The development of Gamma Knife and stereotactic radiosurgery are not only epochal moments in treating the brain but demonstrate the importance of non-invasion.
When someone is diagnosed with a lesion, tumour or growth on the brain, they are given a wide variety of options, but if it is at all possible, they will be advised to have a treatment such as Gamma Knife at a radiotherapy centre.
Besides the fact that Lars Leksell’s pioneering stereotactic radiosurgery treatment is highly effective, fast and takes far less time to treat and recover from than conventional brain surgery would, it also has the key feature that it is non-invasive.
The concept of non-invasive and minimally invasive treatments in medical care is the core philosophy at the heart of modern medicine, and as long as a more minimally invasive treatment is effective, it is more likely to be recommended by a doctor.
Despite it being a more modern philosophical take, the balance between choosing effective treatments and the consequences of said treatments is a question that has been asked since the very start of medicine as we know it.
One of the core principles of medicine is the concept of doing no harm, even if the specific phrase does not appear in historic versions of the Hippocratic Oath.
The concept of “first do no harm”, which is at the core of modern questions about appropriate treatments comes from Hippocrates’ Epidemics Book I (Section II, Second Constitution, Section 5).
In it, he notes that the “physician” must have what he defines as “two special objects” in mind when it comes to the treatment of disease; either they must do good or do no harm to a patient.
This principle is at the core of minimally invasive treatment; doctors should in all fields of medicine avoid overprescribing medication, recommending unnecessarily invasive treatments and doing anything more than is necessary to receive the ideal medical outcome.
In the field of brain surgery, where the margin of error is practically nonexistent, this is even more important, and in many cases outside of critical emergency treatments, the least invasive treatment is the correct option for a patient.
Mr Leksell himself came to this conclusion, albeit in a rather unusual way; he believed strongly in bloodless surgery for reasons that were as much aesthetic and based on an aversion to blood as they are based on fundamental principles or any empirical evidence available in the 1930s.
This led to a decades-long devotion to a form of surgery that required no incision, and this ultimately led to the development of the Gamma Knife and the entire field of stereotactic radiosurgery.
Besides philosophical and aesthetic reasons for wanting minimally invasive treatments, there is the notion of timescales and recovery to consider.
A Gamma Knife treatment takes between 30 minutes and four hours, depending on the complexity of the treatment, and whilst there is a small amount of aftercare, most people are able to go home after their radiotherapy treatment.
Contrast that with an equivalent brain surgery, which typically would require stitches or staples to be applied, and as a result of this and the need to monitor a patient’s condition, people can spend up to a week in the hospital, although this varies considerably depending on the complexity of the treatment.
This is a huge reason why surgery is avoided where possible, as the difference between half a day and a week of monitored recovery, followed by rehabilitation is massive, and the implications on a person from a personal, physical and financial perspective cannot be overlooked.
Mr Leksell was ahead of his time in this consideration, even if it took decades for others inspired by his pioneering work to develop the evidence base to change medicine.
An aspiring neurologist would pick up the mantle and ultimately change the practice of medicine in this direction, although the path he took was far from straightforward itself.
Whilst Hippocrates developed the basic principle and Gamma Knife was one of the first tools developed with this in mind, the man to both coin the term and fundamentally shift medicine in the direction of minimal invasion was John Wickham.
Born in Chichester in 1927, around the time Mr Leksell was starting to develop his philosophy and his skills as a neurologist, Mr Wickham wanted to follow in those footsteps and also become a neurologist, although he would ultimately switch to renal medicine.
Whilst he would be an exceptionally skilled urologist, his greatest achievement was in changing the philosophy of medicine and surgery and giving a phrase to a concept that had been on the minds of countless surgeons and radiologists regardless of speciality.
In 1984, Mr Wickham was the man to coin the term “minimally invasive treatment” in the context of surgery and wrote about it in a famous and influential article in the British Medical Journal in 1987.
From the very first line of the article, he noted that surgeons of the time favoured huge incisions compared to the then-novel practice of “keyhole surgery”, whilst patients wanted the “smallest wound possible”, which in the case of radiosurgery involves no incision whatsoever.
Whilst he invented the term, he noted that the concepts and technologies had been evolving since 1960, around the time that radiosurgery was starting to be adopted, and certain specialist fields had developed either non-invasive or minimally invasive alternative treatments for conditions.
He conceived of a world where, by the year 2017, most non-emergency surgery would be undertaken by radiologists and keyhole surgeons, with open surgeries limited to emergency treatments, and this is essentially how the field of medical development turned out.
Rather ironically, the next article was entitled “Retreat from openness”, and this is the exact world the Gamma Knife developed and a necessity to protect patients, improve recovery and give people more options for treatment without an expectation of a long recovery period.
There has always been and may always be room to develop and improve medical principles; diagnostic techniques are ever-improving and allowing for lesions on the brain to be spotted quicker and treated with similar rapidity, and the future of surgery may involve no incision at all.
Centres of Excellence for Stereotactic Radiosurgery treatment of complex Brain Tumours
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