| “Hey, we’ve got a guy here for you to see…” |
In the treatment of head injury and infection, surgeons of the 17th through 19th centuries set the stage for the development of what we now call neurosurgery. The French surgeon Henri Le Dran was the first to propose that it is the accumulation of intracranial blood, rather than a skull fracture itself, that causes decreased consciousness. Percival Pott expanded on this work and described the clinical difference between a hematoma and an intracranial infection. The first craniotomy based on neurological signs may have been performed in 1871 by Paul Broca. A laborer, having sustained a parietal skull fracture, became aphasic, hemiplegic, and then comatose. After localizing the lesion to his eponymous area, Broca removed a large epidural abscess.
The evolution of modern neurosurgery was driven in large part by the need to deal with emergencies. Cushing’s first research, in Kocher’s laboratory, was on a dog model of increased intracranial pressure. The two world wars provided an unfortunate context for establishing standards for training and technique in neurosurgery.
What has made neurosurgical emergency coverage seem like an unwanted stepchild? Neuroimaging, improvements in operating tools and techniques, and third party insurance all have made elective cases the great majority of most neurosurgeons’ practice and interest. Several factors, among them increasing numbers of lawsuits, have made emergency call more and more burdensome. But before abandoning the ER, consider neurosurgeons’ ongoing fight for their role in such other subdisciplines as spine surgery, endovascular procedures, and stereotactic radiosurgery. It ill behooves us to voluntarily give up our role in such an important and historical part of our still-young profession.
Michael Schulder, MD, is associate professor in the Department of Neurological Surgery and director of image-guided neurosurgery at UMDNJ-New Jersey Medical School.