Summary An ununited accessory ossification centre of

Diagnostic quality Soft tissues the fibular head will have a smooth corticated
Alignment of bones Effusions margin unlike a fracture. A thin line of
Femur: tibia Lipohaemarthrosis
Patella Chondrocalcinosis ossification may also be seen in the medial
Surgical emphysema collateral ligament next to the insertion point on
Bone margins and density Foreign bodies the medial femoral epicondyle. This is caused by
Femur, tibia, patella, fibula
Cartilage and joints
an old avulsion injury of this ligament with
Femorotibial subsequent calcification within the subperiosteal
Patellar-femoral haematoma (Pelligrini-Stieda disease) (fig 9).

P Sanville is Cook research fellow in radiology, D A Nicholson is consultant radiologist, and

P A Driscoll is senior lecturer in emergency medicine at Hope Hospital, Salford.
The line drawings were prepared by Mary Harrison, medical illustrator.
The ABC ofEmergency Radiology has been edited by David Nicholson and Peter Driscoll.

Minimally Invasive Surgery

Neurosurgery
D G T Thomas, N D Kitchen

This is the seventh in a series The introduction of minimlly invasive techniques

ofarticles describing the has greatly improved results for intracranial neuro-
current techniques in minimal surgery. Stereotaxy and improved imaging tech-
access surgery. The articles niques have reduced surgical trauma by allowing
have been written to inform
non-specialists ofdevelopments surgeons to plan the least damaging route to opera-
in this rapidly moving area. tive sites and by increasing surgical precision.
Stereotaxy has also allowed brain biopsies to be
taken from sites such as the brain stem, which were
rarely sampled before because free hand biopsy was
so dangerous. Brain tumours can now be treated by
interstitial radiotherapy-stereotactic insertion of
catheters into the lesion for loading of radioactive
iodine-or radiosurgery-focusing of intense beams
of radiation on lesions without needing surgical
incisions. Endoscopic neurosurgery can be used to
reach cavities such as the ventricular system or
cystic tumours. With interventional neuroradiology
fine catheters can be introduced into most vessels in FIG 1-Stereotactic frame in use during craniotomy. Entry point and
the cranium for embolisation or dilatation. The trajectory to target have been chosen
development of augmentative functional neuro-
surgery means that movement disorders, epilepsy, surgery in animals and has been successfully developed
and intractable pain can be treated with implanted for clinical use in humans over the past 40 years.'
neurostimulating electrodes. Future developments Technically satisfactory systems are now commer-
will probably include frameless stereotaxy, when the cially available, the most popular being the CRW
rigid attachment of stereotactic apparatus to the (Radionics, Boston, USA) (fig 1) and Leksell (Elekta,
patient's head can be dispensed with, and at least Stockholm, Sweden). With such devices a probe can be
partial automation of procedures such brain biopsy. introduced into a known part of the brain identified by
imaging and a knowledge of brain anatomy. A com-
During the last three decades the results of intracranial puter can be used to generate a three dimensional
neurosurgery have improved, largely due to better image so that the surgeon can choose the least damag-
neuroanaesthesia and the introduction of glucocorti- ing route to the operative site.
coids to control cerebral oedema and the operating The basic principle of nearly all current stereotactic
microscope. Most major intracranial neurosurgical equipment is firm fixation of the stereotactic apparatus
Gough-Cooper procedures, however, have a high potential for to the patient's skull vault with metal pins or, more
Department of morbidity and mortality because of the physical sensi- recently, dental fixation (fig 2). The second method is
Neurological Surgery, tivity and neurological eloquence of the structures less invasive and allows the frame to be applied
Institute of Neurology, involved. In minimally invasive neurosurgery surgical repeatedly so that stereotactic imaging, planning of
London WC1N 3BG techniques, particularly stereotaxy, have been coupled treatment, and surgery may be carried out at different
D G T Thomas, professor of with improvements in neuroradiological imaging to times. For stereotactic surgery local anaesthesia can be
neurosurgery increase precision and to reduce trauma to normal used, but general anaesthesia provides optimal control
N D Kitchen, clinical tissues. of intracranial conditions.
research felow
Correspondence to: Stereotactic biopsy and craniotomy
Dr Kitchen. Stereotaxy
Stereotaxy was introduced by Horsley and Clarke at In stereotactic brain biopsy a fine cannula just over
BMJ 1994;308:126-8 the beginning of this century for experimental brain 1 mm in diameter is passed down into the radiographic-

126 BMT VOLUM 308 8JA.uARY 1994

Sites of lesions biopsied under ally visible lesion to obtain a biopsy. The table shows pated diagnosis was confirmed in most of the cases, an
computed tomographic guidance the anatomical sites of lesions that were biopsied in a unexpected diagnosis was made in 51 cases. In 30 of the
in 300 consecutive cases series of 300 consecutive patients in our unit over six cases the biopsy cannula was also used for therapeutic
No of years. The series included 37 brain stem lesions, which purposes, including aspiration of 15 haematomas and
Site cases were rarely biopsied before stereotactic methods three brain abscesses.
Frontal, frontal-parietal,
became available because free hand biopsy was too The success of free hand biopsy of the brain varied
and fronto-temporal 68 dangerous. The differential diagnosis in all cases from unit to unit and depended in particular on the
Parietal 39 included the possibility of malignant brain tumour part of the brain to be sampled. The best reported
Temporal and temporo-
parietal 47 requiring histological verification. Although the antici- figures included mortality of up to 5% and 10% serious
Occipital 10 morbidity of 10%.23 The operative mortality in our
Internal capsule 4 series of 300 patients undergoing biopsy is now down
Corpus callosum 10
Pituitary 7 to 0 3% (one patient) with a serious morbidity of just
Pineal 8 over 2%. More importantly, the success rate in terms of
Third ventricle 7
Thalamus and basal ganglia 34 obtaining a definitive histological diagnosis has risen
Brain stem* 37 from less than 80% in series with free hand biopsy to
Cerebellum 1
Multiple 28 90-95% with stereotactic biopsy. The technique may
be modified and a small craniotomy performed in order
*Including eight cases of to resect small superficial tumours. Such stereotactically
stereotactic aspiration ofbrain stem guided craniotomies allow the surgeon to make smaller
haematomas revealed by computed
tomography. scalp incisions and skull openings as well as providing
accurate guidance to the tumour with a minimum of
brain retraction and dissection. All these features help
to decrease the morbidity associated with such a major
procedure.

Interstitial radiotherapy (brachytherapy)

With interstitial radiotherapy neurosurgery inter-
faces with radiotherapy for the treatment of recurrent
brain tumours. The method allows high doses of
radiation to be given safely to a tumour despite
FIG 2-Patient fitted with repeat stereotactic localiser. Accurate previous external beam radiotherapy.4 The tumour
fixation provided by unique detail impression ofupper dentition mass is first imaged stereotactically-most conveni-
ently with a relocatable device as shown in figure 2-so
that its volume can be estimated (figs 3 and 4).
Scanning is usually done by computed tQmography
though magnetic resonance imaging can also be used.
The operation is then planned, and up to four external
catheters are inserted stereotactically into the tumour.
Seeds of radioactive iodine-125 may then be loaded
into the tumour via a catheter, providing interstitial
radiotherpy for five to seven days after implantation.

Radiosurgery
Radiosurgery was pioneered by Professor Leksell at
the Karolinska Institute, Stockholm. Intense beams of
FIG 3-Senes of axsal slices of brain oy computea tomography. -y radiation from 201 sources of cobalt-60 are closely
Recurrent tumour oudined in white with proposed radiations super- collimated and focused to treat deep seated inoperable
imposed lesions, particularly arteriovenous malformations. The
initial Swedish results are promising but the apparatus
is expensive and complex, and an ordinary linear
accelerator, accurately collimated and used stereo-
tactically, can provide external radiosurgery for small
benign tumours and angiomas and may be as effective.5
Both techniques are currently in use and are minimally
invasive, not needing surgical incisions and requiring
only local anaesthesia. Complications may arise, how-
ever, because of radionecrosis.

Endoscopic neurosurgery
Endoscopic neurosurgery was first performed in
Britain by Dickson Wright at Maida Vale Hospital in
1926, when he used a cystoscope to introduce instru-
ments to coagulate the choroid plexus in a case of
hydrocephalus. The technique was adapted by Griffith
in Bristol,6 and more recently both flexible and rigid
endoscopes have been coupled with stereotactic locali-
sation to reach fluid filled cavities such as the ventricu-
lar system or cystic tumours.' This technique of
minimally invasive neurosurgery is developing
FrIG 4-Three dimensional reconstruction of scans shown in fig 3. Tumour is blue, proposed radiation rapidly, with improved optics and instrument tech-
dose is red, and positions of catheters are green lines. Surrounding fiducial rods are used in nology widening the potential for endoscopic interven-
stereotactic planning tions.

BMJ VOLUME 308 8JANuARY 1994 127

 neurosurgery has been developed. This depends
.mainly on implanted neurostimulating electrodes so
that severe intractable chronic pain may be treated by
spinal cord or deep brain stimulation9 and movement
disorders by thalamic stimulation.10 New minimally
invasive techniques also allow smaller selective resec-
tions to be made in selected cases of epilepsy surgery
(fig 5).
Frameless stereotaxy and robotics
||w i.t ~~~~~~~~~~~~~~~~...t..2 In frameless stereotaxy the rigid attachment of
stereotactic apparatus to a patient's head during
surgery is dispensed with. Instead, landmarks in the
patient's skull and brain are used to register the scan
:~~~~~~~~~~~~~~~~~~~. . : e :..... . images with anatomical brain structures with an
accuracy which approaches that obtained by existing
methods." Technical developments in this area will
FIG 5-Postoperative coronal
probably result in minimally invasive techniques being
brain scan (Tl weighted introduced more widely into general neurosurgery. In
magnetic resonance imaging) the future the increasing application of techniques
showing removal of epileptogenic derived from robotic engineering should allow a degree
mesial temporal structures- of automation in operations such as brain biopsy.
hippocampus and amygdala-
by highly selective stereotactic 1 Redfern RM. Historical perspective. In: Thomas DGT, ed. Stereotactic and
operation. Only minimal image directed surgery of brain tumours. Edinburgh: Churchill Livingstone,
removal oflateral temporal 1993: 1-29.
neocortex is required 2 Lee T, Kenny BG, Hitchcock ER, Teddy PJ, Palvidas H, Harkness W, et al.
Supratentorial masses: stereotactic or freehand biopsy? Br J Neurosurg
1991;5:331-8.
3 Kitchen N, Bradford R, Thomas DGT. Stereotactic surgery: methods of CT
and MRI directed biopsy. In: Thomas DGT, ed. Stereotactic and image
Interventional neuroradiology directed surgery of brain tumours. Edinburgh: Churchill Livingstone, 1993:
3948.
Neuroradiologists can now introduce fine catheters 4 Gutin PH, Phillips TI, Wara WM, Leibel SA, Hosbuchi Y, Levin VA, et al.
into almost any vessel in the cranium, and such vessels Brachytherapy of recurrent malignant brain tumours with removable
iodine-125 sources.JNeurosurg 1984;60:61-8.
can be embolised, blocked with glue, or dilated with a 5 Luxton G, Petrovich Z, Jozsef G, Nedzi LA, Apuzzo MU. Stereotactic
balloon.8 Inoperable aneurysms, large arteriovenous radiosurgery: principles and comparison of treatment methods.
Neurosurgery 1993;32:241-58.
malformations, and carotico-cavemous fistulae can 6 Griffith HB. Endoneurosurgery-endoscopic intracranial surgery. In: Symon I,
now be treated with such minimally invasive tech- eds. Advances and technical standards in neurosurgery. Vol 14. Vienna:
niques with an average morbidity similar to that Springer-Verlag, 1986:2-24.
7 Hellwig D, Bauer BL. Minirnally invasive neurosurgery by means of ultrathin
associated with routine carotid angiography. endoscopes. In: Minimally invasive neurosurgery. Vienna: Springer-Verlag,
1992:63-8.
8 Nichols DA. Endovascular treatment of the acutely ruptured intracranial
aneurysm.JNeurosurg 1993;79:1-2.
Functional neurosurgery 9 Siegfried J. Therapeutical neurostimulation-indications reconsidered.
Acta Neurochir Suppl (Wien) 1991;52:112-7.
Most functional neurosurgical procedures-neuro- 10 Benabid AL, Poilack P, Gervason C, Hoffmann D, Gao DM, Hommel M,
surgical operations designed to improve movement et al. Long-term suppression of tremor by chronic stimulation of the ventral
disorders, epilepsy, or pain used to rely on destruc- intermediate thalamic nucleus. Lancet 1991;337:403-6.
11 Guthrie BL, Kaplan R, Kelly PJ. Neurosurgical stereotactic operating arm.
tive lesions, but recently augmentative functional Stereotact Funct Neurosurg 1990;54-5:497-500.

SOUND BITES
A hospital administrator worth his weight in gold
Research at Victoria Hospital in Dichpalli, India, radically lay in Colonel Ponnaiya's sporting interests. As Lawrie
changed thinking on the transmission of leprosy. It was first showed me around Victoria Hospital we passed an
inspired by the late Dr Frank Davey and nurtured by Dr open area and I remarked that it might make a good
R J W Rees, formerly director of the Medical Research cricket pitch. His eyes lit up and in rapid time a ground,
Council's Mycobacterium Research Unit. The team, in matting, nets, and the necessary equipment were in place.
which I participated examining noses and taking smears After some practice a team from the nearest town,
and biopsies, showed that in early lepromatous leprosy the Nizamabad, accepted our invitation to visit and subse-
nasal discharge is the prime source of exit of Mycobactenium quently we played the return fixture. From the first
leprae from the body and contains many millions of viable match, held on New Year's Day 1973, the hospital team
bacilli often before any gross systemic features are obvious. consisted of patients and staff and never has there been
Victoria Hospital is three hours by road from Hydera- resistance to the stipulation that all are to be treated
bad, the nearest airport, which is two hours by air from equally, both on and off the field. The team has now
Delhi, which, in turn, is 10 hours from London. The travelled extensively, in friendly and tournament com-
hospital secretary, Lieutenant Colonel Lawrie Ponnaiya petitions, throughout Andra Pradesh with immense
was responsible for arranging safe transport of fresh nasal benefit to the morale of patients and staff. The matches
biopsies and sealed specimens of nasal discharge from have enhanced public awareness of the true nature of
Dichpalli to Delhi to catch the overnight flight and arrive leprosy as a curable illness that, with early diagnosis and
fresh in London within 24 hours for inoculation into treatment, should carry no social stigma.-REX BARTON iS
immune deficient mice. Given the intermittency of the a consultant ear, nose, and throat and a head and neck surgeon
public power supply and the capricious nature of the in Leicester
hospital generator even guaranteeing the necessary supply
of ice was a minor miracle but, to my knowledge, not one We welcome contributions to fillers: A patient who changed my
specimen went astray. practice; A paper that changed my practice; A memorable patient;
An equally great service to the hospital and community The message I would most like to leave behind, or similar topics.

128 BMJ VOLUME 308 8 jAuA. 1994