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Neurosurgery

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Neurosurgery
Stereotactic guided insertion of DBS electrodes in neurosurgery
Occupation
Activity sectors
Surgery
Description
Education required

or

or

or

Fields of
employment
Hospitals, Clinics

Neurosurgery (or neurological surgery) is the medical specialty concerned with the prevention, diagnosis, treatment, and rehabilitation of disorders which affect any portion of the nervous system including the brain, spinal cord, peripheral nerves, and extra-cranial cerebrovascular system.[1]

Education and training

In different countries, there are different requirements for an individual to legally practice neurosurgery, and there are varying methods through which they must be educated. In most countries neurosurgeon training is a minimum period of 6–7 years after graduating from the medical school.

United States

In the United States, a neurosurgeon must generally complete four years of college, four years of medical school, and seven years of residency (PGY-1-7).[2] Most, but not all, residency programs have some component of basic science or clinical research. Neurosurgeons may pursue an additional training in a fellowship, after residency or in some cases, as a senior resident. These fellowships include pediatric neurosurgery, trauma/neurocritical care, functional and stereotactic surgery, surgical neuro-oncology, radiosurgery, neurovascular surgery, Interventional neuroradiology, peripheral nerve, spine surgery and skull base surgery.[3] In the U.S., neurosurgery is considered an extremely competitive specialty composed of only 0.6% of all practicing physicians and attracts only the top students of medical schools per year.

United Kingdom

In the United Kingdom, students must gain entry into medical school. MBBS qualification (Bachelor of Medicine, Bachelor of Surgery) takes 4–6 years depending on the student's route. The newly qualified Doctor must then complete Foundation training lasting two years; this is a paid training program in a hospital or clinical setting covering a range of medical specialties including surgery. Junior doctors then apply to enter the neurosurgical pathway. Unlike most other surgical specialties, it currently has its own independent training pathway which takes around eight years (ST1-8); before being able to sit consultant exams with sufficient amounts of experience and practice behind them. Neurosurgery remains consistently amongst the most competitive medical specialties to obtain entry into.[4]

Main divisions of neurosurgery

General Neurosurgery is the practice where a neurosurgeon handles most of the neurosurgery conditions including neuro-trauma and other neuro-emergencies such as intracranial hemorrhage. Most level 1 hospitals have this kind of practice.

Specialized branches have developed to cater special and difficult conditions. These specialized branches co-exist with general neurosurgery in more sophisticated hospitals. To practice these higher specialization within neurosurgery, additional higher fellowship training of 1–2 years is expected from the neurosurgeon. Some of these divisions of neurosurgery are:

  1. Vascular and Endovascular neurosurgery
  2. Stereotactic, Functional and Epilepsy neurosurgery
  3. Oncological neurosurgery
  4. Spine neurosurgery
  5. Skull-Base Surgery
  6. Peripheral nerve surgery
  7. Pediatric neurosurgery

Neuropathology

The pathology confronted by neurosurgeons could be either congenital, acquired, traumatic, infection, neoplastic or degenerative. Conditions like congenital hydrocephalus, pediatric tumors and myelomeningocele are encountered in pediatric age group. Trauma with head or spine injury and AVM bleeds are encountered in young adults. Degenerative spine disease, aneurysm bleeds and Parkinson's disease are encountered in much older population.

The science of Neuropathology is a well developed branch of pathology which immensely help the modern day neurosurgeon.

Neuroanesthesia

Neuroanesthesia is a highly developed science that is linked to neurosurgery. This branch of medicine plays a very important part in day-to-day neurosurgery.

Neurosurgery methods

Neurosurgery
ICD-10-PCS00-01
ICD-9-CM01–05
MeSHD019635
OPS-301 code5-01...5-05

For a satisfactory neurosurgery outcome a reasonable pre-operative diagnosis is essential. Neuroradiology plays a key role not only in diagnosis but also in the operative phase of neurosurgery.

Neuroradiology methods are used in modern neurosurgery diagnosis and treatment. They include computer assisted imaging computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), magnetoencephalography (MEG), and the stereotactic radiosurgery. Some neurosurgery procedures involve the use of intra-operative MRI and functional MRI.

In conventional open surgery the neurosurgeon opens the skull, uses a large opening to access the brain. Technique of using smaller openings and using microscopes and endoscopes were developed later. With this smaller openings and high clarity microscopic visualization of neural tissue excellent results can be obtained. But, the open methods are still used in trauma or emergency situations[10] Principles of Neurosurgery-Rengachari, Ellenbogen, [11] Neurotrauma and Critical Care of the Brain-Jallo, Loftus .'

Microsurgery is utilized in many aspects of neurological surgery. Microvascular techniques are used in EC-IC by-pass surgery and in restoration carotid endarterectomy. The clipping of an aneurysm is performed under microscopic vision. Minimally invasive spine surgery utilizes microscopes or endoscopes. Procedures such as microdiscectomy, laminectomy, and artificial disc replacement rely on microsurgery.[5]

Using Stereotaxy neurosurgeons can approach a minute target in the brain through a minimal opening. This is used in functional neurosurgery where electrodes are implanted or gene therapy is instituted with high level of accuracy as in the case of Parkinson's disease or Alzheimer's disease. Then in the combination method of open and stereotactic surgery intraventricular hemorrhages could be evacuated successfully.[6]

Minimally invasive endoscopic surgery is utilized by neurosurgeons. Techniques such as endoscopic endonasal surgery is used in pituitary tumors, craniopharyngiomas, chordomas, and the repair of cerebrospinal fluid leaks. Ventricular endoscopy is used in the treatment of intraventricular bleeds, hydrocephalus, colloid cysts and neurocysticercosis. Endonasal endoscopy at times is carried out with neurosurgeons and ENT surgeons as a team.

Repair of craniofacial disorders and disturbance of cerebrospinal fluid circulation is done by neurosurgeons, and at times teaming up with maxillofacial and plastic surgeons. Cranioplasty for craniosynostosis is performed by pediatric neurosurgeons with or without plastic surgeons.

Neurosurgeons are involved in Stereotactic Radiosurgery along with Radiation Oncologists in tumor and AVM treatment[13]Intracranial Stereotactic Radiosurgery-Lunsford, Sheehan, [14]Spine Radiosurgery-Gerszten, Ryu. Radiosurgical methods such as Gamma knife, Cyberknife and Novalis Shaped Beam Surgery are used.[7]

Endovascular Neurosurgery utilize endovascular image guided procedures for the treatment of aneurysms, AVMs, carotid stenosis, strokes, and spinal malformations, and vasospasms. Techniques such as angioplasty, stenting, clot retrieval, embolization, and diagnostic angiography are endovascular procedures.[8]

A common procedure performed in neurosurgery is the placement of Ventriculo-Peritoneal Shunt (VP Shunt). In pediatric practice this is for congenital hydrocephalus. The commonest indication in adults is Normal Pressure Hydrocephalus (NPH).

Neurosurgery of the spine covers cervical, thoracic and lumbar spine. Some indications for spine surgery are spinal cord compression from trauma, arthritis or spondylosis. In cervical cord compression patients may have gait difficulty, balance issues, numbness and tingling in hands or feet. Spondylosis is spinal disc degeneration and arthritis that compresses the spinal canal resulting in bone spurring and disc herniation. Power drills and special instruments are used to correct any compression to the spinal canal. Disk herniations of spinal vertebral disks are removed by Kerrison pitiutary ronguers. This is called a discectomy. Laminectomy is removing Lamina portion of the vertebra of the spine to make room for the compressed nerve tissue. Minimally invasive, radiology assisted spine surgery include vertebroplasty and kyphoplasty where some kinds of spinal fractures are managed[12] Essentials of Spinal Cord Injury-Fehlings, Vaccaro, Boakye et al.

Pain surgery handled by the neurosurgeons include implantation of deep brain stimulators, spinal cord stimulators and pain pumps [9] Functional Neurosurgery-Starr, Barbaro, Larson. Surgery of the peripheral nervous system include carpal tunnel decompression and peripheral nerve transposition.

Conditions

Other conditions treated by neurosurgeons include:

See also

References

  1. ^ AANS – Patient Information
  2. ^ ABNS.org
  3. ^ http://www.aans.org/medical_students/questions.asp
  4. ^ "The society of British neurological surgeons". Retrieved 2011-03-11.[dead link‍]
  5. ^ Cyber Museum of Neurosurgery
  6. ^ http://www.world-sci.com/read.aspx?id=135
  7. ^ Stereotactic Radiosurgery Program | UCLA Neurosurgery
  8. ^ Neuroradiology – Information for Patients & Referring Physicians
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