AANS Neurosurgeon | Volume 26, Number 3, 2017

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Evolution of Neurosurgery in Greece

History of Neurosurgery in Greece
The first report of a neurosurgical procedure dates back to Greek mythology when the god of metals and fire, Hephaestus, removed the goddess of wisdom, Athena (Minerva), from Zeus’ (Jupiter) head via a “craniotomy”. Findings from the Minoan period (2000 B.C.) on the island of Crete and from the Bronze Age (1900-1600 B.C.) in the area of Delphi imply that skull trephinations were probably performed for religious reasons at the time. Excavations from the grave of King Agamemnon, the leader of the expedition against Troy in ancient Mycenae, have also brought to light delicately trephined skulls. However, the first written report of therapeutic skull trephination, along with its special instrumentation, belongs to Hippocrates (460–377 B.C.).

The Birth of Minerva (Minerve naissant toute armée du cerveau de Jupiter). Painting by the French painter René-Antoine Houasse (1645–1710).

Since the nineteenth century, following the establishment of the Modern Greek State in 1830, there have been numerous reports on neurosurgical pathologies. In 1877, Professor S. Maginas translated a general surgery book by V. Rossiris (professor of surgery in Magdeburg, Germany) into Modern Greek, which included operative techniques for head injuries. In 1894, the physician S. Apostolidis described five patients with brain lesions and trauma. Two of them presented with epilepsy and the post-mortem examination revealed tumors located in the rolandic area. The other three patients sustained shotgun injuries and survived after surgical interventions.

During the first years of the 20th century, general surgeons E. Kontoleon, K. Mermigas and M. Makkas performed neurosurgical operations predominantly for head trauma. In the early 1920s, more advanced operations on the brain and spine were performed in Evangelismos Hospital in Athens, Greece, by eminent general surgeons P. Kokkalis, G. Karagiannopoulos and N. Sbarounis while under the supervision of the neurologist J. Patrikios, who routinely scrubbed and managed the patients postoperatively.

In 1941, during World War II, the first two neurotraumatology departments were established in Athens, due to the increased need for head trauma management. J. Patrikios set one up at the Evangelismos Hospital and K. Elides set another one up at the Agios Savvas Hospital. In 1951, V. Griponisiotis, who trained in the U.S., Germany and Sweden, became the head of the neurosurgery department at the Evangelismos Hospital in Athens, the largest hospital of Greece. D. Economou, who trained under Clovis Vincent and Demartel in France, as well as under Penfield in Canada, established a modern neurosurgical unit at the Athens Polyclinic in 1953.

Procedures such as fenestrations for discectomy, aneurysm clipping, transsphenoidal approach, stereotaxy, Cloward’s technique and epilepsy surgery were routinely performed. J. Taptas, who is well known for his pioneering work in the cavernous sinus anatomy, chaired the Department of Neurosurgery at the Agios Savvas Hospital in Athens from 1962-1986. In the early 1960s, S. Komninos established the first pediatric neurosurgery department at the Children’s Hospital in Athens. In 1967, V. Griponisiotis became the first professor of neurosurgery in Greece.

Hellenic Neurosurgical Society
In 1966, 22 neurosurgeons founded the Hellenic Neurosurgical Society (HNS) in Athens, and D. Economou was elected its first president. At that time, five neurosurgical departments existed in Greece – all of them in Athens. During the next twenty years, 80 more members joined the society while 13 new neurosurgery departments were also developed.

Currently, the HNS has 75 active members and 275 total members. The society’s first national congress was held in Athens in 1987. Since then, 30 national congresses have been organized. Some of them were joint meetings with other national societies, including societies from the United Kingdom, Germany, Italy, Switzerland, Belgium, Bulgaria and Serbia. Additionally, two international hydrocephalus conferences have been organized in Greece – initiatives of the distinguished Greek neuroscientist A. Marmarou.

In 1993, the first edition of the journal Hellenic Neurosurgery was published under the editorship of the HNS. However, since 2012, the journal World Neurosurgery, published under the editorship of the World Federation of Neurological Societies (WFNS), has been considered the official journal of the HNS.

Active participation in international courses and conferences, as well as the organization of training courses, is essential to the scientific activity of the HNS. During the last three years, the society has organized several international courses in Greece, such as the microanastomosis-microvascular, skull-base and white matter dissection cadaver workshops. Finally, the HNS acts in accordance with the EANS and WFNS, implementing high standards of care in neurosurgery.

International Publication Productivity
The international publication productivity of Greek neurosurgeons was reported recently in a bibliometric analysis. A total of 718 manuscripts were published during the last 60 years. Between 1956 and 1997, the publication output averaged 3.7 per year and ranged between 0 and 12.

A sharp rise in research output is apparent during the 6-year period of 2004-2009 when the mean number of published manuscripts showed a four-fold increase compared to the preceding six years, or 33 versus eight. A likely explanation behind this remarkable increase is the establishment of three additional university departments.

Neurosurgical Service Provision
The population of Greece is 10.8 million. All Greek citizens have access to state or university hospitals through national public health insurance. At the present time, 41 hospitals provide neurosurgical treatment, either through a department or by employing specialist neurosurgeons, mainly for emergency neurosurgery. The total number of neurosurgical beds nationwide is 700. There are approximately 400 certified neurosurgeons nationwide, 180 of them are employed by the State, University or Military Hospitals. In addition, there are 85 trainee posts.

The majority of the departments provide trauma and hemorrhagic stroke management and basic-general neurosurgery. On the other hand, all kinds of major-complex neurosurgical procedures are performed in larger, regional hospitals, including neuro-oncology and skull-base operations, endovascular techniques, functional implants and complex spinal instrumentation, as well as endoscopy and radiosurgery.

Training
There are 16 training units, of which seven are affiliated with a university, providing a ratio of one training department per 650,000 inhabitants. The Ministry of Health directs medical training and, therefore, both the hospital authorities and chief neurosurgeons have no control over trainee selection and employment. Medical school graduates enter residency programs solely through an application process without any form of evaluation, such as an exam or interview.

The training period in neurosurgery lasts for six years, with the first two years spent in general surgery and neurology. Following the completion of training, candidates must complete an exam organized by the Ministry of Health to obtain a license to practice.

Residents are encouraged to be involved in research projects and to publish them in international scientific journals or present them at national or international congresses. Over the last 10 years, cadaver and hands-on workshops have become increasingly popular.

The Impact of the Economic Crisis
Since 2009, Greece has been struggling with a serious debt crisis and general austerity measures have already taken effect. Consequently, health funding is decreasing and has negatively affected neurosurgery – the costliest surgical specialty. Although the clinical practice of neuro-oncology, trauma and general neurosurgery has not felt the effects, elective procedures such as neuromodulation face funding difficulties.

As far as research is concerned, the publication productivity during the last seven years of the economic crisis shows a slight decrease while maintaining satisfactory standards in terms of quality.

Finally, regarding the training, one has to note that many young doctors look for residencies outside Greece, mainly in other European countries such as Germany and the United Kingdom, or even the U.S.

Future Considerations
Greek neurosurgery evolved remarkably during the last 50 years. However, institutional framework changes need to be adopted by the state. Although old problems persist and have increased with the recent financial constraints, a new generation of enthusiastic and well-educated neurosurgeons is determined to improve the standards of care and training.

Over the next few years, the following changes should take place:

  • A substantial decrease in the number of neurosurgical departments and the establishment of large regional centers, while peripheral/rural centers should provide only emergency neurosurgery.
  • A decrease in the number of residents. The available resident posts should be in accordance with the number of state and private jobs available.
  • A decrease in the number of training centers and upgrading the remaining ones to meet EANS standards.
  • The establishment of selection criteria and evaluation procedures for medical graduates for admittance to neurosurgery residency programs.
  • The gradual organization of subspecialty services at large units on a departmental basis. 
  • The gradual establishment of multidisciplinary collaborations with neuro-radiology, neuro-pathology, neuro-oncology, neuro-vascular and complex-spine subspecialties.

 
References
1. Kalyvas, A. V., Kalamatianos, T., & Stranjalis, G. (2017). Letter: Neurosurgical publication output in Greece: Time trends and the impact of the economic crisis. Neurosurgery, 80(5). 

2. Papagrigorakis, M. J., Toulas, P., Tsilivakos, M. G., Kousoulis, A. A., Skorda, D., Orfanidis, G., & Synodinos, P. N. (2014). Neurosurgery during the bronze age: A skull trepanation in 1900 BC Greece. World Neurosurgery, 81(2), 431-435.

3. Stranjalis, G., & Sakas, D. E. (2004). A history of the department of neurosurgery at the Evangelismos Hospital, Athens. Acta Neurochirurgica, 146(10), 1165-1169.

4. Stranjalis, G., & Singounas, E. (1998). Development of neurosurgery in Greece: Past, present, and future. Journal of Neurosurgery, 88(4), 782-785.

5. Stranjalis, G. (1996). The overproduction of neurosurgeons jeopardizes future neurosurgical care. Surgical Neurology, 45(4), 314-319. 

6. Polyzoidis, K. S., & Karavelis, A. (1994). Perspectives in neurosurgery: Neurosurgery in Greece. Neurosurgery

Calendar/Courses

15th Annual WCIRDC California
Nov. 30-Dec. 2, 2017; Universal City, Calif.

Miami Brain Symposium
Dec. 1, 2017; Coral Gables, FL

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