Neurosurgery

Insertion of an electrode during neurosurgery for Parkinson's disease.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Neurosurgery is the surgical discipline focused on treating those central, peripheral nervous system and spinal column diseases amenable to mechanical intervention.

Definition and scope

According to the U.S. Accreditation Council of Graduate Medical Education (ACGME) [2],

“

Neurological Surgery is a discipline of medicine and that specialty of surgery which provides the operative and nonoperative management (ie, prevention, diagnosis, evaluation, treatment, critical care, and rehabilitation) of disorders of the central, peripheral, and autonomic nervous systems, including their supporting structures and vascular supply; the evaluation and treatment of pathological processes that modify the function or activity of the nervous system hello, including the hypophysis: and the operative and nonoperative management of pain. As such, neurological surgery encompasses the surgical, nonsurgical and stereotactic radiosurgical treatment of adult and pediatric patients with disorders of the nervous system: disorders of the brain, meninges, skull base, and their blood supply, including the surgical and endovascular treatment of disorders of the intracranial and extracranial vasculature supplying the brain and spinal cord; disorders of the pituitary gland; disorders of the spinal cord, meninges, and vertebral column, including those that may require treatment by heat fixation, instrumentation,or mendovascular techniques; and disorders of the cranial and spinal nerves throughout their distribution.

”

History

Unearthed remains of successful brain operations, as well as surgical implements, were found in France-- at one of Europe's noted archeological digs.

And, the success rate was remarkable, even circa 7,000 B.C.

But, pre-historic evidence of brain surgery was not limited to Europe. Pre-Incan civilization used brain surgery as an extensive practice as early as 2,000 B.C. In Paracas, Peru, a desert strip south of Lima, archeologic evidence indicates that brain surgery was used extensively. Here, too, an inordinate success rate was noted as patients were restored to health. The treatment was used for mental illnesses, epilepsy, headaches, organic diseases, osteomylitis, as well as head injuries.

Brain surgery was also used for both spiritual and magical reasons; often, the practice was limited to kings, priests and the nobility.

Surgical tools in South America were made of both bronze and man-shaped obsidian (a hard, sharp-edged volcanic rock).

Africa showed evidence of brain surgery as early as 3,000 B.C. in papyrus writings found in Egypt. "Brain," the actual word itself, is used here for the first time in any language. Egyptian knowledge of anatomy may have been rudimentary, but the ancient civilization did contribute important notations on the nervous system.

Hippocrates, the father of modern medical ethics, left many texts on brain surgery. Born on the Aegean Island of Cos in 470 B.C., Hippocrates was quite familiar with the clinical signs of head injuries. He also described seizures accurately, as well as spasms and classified head contusions, fractures and depressions. Many concepts found in his texts were still in good stead two thousand years after his death in 360 B.C.

Ancient Rome in the first century A.D. had its brain surgeon star, Aulus Cornelius Celsus. Hippocrates did not operate on depressed skull fractures; Celsus often did. Celsus also described the symptoms of brain injury in great detail.

Asia was home to many talented brain surgeons: Galenus of Pergamon, born in Turkey, and the physicians of Byzance such as Oribasius (4th century) and Paul of Aegina. An Islamic school of brain surgery also flourished from 800 to 1200 A.D., the height of Islamic influence in the world. Abu Bekr Muhammed el Razi, who lived from 852 to 932 in the Common Era, was perhaps the greatest of Islamic brain srugeons. A second Islamic brain surgeon, Abu l'Qluasim Khalaf, lived and practiced in Cordoba, Spain, and was one of the great influences on western brain surgery.

The Christian surgeons of the Middle Ages were clerics, well educated, knowledgeable in Latin, and familiar with the realm of medical literature. Despite the church's ban on study of anatomy, many churchmen of great renown (advisors and confessors to a succession of Popes) were outstanding physicians and surgeons. Leonardo Davinci's portfolio containing hundreds of accurate anatomical sketches indicates the intense intellectual interest in the workings of the human body despite the Church's ban.

Risks

There are many risks to neurosurgery. Any operation dealing with the brain or spinal cord can cause paralysis, brain damage, severe blood loss or even death.

Conditions

Neurosurgical conditions include primarily brain, spinal cord, vertebral column and peripheral nerve disorders.

Conditions treated by neurosurgeons include:

• Spinal disc herniation
• Spinal stenosis
• Hydrocephalus
• Head trauma (brain hemorrhages, skull fractures, etc.)
• Spinal cord trauma
• Traumatic injuries of peripheral nerves
• Brain tumors
• Infections and infestations
• Tumors of the spine, spinal cord and peripheral nerves
• Cerebral aneurysms
• Some forms of hemorrhagic stroke, such as subarachnoid hemorrhages, as well as intraparenchymal and intraventricular hemorrhages
• Some forms of pharmacologically resistant epilepsy
• Some forms of movement disorders (advanced Parkinson's disease, chorea) - this involves the use of specially developed minimally invasive stereotactic techniques (functional, stereotactic neurosurgery)
• Intractable pain of cancer or trauma patients and cranial/peripheral nerve pain
• Some forms of intractable psychiatric disorders
• Malformations of the nervous system
• Carotid artery stenosis
• Vascular malformations (i.e., arteriovenous malformations, venous angiomas, cavernous angiomas, capillary telangectasias) of the brain and spinal cord
• Peripheral neuropathies such as Carpal Tunnel Syndrome and ulnar neuropathy
• Moyamoya disease
• Congenital malformations of the nervous system, including spina bifida and craniosynostosis

Job field

Neurosurgeons work in a variety of practice settings. Some neurosurgeons practice general neurosurgery, while others choose to limit their practice to specific subspecialties. Some areas of specialty include pediatric, spine, vascular/endovascular, tumor, peripheral nerve, functional, and skull base. Practices range from solo practices to large group practices with multidisciplinary components. Increasingly, neurosurgeons are working together with psychiatrists, neurologists and therapists to provide comprehensive care for patients with neurologic disorders such as back pain. About 20 percent of neurosurgeons practice under the auspices of a university practice plan, while the majority of neurosurgeons maintain private practices often with academic affiliations. Typical work schedules for a neurosurgeon include call coverage for one or more emergency rooms requiring sometimes frequent emergency surgeries. Most averages found online describing typical salary for a practicing neurosurgeon in the United States are between $300,000 and $500,000 annually, though these should be considered as weak small-survey estimates based on the values given by the AAMC.

In the United States neurosurgical training is very competitive and grueling. It usually requires six to eight years of residency after completing medical school, plus the option of a fellowship for subspecialization (lasting an additional one to three years). Most applicants to neurosurgery training programs have excellent medical school grades and evaluations, have published scientific and/or clinical research, and have obtained board scores of 95 or higher. Resident work hour limits are set at 88 hours per week for many programs, although many neurosurgical programs have had problems meeting these new work hour limits due to the small size of residency programs, the high volume of neurosurgical patients, and the need to provide constant coverage in the ER, OR, and ICU. On average 50-60% of neurosurgery applicants match into a residency program (~85% of US senior medical student applicants). [3]

See also

• Harvey Cushing - known as the father of neurosurgery
• Gazi Yasargil - known as the father of modern neurosurgery
• Vascular neurosurgery
• Pediatric Neurosurgery

External links

• Congress of Neurological Surgeons
• American Association of Neurological Surgeons
• American Board of Neurological Surgery
• Neurosurgical Society of Australasia
• Brain Surgery-Neurosurgery Patient Help Site
• European Association of Neurosurgical Societies
• Neurologial Society of India
• Nature Clinical Practice Neurology