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Is modern-day neurosurgery becoming a cooperative?
396
Surg Neurol 1989;32:396-7
Editorial
As Dr. Paul Bucy, the founder and first editor of SURGICAL NEUROLOGY, did, I have frequently invited our editors to submit editorials for publication. As co-editor, Dr. Robert White has been associated closely with SURGI¢^LNEUROLOGYand Dr. Bucy far longer than I have, and he has submitted this editorial, which we are more than glad to publish. I do not share the pessimism that Dr. White expresses in
this article for the future of neurosurgery, and I have written him exactly that point with details, but he hopes, and I agree with him, that this editorial will stir a good deal of interest among other neurosurgeons who may express their varied opinions through the pages of StsR6icAz NEUROLOGY. Eben Alexander, Jr., M.D. Winston-Salem, North Carolina
Is Modern-Day Neurosurgery Becoming a Cooperative? Medical students and residents still stream through my office, requesting advice and guidance regarding a career in neurosurgery. For someone who has enjoyed and literally thrived within the framework o f his career as a neurological surgeon, I find myself very positive in my remarks and recommendations to these young physicians. In recent months, however, I have become increasingly worried about our specialty and its future. I am well aware, of course, that such concerning subjects as subspecialization and credentialing in pediatric neurosurgery, critical care, and vascular surgery have been reviewed by the Neurosurgical Board and have served as topics for presentation and discussion at several of our national meetings--and, to a large degree, remain unresolved. No, what I, personally, am concerned about is an issue that, in my judgment, is equally if not more important and that has not been appropriately addressed by our leadership. It is, simply stated: To what extent should a neurosurgeon cooperate with other specialties? And, in the process, are we in danger of losing our operative identity and independence ? Let me give some exampies: First, orthopedics is rapidly becoming more and more involved in handling literally all diseases relating to the spinal column, including spinal cord injury. Indeed, it has been recommended that the neurosurgeon be responsible for conditions within the dura and that the orthopedist assume responsibility for all extradural spinal abnormalities. There are enough o f us still practicing who can recall the time when only the neurosurgeon undertook spinal surgery. Today, it certainly seems that much of this type o f surgery is performed either independently by the orthopedist or in conjunction with the neurosurgeon. While many will argue that the surgical treatment of the spinal column and spinal cord disorders has been significantly advanced through the combined efforts © 1989 by ElsevierSciencePublishingCo., Inc.
of neurosurgery and orthopedics, some clinicians are already stating that, in time, orthopedics, not neurosurgery, will dominate in the area of spinal disease and its operative correction. Neurosurgeons, such as Doctor John Jane, have literally revolutionized the operative approaches to redesigning the cranial vault, particularly in children. However, in this area and in the management of tumors of the base of the skull, we see the development of an entirely new subspecialty by plastic surgeons, literally to the exclusion of neurosurgeons. True, the neurosurgeons and plastic surgeons may work together, but, often, the neurosurgeon's contribution is nothing more than protecting the brain by "holding it out of the way." Aside from Doctor Jane's stunning work, the mega-advances in the surgery of the cranial vault really belong to the specially trained plastic surgeons. Certainly, carotid endarterectomy, as well as other vascular procedures in the neck and upper thorax have long been undertaken independently by vascular surgeons. Already, we see the emergence of general surgeons as trauma surgeons, assuming total control for the management of all patients suffering injury within the framework of a surgical intensive care unit. We are still asked, of course, to consult on cases with severe brain trauma and to assist in their treatment, but seldom are they admitted directly to our service if they have associated injuries. It is here, in these specialized high-tech units that we are meeting the critical care specialist, who is rapidly assuming primary and often exclusive responsibility for the management of all patients in these intensive care settings, including postoperative neurosurgical patients. One might think that aneurysms and vascular anomalies of the brain and cord would forever remain in the province of neurosurgery, but nowadays, with the rapid advances in invasive neuroradiology leading to the development of new methods to treat these neurovascular conditions (endovascular sur0090-3019/89/$3.50
Editorial
gery), it is certainly reasonable to consider the possibility that, in the future, neurosurgery will be only limitedly involved in the management of these lesions. True, the field of malignant gliomas remains with us, but new technology, emphasizing radiological and chemotherapeutic techniques, must be shared with or may be exclusively handled by radiation therapists and neurologists functioning as oncologists. Even angle tumors and transsphenoidal hypophysectomies are often undertaken in association with otolaryngologists. If all of this seems a bit depressing (I am sure that some will find this cooperation to be exciting), we should also remember that peripheral nerve surgery has long been in the domain of plastic and orthopedic surgery. Additionally, neurosurgeons
Surg N e u r o l 1989;32:396-7
397
have no involvement in the recently developed field of reimplantation surgery. Many will find this trend in neurosurgery to be most appropriate, but isn't there danger that, in time, we will be unable to recognize who we are or what we are supposed to do? In a sense, our specialty will have lost its exclusivity. Perhaps some thought should be given by our leadership to what otolaryngology has d o n e - - t h a t is, define its areas of responsibility, which now include head and neck surgery. Otolaryngologists have demanded departmental status within university faculties. ROBERT J. WHITE, M.D., Ph.D.
Surg Neurol 1989;32:396-7
Editorial
As Dr. Paul Bucy, the founder and first editor of SURGICAL NEUROLOGY, did, I have frequently invited our editors to submit editorials for publication. As co-editor, Dr. Robert White has been associated closely with SURGI¢^LNEUROLOGYand Dr. Bucy far longer than I have, and he has submitted this editorial, which we are more than glad to publish. I do not share the pessimism that Dr. White expresses in
this article for the future of neurosurgery, and I have written him exactly that point with details, but he hopes, and I agree with him, that this editorial will stir a good deal of interest among other neurosurgeons who may express their varied opinions through the pages of StsR6icAz NEUROLOGY. Eben Alexander, Jr., M.D. Winston-Salem, North Carolina
Is Modern-Day Neurosurgery Becoming a Cooperative? Medical students and residents still stream through my office, requesting advice and guidance regarding a career in neurosurgery. For someone who has enjoyed and literally thrived within the framework o f his career as a neurological surgeon, I find myself very positive in my remarks and recommendations to these young physicians. In recent months, however, I have become increasingly worried about our specialty and its future. I am well aware, of course, that such concerning subjects as subspecialization and credentialing in pediatric neurosurgery, critical care, and vascular surgery have been reviewed by the Neurosurgical Board and have served as topics for presentation and discussion at several of our national meetings--and, to a large degree, remain unresolved. No, what I, personally, am concerned about is an issue that, in my judgment, is equally if not more important and that has not been appropriately addressed by our leadership. It is, simply stated: To what extent should a neurosurgeon cooperate with other specialties? And, in the process, are we in danger of losing our operative identity and independence ? Let me give some exampies: First, orthopedics is rapidly becoming more and more involved in handling literally all diseases relating to the spinal column, including spinal cord injury. Indeed, it has been recommended that the neurosurgeon be responsible for conditions within the dura and that the orthopedist assume responsibility for all extradural spinal abnormalities. There are enough o f us still practicing who can recall the time when only the neurosurgeon undertook spinal surgery. Today, it certainly seems that much of this type o f surgery is performed either independently by the orthopedist or in conjunction with the neurosurgeon. While many will argue that the surgical treatment of the spinal column and spinal cord disorders has been significantly advanced through the combined efforts © 1989 by ElsevierSciencePublishingCo., Inc.
of neurosurgery and orthopedics, some clinicians are already stating that, in time, orthopedics, not neurosurgery, will dominate in the area of spinal disease and its operative correction. Neurosurgeons, such as Doctor John Jane, have literally revolutionized the operative approaches to redesigning the cranial vault, particularly in children. However, in this area and in the management of tumors of the base of the skull, we see the development of an entirely new subspecialty by plastic surgeons, literally to the exclusion of neurosurgeons. True, the neurosurgeons and plastic surgeons may work together, but, often, the neurosurgeon's contribution is nothing more than protecting the brain by "holding it out of the way." Aside from Doctor Jane's stunning work, the mega-advances in the surgery of the cranial vault really belong to the specially trained plastic surgeons. Certainly, carotid endarterectomy, as well as other vascular procedures in the neck and upper thorax have long been undertaken independently by vascular surgeons. Already, we see the emergence of general surgeons as trauma surgeons, assuming total control for the management of all patients suffering injury within the framework of a surgical intensive care unit. We are still asked, of course, to consult on cases with severe brain trauma and to assist in their treatment, but seldom are they admitted directly to our service if they have associated injuries. It is here, in these specialized high-tech units that we are meeting the critical care specialist, who is rapidly assuming primary and often exclusive responsibility for the management of all patients in these intensive care settings, including postoperative neurosurgical patients. One might think that aneurysms and vascular anomalies of the brain and cord would forever remain in the province of neurosurgery, but nowadays, with the rapid advances in invasive neuroradiology leading to the development of new methods to treat these neurovascular conditions (endovascular sur0090-3019/89/$3.50
Editorial
gery), it is certainly reasonable to consider the possibility that, in the future, neurosurgery will be only limitedly involved in the management of these lesions. True, the field of malignant gliomas remains with us, but new technology, emphasizing radiological and chemotherapeutic techniques, must be shared with or may be exclusively handled by radiation therapists and neurologists functioning as oncologists. Even angle tumors and transsphenoidal hypophysectomies are often undertaken in association with otolaryngologists. If all of this seems a bit depressing (I am sure that some will find this cooperation to be exciting), we should also remember that peripheral nerve surgery has long been in the domain of plastic and orthopedic surgery. Additionally, neurosurgeons
Surg N e u r o l 1989;32:396-7
397
have no involvement in the recently developed field of reimplantation surgery. Many will find this trend in neurosurgery to be most appropriate, but isn't there danger that, in time, we will be unable to recognize who we are or what we are supposed to do? In a sense, our specialty will have lost its exclusivity. Perhaps some thought should be given by our leadership to what otolaryngology has d o n e - - t h a t is, define its areas of responsibility, which now include head and neck surgery. Otolaryngologists have demanded departmental status within university faculties. ROBERT J. WHITE, M.D., Ph.D.