A Brief History of the British Society for Stereotactic and Functional Neurosurgery
European factors driving British stereotactic surgery included Benabid’s application of thalamic deep brain stimulation (DBS) for Parkinson’s disease in 1987 and Laitinen’s reapplication of Leksell’s pallidotomy in 1992. Prof Alim Benabid from Grenoble and Prof Jean Siegfried from Zurich had independently published papers on the use of DBS for tremor resurrecting the work in 1980 by Brice and McLelland from Southampton.
It was a time when stereotactic surgery was undergoing a revival. Cross sectional imaging with CT was well established and MRI was in its infancy. There were now a few commercially available stereotactic frames for use with CT though these were mainly used for tumour biopsies. However, re-familiarisation with stereotactic frames was leading to a revival in their use for functional neurosurgery. Medtronic had also developed a new DBS electrode and battery.
The British Stereotactic Surgery Group was conceived in 7th May 1992. This was during the 1st meeting of the newly formed International Neuromodulation Society that took place in Rome. At the end of the meeting a few UK Neurosurgeons stayed on to discuss with European colleagues setting up of a European Multicentre Trial of DBS for Tremor. That evening Mr J B Miles from Liverpool and Mr T R K Varma from Dundee met at the Piazza Navona for dinner with their wives. Also present was Miss Ros Mitchell who was then a senior registrar at Liverpool. As the Asti Spumante flowed Mr Varma discussed with Mr Miles the possibility holding a Stereotactic Workshop and tying this in with putting together a British Stereotactic Surgery Group (BSSG).
This initial discussion led in the organization of the First Dundee Stereotactic Workshop in 1993. Prior to the Workshop a group of UK Neurosurgeons met for lunch to discuss the formation of the BSSG. Participants at that meeting were T R K Varma (Dundee), John Miles (Liverpool), David Thomas (London), Fary Afshar (London), David Sandeman (Bristol), Chris Pidgeon (Dublin), Jonathan Benjamin (Romford), Colin Shieff (London) and Ivan Jacobsen (Dundee). There was general but lukewarm support for the formation of an informal group which would meet at intervals.
The Workshop itself gave attendees (mostly trainees but also a few consultants) the opportunity to handle the various stereotactic frames that were available at the time, mainly concentrating on their use for tumour work. David Sandeman had brought along the ISG Viewing Wand which was the first commercially available Frameless Image Guided System– most agreed that it seemed an expensive toy with no real future!
There were also a few talks on the anatomy of the thalamus and basal ganglia along with a brief talk on DBS for tremor. The revival of functional stereotactic surgery was in its infancy though the audience were reminded of the long history of British stereotactic surgery by the late Prof John Gillingham who gave a beautifully illustrated talk on the subject.
There were subsequent Stereotactic Workshops in Dublin (1994) and Dundee (1996, 1998 and 2000). Attempts to hold a meeting of the BSSG alongside the workshops in 1994 and 1996 had little support but at the Dundee Workshop in 1998 there was sufficient support to host what was the first formal meeting of the BSSG.
There was a further meeting of the Group at Dundee in 2000 hosted by Sam Eljamel. In June 2001 Mr. Varma hosted the 3rd meeting of the Group in Liverpool – it was the first stand-alone meeting of the BSSG but despite having Andres Lozano as a guest speaker it was poorly attended. In an attempt to increase membership and attendance it was proposed that membership of the Group should be widened to include all aspects of Functional Neurosurgery – this led to the Group being renamed The British Stereotactic and Functional Neurosurgery Group (BSFNG). The first meeting of the new BSFNG was held at Birmingham in October 2002 – hosted by Ros Mitchell. T R K Varma was the Honorary Secretary/Organizer of the group on an informal basis from 1998 to 2002.
The original BSSG had the blessing of the Society of British Neurological Surgeons (SBNS) but had no formal position in the Society. In 2000/2001 the SBNS was looking to formalize its links with the sub-specialist groups and in 2001 the SBNS “recognized” the BSFNG as the formal representative organization for Functional Neurosurgery. This required a Constitution and the election of an office bearer. Mr. Varma was elected as Secretary of the BSFNG in 2002. He was followed by Laurence Dunn in 2004 and Sam Eljamel in 2006. In 2011 during the meeting held at Bristol and under the leadership of Alex Green, the name BSFNG was changed to the British Society for Stereotactic and Functional Neurosurgery (BSSFN) in keeping with the format of the corresponding European, American and World societies. Keyoumars Ashkan took office in 2016 with the immediate aims of promoting the UK DBS registry and promoting multidisciplinary research and collaboration within the field of functional neurosurgery.
The usefulness of the suggestion in 1993 to establish the BSSG became apparent in the late 90’s when DBS started to be widely used for movement disorders and neurosurgical units were battling to obtain funding for these procedures. At about the same time the British neurologists were pushing for a database of movement disorder surgery in the country – this had little support among the neurosurgeons who saw this as a threat to their practice. Mr. Varma had the unenviable task of speaking at the Association of British Neurologists’ meeting at Southampton and defending the neurosurgical position! Out of this meeting however emerged the possibility of a UK based trial of DBS and subsequently the organization of the PD SURG. The BSSFN was now seen to be the voice of the neurosurgeons specializing in movement disorder surgery in discussions with the PD SURG trial organisers, the SBNS and the commissioning authorities.
In 1992 there were only a handful of British neurosurgical units that undertook any form of stereotactic surgery but by 2005 there were at least 15 units actively undertaking functional stereotactic surgery and supporting the BSFNG. Almost all of the 34 hospitals conducting neurosurgery in Great Britain and Northern Ireland today have now got consultants able to offer framed stereotactic surgery a century on from Horsley’s first experiments. Two thirds of these hospitals have subspecialty trained stereotactic surgeons offering functional procedures including DBS, the majority of them affiliated to universities and conducting clinical or translational research. Far from being the reserve of the eccentric scientist-surgeons looked upon with suspicion by the rest of the neurosurgical fraternity, stereotactic surgery has become an established clinical subspecialty and academic discipline in its own right.
A further society with a focus upon pain that welcomes stereotactic neurosurgeons, the Neuromodulation Society of the United Kingdom and Ireland (NSUKI) was founded in 2001. Alongside BSSFN, such developments prove good indicators of the continued success of the subspecialty in the United Kingdom.
Phil Gildenberg has commented that there are four central tenets of the field of stereotactic surgery. The need to be innovative. That a better way to do something may be more apparent to the most junior member of the team rather than the most senior. That stereotactic surgeons work as a community not in isolation; and that stereotactic surgery is, to a large extent, a basic science. Although not appealing to the neurosurgeon interested only in a better way to cut, it is exciting to one appreciating the associated basic science. Finally, there is awed appreciation for the insight and courage of the true pioneers in the field. The British school exemplifies such values. It is hoped that its practitioners will continue to uphold tradition as we look to the future with excitement.
This article is based on a history of the BSSFN written by Mr. Varma, with contributions from Mr. Tarnaris, Mr. Pereira, Mr. Green and Prof Ashkan.