The practice of stereotactic neurosurgery began at Duke Medical Center in the late 1950s. This was a new technology and only a few neurosurgeons carried out the operations. There were no fellowships and one had to read the original scientific papers of Spiegel and Wycis. The surgical technique was self-taught, and as time passed, neurosurgical meetings devoted to stereotactic neurosurgery were held.

Dr. Claude Bertrand, a Canadian neurosurgeon, built one of the earliest rectilinear frames, which was the first stereotactic instrument used at Duke. Two Bertrand stereotactic frames were purchased for $10,000. One was for Duke and the other for the Durham VA Hospital, which was designated the stereotactic center for all the southeastern VA hospitals.

The first stereotactic patients were those with Parkinson's disease. Tremor and rigidity were their most disabling symptoms, and they responded least to the current medical treatment. The early patients were in the most advanced stages of Parkinsonism, and the surgical results were often not satisfactory. Morbidity from these operations was low, however, since the surgery was conducted with the patient awake using local anesthesia. As the surgery was done on younger patients, the results improved with positive clinical changes lasting as long as 10 years. Neurosurgeons worldwide became interested in the stereotactic technique and much neurological disease was treated.

In 1960 we decided to study children with cerebral palsy. These children suffered from severe muscular rigidity and spasms. Medical treatment at the time resulted in minimal relief of symptoms. The cerebellum controls much of the muscle tone and balance with the cerebellar dentate nucleus specifically controlling muscle tone. Dr. Graham Slaughter, a neurosurgical resident, made a dentate nucleus stereotactic map for us. A stereotactic frame was built for the specific purpose of exploring and lesioning the dentate nucleus to reduce the spasticity of the children with cerebral palsy. The Duke cerebellar instrument was designed with the help of Dr. John Harrison, an Australian engineer working at Duke, and the frame was constructed by our Surgical Instrument shop.

A small number of children were treated and improved in their spasticity, but the effect lasted for only a few months. This short-term effect was probably due to the fact that the lesion made in the dentate nucleus did not destroy the entire nucleus, because the electrodes were not capable of making larger lesions. This was a technological problem at the time that we could not solve, so we ceased treatment of these children.

Dr. Nashold was trained in neurosurgery at the Montreal Neurological Institute of McGill University and was Dr. Penfield's last resident before he retired at age 65. The surgical treatment of epilepsy that he learned from Dr. Penfield was his major interest when he came to Duke. Dr. William Wilson, whom he had met in Montreal when he was studying under Dr. Herbert Jasper, was the chief of the Duke EEG laboratory. Dr. Jasper, one of the world's leading neurophysiologists, had directed the EEG recordings during Dr. Penfield's epilepsy surgery.

Dr. Wilson and Dr. Nashold began a surgical treatment of epilepsy at Duke, and more than 100 patients were successfully treated over the years. An intraoperative EEG was routinely done during the surgery with the patient awake. This was not always satisfactory because of the stress of the operation on the patient. Since many of the patients had complex EEGs, EEG electrodes were stereotactically implanted for longer-term studies. Dr. Wilson studied the EEG of the awake patient for many hours in a quiet room for periods of several weeks before deciding on surgery. We reduced seizures using this method.

The surgical relief of pain was also important for the neurosurgeon. The early pain operations often required a complex operation in an asleep patient. Using stereotactic treatment, a pain operation could be done under local anesthesia. This improved the clinical results for pain relief. Deeper regions of the brain could be explored and treated for types of pain not possible with the older methods of neurosurgery. Patients with pain due to cancer, herpes, infections, and injuries were successfully treated with minimal stress to the patient.

Brain tumors have been successfully visualized by a number of techniques, the latest being the MRI. However, the type of tumor may not necessarily be revealed by these radiographic methods. Over the years neurosurgeons have attempted to obtain a small sample of brain tissue to determine more precisely the nature of the tumor. The brain biopsy method was often crude, done freehand, and was frequently unsuccessful in obtaining enough brain tissue to study. Many tumors were deep in the brain and out of reach of a biopsy. Stereotactic techniques were developed with a new type of biopsy needle that was capable of retrieving enough brain tissue from deep tumors to satisfy the pathologist. This special needle was developed at Duke and was manufactured by the Radionics Corporation. The Nashold stereotactic brain biopsy needle is used today worldwide.

The development of stereotactic techniques is now an important part of neurosurgical methods. As doctors explore the brain to improve neurological diseases, we can expect new MRI imaging methods combined with stereotactic neurosurgery to provide new treatments.