Every sector, every discipline ha its Masters
GIORGIO BRUNELLI, eclectic surgeon shall remain in the history of Medicine. He
was a great Orthopaedic, a world pioneer in Microsurgery, passionate Researcher
of the Central Nervous System and its plasticity
By Luisa Monini
Intelligence, and not only in its most extreme form of genius, is a quality that
often is to be found in the most diverse and unthinkable ways.
This happened too in the cas of Giorgio Brunelli, a world reknown Orthopaedic
and Microsurgeon and a pioneer into diverse sectors of Orthopaedic Surgery,
Microsurgery and Implantology as well as Applied
and Basic Research in the treatment of bone marrow lesions.
Brunelli’s work has been acknowledged and praised internationally; and he gained
recognition from Nobel Prize laureates, such as Rita Levi Montalcini who
sponsored his candidacy to the Nobel Prize for Medicine for his contributions to
Basic and Applied Research and knwoledge of the C.N.S., discarding the common
beliefs according to which the brain must only be an organ to be investigated by
just a restricted group of specialists, such as Neurologists, Anatomists,
Neurosurgeons, Physiologists and just a few others.
“ Brunelli showed” – the Nobel laurewate said -
“ how little we used to know on the huge neuronal plasticity and the
advantages to be achieved about it”.
The choice of studying Medicine came as a consequence and inspiration following
his serving the Army during the war when Brunelli worked in a small field
hospital. This is what the majority of people know about it; yet, what he
confessed to just a few intimate friends in actuality is that upon his return
from the war, he was totally unaware
whether his father – the Chief Veterinary Doctor at the Slaughter House
in Brescia – had enrolled hima t the School of Engineering or Medicine. Yet,
farsighted as he used to be, studied to take two tests that would have been good
in both cases: Chemistry and Physics. He went to the University of Parma and
discovered that he had been enrolled at the School of Medicine. Those were most
uncertain and confused years, and this must not come as a surpise to the reader.
What is most amazing was that Brunelli graduated perfectly on time, in 1949,
after 6 years of study. Unfortunately he did not graduate with top grades, and
he told why in his autobiography:
“My Doctoral work was an istologic research on “Synovial Joints” drafted with
Prof. Marcer, a great Orthopaedic, one of the few to perform the pollicization
of the index finger on veterans “amputees”, a procedure that back then seemed a
miracle since it restored grip to the thumb. My doctoral dissertation had been
very carefully prepared, and I was sure that I would get the top 110 “cum laude”
mark. Unfortunately, Prof. Marcer – who in 1945 replaced prof. Bocchi who had
been replaced because he was a fascist – had to leave his Chair on the eve of my
dissertation since Prof. Bocchi had been reinstated. Bye Bye to my “cum laude”
and I had to geta way with “110 /110”.
His past experiences during the war made the young Doctor to go for
Orthopaedics..
The academic career
A sudden and very successful surgical and academic career: Chief of Surgery at
35, University Chair in 1971. Yet, the most striking among Brunelli’s
achievements is his pioneering work, such as the first hip joint prosthesis
replacement surgical technique in Italy in 1963 and Microsurgery, introduced in
Italy in 1965. He was then officially acknowledged as one of the 5 worldwide
pioneers. In 1972, he was the first to perform brachial plexus surgery and the
first total limb reimplant in Europe in 1973. He earned an Honoris Causa
Degree by the University of Wroslaw, and in the Eighties he focused on
Experimental Research to try to cure bone marrow and paraplegic lesions.
This is his account of those years.” At the end of the 70ies, many were the
patients suffering from arthrosis of the hip to have as many orthopaedic
surgeons who could successfully solve their problem. In Brescia, we had reached
a level of excellence on this gound too, and we had patients coming in
especially from Southern Italy. Those were the years when our surgical ward was
no longer big enough to host all those patients who came with the hope of being
enrolled on the surgical list as soon as possible.
There were many youg paraplegic patients who came to my hospital ward in the
hope of finding a solution to the problems of their legs, like we did for the
paralises of the brachial plexus; yet, all the experiements carried out until
then on animal models unfortunately showed that the bone marrow would not
receive exons from the brain. I endured, and I fully believed that I had to take
up the challenge and would continue my research on bone marrow repair. I set up
the Bone Marrow Lesions Foundation and began an equally laborious and hard
research on the anatomy and physiology of the bone marrow and its chances to be
cured after a lesion”.
Teaching young people
In Brunelli’s professional life, teaching has always been a very important
endeavour. He was the ideal precursor of the toughts and techings of his Italian
and foreign Masters: prof. Poli from Milano, prof. Merle D’Aubignè from Parigi,
prof. Tunnel from the U.S. of America as well as prof. Böhler from Wien and
prof. Möberg from Göteborg.
Teaching had always been for him a great source of excitement and dedication: ”
I have always believed I had to teach to the best of my ability, and except from
a quarrel in 1968, I had always entertained a friendly relationship with my
students”. Brunelli here make reference to a peculiar episode that occured upon
the foundation of the University of Chieti. Back then, he was working as
Ortopaedic Surgeon at the Ospedale Policinico SS Annunziata in Chieti and had
been called to teach anatomy and human physiology: during an exam, he asked a
student to describe the femur, and the student’s answer had been “a long bone
beginning at the level of the hip and ending to the foot”. Of course, he did not
give him a pass. Ouside the classroom, Brunelli found a bunch of students ready
to attack him. He was rescued by some other students who did get a pass.
His scientific “forma mentis” allowed Brunelli to always top praise scientific
thinking, reasearch and critical assessment of patients’ data as well as
tretment, medical and surgical options. This is particularly true for Hand
Surgery which gained several and innovative personal techniques among the
leading ones: microsurgery, miniinvasive surgery, prostheses of the various
joints, metal and plastic materials for surgical use, robotics and a closer
relationship between orthopaedics and all the new scientific discoveries, a
change of pace that would have left a mark for the future.
Medical training and work require years of sacrifice and, as Brunelli used to
say: “young doctors must be prepared to make many sacrifices, must know that
money does not come easily, and must be aware of how much they must give up if
they want to be thorough and
well-trained doctors”.
Brunelli also used to advise youg doctors to spend some time abroad which he
regarded as being key: “Not because here we lack structures and skills; but,
rather the experience one can gain from each one of usi s so different and big
that one can find an add-on to one’s one professional skills everywhere in the
world”.
For him, working abroad could have been a choice of a long post-doctoral stay –
yet, this might have been hindering one’s return home – or, short breaks in
different hospitals to learn super-specialised techniques, following a
post-doctoral period spent into an Italian hospital. Young generations of
doctors are always an injection of new techniques, and this to the benefit of
all: “since the new generations while attending college can bring in new IT
knowledge which simply did not exist when we were young and can therefore have
an easier and faster access –
thanks to new technologies – to scientific discoveries which when I was young
was not even thinkable and this was one of the reason why publishing a
scientific work used to be both hard and a long exercise”. Brunelli knwe all too
well how many hours were spent in the Italian university libraries looking for
references and works which now could be accessed and read after just one
“click”. Yet, are we really so sure of it?.
“All this will allow doctors to make giant strides ahead in their scientific
learning and careers.
Research insights of a genious
Brunelli’s full-fledged research efforts on bone marrow began in the ‘80ies and
his first insight was that, once damaged, bone marrow cannot be repaired. Always
with the goal in mind to resume movement of his patients’ lower limbs following
traumatic events, he was the only Italian to enroll in the European Project
called SUAW ( Stand up and Walk). All media featured it, showing a young guy who
could walk through some microelectrodes implanted – by Brunelli himself – into
his muscles and driven by an outside station. The Project unfortunately came to
an end for unavailability of financial reasources. Brunelli resorted back to
surgery to circumvent axons that could not make their way through the bone
marrow and thought to take the ulnar nerve from an arm to the muscles of the
pelvis and thighs which are fundamental to stabilize the pelvis frontal plane
and gait. This technicque which was first tested on animals was later – upon the
Ethical Committee consensus – tested on one patient, fully informed and willing
to have the technique tested on him. This was the only solution that Medicine
could offer back then. The patient’s name was Angelo Colombo, and was and is
still proud – as he himself says -
to have made his body available to Science. “Surgery was fully successful. At
the beginning, when I wanted to walk and extend my knees, I had to think to move
the fingers of my hand which were fed by the ulnar nerve. After sometime of
intense rehabilitation, based on plasticity of the CNS, I could walk more
spontaneously and automatically, although still rudimentary”.
Research was developing with giant strides and after years of testing with
different surgical protocols both in Italy and abroad, Brunelli decided to
connect – through a nerve graft – the extensions of the brain cells with the
nerves of some muscles of the pelvis and legs, cutting off the bone marrow
underneath the lesion. This was the technique used with a young lady who –
following a road accident – had a total lesion of the bone marrow at the level
of the 8th thoracic vertebra. Gigliola this was her name – sfater surgery and a
period of intense rehabilitation, started to make her first few steps, although
quite rudimentary, first with the help of a walker and later with a tetrapod.
This, because the extensions of the brain cells when reaching the muscles formed
new motor-plaques able to respond to a neuro-transmitter called glutammate in
the C.N.S. and no longer in acetylcoline, a peripheral neuro-transmitter. This
response to glutammate came as totally unexpected and prompted Brunelli to
continue with his research and – thanks to the precious advice of Prof. Rita
Levi Montalcini – became an actual basic and multi-disciplinary research effort,
involving scientists from the University of Brescia. “Though these studies, we
proved the ability of the muscle to change its normal acetilcolinic receptors
into ones able to respond to glutammate, which is the neurotrasmitter of the
brain neurons”. On June 14 2005, the prestigious official magazine of the U.S.
Academy of Sciences (P.N.A.S. 2005, 102, 24, 8752-8757) published the results of
this research.
Also another prestigious scientific magazine from the U.S. “ Current opinion in
neurobiology 2006 “ published an
article titled “ A lost paradigm “ with a clearcut reference to the result from
this research work which lost one paradigm and found a new truth never unveiled
and/or thought by a human being. What remains, is the reality of a young and
beautiful lady who got real benefits from that surgical technique and this has
allowed her ever since to be selfsufficient and lead an alomst normal life.
Yet, research is like a never-ending story, and for aech research protocol that
comes to an end, another one opens up. Based on the analysis of the experimental
results, another mistery became evident:the connection of the grafts had to be
totally casual and was achieved by connecting the graft with the corticospinal
fascium of the bone marrow completely at random.
In the corticospinal tract, several thousands of fibers descend from different
areas of the cerebral cortex and have different functions. Therefore, one might
have expected that the movements so achieved could be global and all muscles
connected with the corticospinal tract of the bone marrow could get contracted
at the same time with many co-contractions without a functional outcome. On the
contrary, and against all odds, already at the beginning of re-innervation and
after a few months following surgery, the animals as well as the patient who
accepted to undergo surgery of her own will, were able to achieve -
based on their own will – perfectly discernible voluntary, useful and
uncostrained movements. The explanation is to be found in a presently still
unknwon feedback mechanism which allows the mental order (from the frontal obes)
to recognise in the brain cortex those motoneurons whcich have been peripherally
connected with the muscles that one must contract (without tedious
co-contractions) and excites them selectively.
Research proves that single and selective movements so achieved do not depend
upon the atcivation of a cortical area, but rather from exciting millions of
single neurons scattered in different areas of the brain cortex.
FMRI proves that single movements are not coming from a small cortical area, but
that the whole motory area is affected and this proves brain plasticity for
multiple single neurons scattered in the brain cortex. With this last research,
Brunelli has assumed brain plasticity not due to the change of function in brain
areas with different functions -
this was known since over one century because of the results of muscle-tendon
tranfers due to partial paralysis of the limb due to chenge of function between
neurons and cortical areas – but also because of the change of function of
single motor neurons (millions) scattered into the brin cortex and aboe to
selectively and contemporarily get activated for movements that before surgery
were not used to perform which they could do simultaneously for a good
functional movement although these motoneurons were far from each other and
having to perform unproper actions without involving neurons having different
functions whcih would cause co-contractions severely imparing their function.
Taking into account the still incomplete knowledge on the anatomy and physiology
of the bone marriow, it is evident that these results are only the beginning of
the surgical treatment of paraplegia and possibly of other bone marrow leasions.
“This is a long and uneven beginning which can only be surpassed through many
other future research efforts either carried out by me or/and by all those who
will do so and come after me”.
Giorgio Brunelli has performed over 25,000
surgical procedures, 3,500 of which with microsurgical techniques.
Author of 466 papers in previewed journals, 30 chapters and 10 scientific texts.
Besides his scientific and surgical work, Giorgio Brunelli was a great athlete
in various disciplines: fencing, swimming, regional university champion of
cross-country sky in 1948. He loved vintage cars and as a gentleman driver he
participated to various races and several Mille Miglia.
Brunelli used to love Nature in all its expressions which he used to portray
with his Nikon but also with his paintings, and calling him an amateur-painter
is highly out of scope. Several exhibitions of his paintings and photos were
organised thoughout the years. He also published several historical novels and,
by virtue of his intellectual passion for neurosciences, scientific essays, such
as “From Neurons to the Self” and “Conscious Ego”.
Profits coming from all his different passions were all channeled to his
Foundation and research projects which will continue, following the path he
opened.