There are approximately 2.5 million emergency department visits and hospitalizations each year associated with traumatic brain injury (TBI), and approximately 50,000 individuals die from TBI per year. Also, there are about 11,000 new spinal cord injuries each year (1). According to a report by Organized Neurosurgery to the Institute of Medicine, there are approximately 3,689 board-certified neurosurgeons for over 5,700 hospitals in the U.S. serving a population of over 340 million people (2), but only about 1,600 of these hospitals provide trauma care. Too few neurosurgeons are available to provide trauma and emergency care with only 83 percent of all neurosurgeons providing 24/7 emergency call. There are only 178 board-certified pediatric neurosurgeons according to the report, and one-fifth of all neurosurgeons report they no longer treat pediatric cases. The neurosurgical work force appears to be aging with 46 percent or more practicing neurosurgeons over the age of 55.
With the aging population and demand for more medical care, the report concludes that the apparent shortage of neurosurgeons is likely to increase. Another report indicated that there is likely a shortage of neurosurgeons in the U.S., noting that of 305 job advertisements, approximately 24 percent were recruiting for emergency department coverage only, and 26 percent indicated they might not be recruiting at all if not for the need of emergency coverage (3). These figures and your own personal experience would indicate that there is just too much neurotrauma in the U.S. and too few neurosurgeons to provide care for all of these patients.
It Takes a Village
Many other specialties are involved in the care of neurotrauma patients. A recent report demonstrated that the vast majority of pediatric concussion patients are treated by their own primary care physician and never come to the attention of a neurosurgeon (4). Neurologists are often involved in the care of neurotrauma victims. Neurointensivists provide help with intensive care unit (ICU) care and may assist in the resuscitation of such patients. Orthopaedic surgeons are often involved in the care of spinal cord injury patients. Trauma surgeons have historically provided care of head-injury patients. Before the evolution of neurosurgery into its own specialty, virtually all such trauma was cared for by general surgeons. Today in the U.S., there is general agreement that craniotomies for trauma should be performed by neurosurgeons in all but the direst cases where neurosurgeons are absolutely not available.
A paper published by a group of trauma surgeons suggests that it may be appropriate to manage certain non-operative head injured patients independently without the input of any neurosurgeon (5). The Neurotrauma Section responded with a letter to the editor of the Journal of the American Medical Association (JAMA) Surgery pointing out that the American College of Surgeons (ACS) Verification Of Trauma Centers require 24-hour availability of a neurosurgeon for Level 1 and Level 2 centers (6). The letter also pointed out that neurosurgeons should continue to oversee the treatment of acute TBI when there is evidence of intracranial pathology and called for a cooperative approach to TBI victims between trauma surgeons and neurosurgeons. The authors of the original article acknowledged this but stood firm on their conclusion that patients with a Glasgow Coma Scale (GCS) score of above 13 could be managed independently without neurosurgeons (7).
Clearly, the disparity between the amount of neurotrauma and the number of neurosurgeons has created pushback from a number of specialties. This may be based on sheer numbers, but neurosurgeons’ attitudes towards the provision of trauma care and participation in trauma committee work may also have something to do with this pushback.
Getting in on the Ground Floor
The neurosurgeon plays an important role in neurotrauma by bringing considerable resources to bear on a very complex set of injuries. These resources include not only his or her specialized training in the management of trauma patients but the team that the neurosurgeon brings to the aid of the neurotrauma patient, including neurosurgery residents and mid-level providers. The neurosurgeon is trained to provide operative care of the neurotrauma patient. Additionally, current neurosurgery tranining requirements include milestones to document competency in pre and postoperative care of such patients, management of these patients in the Neurointensive Care Unit (NCU), and follow-up to ensure that the patient receives optimum rehabilitation.
Beyond treatment of the individual patient, the neurosurgeon is capable of providing expertise and education to the rest of the neurotrauma team through bedside teaching and didactic lectures. Research in neurotrauma has been pioneered by neurosurgeons since the early 20th century beginning with biomechanical studies and progressing through research documenting the pathophysiology of traumatic brain and spinal cord injury and the cell and molecular biology of such injuries. Neurosurgeons have either been the primary investigator or co-investigator in virtually all of the therapeutic trials on traumatic brain and spinal cord injury, and their input has been critical in trial design, execution and analysis.
Responsibilities as a Specialty
The neurosurgeon should play a critical role in making transfer decisions of neurotrauma patients. Communication and teleradiology will assist outside hospitals in deciding whether or not the transfer of a patient is warranted, but this is best done with the input of a neurosurgeon. Neurosurgeons should and do participate in the development of trauma protocols not only at their local hospitals, but on regional and even national levels. Finally, organized neurosurgery has supported ThinkFirst, a program aimed at preventing head and spine injury. Prevention of neurotrauma is recognized as a key responsibility of neurosurgeons (8).
Historically, neurosurgeons have played a vital role in neurotrauma, but not in isolation. The best advances in care for neurotrauma patients have occurred when neurosurgeons work collaboratively with all the other specialists involved in treating neurotrauma victims. Whether the neurosurgeon is called upon to be the captain of the ship or a deckhand will be dictated by the circumstances of the individual case. No matter what this role is, the Neurotrauma Section is dedicated to ensuring that neurosurgeons have the resources they need to continue to serve our patients to the best of our ability.
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References
1. Couldwell, W.T., & Seaver, M.J. (2008). Practicing neurosurgery in the United States. AANS Neurosurg, 17, 6-10.
2. Statement of the American Association of Neurological Surgeons, American Board of Neurological Surgery, Congress of Neurological Surgeons, Society of Neurological Surgeons: A Report Before the Institute of Medicine: Ensuring an Adequate Neurosurgical Workforce for the 21st Century. December 19, 2012. Available at: https://www.cns.org/sites/default/files/legislative/NeurosurgeryIOMGMEPaper121912.pdf.
7. Joseph, B., Pandit, V., & Aziz, H. (2016). Neurosurgeons’ critical role in managing traumatic brain injury–reply. JAMA surgery, 151(2), 200.
