The Special Field of Neurological Surgery
Some readers may recognize the above title as that of an article published by Harvey Cushing in the Bulletin of the Johns Hopkins Hospital in 1905. In the U.S., at least, (and arguably no less worldwide) this is considered to be the “official” beginning of our field. Until then, operations on the nervous system were done by people trained in general surgery (including, of course, Cushing himself) who did not think of themselves as practitioners of a separate specialty. Cushing made the point that surgeons should not be beholden to neurologists who “told them where to operate.” Neurosurgeons should be experts in neurological examination and diagnosis and in furthering their craft by what we now designate as “basic science” and “clinical” research.
Neurosurgery was far from the first specialty to split from its surgical parent. (Remember that surgery and medicine came from different roots, with the former being practiced by “blue-collar” tradesmen as opposed to their “white-collar” physician counterparts, a division that lasted until the late 18th century). By 1905, there were orthopaedists, ophthalmologists, otolaryngologists and obstetricians (including Cushing’s father). On the medical side, pediatrics and neurology had gained distinct recognition. By the time I entered medical school, there were many more clearly defined subspecialties, all of which seemed obvious because they had happened already. Neurosurgery, by contrast, had changed little in the 75 years or so since Cushing’s article. Pediatric neurosurgery was only starting to emerge as a separate discipline. Neurosurgery was considered enough of a specialty in its own right, the further subdivision of which would be pointless at best and at worst, a detriment to resident education and even to patient care.
Times change. No one does general surgery anymore, compared to a generation ago. They do pediatric, colorectal, hepatobiliary, thoracic, vascular or transplant surgery. They subspecialize in wound healing or in critical care. In practice, neurosurgeons have gone down the same road. Rare indeed is the academic neurosurgical department without a subspecialized faculty, and many if not most private groups have done the same. Fellowships are becoming an increasing fact of life in neurosurgery, such that new residents and the medical students coming up behind them take the need for such additional training as a given.
Is it all too much? Is it a bad idea to have neurosurgeons doing only spine or cerebrovascular or skull base or functional surgery (for example)? If so, why train everyone to do everything? And where do you draw the line (will we end up with “official” anterior and posterior skull base specialists? Cervical and subcervical spine surgeons?) But if you believe we should not further subdivide, why should the line drawn 111 years ago by Harvey Cushing remain sacrosanct when so much other subspecialization has happened all around us? Read this issue of AANS Neurosurgeon to explore these complex issues in depth.
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