THE HISTORY OF PAEDIATRIC NEUROSURGERY AT MEDICAL FACULTY OF CHARLES UNIVERSITY IN HRADEC KRÁLOVÉ

51 The main

hers, within the time span of years 1946-1948, he mastered basics of modern neurosurgery, based on specific diagnostics and closely connected with patophysiology. After one and a half years of stay in the U.S.A., as soon as in the year 1948, he started fully paying his professional attention to neurosurgery within the Department of Surgery. In the year 1949 assistant Petr was habilitated as the first new Associate Professor in Hradec Králové. In the same year a separate neurosurgical ward with 8 beds was established within the Department of Surgery. After Department of Surgery having been completed in 1951 there has also appeared Department of Neurosurgery with 30 beds. Between the years 1952 -1958 it became a part of Military Medical Academy, into which for a certain period the Medical Faculty had been transformed. Based on this department existence the first University Neurosurgical Department in Czechoslovakia derived its statutory origin in the year 1952. The wards were filled up suprisingly soon so that extra beds had to be used and number of patients often grew to 40 or more. Establishment of the 8 beds post-operative unit, the first one in the whole hospital, was of quite an outstanding importance for operation results. Also a neurohistopathological laboratory as a part of the department was founded. From the very beginning it performed operation biopsies and tumours classification (Dr. A.Fantiš, since 1962 till now Professor S.Němeček, M.D., DrSc.). EEG laboratory was headed by Ass. Prof. Z.Menšíková, PhD.).
Being the Head of Department Professor Petr was interested in all the fields of Neurosurgery. Since the very beginning he considered the children patients as those demanding special care. Nevertheless, by that time children had to be admitted in the adult wards, without adequate regimen. In terms of by then topical problems -the hydrocephalus treatment -in the year 1949 assistant Petr demonstrated on the VIth Conference of Czechoslovak Surgical Society in Prague a unique drainage operation for communicating hydrocephalus. The principle of this operation consisted in fenestration of anterior wall of dural sac in sacral region, which was first performed in two adults and subsequently also in two children (30). Nevertheless, even on the separate department after the year 1951 an insufficient wards capacity enabled to reserve only one small four-bed room for children. There were admitted neither necessary numbers of children patients, nor for sufficiently long a time (e.g. injuries, meningocele, tumours for irradiation, hydrocephali for follow-ups, other children for check-ups etc.) (7,24). In spite of this numbers of children permanently grew, so that in the year 1952 100 of them were admitted and 50 operated on (24). The ward-rounds in the children room were done first by surgeons without special orientation (Dr. M.Kroó, Dr. R.Malec, Dr. P.Nádvorník), starting from the year 1960 by neurological medical superintendant Dr. V.Rozsíval. In publications from that time assessment of the adult population according to diagnoses prevailed. In some sets the children were not present. Altogether 6 papers only dealt with paediatric problems (1)(2)(3)(4)(5)31). Due to the above mentioned facts Professor Petr planned a separate paediatric ward in his concept of a new neurosurgical department.
A new building of Neurosurgical Department, with a top contemporary equipment, had 95 beds and was opened in the year 1971. It also contained a separate paediatric neurosurgical ward, the first and the only one in Czechoslovakia. The Neurosurgical Department was complemented with the Institute of experimental neurosurgery, consisting of neurobiochemical laboratory (Dr. J.Cerman), neurophysiological laboratory (ass. prof. V.Golda, M.D., PhD.), neuropathological laboratory (Dr. S.Němeček, PhD.), and operation tract for small animals operations. After 3 years lasting cooperations with ass. prof. Z. Menšíková, the EEG laboratory was finally taken over by MUDr. J.Němečková, medical superintendant for EEG. Ass. prof. Z.Černoch, PhD. and MUDr. M.Šercl, PhD. from Radiological Department became exclusively engaged in neuroradiology. Thanks to the help of Professor Petr the Radiological Department in Hradec Králové also acquired the first CT in Czechoslovakia in the year 1978. The microneurosurgery was being gradually developed and also the laser became part of the equipment of this department. To facilitate an operation approach and possibilities of physiological operating urea, manitol, hyperventilation, perioperative lumbar puncture or external lumbar CSF drainage with a regulated flow were used.
Professor Petr's idea to concentrate diagnostics, operations, as well as the laboratories under one roof was especially appreciated in children patients. Such an organization undoubtedly advanced the work standards, which became a subject of admiration (and maybe also of envy?) of even foremost foreign professionals visiting our department. During the years Professor Petr was interested within the field of paediatric neurosurgery mainly in vascular malformations, cerebral and brain stem tumours (17), vascular and tumourous processes in the orbit (18), operations of spinal cord tumours using the laser etc. He further participated by his advice, he indicated or approved of therapeutical approaches and operated some children till as late as 1986 when he passed the Department to Ass. Prof. R.Malec, PhD.
In this article we are concerned with the history of paediatric neurosurgery solely -history of the whole Department of Neurosurgery will be delt with by Assoc. Professor Náhlovský, PhD. -so we would like only to briefly remind Professor Petr's achievements in other fields of neurosurgery. As soon as by the end of the forties Professor Petr started with operating intracranial vessel lesions -aneurysms and arteriovenous malformations ( Professor Petr was also the co-founder of Czechoslovak Neurosurgical Society and was awarded quite a few Czechoslovak and foreign honorary acknowledgements and high distinctions.
On neurologist specialization. This separate ward, the first one in the whole republic, had 15 beds with rooms for bigger children, toddlers, sucklings and newborns, as well as the intensive care unit. Children after serious neurosurgical operations and injuries were temporarily treated on the central postoperative and intensive care unit in the vicinity of operation theatres. On the recommendation of Professor Petr but particularly thanks to the region hospital director MUDr. Svatava Lakosilová and after the approval of Ministry of Health the ordinariate of paediatric neurosurgery by Department of Neurosurgery was established in the year 1979. In 1980 MUDr. Jan Pařízek, until now the head of this part of the department, after 20 years of assistancy became the medical superintendant for paediatric neurosurgery.

Diagnostics
Using of the pneumoencephalography, ventriculography, cisternography and gamagraphy was culminating by that time. Electroencephalography (18), angiography and also native X-ray retained their importance up to now. The same also goes for neurological and ophtalmological clinical investigations.
A marked progress in diagnostics was gained within the decade 1972 -1982 by introducing ultrasound, computerized tomographic (CT) and magnetic resonance investigations (MRI). Introduction of CT in our hospital in 1978 generally led to an improvement in prognoses of operated patients and to a marked decrease of postoperative mortality (12,17,18). From 32 papers mentioned as references to this article in 21 of them the macrodiagnosis was set by the help of CT (6,9,(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(23)(24)(25)(26)(27)(28)(29). In the period of time given above also the digital subtraction angiography and intervention neuroradiology -balloonization and embolizationwere developed. Endovascular embolization therapy, thanks to the introduction of microcatheters in 1988, enabled the selective angiography of separate tributaries of cerebral vascular malformations in order to embolize the active centre of this malformation, so called nid ( At the beginnings the puncture biopsy used to be performed from free-hand, in the year 1990 the stereotactical biopsy was introduced. In 1995 Hobza, Jakubec, Němečková, Němeček, Šercl published a work: Impedance monitoring in the stereotactic localization of intracranial structures (Sbor věd prací LF UK Hradec Králové 1995;38/1: 33-46), in which they found the intraoperative continuous monitoring of tissue impedance to be a safe and very beneficial auxiliary method in the stereotactic localization of normal and pathological intracranial structures. On the 11th International Congress of Neurological Surgery, Amsterdam, July the 6th-11th, 1997, these authors presented results of the continuous bipolar impedance monitoring during various CT-guided stereotactic procedures (needle and open stereotaxy, endoscopy, lasersurgery, bra-chytherapy, drainage, medicament instillation) in more than 90 patients with brain pathologies within the years 1993-1996. Clin Neurol Neurosurg 1997,99 (Suppl 1): S 162 (Abstracts).

Operations
Thanks to the diagnostic process improvement the osteoplastic craniotomies were being performed aimed on the pathological focus. Local anaesthesia was employed at the beginning, later on ether was used. Nevertheless, most children were operated under the endotracheal anaesthesia. The technical development has also helped to introduce operation microscope and laser (Malec, Látr, Náhlovský, Němeček: Our experience with 400 neurosurgical laser operations [in Czech]. Čes a Slov Neurol Neurochir 1996; 59/92:261-264). Also the ultrasound aspirator, high-frequency drill, peroperative electrophysiological monitoring, stereoendoscopy, endovascular procedures using digital subtraction angiography, gamma-knife irradiation etc. started being introduced. Modern anaesthesiology, as well as improvement in operation technique and postoperative care, brought markedly better operation results (18).
Within the span of years 1948 -1999 altogether 7092 children were admitted and 3286 children operated in the Department of Neurosurgery. Qualified paediatric nurse Iva Košťálová participated in statistical processing of these data. In the sets of 5 years (7), 10 years (24), 28 years (tab.1) and 50 years (17,18) intervals there dominated tumours of the skull, brain and orbit, the second and third places being occupied by hydrocephalus operations and craniocerebral injuries. Set of children under the age of 18 years according to diagnoses within the years 1971 -1999 is shown in Tab 1.  . The technology of its production was gradually improved so that the search for thinner and more supple material went on to the suggestions of Hušek from the Tissue Bank to use ovine pericardium (1991) (see publication in J Neurosurg). Many practical conclusions came from the research work "Using the collagen tissues (xenogenic pericardium, allogenic dura mater and fascia lata) for dural plastic in neurosurgery", which had been accomplished by Pařízek, Měřička et al within the years 1986-1990. For reconstruction of dura mater and of the orbit ceiling the autogenic, allogenic and xenogenic tissue grafts were successfully used (8,9,(11)(12)(13)15,17,18,21,27,28). Works concerning dural plastics have been repeatedly awarded the prizes of Czechoslovak Neurosurgical Society. Addendum: Brief history of the tissue bank, Charles University Hospital, Hradec   (14). The publication in Acta Neurochirurgica (Wien) introduced the largest statistics of dural plastic procedures worldwide (Pařízek, Měřička, Hušek et al: Detailed evaluation of 2959 allogeneic and xenogeneic dense connective tissue grafts (fascia lata, pericardium and dura mater) used in the course of 20 years for duraplasty in neurosurgery. 1997;139:827-838). It follows from this work that allogenic fascia lata, decontaminated by the cold shock and conserved in plastic covers by freezing, represents thanks to its plasticity an universal graft. Ovine pericardium is suitable due to its thinness, flexibility, transparency and easy cutting. Born on December the 12th, 1950, graduated in 1975 on the Medical Faculty of Charles University in Hradec Králové. After a short stay in the Neurological Department in Hradec Králové he started working in the Department of Neurosurgery in the year 1976. The first degree specialization he passed in 1979, the second degree -neurosurgical specialization in 1985. Within the years 1986 -1990 he worked on the research project: "Therapeutical use of chronic electrostimulation of the brain." This theme was also the subject of his postgraduate -Candidate of science's degree work defended in 1992. Within the years 1987 -1997 he worked as the Deputy Head for treatment and preventive activities. In the year 1996 he presented the closing communication of the grant: "Our experience with diagnostic and therapeutic cerebral endoscopy." These results were also delivered on the XIth International Congress of Neurological Surgery, Amsterdam, 6-11th July 1997. (Jakubec, Hobza, Zadrobílek, Pařízek, Náhlovský, Malec, Němečková, Šercl: Clin Neurol Neurosurg 1997, 99 (Suppl 1): S 147 (Abstracts): 51 neuroendoscopic interventions from I/1993 to X/1996 were performed in patients aged between 1 month to 68 years. The main indications were para-or intraventricular cystic tumours (23), arachnoid, ependymal or colloid cysts (10), and hydrocephalus (10). The diode laser Diomed 25 was a part of instrumentation. The reliability of histopathological diagnosis after endoscopic biopsy was 91,7% in 36 cases.