The field of neurotrauma provides unique career opportunities for neurosurgeons and is rewarding for the impact that successful intervention can have on the lives of patients and their families. There are many other opportunities to evolve as a surgeon and physician in this discipline including developing advanced surgical techniques, conducting meaningful research, educating others, participating in health care systems development and giving back to the community via prevention efforts.
From the point of view of helping patients, this is one of the few areas of medicine in which we have the opportunity to regularly save people’s lives and even to restore them to normalcy and highly functional states after what could have been a devastating injury. For those for whom we cannot achieve such optimistic outcomes, more and more techniques to mitigate – and even restore – functional problems after neurological injury are emerging in both clinical and research settings. Exploration of the brain-machine interface is becoming more the stuff of the clinical translational research laboratory and less the realm of science fiction.
The Evolution of Neurotrauma
Many people cite the ability to operate on the entire nervous system as one of the attractions to the field of neurosurgery in general, and a fully realized neurotrauma practice can provide this. A paradigm shift in neurotrauma has occurred over the past several years, from a largely non-operative field to one providing rich surgical experiences and technical advances, including the incorporation of minimally invasive techniques, the development of biomaterials and the use of implantable, programmable devices. The neurosurgeon specializing in this area will often perform cranial and brain surgeries for traumatic brain injury (TBI), complex craniofacial reconstruction operations, decompression and stabilization for spinal cord and spinal column injuries, repair and restoration procedures after peripheral nerve injuries, cerebrospinal fluid (CSF) diversion procedures and even functional surgeries to address the aftermath of neurological injury. Indeed, the latter category is emerging as a more common means of helping patients achieve better outcomes, including the implantation and use of medication pumps for spasticity or chronic pain. Future application of various neurostimulation and neuromodulation techniques will expand these opportunities for late interventions after trauma. For those neurosurgeons obtaining additional training in endovascular techniques, the opportunity to treat blunt vascular injuries also exists.
Even the ways isolated cranial trauma is handled have evolved. Whereas straightforward craniotomies for evacuation of hematomas will always be a mainstay of this specialty, several factors have resulted in the evolution of surgical complexity in brain trauma. The use of more aggressive, decompressive surgery, advances in anesthesia and the improved survival rates now achievable with advances in pre-hospital care and management of extracranial injuries have all resulted in the supplanting of the “routine craniotomy” by much more technically and intellectually challenging cranial surgeries. Excellent surgical skills allowing for rapid and safe surgery and control of active bleeding, as well as technical innovation and quick decision-making for the treatment of unique injury patterns are often required while the neurosurgeon is simultaneously managing the commonly encountered physiological problems of cerebral edema, coagulopathy, hypotension, hypoxia and more with the anesthesia team.
Surgical techniques learned in the course of caring for trauma patients are also translatable to many other types of surgery, and an experienced neurotrauma neurosurgeon will find that areas of specific interest can be developed into a growing subspecialty elective practice. Certainly the application of spinal instrumentation, fixation and fusion to both trauma and degenerative spine problems is familiar to most. There are many other overlapping techniques; however, that can be translated to additional areas of neurosurgical expertise and practice expansion. For example, understanding the anatomy and surgical techniques needed for the repair of complex craniofacial trauma can be utilized for other types of surgeries requiring skull base approaches, such as tumors and CSF leaks. The exposures necessary for repair and reconstruction of complex nerve injuries can be applied to compressive nerve pathologies such as neurogenic thoracic outlet syndrome or peripheral nerve tumor resections.
Neurotrauma neurosurgical practice also goes hand-in-hand with neurocritical care. For those who resonate with the intellectual stimulation and challenges associated with complex physiological problems in the intensive care unit (ICU), there is nothing quite like managing a TBI patient with hourly physiological perturbations or helping a complex polytrauma patient with many competing issues to juggle. Indeed, the majority of our advanced neuromonitoring techniques for assessment and management of intracranial pressure, cerebral blood flow and perfusion and cerebral ischemia have been developed and implemented early on primarily in the treatment of TBI. Expansion of these techniques to treatment of patients with vascular pathology, such as aneurysm rupture and ischemic infarction, and other brain pathologies, such as idiopathic intracranial hypertension and even some tumors, ensures that neuromonitoring will remain a mainstay of neurosurgical practice and a fertile area for research of normal and abnormal brain physiology.
Areas of Ongoing Study
Research in the area of neurotrauma has indeed rapidly expanded over the past several years, yet many questions remain. While early efforts in clinical TBI research centered on attempts to identify drug therapies that could improve outcome in large-scale randomized prospective trials, these were largely non-contributory. Recent efforts have focused on answering other types of questions that impact both mortality and quality of survival after TBI. Because survivability after TBI has been dramatically increased, many clinical areas relevant to survivors require further study, including mechanisms to improve early prognostication, risk stratification for patients on antithrombotic medications pre-injury or requiring them post-injury, management of injuries to multiple organ systems in the face of TBI, techniques and indications for CSF diversion and cranial reconstruction, optimal balance and utility of various neuromonitoring and neuroprotective strategies and rehabilitative efficacy, to name a few.
Life expectancy after spinal cord injury has also increased with complication prevention efforts and areas ripe for study include prevention of life-long medical problems associated with immobility, mechanisms of neuroplasticity and techniques for neurorestoration. Spinal column injuries are far more common than spinal cord injuries and areas of ongoing clinical study include safety and efficacy of less invasive surgical and less restrictive non-surgical treatment of these injuries. Patients with peripheral nerve injuries that are not amenable to direct repair may be helped by nerve-transfer surgeries to restore specific motor or sensory functions; the understanding of which requires more widespread availability of well-trained surgeons and research into functional efficacy. Blunt vascular injuries, which can lead to cerebral ischemia, infarction and even death, require further study to refine our understanding of the utility of screening and diagnostic modalities and the efficacy and safety of various medical and interventional therapies, such as antithrombotic medications and stenting.
Basic science research in the area of neurotrauma has enjoyed even more widespread growth, as neuroscience techniques and models have evolved and our understanding of neural function on the cellular, organ and organism level has matured. The findings from basic science research using injury models have widespread applicability to other diseases of neuronal loss, including ischemic and hemorrhagic “stroke” and degenerative diseases such as dementia, enhancing the relevance of the work.
Educational Opportunities
Educational opportunities are available for those who like to teach, no matter the practice setting. From local efforts such as participation in Advanced Trauma Life Support classes to global surgical education and the gamut in between, those interested in teaching surgical techniques, medical knowledge and other domains required for all types of health care providers will have many options to share their expertise in neurotrauma. The World Health Organization (WHO) estimates that the global burden of surgical disease is massive — 321.5 million surgical procedures needed to address the burden of disease for the global population in 2010, much of which was attributable to trauma (over 48 million cases annually) (1).
Trauma systems development for optimal care delivery has been an area of focus for public health and organized surgery leaders in recent decades. Hospitals, health care delivery systems, public health and emergency medical service (EMS) agencies, state and local governments and federal regulatory agencies offer chances for interested neurosurgeons to participate on all levels. This is an especially rewarding pathway to educational, administrative and leadership experience, as approaches to systems-based care are multidisciplinary. The multidisciplinary nature of trauma care allows for cross-pollination of knowledge, and the collegiality afforded by those with common goals is particularly gratifying. While innumerable occasions are afforded to make a difference in the lives of individuals by choosing neurotrauma, even greater opportunities exist for aiding populations through public health and policy involvement.
Prevention is Key
Finally, we as neurosurgeons understand that the best outcome is to never have suffered an injury in the first place. Prevention efforts exist on local, state, national and international levels, but the need for more people to become involved is never-ending. Attending a child’s school assembly, sponsoring a chapter of ThinkFirst or helping with fundraisers for prevention education are but some of the avenues available to contribute. People are oftentimes interested in meeting neurosurgeons, and they respect the training and dedication we possess — the importance of this influence should not be underestimated! Data suggest that the neurosurgery-born ThinkFirst youth prevention programs for neurological injury are especially effective at increasing children’s knowledge about preventing these devastating injuries (2).
In summary, to construct a career that addresses one’s personal strengths, interests and goals, one must be provided with opportunities in addition to will and skill sets. The field of neurotrauma offers a wide world of opportunity to tailor one’s career to any subset of inclinations, whether in clinical, military or academic practice. These openings encompass clinical care, education, research, administration and community involvement. Not only is a career in neurotrauma a viable choice for neurosurgeons, it is one of the most technically challenging, intellectually demanding and ultimately rewarding choices a neurosurgeon can make.
