How will neurosurgery be practiced a generation from now? No one can offer a prediction comparable to a Delphian or Zarathustrian rendering of our specialty 40 years hence. However, historical indicators allow one to postulate with some degree of certainty on the topic, although the timing of endpoints in current trends remains in question. Undoubtedly, sweeping winds of change are inevitable.
Neurological surgery may be considered the oldest surgical specialty, dating back more than 12 millennia. A hundred years ago, Cushing described the specialty of neurosurgery, which would flourish in the modern era. Since then there has been a dramatic escalation in the capabilities of the field. The current generation of neurosurgeons in particular has experienced and benefited from the realization of seminal discoveries, ideas, and disclosures—represented by concepts, tools, and methods employed in everyday practice—that have had immense impact on patient treatment. These advancements collectively include the microscope, the microprocessor, imaging modalities, endoscopy, endovascular techniques, stereotactic radiosurgery, navigation and the currently peripheral but ever-evolving areas of genomics, cellular and molecular neurosurgery, and robotics and nanotechnology used in nanoneurosurgery. These tools, which will allow upcoming generations of neurosurgeons to approach the current catalogue of neurosurgical disease at micro-, molecular and possibly atomic levels, may be considered the neurosurgeon’s “machines of modernity.”
Consideration of these implements, along with what might be termed established concepts of modernity, affords a conceptual aperture through which the practice environment and activities of the future neurosurgeon can be viewed. Major trends in the evolving continuum include progressive minimalism in tools and procedures; guidance systems, including imaging or molecular-based technologies; functional restoration, both genomic and anatomical; individual comprehension of pathological and functional processes; rehearsal using simulation; and biomechanical integration at macro-, micro- and nano-levels.
Beginning with consideration of these trends, it is reasonable to expand visualization over the course of 40 years. Although hardly forming a complete picture, the following predictions suggest the scope of neurosurgical activities in 2050.
Clinical Trends
By 2050 the need for craniotomy will be sharply reduced. Microsurgery of cerebrovascular
disease will be highly limited and relegated principally to revascularization
procedures. Genetic comprehension, endovascular methods and flow-modeling techniques
along with radiosurgery will impact virtually all elements of vascular pathology.
Advanced imaging will define structural alterations in vascularity and regions
of retrievability in stroke.
The role of craniotomy for tumors will be minimal, with endoscopic, molecular, biological, nanotechnological and radiosurgical methodologies predominating as treatment modes. Effective radioprotectors and enhancing agents in nanoconstructs will refine energy delivery with the precision of cellular targeting offered by nanoparticle localization. Tunable lasers and high-energy ultrasound will be valuable therapeutic modalities. A combination of imaging and nanobiological methods will precisely diagnose histological phenotypes, and advancements in genetic profiling will allow preventative surveillance.
Most spinal surgeries will be minimally invasive with frequent use of biologics as adjuvants. Nanoarray screening of high-risk genotype will augment imaging surveillance for degenerative and congenital spinal disorders.
Functional surgeries will be completely restorative, with the use of ablation fading into history. Structural and metabolic imaging will define aberrant pathways and regions of degeneration or aberrant activity. Modulation, cellular constructs, and restorative nanoarrays will be actively employed in extrapyramidal disease, epilepsy, pain, and a spectrum of other syndromes. Refinements in functional imaging of neuropsychiatric disorders will lead to the increased role of minimally invasive neurosurgical methods in management of obsessive-compulsive disorder, depression, autism and Alzheimer’s disease, among others.
Surgery and management of craniospinal trauma will evolve as a separate neurosurgical discipline. Functional retrieval and restorative methods in trauma will enter an active phase in which modulation is used in comatose patients, and nanocellular amalgams are employed for injuries of the spine and cerebrum. Brain-machine interface devices will be in common use for rehabilitation. Genotyping will refine management of minor traumatic brain injury. Prediction of sequellae will come into clearer focus.
Pediatric neurosurgeons will use predictive genetic screening to identify potential neurological pathology in a fetus, and techniques for intrauterine surgeries will be refined. Nanotechnology will be used to improve cerebrospinal fluid diversionary methods.
Training and Preparations
Rapid changes in economic, social, political and scientific trends in the
global community will demand reassessment of needs, individuals, and training
in neurosurgery. The role and definition of the neurosurgeon in the constellation
of healthcare will undergo a metamorphosis based on technical evolution. In
highly developed countries, demand for uniform outcomes will result in an attenuated
role and training for the generalist and further definition of specialists
and subspecialists, whose training and exposure will expand.
Spinal surgery, because of its unique catalogue of diseases and methods, will become a separate specialty.
In all surgical specialties, a central component of the training process will be virtual reality simulation, which will largely circumvent the need for “practical seminars” remote from residency or central training sites.
Because of the characteristics and needs of the specialty, individuals with engineering backgrounds will predominate in advanced clinical and research areas, and they will make the seminal contributions for the future.
Individuals with administrative policy and business backgrounds will assume the primary roles in administrative leadership, particularly at medical schools and larger healthcare institutions related to training and research. Departmental leadership will be clearly and equally partitioned into administrative, academic, and clinical areas.
Recertification will be more frequent than the current 10-year requirement, and the process will be facilitated by electronic media and methods.
Organized Neurosurgery
It is apparent, given the accessibility of air travel and the proliferation
of the Internet and communication devices, that the world is “flattening.”
The globalization apparent in all aspects of daily life is highly relevant
to all in neurosurgery. The sharing of ideas and problems with colleagues the
world over will dominate our future. Organizations with a global reach not
only will be the most influential but also will be the creative force guiding
neurosurgical patient care toward greater organization and efficiency worldwide.
The development of a global network for sharing ideas and problems will naturally
evolve, providing the impetus for progress.
Given issues related to subspecialization, communication capabilities and the evolution of socioeconomic trends, particularly those involving industry, it is highly likely that the practice of holding two major national meetings annually in North America will end. However, truly global gatherings for the exchange of ideas and information in multiple relevant dimensions of the field will take place more frequently.
As a result of the information deluge, the body of useful knowledge is rapidly expanding. However, the expense associated with meaningful peer review and paper dissemination of new scientific data is becoming increasingly burdensome. It is inevitable that neurosurgurical journals primarily will be published electronically, complemented by intermittent and attenuated printed offerings.
Change is inevitable. We will have to reinvent ourselves. Neurological surgery, in its microcosm within the universe of social, political, economic, and scientific evolution, is fragile. Cushing could not have imagined neurosurgery in 2009; in fact, those of us who entered the field a generation ago could not have imagined it either! Neurosurgeons reading this article in 2050 will judge the accuracy of the foregoing predictions. Their judgment will be tempered by evaluation of their own progress as stewards of neurosurgery, even as they seek to navigate the winds of change that will sweep them into the next century.
Michael L.J. Apuzzo, MD, PhD (hon), is the Edwin M. Todd/Trent H. Wells Jr. Professor of Neurological Surgery, Radiation Oncology, Biology and Physics at the Keck School of Medicine of the University of Southern California, Los Angeles. The author reported no conflicts for disclosure.
For Further Information
- Apuzzo MLJ, Elder BJ, Liu CY: The metamorphosis of neurological surgery and the reinvention of the neurosurgeon. Neurosurgery (in press)
- Apuzzo MLJ, Liu CY, Sullivan D, Faccio RA: Surgery of the human cerebrum—a collective modernity. Neurosurgery 61:SHC5-SHC31, 2007
- Elder, JB, Hoh DJ, Oh BC, Heller AC, Liu CY, Apuzzo MLJ: The future of cerebral surgery: a kaleidoscope of opportunities. Neurosurgery 62(6):SHC1555-SHC1582, 2008
- Hoh DJ, Liu CY, Chen JC, Pagnini PG, Yu C, Wang MY, Apuzzo ML: Chained lightning: part III&Mdash;emerging technology, novel therapeutic strategies, and new energy modalities for radiosurgery. Neurosurgery 61:1111-1130, 2007
- Spicer MA, van Velsen M, Caffrey JP, Apuzzo MLJ: Virtual reality neurosurgery: a simulator blueprint. Neurosurgery 54:783—798, 2004