AANS Neurosurgeon | Volume 25, Number 4, 2016


The Special Field of Neurological Surgery

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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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Juan Jose Gil Cruz | December 14, 2016 at 11:12 am

Siempre ha sido un reto para los neurocirujanos poder abordar todas las multiplicidad de patologías que puedan existir, tanto cráneo encefálicas como raquimedulares por que ya hace algun tiempo le cedimos el edpacio de las patologias de los nervios perisfericos a los cirujanos de mano y extremidades.
Afortunadamente fui formado en una escuela en la cual era una exigencia tener que abordar todas las patologias del sistema nervioso, esto nesesita muchas horas de estudio, actualizacion en las siempre cambiantes novedades de las tecnicas quirurgicas y tecnologicas.
La historia de la Neurocirugia la comenzo Cusching pero constante y consecutivamente han sido incorporados campos que en otras epocas hubiesen sido mas que increibles, siendo en un futuro no muy lejano que seamos dezplazados por la sfware, nanorobotica y formulas inmunológicas.
Excelente descripción suya de ese capítulo tan lindo de la Neurocirugía.
Mantendremos el contacto.

Joseph Kamelgard, MD, FACS | December 21, 2016 at 7:03 pm

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Reminds me about the difference between the generalist and the specialist. The generalist learns less and less about more and more, till he/she knows nothing about everything. The specialist learns more and more about less and less till he/she knows everything about nothing.

Brig (Dr) Harjinder S Bhatoe | December 29, 2016 at 12:07 am

This is a precise comment and observation on the present status of Neurosurgery as we know it. Mind you, different from Cushing’s era, we are living in an age of information explosion and the needs of the population that we serve. A neurosurgeon working in resource challenged environment will be required to do most of the procedures (those on cranium, spine, and peripheral nerves). A neurosurgeon working in a country with better resources and affordability, will tend to restrict his/her practice to some particular anatomical regions or pathologies, while those in advanced countries such as the US, can look beyond “General Neurosurgery” and hone their skills in one particular field. This brings us to the training requirements. Will the neurosurgery residency period be truncated, and once qualified, the neurosurgeons join specialized stream of their liking for the next level? I think the solution can be found if the existing curriculum is modified so that the neurosurgery residents get formal exposure to sub specialties in their final year.