Neurosurgery

Introduction

The medical specialty of neurosurgery, also referred to as neurological surgery or brain surgery, focuses on the surgical treatment of illnesses affecting any part of the nervous system, including the brain, spinal cord, and peripheral nervous system.

Education and Context

varied nations have varied standards for who can legally practice neurosurgery, and different educational pathways are available for that person to follow. After graduating from medical school, neurosurgeon training typically takes seven years or longer in most countries.

United States

A neurosurgeon in the United States typically has to finish four years of undergraduate study, four years of medical school, and seven years of residency. Basic scientific and/or clinical research are components of most, but not all, residency programs.

Following residency, neurosurgeons may seek further training as fellow or, in certain circumstances, as senior residents through an enfolded fellowship.

Children’s neurosurgery, trauma/neurocritical care, functional medicine, surgical neuro-oncology, radiosurgery, neurovascular, skull-base, peripheral nerve, and intricate spinal procedures in addition to stereotactic surgery.

Typically, fellowships last between one and two years. Neurosurgery is a relatively rare and fiercely competitive specialty in the United States, making up less than 0.5 percent of all physicians.

United Kingdom

In the UK, applicants must be admitted to medical school. Depending on the student’s path, obtaining the MBBS (Bachelor of Medicine, Bachelor of Surgery) degree can take four to six years.

The next step for the recently licensed physician is to complete two years of paid foundation training in a hospital or clinical setting, which covers a variety of medical disciplines, including surgery.

Next, junior physicians apply to work in neurosurgery. It now has its own specialty, unlike most other surgical specialties.

Before candidates with enough experience and practice can appear for consultant exams, they must complete an autonomous training track that takes eight years (ST1–8). It is still very difficult to gain admission into the medical specialty of neurosurgery.

India

In India, an MBBS degree is required to become a neurosurgeon. In India, there are two routes to becoming a neurosurgeon after earning an MBBS degree.

There are two possible career paths: directing neurosurgery residency for years after MBBS or doing a three-year general surgery residency followed by a three-year neurosurgical residency. A three-year neurosurgery course is offered following general surgery in the majority of the nation’s medical institutions and teaching hospitals.

Six years of post-MBBS neurosurgery residency are offered by a few hospitals and institutes around the nation.

The degree that is accepted in India for medicine and neurosurgery is recognized by the National Board as either the Doctorate of Neurosurgery (DrNB Neurosurgery) or the MCh degree, which are both accepted as interchangeable credentials.

Following graduation, a neurosurgeon may seek additional fellowship work or work as an independent consultant in the nation.

The question of whether three years is sufficient training for neurosurgery is still being debated throughout the nation, with many neurosurgeons arguing that at least six years are needed. Despite being one of the most competitive specialties in the nation, neurosurgery also has a high dropout rate because of its demanding and demanding nature.

Training at a large volume facility can potentially need more than 70 hours of work each week. However, because it’s a very hard job with comparable or higher pay for fewer hours worked in other specialties, a significant risk of lawsuits, a high death rate, and a dismal prognosis for patients, competitive seats occasionally remain unfilled.

History

Although intentional incisions made in the brain to relieve pain have been used for thousands of years, significant advances in this field have only been made in the past century.

Ancient

Trepanation is a method that the Incas seem to have used long before the European takeover. Al-Zahrawi treated head injuries, skull fractures, spinal injuries, hydrocephalus, subdural effusions, and headaches surgically in Al-Andalus between 936 and 1013 AD.

Neurosurgery was used by physicians and surgeons to treat depressed skull fractures during the Roman Empire. Basic variations of King Henri II had neurosurgery in 1559 following a catastrophic jousting mishap in which he was wounded by Gabriel Montgomery.

Professionals in their fields at the time, Ambroise Paré and Andreas Vesalius, tried their own remedies for Henri, but they were unsuccessful. Hua Tuo invented mafeisan, the first general anesthesia, in China, and utilized it for brain surgery.

Modern

History of tumor removal: The first successful brain tumor surgery was carried out in 1879 by Scottish surgeon William Macewen (1848–1924), who located the tumor solely based on neurological indications.

The first primary brain tumor ectomy, which was different from Macewen’s procedure, was carried out on November 25, 1884, by English surgeon Rickman Godlee (1849–1925) after English physician Alexander Hughes Bennett (1848–1901) utilized Macewen’s approach to locate it.

In that Macewen used trepanation to operate outside of the “brain proper,” whereas Bennett worked on the exposed brain. Hermann Schloffer, an Austrian surgeon, was the first to surgically remove a pituitary tumor on March 16, 1907.

A type of neurosurgical psychosurgery that treats mental illnesses by breaking connections in the brain’s prefrontal cortex is called.

Lobotomy: often referred to as leucotomy. Portuguese neurologist António Egas Moniz, who developed the technique, was awarded a share of the 1949 Nobel Prize in Physiology or Medicine.

After the procedure, some patients saw some degree of improvement, although problems and impairments—sometimes severe ones—were common.

Because of the procedure’s careful consideration of both hazards and advantages, controversy surrounded it from the beginning. Nowadays, it is largely disapproved of as a treatment and violates patients’ rights.

The history of electrodes in the brain: begins with Richard Caton’s discovery in 1878 that electrical signals might pass through the brains of animals.

Jose Delgado created the first electrode in 1950, which was used to induce movement and direction changes in a bull by implanting it in its brain.

The neurological device known as the cochlear implant, which gave deaf people the ability to hear, was first made available for purchase in 1972. In 1998, a human participant received the first Brain Computer Interface (BCI) implanted by researcher Philip Kennedy.

According to a 2010 assessment of the top 100 neurosurgery publications, the majority of the articles discuss novel neurosurgical procedures, clinical trials assessing surgical and medical treatments, and systems for grading and classifying illnesses.

Modern surgical Instruments

Expertly designed instruments were responsible for the majority of neurosurgery’s breakthroughs.

Chisels, curettes, dissectors, distractors, elevators, forceps, hooks, impactors, probes, suction tubes, power tools, and robots are examples of contemporary neurosurgical instruments.

The majority of these contemporary instruments have been used in medicine for a sizable amount of time. The precision with which these instruments were made made them unique in the field of neurosurgery.

The edges on these tools are created to within a millimeter of the appropriate accuracy. Other instruments, including robots and portable power saws, are only being often utilized in neurological operating rooms as of late.

For instance, the University of Utah created a CAD-CAM (computer-aided design/computer-aided manufacturing) tool that defines a cutting tool path for a robotic cranial drill using an image-guided system.

Organized Neurosurgery

Approximately 50,000 neurosurgeons worldwide are represented by the 130 member societies that make up the World Federation of Neurosurgical Societies (WFNS), a professional, scientific, non-governmental organization that was founded in Switzerland in 1955.

These member societies are comprised of 5 Continental Associations (AANS, AASNS, CAANS, EANS, and FLANC), 6 Affiliate Societies, and 119 National Neurosurgical Societies. It is seen as consultative in the UN.

World Neurosurgery is the organization’s official journal. The World Federation of Skull Base Societies and the World Academy of Neurological Surgery (WANS) are the other international organizations.

Main Divisions

The majority of neurosurgical disorders, including neuro-trauma and other neuro-emergencies such as cerebral hemorrhage, are treated in general neurosurgery. This type of practice is seen in most level 1 hospitals.

In order to handle unique and challenging circumstances, specialized branches have evolved. In more advanced facilities, these specialized subspecialties coexist with general neurosurgery.

A neurosurgeon must complete an extra one to two years of higher fellowship training in order to practice advanced specialization in neurosurgery. Among these subspecialties within neurosurgery are:

• Vascular neurosurgery involves carotid endarterectomy (CEA) and aneurysm cutting.
• Functional neurosurgery, stereotactic neurosurgery, and epilepsy surgery (which includes the more radical and infrequent partial or total lobectomy or even hemispherectomy, which involves removing part or all of one of the lobes or one of the cerebral hemispheres of the brain) are among the procedures used in oncological neurosurgery and the treatment of very severe neurological trauma, such as gunshot or stab wounds to the brain.
• Neurosurgical oncology, also known as oncological neurosurgery, treats benign and malignant tumors of the central and peripheral nervous systems as well as precancerous lesions in both adults and children. These conditions include spinal cancer, brain stem cancer, astrocytoma, pontine glioma, medulloblastoma, meningeal and intracranial space tumors, secondary metastases to the brain, spine, and nerves, and tumors of the peripheral nervous system.
• surgery on the skull base
• neurosurgery of the spine
• Surgery on peripheral nerves
• Pediatric neurosurgery (for congenital neurological problems, cancer, seizures, bleeding, stroke, or cognitive issues)

Commonly Performed Surgeries

The National Surgical Quality Improvement Program (NSQIP) of the American College of Surgeons conducted an investigation and found that, between 2006 and 2014, the following surgeries were done by neurosurgeons most frequently:

• ACDF stands for anterior cervical discectomy and fusion.
• Brain tumor removal via craniotomy (CBT)
• Discectomy
• Laminectomy
• Lumbar fusion on the posterior side (PLF)

Neuropathology

Within the field of pathology, neuropathology is a specialization that focuses on diseases of the brain, spinal cord, and neural tissue. Both the central and peripheral nervous systems are included in this.

Either surgical biopsies or post-mortem autopsy yield tissue for investigation. Nervous and muscular tissue are often sampled tissues. Applications of neuropathology that are often used include examining tissue samples in individuals suffering from neurological disorders involving degeneration of the brain or spinal cord, such as Parkinson’s disease.

Alzheimer’s disease, dementia, Huntington’s disease, amyotrophic lateral sclerosis, and mitochondrial disease.

History

Although pathology has been studied for millennia, medicine has only recently, in the last few centuries, concentrated on treating tissue diseases by treating the organs and tissues themselves.

Thomas Hodgkin began examining the injured tissue in 1810 to try to determine the cause. This coincided with the development of microscopy, which led to the current understanding of how human body tissue is investigated.

Neuroanesthesia

Within the realm of anesthesiology, neuroanesthesia focuses on neurosurgery. During the course of an “awake” brain operation, anesthesia is not administered.

During awake brain surgery, the patient is sedated at the start and finish of the process, but they are awake during most of it.

When a tumor lacks distinct limits and the surgeon wants to determine whether it is encroaching on vital brain regions that are involved in speech, thought, vision, and hearing, they will perform this operation. Additionally, it will be carried out for procedures where the surgeon is attempting to prevent epileptic episodes.

History

Hippocrates, the 460–370 BCE physician, told tales of trepanning his patients with various wines to make them sleepy. Physician, pharmacologist, and botanist Dioscorides described in 60 CE the use of mandrake, henbane, opium, and wine to induce sleep in patients undergoing trepanning.

Two brother surgeons in Paramara, modern-day India, employed “samphire” to put a patient to sleep in 972 CE so they could remove a minor tumor. The patient was then awakened by having vinegar and onion poured into their mouth.

Humphry Davy popularized a type of neuroanesthesia in the 18th century using a mixture of carbon dioxide, hydrogen, and nitrogen.

Neurosurgery Methods

Modern neurosurgery uses a variety of imaging techniques for diagnosis and therapy. These include magnetoencephalography (MEG), positron emission tomography (PET), magnetic resonance imaging (MRI), computer-assisted imaging computed tomography (CT), and stereotactic radiosurgery.

In certain neurosurgical procedures, functional and intra-operative magnetic resonance imaging are used. In traditional neurosurgery, the brain is accessed by the neurosurgeon making a wide incision in the skull.

These days, endoscopy and microscope-assisted techniques involving tiny incisions are also being employed. Excellent outcomes are obtained using techniques that combine high-clarity microscopic viewing of brain tissue with tiny craniotomies.

Open techniques are nevertheless, frequently applied in emergency or trauma scenarios. Many facets of neurological surgery involve the use of microsurgery.

Microvascular methods are employed in both the restorative carotid endarterectomy and EC-IC bypass surgery. Microscopically visible procedures are used to cut an aneurysm. Endoscopes or microscopes are used in minimally invasive spine surgery.

Microsurgery is required for procedures like artificial disc replacement, laminectomy, and microdiscectomy. Through a small aperture in the brain, neurosurgeons can reach a tiny target by using stereotaxy.

In functional neurosurgery, this is utilized to accurately implant electrodes or initiate gene therapy for conditions like Parkinson’s disease or Alzheimer’s disease. Intraventricular hemorrhages may be successfully drained by combining open and stereotactic surgery techniques.

Other terms for conventional surgery employing image guidance technology include computer-assisted surgery, guided surgery, stereotactic navigation, and surgical navigation.

Curve Image Guided Surgery and other image-guided surgical technologies function similarly to an automobile or mobile Global Positioning System (GPS) and StealthStation, which transmit the patient’s anatomy and the surgeon’s exact motions with regard to the patient to computer monitors in the operating room by the use of cameras or electromagnetic fields.

With the use of these advanced computerized devices, the surgeon can better navigate the patient’s anatomy, including the tumor, both before and during the operation. Electrocorticography (ECoG) has been used in real-time functional brain mapping to pinpoint specific functional areas.

Neurosurgeons often use minimally invasive endoscopic surgery when necessary. Cerebrospinal fluid leaks, chordomas, pituitary tumors, and craniopharyngiomas are treated using techniques including endoscopic endonasal surgery.

Treatment for intraventricular bleeding, hydrocephalus, colloid cysts, and neurocysticercosis involves the use of ventricular endoscopy. ENT and neurosurgeons sometimes collaborate to perform endonasal endoscopic procedures.

Neurosurgeons treat problems of the craniofacial region and disrupt the circulation of cerebrospinal fluid. Occasionally, they work in tandem with plastic and maxillofacial surgeons.

Plastic surgeons or pediatric neurosurgeons work together to conduct cranioplasty for craniosynostosis. In stereotactic radiosurgery, neurosurgeons and radiation oncologists collaborate to treat tumors and AVMs.

Additionally, radiological techniques like Novalis Radiosurgery, Cyberknife, and Gamma Knife are employed. Endovascular image-guided treatments are used in endovascular neurosurgery to treat vasospasms, aneurysms, AVMs, strokes, and spinal abnormalities.

Endovascular procedures include angioplasty, stenting, clot retrieval, embolization, and diagnostic angiography. In neurosurgery, the ventriculoperitoneal shunt (VP shunt) is a frequently placed device.

This is frequently used in pediatric treatment when a patient has congenital hydrocephalus. Normal pressure hydrocephalus is the most frequent reason for adults to undergo this surgery (NPH). Thoracic, lumbar, and cervical spine are all included in neurosurgery of the spine.

Some indications for spine surgery include spondylosis, arthritis of the spinal discs, and spinal cord compression from trauma. Patients with cervical cord compression may have numbness and tingling in their hands or feet, balance problems, and/or gait difficulties.

Degeneration of the spinal discs and arthritis can cause spondylosis, a disorder that can compress the spinal canal. Disc herniation and bone spurring are frequent outcomes of this disease. In order to address any spinal canal compression issues, power drills.

And specialized tools are frequently utilized. Specialized rongeurs are used to eliminate disc herniations of the spinal vertebral discs. A discectomy is a name given to this operation.

After a disc is removed, it is often replaced with an implant that fuses the bony structures of the vertebral bodies above and below. To preserve mobility, a movable disc might be inserted into the disc space instead.

Surgery on the cervical disc frequently uses this. Occasionally, a laser discectomy may be utilized to decompress a nerve root in place of disc removal. This technique is primarily applied on lumbar discs.

The lamina of the spine’s vertebrae is removed during a laminectomy to create space for the compressed nerve tissue. A subspecialty of functional neurosurgery deals with chronic pain surgery.

Implanting deep brain stimulators, spinal cord stimulators, peripheral stimulators, and pain pumps are a few of the methods. Peripheral nerve transposition and carpal tunnel decompression are two popular treatments that fall under the category of peripheral nervous system surgery.

Treatment also includes additional disorders involving the peripheral nervous system and numerous other forms of nerve entrapment.

Conditions

Neurosurgeons treat the following conditions, among others:

• Meningitis and other infections of the central nervous system, such as abscesses
• Herniation of the spinal disc
• The conditions are known as lumbar and cervical spinal stenosis
• Headache
• Head trauma, including fractures to the skull and brain hemorrhages.
• trauma to the spinal cord.
• Peripheral nerve trauma injuries.
• the spinal cord, peripheral nerve, and spine tumors.
• Intracerebral bleeding, including intracellular, interdepartmental, and subarachnoid hemorrhages.
• Certain types of epilepsy resist medication.
• Abrasive surgery and deep brain stimulation surgery are two examples of particularly designed
• minimally invasive stereotactic procedures (functional, stereotactic neurosurgery) that are used to treat certain movement disorders, such as advanced Parkinson’s disease and chorea.
  Incapable pain in cancer or trauma patients as well as discomfort in the cranium or peripheral nerves.
• Certain types of untreatable mental illnesses
• Vascular anomalies of the brain and spinal cord, including capillary telangiectasias, venous angiomas, and arteriovenous.
• malformations Moyamoya disease.

Recovery

Postoperative Pain

Following brain surgery, pain can be quite severe and can prolong recuperation, lengthen hospital stays, and raise the possibility of complications. After brain surgery, severe acute pain may also raise the chance of developing a chronic headache after craniotomy.

Adults with pain can benefit from nonsteroidal anti-inflammatory medicines (NSAIDs), which have been demonstrated to alleviate pain for up to 24 hours after surgery. There is inadequate evidence to justify the use of dexmedetomidine and other medicines.

Pregabalin or gabapentin to lessen pain following surgery. Scalp infiltration and blocks are also supported by low-quality evidence to lessen postoperative discomfort. Pregabalin or gabapentin may help lessen nausea and vomiting after surgery, according to very poor-quality medical research.

FAQ