For centuries, each succeeding generation has had the presumption of modernity. It is easy for us today in 2050 to look back at the neurosurgery of 40 plus years ago and smirk at how primitive many of the procedures from that era now appear. But before doing so, we should consider that our descendants in 2100 might be similarly inclined when they consider how we practice now, at the midpoint of the 21st century.
Changes in the world at large have been reflected in the neurosurgical advances since the first decade of the century. Until not so long ago, the diagnosis of a glioma was viewed as a death sentence, with tumor grade the main factor for determining life expectancy. Younger neurosurgeons may not appreciate the long struggle required to make glioblastoma a manageable disease with an average life expectancy of more than 10 years and a high likelihood of cure for less aggressive tumors. They might smile ruefully at the aggressive surgery done for so long, on so many patients, and with relatively little effect. Forgotten as well are the dire warnings that society would be overwhelmed by exponential increases in elderly patients with Alzheimer’s disease. But that was before the availability of the vaccine against the L40 virus and of implanted nanoarrays for the fortunately rare nonresponders who still do develop Alzheimer’s.
Beyond these examples specific to neurosurgery, technology has changed the general practice and education of new surgeons for the first time in millennia. The idea of “cutting and sewing” as fundamental surgical skills belongs to a bygone era, one before the advent of biostaplers and surgical glues. And surely training residents by guiding their first halting surgical steps in living persons—patients—now seems terribly barbaric. Only those of a certain age will recall that this was the only possible way to teach surgery before 3-D haptic simulation became routine, or that enforced insomnia was a “rite of passage” for those who would become neurosurgeons.
Much of neurosurgery today might not have been considered “surgical” 40 or 50 years ago. Effective, patient-specific radiosensitizers have made ever larger tumors of the brain and skull base amenable to stereotactic radiosurgery, performed now in many cases without the involvement of neurosurgeons. This has been the price of progress and technological improvements in the delivery of ionizing radiation and focused ultrasound. But as in many previous instances, any perceived “loss of turf” has been made up by the growth in surgery for Alzheimer’s, depression, endovascular procedures for alleviating cerebral ischemia, and minimally invasive spinal reconstruction. For those who miss the days of “big” surgery, there still are patients with head trauma for whom to care.
Preparing this column for the AANS Neurosurgeon has been a great exercise in nostalgia. The simple act of typing, as opposed to preparing a holorecord for phonemail, is a reminder of the pleasure that could be had from putting finger to keyboard (itself reminiscent of neurosurgery’s hands-on era: the whir of the electric drill, the scent of the Bovie).
As was true back in 2009, surgery of all kinds, including that of the nervous system, will continually be redefined by scientific and technological progress and by its practitioners—ourselves and our descendants.
Michael Schulder, MD, is a member of the AANS Neurosurgeon Editorial Board. He is vice chair of the Department of Neurosurgery and director of the Harvey Cushing Brain Tumor Institute at the North Shore Long Island Jewish Health System, Manhassett, N.Y. The author reported no conflicts for disclosure.