American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Neurological Surgery

Neurological Surgery is a discipline of medicine and that specialty of surgery that provides the operative and nonoperative management (i.e., critical care, prevention, diagnosis, evaluation, treatment, and rehabilitation) of disorders of the central, peripheral, and autonomic nervous systems, including their supporting structures and vascular supply; the evaluation and treatment of pathological processes which modify the function or activity of the nervous system, including the hypophysis; and the operative and nonoperative management of pain. As such, neurological surgery encompasses treatment of adult and pediatric patients with disorders of the nervous system: disorders of the brain, meninges, and skull, and their blood supply, including the extracranial carotid and vertebral arteries; disorders of the pituitary gland, disorders of the spinal cord, and vertebral column, including those which may require treatment by spinal fusion or instrumentation; and disorders of the cranial and spinal nerves throughout their distribution.

As of July 1, 2009, the training program in neurological surgery no longer requires a prerequisite year of general surgery. The neurological surgery training program is at least 72 months in duration. Programs can be approved for up to 84 months of training: 72 months for clinical and didactic education and 12 months for research or subspecialty training.

For more information, visit the American Board of Neurological Surgery and the American Association of Neurological Surgeons.

The description of this surgical specialty was adapted from a description set forth by the American Board of Medical Specialties (ABMS) and the Neurological Surgery Residency Review Committee (RRC-NS).

Neurosurgery as a Career

Neurosurgery is a surgical specialty that involves the conservative and surgical management of a wide variety of disorders affecting the brain, the spinal cord and spinal column, and the peripheral nerves. Common conditions managed by neurosurgeons include brain tumors, intracranial aneurysms, head injuries, and a broad spectrum of disorders affecting the spine including spinal canal stenosis, herniated discs, tumors, fractures, and spinal deformities.

I have been a neurosurgeon for the past 12 years. My training after medical school included a one-year general surgery internship, five years of neurosurgical residency, and an optional one-year fellowship in spinal surgery. During that time period I was fortunate to witness numerous advances in neurosurgery that have served to revolutionize the field. Neurosurgery today is one of the most technologically involved surgical specialties with many contributions from computer-based neuronavigational technology, spinal biomechanics and instrumentation, gene therapy for brain tumor management, and catheter-driven endovascular techniques, as well as continued advances in neuroradiological technology. No surgical specialty offers as broad a spectrum of pathological disorders and options for management as neurosurgery does today.

This rapid advancement of the field in the past decade has generated the development of numerous subspecialities within the field. Although most neurosurgeons today continue to practice general neurosurgery, more and more neurosurgeons finishing their training are electing to enter optional one-year fellowships in neuro-oncology, spinal surgery, epilepsy surgery, functional neurosurgery, cerebrovascular surgery, or pediatric neurosurgery. This high degree of surgical subspecialization only serves to further drive the technical and technological advances that highlight neurosurgery today.

The life of a neurosurgeon can be very demanding. Many operations can be long and technically difficult. Surgical emergencies such as bleeding within the brain or sudden compression of the spinal cord can occur at any hour of the day or night and demand immediate attention. Cases involving severe brain injury, paralysis from damage to the spinal cord, or a brain tumor in a child can be emotionally draining for the neurosurgeon taking care of these patients. Yet despite these challenges and demands, neurosurgery today can also offer a great deal of personal satisfaction. This comes in restoring a patient to normal function by relieving incapacitating pain, improving motor function, controlling a seizure disorder, or eliminating a tremor.

The individual subspecialties in neurosurgery each offer unique opportunities. Cerebrovascular neurosurgeons deal with disorders involving the blood flow to and within the brain. They perform operations to relieve narrowing of the carotid arteries in the neck or eliminate aneurysms or arteriovenous malformations within the brain. Some operations can only be performed under controlled, temporary cardiac arrest.

Neurosurgeons who specialize in spinal surgery manage a wide variety of disorders involving the spinal column and spinal cord. These include arthritic conditions such as herniated discs and bone spurs that can put pressure on the nerve roots and the spinal cord, tumors of the spine and spinal cord, spinal fractures, and deformities of the spine such as scoliosis and spondylolisthesis. It is a field that has undergone rapid technological advances in the last decade which have increased the number of patients that can be successfully managed with spinal surgery.

Pediatric neurosurgeons are challenged with unique neurological disorders affecting children. In addition to managing patients with head injuries, brain and spinal tumors, vascular malformations, and seizure disorders, the pediatric neurosurgeon spends a great deal of time managing children with hydrocephalus. Advances in programmable shunt devices have greatly improved the success of shunt surgery.

Neurosurgeons who specialize in treating patients with complex seizure disorders are part of a team of physicians that manage this problem. While most patients with seizures can be successfully managed with medication, a few continue to have seizures despite heavy medication. These patients undergo an operation in which a grid of electrodes are placed on the surface of the brain and left in place for several days. During this time the source of the abnormal electrical activity within the brain is precisely mapped and localized. When the focus of the seizure has been localized within the brain, the patient then undergoes a second operation to have that portion of the brain removed. This procedure can dramatically reduce the number of seizures and give the seizure patient a relatively normal life.

Neurosurgeons who specialize in functional surgery are experiencing a dramatic surge in technology. Functional surgery deals with a variety of disorders of the brain that can be incapacitating to a patient. Movement disorders that can occur with such diseases as multiple sclerosis and Parkinson's disease can virtually isolate a patient from society. With recent advances in computer navigational technology which allows for the extremely precise placement of recording electrodes within the deep brain nuclei, as well as advances in recording capabilities that now allow for recording electrical activity within small groups of neurons, surgery for these conditions can result in a high degree of success in controlling or eliminating these movement disorders.

Neurosurgery is a very demanding, yet extremely rewarding specialty. It offers a wide variety of clinical challenges and surgical options. It is well suited to those individuals seeking a career in surgery who have a strong interest in the human nervous system and the various disorders that can affect it. The technological advances that continue to evolve will help keep neurosurgery a fresh and exciting field for decades to come.

Iain H. Kalfas MD, FACS
Cleveland, OH