Origins and Development of Neuroguided Surgery The central nervous system is the most complex and important tissue structure in the human body. It has always been the dream and challenge of neurosurgeons to localize the structures of the central nervous system in three dimensions (3D) and to accurately find and remove lesions in the intricate neurovascular structures without damaging these structures. Throughout the history of neuronavigation surgery, like human navigation, it has also undergone the development from primary to advanced, from mono-functional to multi-functional, experiencing the transformation and development of the localization of brain surface structures (early neurosurgery), framed navigation surgery and microsurgery (modern neurosurgery), and frameless navigation surgery and intraoperative image navigation surgery (micro-invasive neurosurgery).
1. Localization of brain surface structures Archaeologists have found some strange holes in human skulls excavated during the Neolithic period (7000-3000 B.C.). It was confirmed by modern radio-diffraction techniques that these holes were not caused by trauma or natural weathering, but by human tools. Therefore, it can be speculated that human ancestors mastered the simplest craniotomy technique of cutting holes in the skull DD to treat intracranial disorders during their struggle with nature.
The ancient Egyptian papyri from 2600 B.C. and the Chinese Yellow Emperor’s Classic Su Wen contain records of cranial drilling to treat illnesses. The great ancient Greek physician, poet and philosopher Hippocrates (460-370 B.C.) recorded cases of brain and spinal cord surgery in his monumental work. China’s Hua Tuo (2 AD) not only specialized in Chinese surgery and invented “Ma Bo Tang” (a thousand years before Western anesthesia!) ), but also in craniotomy.
In the 14th and 16th centuries, capitalism emerged in Europe after the Renaissance. At that time, surgeons came from missionaries or shavers, and in addition to trauma surgery and general surgery, some surgeons also performed simple craniotomies to treat traumatic brain injuries. One of them was Dr. Paré of France who treated the traumatic brain injury of King II of France. Due to the limitations of the time, early surgeons could only perform craniotomy according to the point of injury. Later, through the study of autopsies, the localization of brain surface structures could be performed based on anatomical landmarks such as elevations and grooves on the scalp or skull surface. For example, Broca (1860) discovered the motor-verbal area in charge of speech, and Horseley (1857-1916) published a monograph describing the relationship between the cerebral sulcus and its supracranial bones.
Since early surgeons also performed neurosurgery, only a few sulci on the surface of the brain could be roughly located, often with large skin incisions and bone windows to avoid localization errors (in centimeters) as well as poor illumination and coarse surgical tools. The deep brain structures cannot be located, and it is very difficult to operate in the brain parenchyma, just like a boat on the ocean, often lost.
3, framed navigation surgery – the positioning of deep brain structures framed navigation surgery, also known as stereotactic surgery, it is a metal bracket that can be fixed on the skull, with a scale, through the X-ray, CT or MRI scan can be set out the location of the intracranial target, and expressed by the number of coordinates. 1906 British Horsley and Clarke developed a stereoscopic In 1947, Spiegel and Wycis invented the human stereotactic apparatus and used ventriculography to locate and destroy deep brain structures to treat mental illness. Later, Leksell, Reichert and other directional instruments appeared one after another, and China’s Jiang Dajie in 1960 to develop China’s own directional instrument, and successfully applied to patients.
As early framed navigation surgery applied ventriculography or pneumoencephalography and X-ray photography technology, not only the positioning is less accurate, but also has considerable trauma, after the 1960s and 1970s, due to the widespread use of CT and MRI technology, greatly improved the accuracy and safety of framed navigation surgery, so that framed navigation surgery rejuvenated. However, frame-guided surgical devices have the following disadvantages that are difficult to overcome, limiting its application: ① positioning and guiding devices are bulky and lack flexibility; ② frame devices cause patient discomfort; ③ positioning and guiding are not real-time, non-intuitive and complicated calculation methods; ④ not suitable for children or thin skull; ⑤ because the positioning frame affects the tracheal intubation, for those who need general anesthesia must first tracheal intubation, and then wear the positioning frame, which will increase the anesthesia and surgery time. This will increase the anesthesia and operation time, and cannot be used for functional MRI examination. Based on its limitations, frame-guided surgery is mainly used to treat extrapyramidal diseases such as Parkinson’s disease, malignant pain, psychosis, epilepsy, destruction of the pituitary gland, removal of foreign bodies, biopsy and placement of deep electrodes.
4, frameless navigation surgery DD brain and spinal cord all-round positioning frameless navigation surgery is also known as image navigation surgery or neuronavigation surgery. As a result of frame-guided surgery has the above-mentioned shortcomings, many knowledgeable people are committed to finding new solutions. late 1980s, some of the following technological developments, for the birth of frameless navigation surgery laid the foundation: ① high-resolution, 3D neuroimaging technology development and application, such as CT and MRI not only scan time is shortened, but also can thin layered imaging and 3D reconstruction; ② 3D digital translator In 1985, Kwoh et al. applied the industrial robot PUMA to perform brain disease surgery under CT positioning, but the robot was too bulky and its use was limited. Schlondroff (Germany) and Watanabe (Japan) successively developed various frameless navigation systems. After more than 10 years of development, the navigation system has developed from articulated arm positioning system to active or passive infrared positioning device; the navigation of surgical microscope has developed from simple positioning to dynamic positioning and navigation. China’s Shanghai, Beijing, Guangzhou and Tianjin have introduced neuronavigation equipment in 1997 to carry out clinical applications and research. In recent years, domestic neuronavigation devices have been put into production in Shenzhen and Shanghai, for example, the FDM neuronavigation system developed by the Digital Medicine Research Center of Fudan University and Huashan Hospital has been approved by the state for marketing [3]. Since navigational surgery combines modern neuroimaging diagnostic techniques, stereotactic surgery and microsurgery techniques with high performance computers, it can accurately, dynamically and in near real time display the 3D spatial location of anatomical structures and lesions of the nervous system and their proximity. Therefore, it has the following advantages over framed navigation surgery: (i) preoperative surgical plan design; (ii) intraoperative near real-time 3D spatial localization; (iii) display of structures around the operative field; (iv) indication of the 3D spatial relationship between the current surgical position and the target lesion; (v) intraoperative real-time adjustment of the surgical approach; (vi) display of structures that may be encountered in the approach; (vii) display of important structures; and (viii) display of the extent of lesion removal. Through improved scanning and registration techniques, the frameless navigation system has achieved positioning errors comparable to framed systems (<1-3 mm). Frameless navigation not only overcomes the shortcomings of framed navigation, but also greatly expands the scope of surgery, and it is now applied to various intracranial occupying lesions such as brain tumors, cysts and abscesses, hematomas, vascular malformations, dural arteriovenous fistulas, skull base tumors, and epilepsy, congenital or acquired malformations, sinus and paranasal sinus, spinal and spinal cord lesions. Nowadays, frameless navigation surgery has become an important component of microinvasive neurosurgery. Navigation technology has not only made the dreams of generations of neurosurgeons come true, but also made micro-neurosurgery, locked-hole surgery, endoscopic neurosurgery, and skull base surgery like a tiger with wings, changing the backward situation of modern neurosurgery that relies on subjectivity and experience in surgical plan design, lesion localization and resection, despite advanced diagnostic imaging and micro-invasive surgical techniques, making modern neurosurgery more minimally invasive, precise safe and effective. Frameless navigation technology is also used in other medical disciplines, such as maxillofacial surgery, otorhinolaryngology, radiosurgery and conventional general radiotherapy. The latter has evolved into conformal radiotherapy and 3D intensity modulated radiotherapy with the application of navigation and positioning technology.