Is Neursurgery a dying field?

[craig.wilson795]

Brain tumours and spine tumours by radiation specialists. Gamma knife operated by radiation specialists

Aneurysms and AVMs by interventional neuroradiologists (endovascular neurosurgery)

Select spine procedures by interventional neuroradiologists

Spine surgery being replaced by non surgical methods (injections, biochemical injections for osteogenesis, other non surgical methods)

Functional neurosurgery incorporating ultrasound for cerebral lesions



Doesn't this mean that neurosurgery will soon, for the most part, cease to exist?

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[BurghStudent]

I'm too early in my education to give a full opinion, but I was thinking about this the other day. In a sense, everything is becoming micro. Only neurosurgeons can resect tumors, but there are other ways as you mention. With the recent research focus on gene therapy, immune-cell based therapy etc, I feel that some parts of the practice will transform into 'molecular neurosurgery' to get to places and do things in the brain a blade can't. And once that happens, I don't see why it would take a neurosurgeon, and not a neurologist, to deliver these therapies.

 

[james2333]

Brain tumours and spine tumours by radiation specialists. Gamma knife operated by radiation specialists

Aneurysms and AVMs by interventional neuroradiologists (endovascular neurosurgery)

Select spine procedures by interventional neuroradiologists

Spine surgery being replaced by non surgical methods (injections, biochemical injections for osteogenesis, other non surgical methods)

Functional neurosurgery incorporating ultrasound for cerebral lesions



Doesn't this mean that neurosurgery will soon, for the most part, cease to exist?

Not even close.

First of all neuro-trauma (decompressive craniotomies, craniectomies and cauda-equina decompression) will always exist.

Aneurysms- true the majority are becoming coiled vs. open clipping, but Neurosurgery has taken over the field of endovascular intervention. Now you have to be a neurosurgeon in order to do endovascular interventions. Also, not all lesions can be coiled (shape, dome vs. fusiform, size, calcification/stiffness and location) are always considerations to factor. There are still many aneurysms that require open clipping. Also the new pipeline stents are associated with risk of thrombosis so it will be interesting to see what the new data shows with this regards. That is, whether or not these flow diverting stents will become the standard of care for supraclinoid ICA aneurysms in the future.

AVMs- standard of care is surgical resection. You can pre-op embolize before the operation but YOU DO NOT coil avms

The spine procedures that you are referring to (kyphoplasty/ vertebroplasty) are only indicated for metastatic lesions or patients that have contraindications for surgery. These procedures are not considered standard of care , nor will they ever be. Fusions/lamis (bread and butter of spine) will always exist.

Cancer- These new immunotherapies that you speak of, such as DC-VAX are only administered in conjunction with the standard of care for current treatments. IE DC-VAX for treatment of GBM. Surgical resection+radiation+ temodar is the current standard. DC-VAX is being administered as adjunctive therapy. Even though initial DC-VAX results were considered encouraging before phase III, new and recent data is not as encouraging. The blood brain barrier will always be a problem for drug delivery into the brain, even though chemo can be administered intrathecally, these procedures/administrations are usually used in palliative/ late stage treatment. Radiotherapy, Gamma knife are always used either in conjunction with surgical resection or as a late stage alternative for palliative care. Also consider that a neurosurgeon MUST be involved in RAD ONC planning for treatment of tumors. For gamma knife, a neurosurgeon must be present to bolt on the frame and they are usually involved with the mapping/planning portion of the procedure.

Neurosurgery will always exist.

 

[mmmcdowe]

Certainly not in our lifetime.

 

[gonogo]

Now you have to be a neurosurgeon in order to do endovascular interventions.

This is a completely false statement. While there are many neurosurgeons in the field, there are at least as many interventional neuroradiologists performing endovascular procedures. A lot, if not most, of the very academic programs are led by neuroradiologists. In the community setting many radiology practices offer the full gamut of neurointerventions. I'd say the field right now consists of 40% radiologists, 40% neurosurgeons and 20% neurologists, with the fastest growing group probably being neurologists.

I do agree with most of your other statements. Neurosurgery won't disappear, at least most definitely not in the near future.

 

[TUGM]

Radiologists pioneered NIR/ESN, but due to the rigorous training and lifestyle, there aren't as many radiologists entering this field these days. Neurosurgery does seem to be gaining control over the field, but there are several prolific places where neurologists control. I'd like to see an end to the turf battles - the best practices I've seen have all 3 types of doctors... but that'll never happen as long as people bow their heads to the almighty dollar.

Neurosurgery isn't going anywhere anytime soon though. Cranies and spine surgeries... though some neurointensivists (non-NSG) are trained to do decompressive procedures and place EVDs.

 

[Conqueror]

Brain tumours and spine tumours by radiation specialists. Gamma knife operated by radiation specialists
Neurosurgeons always needed for large or compressive lesions. Also many tumors not radiosensitive or too close to important structures to radiate. Last, all Gamma Knife/SRS is teamed between RadOnc and Neurosurgery, you can bill half a craniotomy by reviewing a Gamm Knife plan.
Aneurysms and AVMs by interventional neuroradiologists (endovascular neurosurgery)
Sure there are some NIR guys but there are also a ton of neurosurgeons doing these procedures, plus we own the open vascular market.
Select spine procedures by interventional neuroradiologists
Rare, and most of those (ie kyphoplasty, vertebroplasty) also done by many neurosurgeons.
Spine surgery being replaced by non surgical methods (injections, biochemical injections for osteogenesis, other non surgical methods)
Not really. Some of these may be in the research pipeline but aren't really "stealing" any surgical volume in the foreseeable future. Besides, if they do come along, we'll just learn to do the injections and own that too.
Functional neurosurgery incorporating ultrasound for cerebral lesions
Who do you think pioneered focused ultrasound and will own its clinical applications?

 

[stems]

Not even close.

First of all neuro-trauma (decompressive craniotomies, craniectomies and cauda-equina decompression) will always exist.

Aneurysms- true the majority are becoming coiled vs. open clipping, but Neurosurgery has taken over the field of endovascular intervention. Now you have to be a neurosurgeon in order to do endovascular interventions. Also, not all lesions can be coiled (shape, dome vs. fusiform, size, calcification/stiffness and location) are always considerations to factor. There are still many aneurysms that require open clipping. Also the new pipeline stents are associated with risk of thrombosis so it will be interesting to see what the new data shows with this regards. That is, whether or not these flow diverting stents will become the standard of care for supraclinoid ICA aneurysms in the future.

AVMs- standard of care is surgical resection. You can pre-op embolize before the operation but YOU DO NOT coil avms

The spine procedures that you are referring to (kyphoplasty/ vertebroplasty) are only indicated for metastatic lesions or patients that have contraindications for surgery. These procedures are not considered standard of care , nor will they ever be. Fusions/lamis (bread and butter of spine) will always exist.

Cancer- These new immunotherapies that you speak of, such as DC-VAX are only administered in conjunction with the standard of care for current treatments. IE DC-VAX for treatment of GBM. Surgical resection+radiation+ temodar is the current standard. DC-VAX is being administered as adjunctive therapy. Even though initial DC-VAX results were considered encouraging before phase III, new and recent data is not as encouraging. The blood brain barrier will always be a problem for drug delivery into the brain, even though chemo can be administered intrathecally, these procedures/administrations are usually used in palliative/ late stage treatment. Radiotherapy, Gamma knife are always used either in conjunction with surgical resection or as a late stage alternative for palliative care. Also consider that a neurosurgeon MUST be involved in RAD ONC planning for treatment of tumors. For gamma knife, a neurosurgeon must be present to bolt on the frame and they are usually involved with the mapping/planning portion of the procedure.

Neurosurgery will always exist.

Radiation oncologists are moving away from frame based SRS (with Gamma-knife) to Linac based SRS where a frame (and neurosurgeon) is not needed. This process is accelerating for three reasons:
1. Gamma knife treatment machines are more expensive to maintain (have to switch out the Co-60 every couple of years). Also multiple studies have shown equivalence to Linac based SRS.
2. Medicare just equalized the payments between gamma knife based SRS and Linac based SRS (They used to pay twice as much!)
3. A hospital can do a lot more with a Linac based stereotactic machine as compared to gamma knife.

A radiation oncologist might still include a neurosurgeon in the care of the patient (out of courtesy) if they were the referring physician, but they are certainly not required or needed for Linac based SRS.

 

[james2333]

Radiation oncologists are moving away from frame based SRS (with Gamma-knife) to Linac based SRS where a frame (and neurosurgeon) is not needed. This process is accelerating for three reasons:
1. Gamma knife treatment machines are more expensive to maintain (have to switch out the Co-60 every couple of years). Also multiple studies have shown equivalence to Linac based SRS.
2. Medicare just equalized the payments between gamma knife based SRS and Linac based SRS (They used to pay twice as much!)
3. A hospital can do a lot more with a Linac based stereotactic machine as compared to gamma knife.

A radiation oncologist might still include a neurosurgeon in the care of the patient (out of courtesy) if they were the referring physician, but they are certainly not required or needed for Linac based SRS.

Even if a neurosurgeon is not directly involved by bolting on the frame (IE gamma knife), I find it difficult to believe that they won't be involved in the planning process. Most patients that require RAD ONC to the brain and/or spine will be referred by a neurosurgeon. Neuro-onc fellowships for neurosurgeons specifically train individuals to be involved in both open procedures and in planning for rad onc procedures. My point is that they will always be involved.

 

[stems]

Even if a neurosurgeon is not directly involved by bolting on the frame (IE gamma knife), I find it difficult to believe that they won't be involved in the planning process. Most patients that require RAD ONC to the brain and/or spine will be referred by a neurosurgeon. Neuro-onc fellowships for neurosurgeons specifically train individuals to be involved in both open procedures and in planning for rad onc procedures. My point is that they will always be involved.

Again my point being is that neurosurgeons are not needed in the planning or treatment of patients with Linac based SRS. Also if the referral comes from the medical oncologist, or if it's a relapse and the patients following up with the radiation oncologist the neurosurgeon is generally not involved. I know this from personal experience at three large cancer centers.

 

[james2333]

Again my point being is that neurosurgeons are not needed in the planning or treatment of patients with Linac based SRS. Also if the referral comes from the medical oncologist, or if it's a relapse and the patients following up with the radiation oncologist the neurosurgeon is generally not involved. I know this from personal experience at three large cancer centers.

I'm not denying that you can avoid going through a neurosurgeon to radiate CNS tumors. I agree with you. But I don't believe you'll see that integrated into common practice across the US. If a patient has a CNS mass, they will always be evaluated by a neurosurgeon. Of course a multi-disciplinary approach is the desired outcome, but circumventing neurosurgery to treat tumors is not something that will ever happen. If the neurosurgeon desires to be involved in treatment planning, he/she will be. Perhaps at larger dedicated cancer treatment facilities you'll see rad onc play more of an independent role, but outside these dedicated institutions it will be unlikely.

 

[TSDentSurg]

Neurosurgery will always be needed, even though interventional neuroradiology, radiation oncology, and nuclear medicine are making big strides.

Even though an interventional neuroradiologist has the skills to do a CT-guided MWA/IRE to treat a brain tumor, and place an EVD to deal with post-op intracranial hypertension, and a radiation oncologist can sterilize a tumor with 80 Sv of precisely-targeted gamma or proton radiation, and a nuclear medicine physician can design and dose an alpha-emitting radiolabeled mAb for an interventional neuroradiologist to deliver via superselective intra-arterial cerebral infusion, a neurosurgeon will and should be involved in their care, if only as a last resort by providing open surgery.

And neurosurgeons will always be needed for trauma, despite the fact that any EM physician, interventional neuroradiologist, or neurointensivist can treat epidural and subdural hematomas by placing an EVD to treat the intracranial hypertension and waiting for the clot to liquify so it can be sucked out via a burr hole and drainage catheter. How would those physicians treat the skull fractures? What would they do about spinal fractures?

Neurosurgery will always be with us, it may change its practice, but it will always be here.

 

[Yoyomama88]

EVDs suck out CSF fluid correct? These are placed for epidural and subdural hematomas simply to lower the ICP even if there isn't any bleeding in the ventricles? Am i understanding this correctly?

 

[TSDentSurg]

EVDs suck out CSF fluid correct? These are placed for epidural and subdural hematomas simply to lower the ICP even if there isn't any bleeding in the ventricles? Am i understanding this correctly?

Yes. They're also used occasionally to directly infuse medication into the CSF; heard of it used for severe amoebic and fungal encephalitis.

 

[rigid]

And neurosurgeons will always be needed for trauma, despite the fact that any EM physician, interventional neuroradiologist, or neurointensivist can treat epidural and subdural hematomas by placing an EVD to treat the intracranial hypertension and waiting for the clot to liquify so it can be sucked out via a burr hole and drainage catheter.

Where are you getting your information from?

 

[BurghStudent]

I'm worried about the trend in the length of residency. In all honesty, does it take 7 years to train a neurosurgeon? If you look at the literature, the neurosurgery community is worried about attracting top medical students to the profession. I think turf wars are a part of medicine, but do you see neurosurgery being as desirable in the near future?

 

[deleted500612]

Keep in mind that the brain is pretty much the only organ that is not even close to being fully understood yet. As our knowledge of the field steadily increases in the future, one could logically assume that the scope of practice and demand for neurosurgery and neurology would increase as well.

 

[TSDentSurg]

Where are you getting your information from?

From seven simple observational points:

1. EDHs and SDHs cause intracranial hypertension due to the pressure of the clot.
2. Intracranial hypertension will lower CPP which will lead to cerebral ischemia and infarction.
3. EVDs relieve intracranial hypertension.
4. Some INRs and neurointensivists are trained to place EVDs during fellowship.
5. As an EDH or SDH ages, the jelly-like clot liquifies.
6. It is a small step from placing an EVD to doing a burr hole craniotomy to drain the liquified clot.
7. Also, INRs can perform meningeal artery embolization for EDHs in the acute phase to stop the hematoma from expanding.

The goal of all medicine and surgery and radiological intervention is to facilitate the body's natural healing abilities. As physicians and surgeons and IRs, we should do the minimum that is required to give our patient's natural healing mechanisms the ability and time to work.

 

[mmmcdowe]

I'm worried about the trend in the length of residency. In all honesty, does it take 7 years to train a neurosurgeon? If you look at the literature, the neurosurgery community is worried about attracting top medical students to the profession. I think turf wars are a part of medicine, but do you see neurosurgery being as desirable in the near future?

FWIW while some programs went from 6-7, others went from 8-7. Given this was a organizational decision, it is probably going to be many years before said organization increases it, if ever. It has always been long and yet this application cycle there were 360 applicants for 206 spots, or something like that.

 

[mmmcdowe]

From seven simple observational points:

1. EDHs and SDHs cause intracranial hypertension due to the pressure of the clot.
2. Intracranial hypertension will lower CPP which will lead to cerebral ischemia and infarction.
3. EVDs relieve intracranial hypertension.
4. Some INRs and neurointensivists are trained to place EVDs during fellowship.
5. As an EDH or SDH ages, the jelly-like clot liquifies.
6. It is a small step from placing an EVD to doing a burr hole craniotomy to drain the liquified clot.
7. Also, INRs can perform meningeal artery embolization for EDHs in the acute phase to stop the hematoma from expanding.

The goal of all medicine and surgery and radiological intervention is to facilitate the body's natural healing abilities. As physicians and surgeons and IRs, we should do the minimum that is required to give our patient's natural healing mechanisms the ability and time to work.

EDHs often continue to bleed from the lacerated vessel and then you die from herniation when you drop a drain and it sucks out the only thing besides brain (the csf) that is holding the blood to a confined area. Assuming there is time to find it, not all lacerated arteries can be embolized. SDHs can be too big or to oozy for just a burr hole too. I think rigid is trying to emphasize that not all of them can be treated at this point with burr holes and EVDs aren't the treatment in general. Certainly, determining when is appropriate shouldn't be in the hands of other specialties who are not trained to make such decisions.

 

[TSDentSurg]

EDHs often continue to bleed from the lacerated vessel and then you die from herniation when you drop a drain and it sucks out the only thing besides brain (the csf) that is holding the blood to a confined area. Assuming there is time to find it, not all lacerated arteries can be embolized. SDHs can be too big or to oozy for just a burr hole too. I think rigid is trying to emphasize that not all of them can be treated at this point with burr holes and EVDs aren't the treatment in general. Certainly, determining when is appropriate shouldn't be in the hands of other specialties who are not trained to make such decisions.

Well, I did mean my previous post for smaller acute EDHs and SDHs...not the big ones where you have Cushing's triad and blown pupils. A neurosurgeon should evaluate the patient, and if he and the diagnostic neuroradiologist agrees that the patient doesn't need an emergency craniotomy, non-operative management by an INR should be done. And what would a neurosurgeon do with those on Pradaxa or those with bleeding disorders?

I agree, not at the moment with how current INRs are trained, which is why I believe the interventional neuroradiology speciality should have its own direct from medical school residency that includes a year each of GS and NS training, much like how general interventional radiology has its own direct from med school residency that includes two years of either GS or IM training.

Also, you could inject thrombolytics through the burr hole while sucking the clot out.

 

[mmmcdowe]

Thrombolytics can cause the bleeding to resume in acute hematomas and are not super effective at getting all the clot out of chronic ones from a burrhole alone. I think the point that theoretically other fields could play a role is valid, but i think your basis for how needs to be reconsidered.

 

[womp]

Select spine procedures by interventional neuroradiologists

For spine, the main turf battles are with the ortho spine guys. And that's not really that big of a deal. Neuroradiologists are like a pimple when it comes to spine turf battles.

 

[BurghStudent]

So, if we look at the history, cardiothoracic surgery used to be what neurosurgery is today. CT got the axe, and interventional cardiology took over. Recently, ophthalmology has also taken a beating. I ask not as a criticism, but to inform myself, what is keeping neurosurgery afloat? Meaning, what ensures that neurosurgery will more or less retain its current salary?

 

[TUGM]

Lol it always comes down to the salary doesn't it? Neurosurgeons are more aggressive than their CT surgeon counterparts because they are the ones who are trying very hard to keep the NIR pie to themselves. Neuroradiologists have pretty much lost that turf battle. Without solid data pertaining to good outcomes with IACT, the NIR volume (diagnostic angios, aneurysm coolings) stays relatively low, which means that NSG can hold its turf at the moment without neurologists ripping it away.

Also neuro-spine surgery continues to be huge money makers for the hospital, and in turn reimburses well for neurosurgeons. In conjunction with the relatively low numbers of neurosurgeons being trained every year, there is still plenty of demand for them, more or less "ensuring" that they will "more or less retain" their current salaries.

We will see what the future holds in terms of IACT blowing up or not. If it does, I imagine that neuro-IR will become what I-cards was previously.

 

[TUGM]

Also, I mean if you really look at it, the CT surgeons of today still make >500K on average. Sure there are a lot less in number and all of them have absolutely ****ty lifestyles. But then again, so do neurosurgeons, especially those that do NIR.

24/7 acute stroke/NIR call for 1 week straight... really separates the lions from mere mortals.

 

[Kazaki]

Neurosurgery will always be needed, even though interventional neuroradiology, radiation oncology, and nuclear medicine are making big strides.

Even though an interventional neuroradiologist has the skills to do a CT-guided MWA/IRE to treat a brain tumor, and place an EVD to deal with post-op intracranial hypertension, and a radiation oncologist can sterilize a tumor with 80 Sv of precisely-targeted gamma or proton radiation, and a nuclear medicine physician can design and dose an alpha-emitting radiolabeled mAb for an interventional neuroradiologist to deliver via superselective intra-arterial cerebral infusion, a neurosurgeon will and should be involved in their care, if only as a last resort by providing open surgery.

And neurosurgeons will always be needed for trauma, despite the fact that any EM physician, interventional neuroradiologist, or neurointensivist can treat epidural and subdural hematomas by placing an EVD to treat the intracranial hypertension and waiting for the clot to liquify so it can be sucked out via a burr hole and drainage catheter. How would those physicians treat the skull fractures? What would they do about spinal fractures?

Neurosurgery will always be with us, it may change its practice, but it will always be here.

You're a dental student, what are you doing talking about medicine?

 

[Mad Jack]

You're a dental student, what are you doing talking about medicine?

Given that he hasn't logged on in over a year, I think the world may never know

Always read the last post date in a thread before replying, lest you bump a necro thread like this one.

 

[Kazaki]

Given that he hasn't logged on in over a year, I think the world may never know

Always read the last post date in a thread before replying, lest you bump a necro thread like this one.

oh haha

 

[Radz123]

Not dying just evolving. It'll continue its merger toward interventional work just like CT, Trauma, Vascular etc.

 

[NWwildcat2013]

This is a completely false statement. While there are many neurosurgeons in the field, there are at least as many interventional neuroradiologists performing endovascular procedures. A lot, if not most, of the very academic programs are led by neuroradiologists. In the community setting many radiology practices offer the full gamut of neurointerventions. I'd say the field right now consists of 40% radiologists, 40% neurosurgeons and 20% neurologists, with the fastest growing group probably being neurologists.

I do agree with most of your other statements. Neurosurgery won't disappear, at least most definitely not in the near future.

I didn't even know neurologists could do this. I've always found it strange that endovascular intervention hasn't been primarily neurology turf because it seems analogous to interventional cards or GI. Why did neurology not develop like those two?

 

[neusu]

I didn't even know neurologists could do this. I've always found it strange that endovascular intervention hasn't been primarily neurology turf because it seems analogous to interventional cards or GI. Why did neurology not develop like those two?

Cardiologists were very proactive about developing interventional cardiology. Cardiac surgeons were busy with CABGs and AVRs and didn't see the need to expand their scope.

Neurosurgeons learned from the cardiac surgeons mistakes, and have been instrumental in developing neurointerventional. Neurologists, not so much.

 

[slants]

I didn't even know neurologists could do this. I've always found it strange that endovascular intervention hasn't been primarily neurology turf because it seems analogous to interventional cards or GI. Why did neurology not develop like those two?

I think neusu give a good answer here. I think also a thing to think about is a lot of CT surgeons used to get their referrals from a cardiologist. When a cardiologist partner can do endovascular and some jerk CT surgeon can crac the chest, it makes sense that cardiology blew up. Most ER docs and PCPs directly call or refer to the neurosurgeon when aneurysms and AVMs are found. But I think this will only slow the inevitable. Over time more and more neurologists are going to provide the neuro interventional care.

 

[NWwildcat2013]

I think neusu give a good answer here. I think also a thing to think about is a lot of CT surgeons used to get their referrals from a cardiologist. When a cardiologist partner can do endovascular and some jerk CT surgeon can crac the chest, it makes sense that cardiology blew up. Most ER docs and PCPs directly call or refer to the neurosurgeon when aneurysms and AVMs are found. But I think this will only slow the inevitable. Over time more and more neurologists are going to provide the neuro interventional care.

This seems to be at odds with what neusu posted and other posts I've read by neusu. I can't find it but something about neurologists thinking they have a horse in the interventional race when the reality is that they don't.

 

[neusu]

I think neusu give a good answer here. I think also a thing to think about is a lot of CT surgeons used to get their referrals from a cardiologist. When a 4cardiologist partner can do endovascular and some jerk CT surgeon can crac the chest, it makes sense that cardiology blew up. Most ER docs and PCPs directly call or refer to the neurosurgeon when aneurysms and AVMs are found. But I think this will only slow the inevitable. Over time more and more neurologists are going to provide the neuro interventional care.

Cardiology has always been a difficult pathway. Interventional cardiology only more so.

Neurosurgery has always been a difficult pathway. Neuro-interventional is in keeping with what we already do with emergency management of sah, iph, and now large vessel occlusion and so forth.

Neurology has never been seen as terribly difficult. More so, after residency, the vast majority of neurology is done in the outpatient clinic setting or on a non-emergent setting. Interventional neurology is a paradigm shift for this field. Getting your average neurologist to sign on to this (e.g. be available 24x7 to come in on a moments notice,) is not going to happen. More so, the general consensus with the ER docs, the hospitalists, and the numerous other services in the hospital is that if you want it done, done now, and done right, call neurosurgery. That isn't to say neurologists can't, and don't do an exceptional job. Simply the inertia for the field to overcome to establish themselves in the way cardiologists have, is insurmountable.

Just my $0.02