US 3357431 A
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Description (OCR text may contain errors)
Dec. 12, 1967 e. N. NEWELL NEUROSURGICAL APPARATUS 4 Sheets-Sheet 1 Filed March 5, 1965 R m m l o w Q Q in NM m. W, 4 mp? QM. W \N f 0 0 ev WW 7 v- ATiORNEYS Dec. 12, 1967 G. N. NEWELL 3,357,431
NEUROSURGICAL APPARATUS Filed March 3, 1965 4 Sheets-Sheet 2 INVENTOR 650261 NOD05? A/f/VL ZL XMW ATTORNEYS Dec. 12, 1967 G. N. NEWELL 3,357,431,
NEUROSURGICAL APPARATUS Filed March 5, 1965 4 Sheets-Sheet 5 Z kg INVENTOR 7 6.50265 M0005? Milt [Z1 1 iwk W ATTORNEYS Dec. 12, 1967 G. N. NEWELL 3,357,431
NEUROSURGI CAL APPARATUS Filed March 3, 1965 4 Sheets-Sheet 4 III [III lllllllllllllll Hllllllllllllllllllun lulluullml m INVENTOR smea #00051 Niki/64L- BY MW A TORNEY5 United States Patent Ofifice 3,357,43l Patented Dec. 12, 1967 3,357,431 NEUROSURGICAL APPARATUS George Nodder Newell, Edinburgh, Scotland, assignor to Allen & Hanburys Limited, London, England, a British company Filed Mar. 3, 1965, Ser. No. 436,734 11 Claims. (Cl. 128-403) ABSTRACT OF THE DISCLOSURE The present invention involves stereotactic neurosurgical apparatus used for locating lesions in the brain.
This application is a continuation-in-part of my copending US. application Ser. No. 41,693, filed July 8, 1960, now abandoned.
The present invention is concerned with neurosurgical apparatuses. More particularly, the present invention relates to a stereotactic neurosurgical apparatus useful for strategically placing lesions as a treatment or part of the treatment for certain nervous disorders, intractable pain and psychiatric disorders. The relief of the more distressing symptoms of Parkinsonism and other hyperkinetic disorders by the production of destructive coagulative lesions of the brain by diathermy or chemical means is becoming an accepted surgical procedure. In surgical procedures of this kind, it is essential to ensure that the lesion is located with extreme accuracy and that the apparatus used should enable the production of the minimum lesion consistent with relief of the condition to be treated. It is desirable, too, that it should be possible to apply the apparatus to the head of a patient with a minimum amount of discomfort to the patient and in as short a time as possible consistent with accuracy.
Stereotactic devices are known but all suffer from one or more disadvantages such as the distress caused the patient when the procedure is lengthy, the degree of accuracy in localizing the site of the lesion is less than is desirable, the method of adjustment is difficult and inconvenient for the surgeon or there is the risk that the position of the apparatus will inadvertently be altered Iduring the operation, such as by movement of the patients ead.
An object of the present invention is to provide an instrument capable of insuring the production of surgical destructive coagulative lesions of the brain by diathermy or chemical meanswith greater accuracy than was hitherto possible and which overcomes the disadvantages of the known apparatuses.
The present invention provides a surgical stereotactic instrument comprising a crest frame adapted to be fixed to the cranium of a patient along the mid-sagittal plane and a carriage, to which the rest of the instrument is attached, which includes sights positioned one on each side of the head of the patient, the sights being movable together backwards and forwards, and upwards and downwards with respect to the frame, treatment supporting means carried by the frame so as to be located in a fixed position determined by the adjustment of the frame and treatment means.
The preferred embodiments of the invention are illusrated in the accompanying drawings wherein:
FIGURE 1 is a perspective view of the stereotactic instrument placed on the head of a patient to be treated;
FIGURE 2 is a sectional view taken along lines 2-2 of FIGURE 1;
FIGURE 3 is a sectional view taken along lines 33 of FIGURE 2;
FIGURE 4 is a sectional view taken along lines 44 of FIGURE 1;
FIGURE 5 is a sectional view taken along lines 5--5 of FIGURE 1;
FIGURE 6 is a sectional view taken along lines 66 of FIGURE 5;
FIGURE 7 is a sectional view taken along lines 77 of FIGURE 1;
FIGURE 8 is a view similar to that in FIGURE 2 of a modified embodiment; I
FIGURE 9 is a sectional view taken along lines 9) of FIGURE 8.
For convenience of description the instrument is herein described with the parts of the instrument in the positions which they occupy when the instrument is fittted to the head of a patient during a neurosurgical operation. Before the instrument is fitted on the cranium of a patient, three screws A, A and A" are placed in the outer table of the skull according to a simple procedure to be described. There is a constant anatomical relationship between the globus pallidus, and the thalamus, the anterior and posterior commissures and the mid-sagittal plane of the head.
Thus, the first step in using this stereotactic instrument to treat a patient is to inspect the patients cranium, and to note the positions of the lamboid and interparietal sutures. Knowledge of the anatomy of the brain, then enables a prediction to be made of the approximate position of the mid-sagittal plane, i.e. the mid-line of the brain. A series of small lead shots are inserted into holes made in the skull at three points astride the mid-saggital lane as predicted. Air is then injected into the ventricular system and subarachnoid space of the brain and since the air is less opaque than the surrounding brain, an X-ray film shows the position of the anterior and posterior commissures, and the exact position of the mid-sagittal plane. The inserted lead shots, having been placed in three groups each of which is astride the midline, appear on the X-ray film. One shot in each group can be seen to lie on the exact mid-saggital plane. Each of the three shots lying along that plane is removed and replaced by screws A, A and A" which are left in permanently.
The stereotactic instrument can then be put in place. This instrument comprises a main crest frame 1 adapted to be fitted lengthwise on the cranium of a patient in the manner of a crest of a helmet. Three locating screws 2, 2' and 2 rotatable in the frame 1 engage screws A, A and A" thus fixing the frame in position in the central longitudinal plane of the head of a patient. These locating screws have knurled upper or outer heads 3, 3' and 3" which can be rotated to adjust the spacing of the frame from the patients head. Slidable carriage 4 to which all of the rest of the instrument is attached, slides into the crest frame 1 and is clamped in place by rotating knurledheaded screw 5. The body of the instrument can be moved in the central longitudinal plane of the head of the patient by movement of the carriage 4 along the frame 1. This movement is most easily accomplished by providing carriage 4 with lips 4a and crest frame 1 with spaced rails 1a. Carriage 4 can then he slid onto the crest frame 1 at any place where there is a space in the rails 1a and clamped in the desired position by tightening screw 5.
The frame 1 and the carriage 4 are provided with a scale 32 and an indicator 33 to enable the relative positions of the carriage and the frame to be accurately fixed. A support column 6 comprising telescoping portions 6a and 6b is mounted on a horizontally rotatable cylinder 28 and extends vertically upwards from the carriage. A screw 7 with a knurled head 8 fits inside the column 6. When it is desired to adjust the height of the column 6 upward or downward with respect to the frame, such is accomplished merely by rotating knurled head 8. A calibrated scale 34 is provided on the telescoping sections 6a and 6b to assist accurate positioning of the height of column 6. The position of the column 6 is adjus'ted radially (in a plane parallel with the central longitudinal plane of the head of the patient) by rotation of knurled head 9 of arm 10. This arm extends above the carriage connected to the cylinder 28 and rotates worm gearing 31. The worm gearing 31 is rotated by screw'10 forward or backward to the desired position. A screw 30' locks the gears and cylinder in the desired position.
A cross-arm or support bar 12 is attached near the top of support column 6 and extends transversely above the head of the patient in a horizontal plane. Cross-arm 12 ha's'a slot 13 through which an electrode 14 can be passed. Extending vertically downwards from near each end of the cross-arm are vertical sight arms 15 and 16. The
lower ends of these sight arms carry sight means 17 and 18. These means preferably comprise one radio-opaque ring on one arm and a stud on the other, both pref e'r'ably being'm'oiinted in a radio-translucent Tufnel. The sights can be rotated on an arc by turning arm 10' or they may be moved upward or downward by turning knurled head 8'. With the aid of radiography, these sights can be used to select a portion of the brain to be treated. This portion is hereinafter referred to as point X.
The horizontal cylinder 28 mounted on the carriage 4 has a scale portion thereon 19 and a longitudinal slot 20 therethrough. Sleeve 21 ismounted on cylinder 28 and carries guide tube 22 for an electrode which passes through slot 20. This guide tube 22 and sleeve 21 can be placed iii a desired position by slidih'g' them along the slot 20 and clamping them in place by tightening knurled headed screw 23. The calibrated scale portion 19 provides accurate positioning of the sleeve and guide tube.
Treatment means 14 preferably comprises a tipped electrode having an adjustable stop member 24. This electrode passes through slot 13 and through guide tube 22 to contact the area to betreated.
The various movable parts of the instrument are adjustable at will so that they can be correctly arranged with respect to point X.
A handle 25 extends upwards from the frame 1 and is mounted so that its position backwards and forwards on the frame can be adjusted. This handle 25 has two handgrips 26 and 27, extending in opposite directions lengthwise of the frame. One of these grips is for use by the surgeon,- whose hands will always be sterile during an operation, and the other is for use by the radiologist Whose hands may not necessarily be sterile during the opera tion. The handgrips are used to adjust the position of the patients head by setting the grips at a convenient angle for the surgeon and radiologist who then directly adjust the position of the patients head by moving the handle, without disturbing the setting of the instrument. This is because the head and instrument move as a unit.
To determine point X, the treatment point, a radioopaque agent is injected to outline the anterior commissure. For. practical purposes the globus pallidus lies 3 mm. posterior to the anterior commissure and 1 mm. below the intercommissural line. The sights 17 and 18 are aligned on this area and are adjusted to the correct position by the two knurled heads 8 and 9. Knurled head 8 moves the sights up and down while knurled head 9 moves them on an arc. The radiologist, by the use of an X-ray image intensifier, can see the sights and position them correctly in relation to the anterior commissure as described above. By this means the target area, point X, is known to be between the two sights.
Inspection of the X-ray film earlier obtained, and knowledge of the anatomy of the brain enables the position of the globus pallidus along the sight line to be calculated. This is normally 16 mm. from the midline although enlargement of the third ventricle increases this measurement proportionally. The sleeve 21 which carries the electrode guide tube 22 is moved 16 mm. to one side of the midline as measured on the calibrated scale 19 of the cylinder 28. The sleeve is clamped in position by screw 23. A hole is made in the occipital region of the skull immediately below the electrode guide tube. The electrode stop 24 is adjusted so that in use the electrode tip will lie on the target line between the sights.
To effect treatment electrode 14 is then passed gently through slot 13, guide tube 22 into the hole in the patients head, through the occipital lobe and into the thalamus. The contact .of the electrode with the pulvinar or posterior end of the thalamus can be clearly felt by the surgeon. Confirmation that the electrode is in the thalamus is evident on low voltage stimulation since the patient experiences a tingling sensation at the side of the mouth and between the thumb and index finger. Electro-coagulation is carried out for a set period of time by applying a predetermined voltage to the electrode. The patient is observed during this period and tremor is often damped down and may disappear. Certain symptomatic occurrences may be followedby the surgeon to enable him to decide upon the length of treatment required. The electrode 14 is pushedfurther into the brain to its final target in the globus pallidus. Electro-coagulation is again carried out.
The electrode is withdrawn and replaced by a tube t, through which a stainless steel ball b is placed as a marker in the lesion. The stereotactic instrument is then removed from the head.
In a modified embodiment of the present invention, cylinder 28 extends lengthwise in the horizontal plane so that sight arms 15 and 16 pass through it at 15a and (FIGURE 8). A further modification includes an additional guide tube 22' attached to and extending through the sleeve 21 at an angle for guiding electrode 14 atan angle. This enables the electrode 14 to be introduced into the skull at an angle so that the end is brought nearer the center line (see guide tube 22, FIGURE 8). Wheri the guide tube 22' is added, a curso'rand scale 40are provided. These are clipped on to the instrument as shown in FIGURE 8, prior to the time at which the apparatus is placed on the patients head, to facilitate exact calculation of the position of the electrode.
Other and further uses of and for. the aforedescribed invention will be appreciated by thoseskilled in that art by reference to this specification and the appended claims.
What is claimed is:
1. A surgicalstereotactic instrument which comprises:
(a) a crest frame adapted to be fitted to the cranium of a patient to be treated along the mid-sagittal plane;
(b) a carriage movably attached to the crest frame;
(0) a cylinder attached transversely to said carriage;
(d) a column mounted on the cylinder and extending vertically upward therefrom;
(e) a cross-arm having a slot therethrough attached substantially perpendicularly to said column and when fitted to a patients head extending across the patients cranium transverse to the mid-sagittal plane thereof;
(f) two sight arms, one attached near each end of the cross-arm, both arms extending vertically in the same plane as the column;
(g) two sights, each of which are attached to the distal ends of the sight arms;
(h) a guide tube slidably attached to the cylinder; and
(i) treatment means passing through the slot in the cross-arm. and guided by the guide tube to contact the point to be treated.
2. An instrument according to claim 1 which further comprises:
(a) a handle having at least one hand grip affixed to and extending upward from the carriage;
(b) gear means attached to the carriage and the cylinder; and
(c) a knob operating a shaft for turning the gear means, whereby as the gear is turned the cylinder rotates in the horizontal plane and the column moves in an are substantially along the mid-sagittal plane.
3. An instrument according to claim 2 which further comprises:
(a) a scale disposed on the crest frame; and
(b) indicator means to determine and show the relative position of the carriage along the frame.
4. An instrument according to claim 3 which further comprises:
(a) a scale portion on the cylinder, said cylinder also having a slot therethrough along the scale portion; and
(b) a sleeve to which said guide means is attached, which sleeve is attached to the cylinder and is slidable along the length of the slot through the scale portion, the guide means being disposed on the sleeve so as to extend through the slot in the scale portion;
whereby as the sleeve is slid along the cylinder the scale on the cylinder shows the position of the sleeve and guide means.
5. An instrument according to claim 4 wherein the column comprises at least two telescoping sections and a knurled head operating screw means connected thereto so that when the head is rotated in one direction the column rises and when the head is rotated in the opposite direction the column closes.
6. An instrument according to claim 5 wherein the sights comprise a radio-opaque ring attached at the distal end of one cross-arm and a stud attached at the distal end of the other cross-arm.
7. An instrument according to claim 6 wherein the treatment means comprises a tipped electrode having an adjustable stop member whereby, when the electrode passes through the slot in the cross-arm and the guide tube into the patients head, the stop member limits the downward travel of the electrode by contacting the upper surface of the slot.
8. A surgical stereotactic instrument which comprises:
(a) a crest frame having rails along its outer surfaces adapted to be removably secured to the cranium of a patient to be treated along the mid-sagittal plane;
(b) a carriage having a mating means attached to the crest frame and slidable along the rails;
(c) a scale disposed upon the frame;
(d) indicator means to determine and show the relative position of the carriage on the frame;
(e) a cylinder rotatably attached to the carriage transverse to its longitudinal axis and having a scale portion thereon and a slot extending through the scale portion along the length thereof;
(f) a column mounted on the cylinder and extending vertically upward therefrom comprising at least two telescoping sections;
(g) a knurled head operating screw means attached to the innermost section of the column so that rotation of the head in one direction causes the column to rise and rotation of the head in the opposite direction causes the column to telescope closed;
(h) a cross-arm having a slot therethrough attached to the upper portion of the innermost section of the column and extending transversely of the mid-sagittal plane of the patients cranium;
(i) two sight arms, each of which is attached to the cross-arm near its end;
(j) two sights comprising a radio-opaque ring and a stud, the ring being attached at a distal end of one sight arm and the stud being attached at the distal end of the other sight arm;
(k) a sleeve disposed around the cylinder and attached to the tube therein so that movement of the sleeve causes the tube to extend from and retract back into the cylinder;
(1) a guide tube attached to the sleeve and extending therethrough and through the slot in the scale portion in a substantially vertical position;
(m) means for temporarily securing the sleeve in a desired position;
(n) a tipped electrode sized to fit through the slot in the cross-arm and to pass through the guide tube into the patients head in a hole made for treatment;
(0) a stop member adjustably afiixed to the electrode to limit the downward travel of the electrode by contacting the upper surface of the slot;
(p) gear means attached to the cylinder and the carriage;
(q) means for turning the gear means and thus rotating the cylinder in the horizontal plane; and
(r) a handle attached to the carriage having two hand grips at the upper end thereof.
9. An instrument according to claim 8 wherein the cylinder has slots through its ends and the sight arms pass through the slots.
10. An instrument according to claim 9 comprising an additional guide tube attached to and extending through the sleeve at an angle and extending through the slot in the scale portion at an angle.
11. An instrument according to claim 10 comprising a scale and cursor removably attachable t0 the frame and carriage for calculating the position of the angled electrode.
References Cited UNITED STATES PATENTS 11/1962 Dobbeleer c 128303 XR 12/1965 Vladyka et al. l28-303 XR