FOREWORD

THE SUPRATENTORIAL CRANIAL SPACE: MICROSURGICAL ANATOMY SURGICAL APPROACHES

AND

eurosurgeons throughout the world salute Neurosurgery and Editor-in-Chief Michael L.J. Apuzzo on the 25th anniversary of the birth of this magnificent contributor of academic and scientific information to our specialty. This journal has elevated the care of neurosurgical patients everywhere. I am deeply appreciative to Dr. Apuzzo and the editorial board for giving me the opportunity to work with them on this supplement. I also salute Carl Zeiss, Inc., and Medtronic Midas Rex on the occasion of this publication and thank them for the grant that made this supplement possible. The increased safety and accuracy and improved results obtained with the Zeiss microscope are among my greatest professional blessings and are a great contributor to the quality of life of my patients. Medtronic Midas Rex, through the increased ease and delicacy of bone removal made possible with the use of their drills, has also made a contribution to the care of neurosurgical patients worldwide and has allowed neurosurgeons to focus on operating accurately and precisely in the delicate neural tissue that is the basis of our specialty. Both Midas Rex and Zeiss have continued to invest in modifying and upgrading their instruments by integrating them with modern technological advances to aid us in our work and provide new benefits for our patients. Both Zeiss and Midas Rex have assisted with educational endeavors, such as this supplement, that have improved neurosurgical care on every continent and have made the academic aspects of my career much more rewarding. I am grateful for their support of the publication of my studies of microsurgical anatomy and for partnering with neurosurgeons throughout the world to improve neurosurgical care. As stated in the Millennium issue of Neurosurgery, this work on microsurgical anatomy has grown out of my personal desire to improve the care of my patients. It represents a 40-plus-years attempt to gain an understanding of the anatomy and intricacies of the brain with the goal of improving the safety, gentleness, and accuracy of my operations on my patients. In this Foreword, I share some of my thoughts about neurosurgery, some of which were included in addresses that I delivered as president of the AANS and the CNS (1, 2). Neurosurgeons share a great professional gift; our lives have yielded an opportunity to help people in a unique and exciting way. I would like to reflect on the joy and excitement of being allowed to participate in the miracle that we call neurosurgery. In my early years, I never imagined that my life would hold as exciting and delicate a challenge as that of being a physician or a neurosurgeon. Neurosurgeons work is performed in response to the idea that human life is sacred, that it makes sense to spend

years of ones life in study to prepare to help others. Our training brings into harmony a knowledgeable mind, a skilled set of hands, and a well-trained eye, all of which are guided by a caring human being. The skills that we use have been described as the most delicate, the most fateful, and, to the layperson, the most awesome of any profession. The Gallup Poll has reported that neurosurgeons are among the most prestigious and highly skilled members of American society. We share the opportunity to serve people in this unique way, dealing surgically with the most delicate of tissues. Our ranking among the most highly skilled members of society tends to lead us to forget that our work and success are made possible by the benevolent order built into the universe around us. That people heal and survive after surgery provides us with our work and serves as a constant reminder of this benevolent, protective order. We are surrounded by biological and physical forces that could overcome us, outstripping our finest medical and scientific achievements. The momentous process of injured tissues knitting together is as essential to the work of the surgeon as the air people breathe is to their survival. That humanity survives and that neurosurgeons can play a role in the process of healing are examples of the compassion and love that surround us. A patient who writes a thank-you note or praises my efforts leads me to inwardly reflect that the great gift we have been given is that we were created to help each other. The next gift that we share is a historical one based on the standards set by early physicians. Hippocrates taught that medicine is a difficult art that is inseparable from the highest morality and love of humanity. The noble values and loyal obedience of generations of physicians since Hippocrates have raised the calling to the highest of all professions. Many of us were attracted to neurosurgery by both the meticulousness of surgical craftsmanship and the intellectual challenge posed by modern clinical neurology and neurophysiology. All of us have submitted ourselves to the discipline of rigorous training, possibly the most demanding in modern society, and are capable of giving a great deal of ourselves. Our work has grown out of the belief in absolute standards of value and worth in humanity. These values are reflected in the increasing importance of one man, one woman, or one child in American society and throughout the world. An example of the evolving importance of the individual is found in examining great human creations such as the Egyptian pyramids and the Great Wall of China. Through the decades and the centuries, humankind has evolved to the point where the pyramids of modern society are some of our medical centers.

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In them, societys most highly trained teams, using humankinds most advanced technology at great cost, are allowed to work for days trying to improve the lives of individual patients without regard to whether the patients are rich or poor. Issues related to the dignity and worth of a single man, woman, or child are clearer now than they were a century or two ago and provide the driving force behind our work. These values and standards, which are inseparable from the highest morality and love of humanity, are built into us just as the process of healing is built into nature. Another circumstance leading to the esteem that neurosurgeons enjoy is the magnificent tissue with which we work. The brain is the crown jewel of creation and evolution. It is a source of mystery and wonder. Of all of the natural phenomena to which science can draw attention, none exceeds the fascination that greets the workings of the human brain. The brain holds the greatest unexplored biological frontiers. It is the most frequent site of crippling, incurable disease. The brain, although it does not move, is the most metabolically active of all organs, receiving 20% of cardiac output while representing only 3% of total body weight. It is the only organ in the body that is hidden and completely enclosed within a fortress of bone. It is exquisitely sensitive to touch, anoxia, and derangements of its internal environment. Its status determines whether the humanity within us lives or dies. It yields all that we know of the world. It controls both the patient and the surgeon. Brain accounts for the mind, and through the mind, we are lifted from our immediate circumstances to consciousness and given an awareness of ourselves, our universe, our environment, and even the brain itself. Here, in two handfuls of living tissue, we find an ordered complexity sufficient to preserve the record of a lifetime of the richest human experience and create computers that can store amounts of data that can be comprehended only by the mind. Perhaps the most significant achievement of this tissue is the ability, on the one hand, to conceive of a universe more than a billion light-years across and, on the other, to conceptualize a microcosmic world out of the reach of the senses and to model words completely separate from the reality that we can see, hear, smell, touch, and taste. Mind and brain are the source of happiness, knowledge, and wisdom. The brain is not the seat of the soul, but it is through the brain and mind that we become aware of our souls. In my early years, never in my wildest flights of imagination did I consider that life would yield such rewarding and challenging work as that of being a physician, and I was unaware that neurosurgery even existed. My early life was without exposure to physicians or to hospitals, electricity, or other modern conveniences. My birth was aided by a midwife in exchange for a bag of corn. As I entered college, the goal of being a physician seemed so unattainable that I had not entertained that possibility. I first pursued chemistry, but the missing human element led me to major in social work. Social work also failed to satisfy me because it lacked the opportunity to touch and help others by working with my hands. That I might become a physician did not enter my mind until a psychology instructor invited me to see a brain operation performed in his laboratory. To my amazement, a tiny lesion improved the small animals behavior, but without affecting its motor skills. That day, I sensed some of the amazement that must have been experienced in the 1870s when Broca presented his early observations regarding the cerebral localization of speech in his patient, Tan, and when Fritsch and Hitzig described their experiments in the cerebral motor cortex. Before their time, interest in the brain and its function centered on philosophical discussions of the brain as the seat of the mind and the soul and not as a site possessing the localizing features suitable for the application of a physicians or surgeons skills. On that day in the psychology laboratory, I learned that surgery based on these concepts was possible, and I knew that I had found my calling. I know that many neurosurgeons have had a similar meaningful experience. In medical school, I began to work in a neuroscience laboratory in my spare time. At the end of my residency, I completed a fellowship in neuroanatomy. It was during this fellowship that I realized the potential for greater knowledge of microsurgery and microneurosurgical anatomy to improve the care of my patients. I resolved early in my career to incorporate this new technique into my practice, because it seemed to increase the safety with which I could delve deep into and under the brain during surgery. One of my favorite personal goals has been to find images of a single operation performed perfectly, because the inner discipline of striving toward perfection leads to improvement. Such images are the essential building blocks for the improvement of operative techniques. During my training and thereafter, I lay awake many nights, as I know all neurosurgeons have, worrying about a patient who was facing a necessary, critical, high-risk operation the next day. With the use of this new technique, I found that difficult operations that carried significant risk were performed with greater accuracy and less postoperative morbidity. During my training, I did not see a facial nerve preserved during the surgical removal of an acoustic neuroma. Today, that goal is accomplished in a high percentage of surgical patients with acoustic neuromas. In the past, in operating on patients with pituitary tumors, there was minimal discussion of preserving the normal pituitary gland; today, however, the combination of new diagnostic and surgical techniques has made tumor removal with the preservation of normal pituitary function a frequent achievement. The application of microsurgery in neurosurgery has yielded a whole new level of neurosurgical performance and competence, and the microsurgical anatomy is the roadmap for applying microsurgical techniques. As I started to work with microsurgical techniques, I realized that there was a need to train many neurosurgeons in their use. When I moved to the University of Florida, I began trying to develop a center for teaching neurosurgeons these techniques. Eventually, with the help of private contributions, my institution was able to purchase the necessary microscopes and equipment for a laboratory in which seven surgeons could learn at one time. The next task was to find seven individuals who were willing to come to the university for a course.

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Finally, after much solicitation, seven surgeons joined us for a 1-week course. I was quite apprehensive about that course, because I was not sure that we could keep seven surgeons busy learning microvascular skills for a whole week. It was comforting to learn that Harvey Cushing, early in his career, had developed a similar laboratory in which surgeons could practice and perfect their operative skills. I still remember and am grateful to each member of the initial group of neurosurgeons who were willing to invest 1 week of their valuable time in our first course more than 25 years ago. During the first afternoon of that course, I walked into the laboratory and, to my amazement, found seven surgeons working quietly and diligently. Nothing was said for long periods of time. In the midst of this intense endeavor and amazing quietness, I realized that we had tapped into a great force: the desire of neurosurgeons to improve themselves. Each individual neurosurgeon can acquire new skills so that a new level of performance in the specialty is achieved. Microtechniques are now being applied throughout neurosurgery, thus adding a new level of delicacy and gentleness to our specialty. The competence of the whole specialty has been improved, and with this experience has come the realization that neurosurgeons, as a group, are constantly aspiring to and achieving higher levels of performance that are not based on advances in diagnostic equipment and medication but are dependent on inspired individuals striving to improve their surgical skills and knowledge to better serve their patients. Every year provides multiple examples of modifications in microsurgery that make operations more successful. It is interesting how the insights gained from recent patients, even after many years of practice, when combined with an intense desire to improve ones skill and competence, lead to new insights. After years of retirement, J. Lawrence Pool, who led the neurosurgical program at Columbia University, recently wrote, As I look back on the pattern of my life I see how fortunate it was that I had chosen a career in neurosurgery, which I passionately loved despite its long hours and many grueling experiences. He concluded with a statement about his belief that the best surgeons have a strong sense of compassion. It is important that we grow in compassion as we grow in competence. Competence is the possession of a required skill or knowledge. Compassion, on the other hand, does not require a skill or knowledge; it requires an innate feeling, commonly called love, toward someone else. Both competence and compassion need to be developed simultaneously, just as the giant oak develops its root system along with its leaves and branches. Competence without compassion is worthless. Compassion without competence is meaningless. It is a great challenge to guide patients competently and compassionately through neurosurgery. Death and darkness crowd near to our patients as we help them search for the correct path. Neurosurgical illness threatens not only their physical but also their financial security, because it is so expensive and the potential for disability is so great. No experience draws more frequently than the performance of neurosurgical procedures on the passage in Psalm 23, though I walk through the valley of the shadow of death. . . . Neurosurgeons competence should be reflected in our training, knowledge, and skill; our compassion should be reflected in our kindness, sincerity, and concern. The Saints and Buddhas taught that compassion and wisdom, which lead to competence, are one. Our patients are looking for help from someone who is knowledgeable, patient, and wise and who can provide clarity, wisdom, and enlightenment so that they can face life after surgery on the brain. That is the essence of integrating competence and compassion. Neurosurgeons have the responsibility to develop the dialogue in understandable terms to help the patient, the patients family, and society understand the meaning of the patients illness. One of my personal precepts is, The best ally in the treatment of neurosurgical illness is a well-informed patient. Success requires more than advancing and applying medical knowledge. It also requires increased compassion so that we can respond sympathetically and with the best of our knowledge to all of our patients questions and provide them with timely information that will help them understand their illness and plan their lives. There comes a time in our work when we can make as much of a difference in each others lives by sitting for 30 minutes, 1 hour, or longer to answer questions as we can by hours in surgery. There is no substitute for an honest, concerned, and sympathetic attitude. Success may not mean that every patient survives or is cured, because some problems are insolvable and some illnesses are incurable. Instead, success should mean giving every patient the feeling that he or she is cared about, no matter how desperate their situation, that their pain is felt, their anger is understood, and that we care and will do our best. The greatest satisfaction in life comes from offering what you have to give. Devotion and giving to others provides purpose and meaning to life. This 25th anniversary issue on the supratentorial area and the Millennium issue of Neurosurgery on the posterior fossa represent a distillation of more than 40 years of work and study in which 62 residents and fellows have participated, resulting in several hundred publications. In this supplement, we attempt not only to display the brain and the cranial base in the best views for understanding the anatomy but also to show the anatomy exposed in the surgical routes to the supratentorial area and the anterior part of the cranial base. For those who want even greater detail than that displayed in this supplement, our prior work, published largely in Neurosurgery and the Journal of Neurosurgery, can be consulted. It has been gratifying to view the role of our fellows and trainees in spreading this knowledge to other countries and around the world and to see the benefits of neurosurgeons applying this knowledge to improve their patients operations. Especially gratifying have been the relationships with Toshio Matsushima of Fukuoka, Japan, and Evandro de Oliveira of So Paulo, Brazil, whose studies of microsurgical anatomy have elevated the care of neurosurgical patients around the world. The following are the residents and fellows who have worked in the laboratory:
Hajime Arai, Japan Allen S. Boyd, Jr., Tennessee Robert Buza, Oregon Alberto C. Cardoso, Brazil Christopher C. Carver, California Patrick Chaynes, France Evandro P. de Oliveira, Brazil W. Frank Emmons, Washington J. Paul Ferguson, Georgia Andrew D. Fine, Florida

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Brandon Fradd, Florida Kiyotaka Fujii, Japan Hirohiko Gibo, Japan John L. Grant, Virginia Kristinn R.G. Gudmundsson, Iceland David G. Hardy, England Frank S. Harris, Texas Tsutomu Hitotsumatsu, Japan Takuya Inoue, Japan Tooru Inoue, Japan Yukinari Kakizawa, Japan Toshiro Katsuta, Japan Masatou Kawashima, Japan Chang Jin Kim, South Korea Robert S. Knego, Florida Shigeaki Kobayashi, Japan Chae Heuck Lee, South Korea Xiao-Yong Li, China William Lineaweaver, California J. Richard Lister, Illinois Qing Liang Liu, China Jack E. Maniscalco, Florida Richard G. Martin, Alabama Carolina Martins, Brazil Haruo Matsuno, Japan Toshio Matsushima, Japan J. Robert Mozingo, deceased Hiroshi Muratani, Japan Antonio C.M. Mussi, Brazil Shinji Nagata, Japan Yoshihiro Natori, Japan Kazunari Oka, Japan Michio Ono, Japan T. Glenn Pait, Arkansas Wayne S. Paullus, Texas David Perlmutter, Florida Mark Renfro, Texas Wade H. Renn, Georgia Saran S. Rosner, New York Naokatsu Saeki, Japan Shuji Sakata, Japan Eduardo R. Seoane, Argentina Xiang-en Shi, China Ryusui Tanaka, Japan Necmettin Tanriover, Turkey Helder Tedeschi, Brazil Erdener Timurkaynak, Turkey Jay Ulm, Florida Hung T. Wen, Brazil C.J. Whang, South Korea Isao Yamamoto, Japan Arnold A. Zeal, Florida

Keene family, which made the first $1 million gift to the University of Florida, a gift that has supported our work for many years. That gift was followed by additional endowments that have grown to nearly $20 million, which supports many aspects of education and research in neurosurgery and the neurosciences at the University of Florida. These gifts have endowed the following chairs and professorships:
The The The The The The The The The The The R.D. Keene Family Chair C.M. and K.E. Overstreet Chair Mark Overstreet Chair Albert E. and Birdie W. Einstein Chair James and Newton Eblen Chair Dunspaugh-Dalton Chair Edward Shed Wells Chair Robert Z. and Nancy J. Greene Chair L.D. Hupp Chair William Merz Professorship Albert L. Rhoton, Jr. Chairmans Professorship

Special thanks go to our medical illustrators, David Peace and Robin Barry, who have worked with us for 2 decades. David and Robins illustrations have graced hundreds of neurosurgical publications, including the covers of Neurosurgery and the Journal of Neurosurgery, for decades. I also extend special thanks to Ron Smith, who has directed the microsurgery laboratory for many years, and to Laura Dickinson and Fran Johnson, who have labored over these and earlier manuscripts. It is these individuals to whom this volume is dedicated. This work has been sustained by numerous private contributions to our department and the University of Florida. Most prominent among these donations has been that of the R.D.

The most recent of these is the series of gifts and matching funds totaling $5 million to establish the Albert L. Rhoton, Jr. Neurosurgery Professorship held by William A. Friedman, who followed me as chair of the Department of Neurosurgery. The efforts of the numerous clinicians and scientists recruited as a result of the endowed chairs contributed greatly to the founding of the Evelyn F. and William L. McKnight Brain Institute of the University of Florida, where our studies of microsurgical anatomy are being completed. With this supplement, we join our donors in their aspiration to improve the lives of patients who undergo brain surgery throughout the world. Albert L. Rhoton, Jr. Gainesville, Florida

REFERENCES
1. Rhoton AL Jr: Presidential address: Improving ourselves and our specialty. Clin Neurosurg 26:xiiixix, 1979. 2. Rhoton AL Jr: Neurosurgery in the decade of the brain: The 1990 AANS presidential address. J Neurosurg 73:487495, 1990.

The cerebral circulation from Vesalius De Humani Corporis Fabrica (1543). Courtesy, Yale Medical Library.