Author: James S. Harrop, MD, FACS
To answer this question, it is important to re-evaluate the origin and evolution of Neurosurgery as our specialty. Harvey Cushing is considered the Pioneer of Neurosurgery. He was trained as a general surgeon under Halsted and Brigham, the premier teachers and leaders in general surgery. His practice evolved with his interests and patient referrals. He identified a subpopulation of neurosurgery patients who lacked direction or understanding of their disorders and had extremely poor outcomes. He united the treatment of these patients through structured study and investigation of their disorders and created the field of Neurosurgery.
The new specialty of Neurosurgery showed great success. In the beginning of Cushing's career, surgical mortality with treating an intracranial tumor was 100 percent. By the end of his career he had removed over 2,000 tumors due to his success with developing new approaches and management. The General Surgery discipline did not decline with the departure of neurosurgery; instead it also continued to grow.
History has established an inflection point of when a discipline should depart. The "parent" group should neglect the disease treatment, and removal of these treating surgeons should not create a decline in the treatment of the general neurosurgical patient. So we ask these questions:
- Is spine surgery inadequately treating its patients in its present structure?
- Would spine surgery leave Neurosurgery in a better or worse position?
I would argue that the answer to the first question is "No." Over the last several decades, spine patients have witnessed a rapid improvement in the quality care of their care. Our understanding of deformity, biomechanics, instrumentation and spinal cord injury physiology has advanced at full tilt. Neurosurgeons have embraced their Orthopedic colleagues in Spine which has resulted in progressive developments in surgical techniques such as: minimally invasive surgery, robotics, and treatment of deformity. Current spine patients are receiving better overall treatment over the last several decades in terms of understanding their pathophysiology etiology in surgical treatment. Therefore, this does not correlate with Dr. Cushing's experience as changes of isolation may result in a decrease and decline in our present advancement.
Neurosurgery is composed of numerous subspecialty fields: functional, tumor, pediatrics, spinal disorders, cerebrovascular and peripheral nerve issues. Two specialties added requirements and differentiated themselves from the general Neurosurgery community. Pediatric Neurosurgery and Vascular Neurosurgery have separate fellowships and educational paradigms. Has this resulted in improvement in a treatment of an underserved patient population as was seen with Dr. Cushing? Will it affect our overall Neurosurgical community positively or negatively? I do not have these answers but I believe they will be answered over the next several decades.
Spinal treatment is drastically different than both Pediatric and Vascular Neurosurgery in that the typical General Neurosurgeon's practice focuses mainly on treating disorders of the spine. Separation and isolation of these disorders would most likely deteriorate overall treatment of neurosurgical diseases. While this isolationism might be tolerated in an academic urban center due to the overlapping care, could this happen in rural areas while maintaining overall care algorithms? Today, a nonacademic neurosurgeon is, by default, a spine surgeon who also treats other neurological disorders due to their diverse training, education, and dedication to their patients. By separating spine surgery from today's neurosurgical algorithm, there would be an abandonment of patients with significant issues such as - ICH, hydrocephalus, trauma, and peripheral nerve.
Unlike several other fields, the importance of having a diffuse neurological knowledge is paramount in neurosurgery since there is significant overlap in treating neurological disorders. For example, a patient that presents with arm and hand numbness may have carpal tunnel syndrome, cubital tunnel syndrome, cervical radiculopathy, or even an intracranial mass. Without this broad knowledge, these patients would unfortunately fall through the cracks since no definite spine issue is identified. Should these patients be examined with our diffuse knowledge and understanding of neurologic problems? Or should the possibility of a spine problem be simply ignored if the MRI is normal? As a Neurosurgeon, as well as a spinal surgeon, I am able to work through complex differentials and help my patients due to my diversified training. Would Harvey Cushing choose to limit his understanding of neurosurgical problems? Probably not.
In summary, I believe separation of spine surgery from Neurosurgery is not in the best interest of our patients since it does not appear to accelerate our growth and understanding of spine disorders and it would weaken the overall neurosurgery community, limiting patient treatment. Our commitment is to our patients and we should not diverge unless we see a benefit from all sides like other pioneers in our field.