurgical anatomy of theseneurosurgeons have elevated the care of neurosurgical patientsaround the world. The residents and fellows who have worked inthe laboratory are as follows:

1. Hiroshi Abe, Japan 2. Akin Akakin, Turkey3. Felipe Alencastro, Brazil 4. Hajime Arai, Japan5. Huseyin Biceroglu, Turkey 6. Allen S. Boyd, Jr., Tennessee7. Robert Buza, Oregon 8. Alvaro Campero, Argentina9. Alberto C. Cardoso, Brazil 10. Christopher C. Carver, California1. Patrick Chaynes, France 12. Chanyoung Choi, South Korea3. Evandro de Oliveira, Brazil 14. Hatem El Khouly, Egypt5. W. Frank Emmons, Washington 16. J. Paul Ferguson, Georgia7. Juan C. Fernandez-Miranda, Spain 18. Andrew D. Fine, Florida9. Brandon Fradd, Florida 20. Kiyotaka Fujii, Japan1. Yutaka Fukushima, Japan 22. Takeshi Funaki, Japan3. Adriano Garcia-Scaff, Brazil 24. Hirohiko Gibo, Japan5. John L. Grant, Virginia 26. Kristinn Gudmundsson, Iceland7. David G. Hardy, England 28. Frank S. Harris, Texas9. Tsutomu Hitotsumatsu, Japan 30. Kazuhiro Hongo, Japan1. Kohei Inoue, Japan 32. Takuya Inoue, Japan3. Tooru Inoue, Japan 34. Wonil Joo, South Korea5. Yasuhiro Kakazu, Japan 36. Yukinari Kakizawa, Japan7. Toshiro Katsuta, Japan 38. Masatou Kawashima, Japan9. Chang Jin Kim, South Korea 40. Mathew M. Kimball, Florida1. Martin Kitroser, Argentina 42. Robert S. Knego, Florida3. Shigeaki Kobayashi, Japan 44. Chae Heuck Lee, South Korea5. Xiao-Yong Li, China 46. William Lineaweaver, Mississippi7. J. Richard Lister, Florida 48. Qing Liang Liu, China9. Jack E. Maniscalco, Florida 50. Richard G. Martin, Alabama1. Carolina Martins, Brazil 52. Haruo Matsuno, Japan3. Toshio Matsushima, Japan 54. Koji Mizokami, Japan5. J. Robert Mozingo, deceased 56. Hiroshi Muratani, Japan7. Antonio C.M. Mussi, Brazil 58. Shinji Nagata, Japan9. Yoshihiro Natori, Japan 60. Hiroyuki Nishimura, Japan1. Kazunari Oka, Japan 62. Michio Ono, Japan3. Shigeyuki Osawa, Japan 64. T. Glenn Pait, Arkansas5. Wayne S. Paullus, Texas 66. David Perlmutter, Florida7. Mark Renfro, Texas 68. Wade H. Renn, Georgia9. Saran S. Rosner, New York 70. Pablo Rubino, Argentina1. Naokatsu Saeki, Japan 72. Shuji Sakata, Japan3. Askin Seker, Turkey 74. Eduardo R. Seoane, Argentina
5. Xiang-en Shi, China 76. Satoru Shimizu, Japan

7. Aldo C. Stamm, Brazil 78. Yusuke Takemura, Japan9. Ryusui Tanaka, Japan 80. Necmettin Tanriover, Turkey1. Helder Tedeschi, Brazil 82. Erdener Timurkaynak, Turkey3. Xiaoguang Tong, China 84. Satoshi Tsutsumi, Japan5. A. Jay Ulm, Louisiana 86. Rowan Valentine, Australia7. Jian Wang, China 88. Hung T. Wen, Brazil9. C. J. Whang, South Korea 90. Isao Yamamoto, Japan1. Alexandre Yasuda, Brazil 92. Satonobu Yoshimoto, Japan3. Fumitaka Yoshioka, Japan 94. Nobutaka Yoshioka, Japan5. Arnold A. Zeal, Florida

CONCLUSION

Special thanks go to our medical illustrators, David Peace andRobin Barry, who have worked with us for more than 3 decades.Their illustrations have graced hundreds of neurosurgical publi-cations including the covers of Neurosurgery and Journal ofNeurosurgery. I also extend special thanks to Laura Dickinsonwho has labored with me on this and earlier manuscripts.

Our work has been sustained by numerous private contributionsto our department and the University of Florida. Most prominentamong these has been the R.D. Keene family who made the first$1 million gift to the University of Florida, a gift that hassupported our work for many years. The gift was followed byadditional endowments that have grown to nearly $20 million,which support multiple subspecialty educational and researchefforts in neurosurgery at the University of Florida. These giftshave endowed the following chairs and professorships:

The R.D. Keene Family Chair

The C.M. and K.E. Overstreet Chair

The Mark Overstreet Chair

The Albert E. and Birdie W. Einstein Chair

The James and Newton Eblen Chair

The Dunspaugh-Dalton Chair

The Edward Shed Wells Chair

The Robert Z. and Nancy J. Greene Chair

The L.D. Hupp Chair

The William Merz Professorship

The Albert L. Rhoton, Jr., Neurosurgery Chairman’s Professor-ship

One of the most recent of these is the series of gifts andmatching funds currently totaling $5 million establishing theAlbert L. Rhoton, Jr., Neurosurgery Chairman’s Professorshipheld by William A. Friedman, who has followed me as Chairmanof Neurosurgery. The efforts of the numerous clinicians andscientists recruited as a result of the endowed chairs contributedgreatly to the founding the Evelyn F. and William L. McKnightBrain Institute of the University of Florida where our studies ofmicrosurgical and endoscopic anatomy are being completed. Wejoin our donors in their aspiration to improve the life of patientshaving brain surgery throughout the world.

Before closing, I would like to thank my wife, Joyce, who hasallowed surgical anatomy of the brain to become a hobby that has
consumed much of my time away from the medical center (Figure

ms

IpamGtacao


8). I would also like to thank Dr. Apuzzo, not only from the bottom ofy heart, but from the depths of my most valuable earthly posses-

ion, my brain, for allowing me to share this with you.

t may be that the early experience of using teaching as aersonal learning technique motivated me to continue teachingnd working with neurosurgical groups after retirement followingore than 40 years of clinical practice. I feel very fortunate thatod has given me some basic knowledge of the construction of

he brain that has helped make surgery for my patients moreccurate, gentle, precise, and safe and has allowed me toontinue to teach at this stage of my life. Teaching has given men opportunity to look into the eyes of aspiring young and tested

Figure 8. (A) Climbing the Harbor Bridge in Sydney, Australia, with Joycefollowing the 2001 World Congress of Neurological Surgery. (B) The Giza

lder neurosurgeons on every continent. In each case and on

selves and our specialty. Clin Neurosurg 26:xiii-xix,1979.

4

5

6

7. Rhoton AL Jr: Cranial anaproaches. Neurosurgery 53(


every continent, I have found an intense desire by neurosur-geons to improve their skills and knowledge and their compe-tence to improve the lives of their patients. This journal, WORLDNEUROSURGERY, will make this job easier.

In closing, I would like to recall the following prayer for physicianssent to me by a patient with a meningioma: “Lord, Thou GreatPhysician, give skill to my hands, clear vision to my mind,kindness and sympathy to my ears. Give me singleness ofpurpose, strength to lift at least a part of the burden of mysuffering fellow men, and a true realization of the rare privi-lege that is mine.” Please accept my sincere appreciation forallowing me to join you in playing a part in the miracle we call

Pyramids with Joyce following a meeting of the Middle East NeurosurgicalSociety.

neurosurgery.

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9

REFERENCES

1. Osler W: As cited in Camac CNB: Counsels and Idealsfrom the Writings of William Osler. Boston:Houghton Mifflin; 1906.

2. Pool JL: Adventures and Ventures of a New YorkNeurosurgeon. Torington, Conn: Rainbow Press;1988:189-191.

3. Rhoton AL Jr: Presidential Address: Improving our-

. Rhoton AL Jr: Neurosurgery in the decade of thebrain: The 1990 Presidential Address. J Neurosurg73:487-495, 1990.

. Rhoton AL Jr: The posterior cranial fossa: microsur-gical anatomy and surgical approaches. Neurosur-gery 47(Suppl):S1-S297, 2000.

. Rhoton AL Jr: The supratentorial cranial space: mi-crosurgical anatomy and surgical approaches. Neu-rosurgery 51(Suppl):S1-410, 2002.

tomy and surgical ap-Suppl):S1-S746, 2002.

ww

. Rhoton AL Jr: Microsurgical anatomy and neurosur-gical pathology. Clin Neurosurg 51:11-25, 2004.

. Rhoton AL Jr: 3D anatomy and surgical approachesof the temporal bone and adjacent areas. Neurosur-gery 51:S1-250, 2007.

Conflict of interest statement: The author declares that thearticle content was composed in the absence of anycommercial or financial relationships that could beconstrued a potential conflict of interest.

1878-8750/$ - see front matter © 2011 Elsevier Inc.
All rights reserved.DOI: 10.1016/j.wneu.2011.01.025
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Fifty Years of Neurosurgery