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Every sector, every discipline ha its Masters.
GIORGIO BRUNELLI, eclectic surgeon shall remain in the history of Medicine. He was a great Orthopedic, a world pioneer in Microsurgery, passionate Researcher of the Central Nervous System and its plasticity.

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 case of Giorgio Brunelli, a world renown Orthopedic 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 spinal cord 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 knowledge 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 laureate 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 him at 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 surprise 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 a histologic research on “Synovial Joints” drafted with Prof. Marcer, a great Orthopedic, 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 get away with “110 /110”.
His past experiences during the war made the young Doctor to go for Orthopedics.

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 spinal cord 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 orthopedic surgeons who could successfully solve their problem. In Brescia, we had reached a level of excellence on this ground 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 young 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 paralyses of the brachial plexus; yet, all the experiments 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 Spinal Cord 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 endeavor. He was the ideal precursor of the thoughts and teachings 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 occurred upon the foundation of the University of Chieti. Back then, he was working as Orthopedic Surgeon at the Ospedale Policlinico 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. Outside 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, research and critical assessment of patients’ data as well as treatment, medical and surgical options. This is particularly true for Hand Surgery which gained several and innovative personal techniques among the leading ones: microsurgery, noninvasive surgery, prostheses of the various joints, metal and plastic materials for surgical use, robotics and a closer relationship between orthopedics 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 young 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 us 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-specialized 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 knew 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 genius
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 resources. 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 technique 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 spinal cord underneath the lesion. This was the technique used with a young lady who – following a road accident – had a total lesion of the spinal cord at the level of the 8th thoracic vertebra. Gigliola, this was her name, after 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 glutamate in the C.N.S. and no longer in acetylcholine, a peripheral neuro-transmitter. This response to glutamate 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 acetylcholinic receptors into ones able to respond to glutamate, which is the neurotransmitter 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 clear-cut 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 self-sufficient and lead an almost normal life.

Yet, research is like a never-ending story, and for each research protocol that comes to an end, another one opens up. Based on the analysis of the experimental results, another mystery became evident: the connection of the grafts had to be totally casual and was achieved by connecting the graft with the corticospinal tract of the spinal cord 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 spinal cord 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 unconstrained movements. The explanation is to be found in a presently still unknown feedback mechanism which allows the mental order (from the frontal lobes) to recognize in the brain cortex those motoneurons which 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 activation 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 motor 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 transfers due to partial paralysis of the limb due to change of function between neurons and cortical areas – but also because of the change of function of single motor neurons (millions) scattered into the brain cortex and able 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 improper actions without involving neurons having different functions which would cause co-contractions severely impairing their function. Taking into account the still incomplete knowledge on the anatomy and physiology of the spinal cord, it is evident that these results are only the beginning of the surgical treatment of paraplegia and possibly of other bone marrow lesions.
“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 successful 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 organized throughout 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.

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