Surgery of the Human Cerebrum Part III.pdf

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

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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