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Neurosurgery or neurological surgery, known in common parlance as brain surgery, is the
medical specialty A medical specialty is a branch of medical practice that is focused on a defined group of patients, diseases, skills, or philosophy. Examples include those branches of medicine that deal exclusively with children (pediatrics), cancer (oncology), ...
that focuses on the surgical treatment or rehabilitation of disorders which affect any portion of the
nervous system In biology, the nervous system is the complex system, highly complex part of an animal that coordinates its behavior, actions and sense, sensory information by transmitting action potential, signals to and from different parts of its body. Th ...
including the
brain The brain is an organ (biology), organ that serves as the center of the nervous system in all vertebrate and most invertebrate animals. It consists of nervous tissue and is typically located in the head (cephalization), usually near organs for ...
,
spinal cord The spinal cord is a long, thin, tubular structure made up of nervous tissue that extends from the medulla oblongata in the lower brainstem to the lumbar region of the vertebral column (backbone) of vertebrate animals. The center of the spinal c ...
,
peripheral nervous system The peripheral nervous system (PNS) is one of two components that make up the nervous system of Bilateria, bilateral animals, with the other part being the central nervous system (CNS). The PNS consists of nerves and ganglia, which lie outside t ...
, and cerebrovascular system. Neurosurgery as a medical specialty also includes non-surgical management of some neurological conditions.


Education and context

In different countries, there are different requirements for an individual to legally practice neurosurgery, and there are varying methods through which they must be educated. In most countries, neurosurgeon training requires a minimum period of seven years after graduating from medical school.


United Kingdom

In the
United Kingdom The United Kingdom of Great Britain and Northern Ireland, commonly known as the United Kingdom (UK) or Britain, is a country in Northwestern Europe, off the coast of European mainland, the continental mainland. It comprises England, Scotlan ...
, students must gain entry into medical school. The MBBS qualification (
Bachelor of Medicine, Bachelor of Surgery A Bachelor of Medicine, Bachelor of Surgery (; MBBS, also abbreviated as BM BS, MB ChB, MB BCh, or MB BChir) is a medical degree granted by medical schools or universities in countries that adhere to the United Kingdom's higher education trad ...
) takes four to six years depending on the student's route. The newly qualified
physician A physician, medical practitioner (British English), medical doctor, or simply doctor is a health professional who practices medicine, which is concerned with promoting, maintaining or restoring health through the Medical education, study, Med ...
must then complete foundation training lasting two years; this is a paid training program in a hospital or clinical setting covering a range of medical specialties including surgery. Junior doctors then apply to enter the neurosurgical pathway. Unlike most other surgical specialties, it currently has its own independent training pathway which takes around eight years (ST1-8); before being able to sit for
consultant A consultant (from "to deliberate") is a professional (also known as ''expert'', ''specialist'', see variations of meaning below) who provides advice or services in an area of specialization (generally to medium or large-size corporations). Cons ...
exams with sufficient amounts of experience and practice behind them. Neurosurgery remains consistently amongst the most competitive medical specialties in which to obtain entry.


United States

In the
United States The United States of America (USA), also known as the United States (U.S.) or America, is a country primarily located in North America. It is a federal republic of 50 U.S. state, states and a federal capital district, Washington, D.C. The 48 ...
, a neurosurgeon must generally complete four years of
undergraduate education Undergraduate education is education conducted after secondary education and before postgraduate education, usually in a college or university. It typically includes all postsecondary programs up to the level of a bachelor's degree. For example, ...
, four years of
medical school A medical school is a tertiary educational institution, professional school, or forms a part of such an institution, that teaches medicine, and awards a professional degree for physicians. Such medical degrees include the Bachelor of Medicine, ...
, and seven years of residency (PGY-1-7). Most, but not all, residency programs have some component of basic science or clinical research. Neurosurgeons may pursue additional training in the form of a fellowship after residency, or, in some cases, as a senior resident in the form of an enfolded fellowship. These fellowships include pediatric neurosurgery, trauma/neurocritical care, functional and
stereotactic Stereotactic surgery is a minimally invasive form of surgery, surgical intervention that makes use of a three-dimensional coordinates, coordinate system to locate small targets inside the body and to perform on them some action such as ablation, ...
surgery, surgical neuro-
oncology Oncology is a branch of medicine that deals with the study, treatment, diagnosis, and prevention of cancer. A medical professional who practices oncology is an ''oncologist''. The name's Etymology, etymological origin is the Greek word ὄγ ...
, radiosurgery, neurovascular surgery, skull-base surgery, peripheral nerve and complex spinal surgery. Fellowships typically span one to two years. In the U.S., neurosurgery is a very small, highly competitive specialty, constituting only 0.5 percent of all physicians.


History

Neurosurgery, or the premeditated incision into the head for pain relief, has been around for thousands of years, but notable advancements in neurosurgery have only come within the last hundred years.


Ancient

The
Inca The Inca Empire, officially known as the Realm of the Four Parts (, ), was the largest empire in pre-Columbian America. The administrative, political, and military center of the empire was in the city of Cusco. The History of the Incas, Inca ...
s appear to have practiced a procedure known as
trepanation Trepanning, also known as trepanation, trephination, trephining or making a burr hole (the verb ''trepan'' derives from Old French from Medieval Latin from Ancient Greek, Greek , literally "borer, auger"), is a surgical intervention in which a ...
since before European colonization. During the
Middle Ages In the history of Europe, the Middle Ages or medieval period lasted approximately from the 5th to the late 15th centuries, similarly to the post-classical period of global history. It began with the fall of the Western Roman Empire and ...
in
Al-Andalus Al-Andalus () was the Muslim-ruled area of the Iberian Peninsula. The name refers to the different Muslim states that controlled these territories at various times between 711 and 1492. At its greatest geographical extent, it occupied most o ...
from 936 to 1013 AD,
Al-Zahrawi Abū al-Qāsim Khalaf ibn al-'Abbās al-Zahrāwī al-Ansari (;‎ c. 936–1013), popularly known as al-Zahrawi (), Latinisation of names, Latinised as Albucasis or Abulcasis (from Arabic ''Abū al-Qāsim''), was an Arabs, Arab physician, su ...
performed surgical treatments of head injuries, skull fractures, spinal injuries, hydrocephalus, subdural effusions and headache. During the
Roman Empire The Roman Empire ruled the Mediterranean and much of Europe, Western Asia and North Africa. The Roman people, Romans conquered most of this during the Roman Republic, Republic, and it was ruled by emperors following Octavian's assumption of ...
, doctors and surgeons performed
neurosurgery Neurosurgery or neurological surgery, known in common parlance as brain surgery, is the specialty (medicine), medical specialty that focuses on the surgical treatment or rehabilitation of disorders which affect any portion of the nervous system ...
on depressed skull fractures. Simple forms of neurosurgery were performed on King Henri II in 1559, after a
jousting Jousting is a medieval and renaissance martial game or hastilude between two combatants either on horse or on foot. The joust became an iconic characteristic of the knight in Romantic medievalism. The term is derived from Old French , ultim ...
accident with Gabriel Montgomery fatally wounded him. Ambroise Paré and
Andreas Vesalius Andries van Wezel (31 December 1514 – 15 October 1564), latinized as Andreas Vesalius (), was an anatomist and physician who wrote '' De Humani Corporis Fabrica Libri Septem'' (''On the fabric of the human body'' ''in seven books''), which is ...
, both experts in their field at the time, attempted their own methods, to no avail, in curing Henri. In China, Hua Tuo created the first general
anaesthesia Anesthesia (American English) or anaesthesia (British English) is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prev ...
called mafeisan, which he used on surgical procedures on the brain.


Modern

History of tumor removal: In 1879, after locating it via neurological signs alone, Scottish surgeon William Macewen (1848–1924) performed the first successful brain tumor removal. On November 25, 1884, after English physician Alexander Hughes Bennett (1848–1901) used Macewen's technique to locate it, English surgeon Rickman Godlee (1849–1925) performed the first primary brain tumor removal, which differs from Macewen's operation in that Bennett operated on the exposed brain, whereas Macewen operated outside of the "brain proper" via
trepanation Trepanning, also known as trepanation, trephination, trephining or making a burr hole (the verb ''trepan'' derives from Old French from Medieval Latin from Ancient Greek, Greek , literally "borer, auger"), is a surgical intervention in which a ...
. On March 16, 1907, Austrian surgeon Hermann Schloffer became the first to successfully remove a pituitary tumor.
Lobotomy A lobotomy () or leucotomy is a discredited form of Neurosurgery, neurosurgical treatment for mental disorder, psychiatric disorder or neurological disorder (e.g. epilepsy, Depression in childhood and adolescence, depression) that involves sev ...
: also known as leucotomy, was a form of psychosurgery, a neurosurgical treatment of
mental disorder A mental disorder, also referred to as a mental illness, a mental health condition, or a psychiatric disability, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. A mental disorder is ...
s that involves severing connections in the brain's
prefrontal cortex In mammalian brain anatomy, the prefrontal cortex (PFC) covers the front part of the frontal lobe of the cerebral cortex. It is the association cortex in the frontal lobe. The PFC contains the Brodmann areas BA8, BA9, BA10, BA11, BA12, ...
. The originator of the procedure, Portuguese neurologist António Egas Moniz, shared the
Nobel Prize for Physiology or Medicine The Nobel Prize in Physiology or Medicine () is awarded yearly by the Nobel Assembly at the Karolinska Institute, Nobel Assembly at the Karolinska Institute for outstanding discoveries in physiology or medicine. The Nobel Prize is not a single ...
of 1949. Some patients improved in some ways after the operation, but complications and impairmentssometimes severewere frequent. The procedure was controversial from its initial use, in part due to the balance between benefits and risks. It is mostly rejected as a treatment now and non-compliant with patients' rights. History of electrodes in the brain: In 1878, Richard Caton discovered that electrical signals transmitted through an animal's brain. In 1950 Jose Delgado invented the first electrode that was implanted in an animal's brain (bull), using it to make it run and change direction. In 1972 the
cochlear implant A cochlear implant (CI) is a surgically implanted Neuroprosthetics, neuroprosthesis that provides a person who has moderate-to-profound sensorineural hearing loss with sound perception. With the help of therapy, cochlear implants may allow for imp ...
, a neurological prosthetic that allowed deaf people to hear was marketed for commercial use. In 1998 researcher Philip Kennedy implanted the first Brain Computer Interface (BCI) into a human subject.http://biomed.brown.edu/Courses/BI108/BI108_2005_Groups/03/hist.htm A survey done in 2010 on 100 most cited works in neurosurgery shows that the works mainly cover clinical trials evaluating surgical and medical therapies, descriptions of novel techniques in neurosurgery, and descriptions of systems classifying and grading diseases.


Modern surgical instruments

The main advancements in neurosurgery came about as a result of highly crafted tools. Modern neurosurgical tools, or instruments, include
chisel A chisel is a hand tool with a characteristic Wedge, wedge-shaped cutting edge on the end of its blade. A chisel is useful for carving or cutting a hard material such as woodworking, wood, lapidary, stone, or metalworking, metal. Using a chi ...
s, curettes, dissectors, distractors, elevators, forceps, hooks, impactors, probes, suction tubes, power tools, and robots. Most of these modern tools have been in medical practice for a relatively long time. The main difference of these tools in neurosurgery, were the precision in which they were crafted. These tools are crafted with edges that are within a millimeter of desired accuracy. Other tools, such as handheld power saws and robots, have only recently been commonly used inside of a neurological operating room. As an example, the University of Utah developed a device for computer-aided design / computer-aided manufacturing (CAD-CAM) which uses an image-guided system to define a cutting tool path for a robotic cranial drill.


Organised neurosurgery

The World Federation of Neurosurgical Societies (WFNS), founded in 1955, in
Switzerland Switzerland, officially the Swiss Confederation, is a landlocked country located in west-central Europe. It is bordered by Italy to the south, France to the west, Germany to the north, and Austria and Liechtenstein to the east. Switzerland ...
, as a
professional A professional is a member of a profession or any person who work (human activity), works in a specified professional activity. The term also describes the standards of education and training that prepare members of the profession with the partic ...
,
scientific Science is a systematic discipline that builds and organises knowledge in the form of testable hypotheses and predictions about the universe. Modern science is typically divided into twoor threemajor branches: the natural sciences, which stu ...
, non governmental organization, is composed of 130 member societies: consisting of 5 Continental Associations ( AANS, AASNS, CAANS, EANS and FLANC), 6 Affiliate Societies, and 119 National Neurosurgical Societies, representing some 50,000 neurosurgeons worldwide. It has a consultative status in the
United Nations The United Nations (UN) is the Earth, global intergovernmental organization established by the signing of the Charter of the United Nations, UN Charter on 26 June 1945 with the stated purpose of maintaining international peace and internationa ...
. The official Journal of the Organization is World Neurosurgery. The other global organisations being the World Academy of Neurological Surgery (WANS) and the World Federation of Skull Base Societies (WFSBS).


Main divisions

General neurosurgery involves most neurosurgical conditions including neuro-trauma and other neuro-emergencies such as
intracranial hemorrhage Intracranial hemorrhage (ICH) refers to any form of Hemorrhage, bleeding Internal bleeding, within the Human skull, skull. It can result from trauma, vascular abnormalities, hypertension, or other medical conditions. ICH is broadly categorized ...
. Most level 1 hospitals have this kind of practice. Specialized branches have developed to cater to special and difficult conditions. These specialized branches co-exist with general neurosurgery in more sophisticated hospitals. To practice advanced specialization within neurosurgery, additional higher fellowship training of one to two years is expected from the neurosurgeon. Some of these divisions of neurosurgery are: # Vascular neurosurgery includes clipping of
aneurysm An aneurysm is an outward :wikt:bulge, bulging, likened to a bubble or balloon, caused by a localized, abnormal, weak spot on a blood vessel wall. Aneurysms may be a result of a hereditary condition or an acquired disease. Aneurysms can also b ...
s and performing carotid endarterectomy (CEA). # Stereotactic neurosurgery, functional neurosurgery, and
epilepsy surgery Epilepsy surgery involves a neurosurgery, neurosurgical procedure where an area of the brain involved in seizures is either resected, ablative brain surgery, ablated, disconnected or stimulated. The goal is to eliminate seizures or significantly ...
(the latter includes partial or total corpus callosotomy – severing part or all of the
corpus callosum The corpus callosum (Latin for "tough body"), also callosal commissure, is a wide, thick nerve tract, consisting of a flat bundle of commissural fibers, beneath the cerebral cortex in the brain. The corpus callosum is only found in placental ...
to stop or lessen seizure spread and activity, and the surgical removal of functional, physiological and/or anatomical pieces or divisions of the brain, called epileptic foci, that are operable and that are causing seizures, and also the more radical and rare partial or total lobectomy, or even
hemispherectomy Hemispherectomy is a surgery that is performed by a Neurosurgery, neurosurgeon where an unhealthy Cerebral hemisphere, hemisphere of the brain is disconnected or removed. There are two types of hemispherectomy. ''Functional'' ''hemispherectomy'' ...
– the removal of part or all of one of the lobes, or one of the cerebral hemispheres of the brain; those two procedures, when possible, are also very, very rarely used in oncological neurosurgery or to treat very severe neurological trauma, such as stab or gunshot wounds to the brain) # Oncological neurosurgery also called neurosurgical oncology; includes pediatric oncological neurosurgery; treatment of benign and malignant central and peripheral nervous system cancers and pre-cancerous lesions in adults and children (including, among others, glioblastoma multiforme and other
gliomas A glioma is a type of primary tumor, primary Neoplasm, tumor that starts in the glial cells of the Human brain, brain or spinal cord. They are Malignancy, malignant but some are extremely slow to develop. Gliomas comprise about 30% of all brain ...
, brain stem cancer, astrocytoma, pontine glioma, medulloblastoma, spinal cancer, tumors of the meninges and intracranial spaces, secondary metastases to the brain, spine, and nerves, and peripheral nervous system tumors) # Skull base surgery # Spinal neurosurgery # Peripheral nerve surgery # Pediatric neurosurgery (for cancer, seizures, bleeding, stroke, cognitive disorders or congenital neurological disorders)


Commonly performed surgeries

According to an analysis by the American College of Surgeons
National Surgical Quality Improvement Program The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was started in the American Veterans Health Administration (VHA). In the mid-1980s the VHA was criticized for their high operative mortality. To that end, C ...
(NSQIP), the most common surgeries performed by neurosurgeons in between 2006 and 2014 were the following: * Anterior cervical discectomy and fusion (ACDF) *
Craniotomy A craniotomy is a surgery, surgical operation in which a bone flap is temporarily removed from the Human skull, skull to access the Human brain, brain. Craniotomies are often critical operations, performed on patients who are suffering from brain ...
for
brain tumor A brain tumor (sometimes referred to as brain cancer) occurs when a group of cells within the Human brain, brain turn cancerous and grow out of control, creating a mass. There are two main types of tumors: malignant (cancerous) tumors and benign ...
(CBT) *
Discectomy A discectomy (also called open discectomy, if done through a 1/2 inch or larger skin opening) is the surgical removal of abnormal disc material that presses on a nerve root or the spinal cord. The procedure involves removing a portion of an int ...
*
Laminectomy A laminectomy is a surgical procedure that removes a portion of a vertebra called the Lamina of the vertebral arch, lamina, which is the roof of the spinal canal. It is a major spine operation with residual scar tissue and may result in postla ...
* Posterolateral lumbar fusion (PLF)


Neuropathology

Neuropathology is a specialty within the study of
pathology Pathology is the study of disease. The word ''pathology'' also refers to the study of disease in general, incorporating a wide range of biology research fields and medical practices. However, when used in the context of modern medical treatme ...
focused on the disease of the brain, spinal cord, and neural tissue. This includes the central nervous system and the peripheral nervous system. Tissue analysis comes from either surgical biopsies or post mortem autopsies. Common tissue samples include muscle fibers and nervous tissue. Common applications of neuropathology include studying samples of tissue in patients who have
Parkinson's disease Parkinson's disease (PD), or simply Parkinson's, is a neurodegenerative disease primarily of the central nervous system, affecting both motor system, motor and non-motor systems. Symptoms typically develop gradually and non-motor issues become ...
,
Alzheimer's disease Alzheimer's disease (AD) is a neurodegenerative disease and the cause of 60–70% of cases of dementia. The most common early symptom is difficulty in remembering recent events. As the disease advances, symptoms can include problems wit ...
,
dementia Dementia is a syndrome associated with many neurodegenerative diseases, characterized by a general decline in cognitive abilities that affects a person's ability to perform activities of daily living, everyday activities. This typically invo ...
,
Huntington's disease Huntington's disease (HD), also known as Huntington's chorea, is an incurable neurodegenerative disease that is mostly Genetic disorder#Autosomal dominant, inherited. It typically presents as a triad of progressive psychiatric, cognitive, and ...
,
amyotrophic lateral sclerosis Amyotrophic lateral sclerosis (ALS), also known as motor neuron disease (MND) or—in the United States—Lou Gehrig's disease (LGD), is a rare, Terminal illness, terminal neurodegenerative disease, neurodegenerative disorder that results i ...
, mitochondria disease, and any disorder that has neural deterioration in the brain or spinal cord.


History

While pathology has been studied for millennia only within the last few hundred years has medicine focused on a tissue- and organ-based approach to tissue disease. In 1810, Thomas Hodgkin started to look at the damaged tissue for the cause. This was conjoined with the emergence of microscopy and started the current understanding of how the tissue of the human body is studied.


Neuroanesthesia

Neuroanesthesia is a field of
anesthesiology Anesthesiology, anaesthesiology or anaesthesia is the medical specialty concerned with the total perioperative medicine, perioperative care of patients before, during and after surgery. It encompasses anesthesia, intensive care medicine, critica ...
which focuses on neurosurgery. Anesthesia is not used during the middle of an "awake" brain surgery. Awake brain surgery is where the patient is conscious for the middle of the procedure and sedated for the beginning and end. This procedure is used when the tumor does not have clear boundaries and the surgeon wants to know if they are invading on critical regions of the brain which involve functions like talking,
cognition Cognition is the "mental action or process of acquiring knowledge and understanding through thought, experience, and the senses". It encompasses all aspects of intellectual functions and processes such as: perception, attention, thought, ...
, vision, and hearing. It will also be conducted for procedures which the surgeon is trying to combat epileptic seizures.


History

The physician
Hippocrates Hippocrates of Kos (; ; ), also known as Hippocrates II, was a Greek physician and philosopher of the Classical Greece, classical period who is considered one of the most outstanding figures in the history of medicine. He is traditionally referr ...
(460–370 BCE) made accounts of using different wines to sedate patients while trepanning. In 60 CE,
Dioscorides Pedanius Dioscorides (, ; 40–90 AD), "the father of pharmacognosy", was a Greek physician, pharmacologist, botanist, and author of (in the original , , both meaning "On Materia medica, Medical Material") , a 5-volume Greek encyclopedic phar ...
, a physician, pharmacologist, and botanist, detailed how mandrake,
henbane Henbane (''Hyoscyamus niger'', also black henbane and stinking nightshade) is a poisonous plant belonging to tribe Hyoscyameae of the nightshade family ''Solanaceae''. Henbane is native to Temperate climate, temperate Europe and Siberia, and natu ...
,
opium Opium (also known as poppy tears, or Lachryma papaveris) is the dried latex obtained from the seed Capsule (fruit), capsules of the opium poppy ''Papaver somniferum''. Approximately 12 percent of opium is made up of the analgesic alkaloid mor ...
, and alcohol were used to put patients to sleep during trepanning. In 972 CE, two brother surgeons in Paramara, now India, used "samohine" to sedate a patient while removing a small tumor, and awoke the patient by pouring onion and vinegar in the patient's mouth. The combination of carbon dioxide, hydrogen, and nitrogen, was a form of neuroanesthesia adopted in the 18th century and introduced by
Humphry Davy Sir Humphry Davy, 1st Baronet (17 December 177829 May 1829) was a British chemist and inventor who invented the Davy lamp and a very early form of arc lamp. He is also remembered for isolating, by using electricity, several Chemical element, e ...
.


Neurosurgery methods

Various Imaging methods are used in modern neurosurgery diagnosis and treatment. They include computer assisted imaging computed tomography (CT),
magnetic resonance imaging Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and ...
(MRI),
positron emission tomography Positron emission tomography (PET) is a functional imaging technique that uses radioactive substances known as radiotracers to visualize and measure changes in metabolic processes, and in other physiological activities including blood flow, r ...
(PET),
magnetoencephalography Magnetoencephalography (MEG) is a functional neuroimaging technique for mapping brain activity by recording magnetic fields produced by electric current, electrical currents occurring naturally in the human brain, brain, using very sensitive magn ...
(MEG), and stereotactic radiosurgery. Some neurosurgery procedures involve the use of intra-operative MRI and functional MRI. In ''conventional neurosurgery'' the neurosurgeon opens the skull, creating a large opening to access the brain. Techniques involving smaller openings with the aid of microscopes and endoscopes are now being used as well. Methods that utilize small craniotomies in conjunction with high-clarity microscopic visualization of neural tissue offer excellent results. However, the open methods are still traditionally used in trauma or emergency situations. ''Microsurgery'' is utilized in many aspects of neurological surgery. Microvascular techniques are used in EC-IC bypass surgery and in restoration carotid endarterectomy. The clipping of an aneurysm is performed under microscopic vision. Minimally-invasive spine surgery utilizes microscopes or endoscopes. Procedures such as microdiscectomy,
laminectomy A laminectomy is a surgical procedure that removes a portion of a vertebra called the Lamina of the vertebral arch, lamina, which is the roof of the spinal canal. It is a major spine operation with residual scar tissue and may result in postla ...
, and artificial disc replacement rely on microsurgery. Using ''stereotaxy'' neurosurgeons can approach a minute target in the brain through a minimal opening. This is used in functional neurosurgery where electrodes are implanted or
gene therapy Gene therapy is Health technology, medical technology that aims to produce a therapeutic effect through the manipulation of gene expression or through altering the biological properties of living cells. The first attempt at modifying human DNA ...
is instituted with high level of accuracy as in the case of Parkinson's disease or Alzheimer's disease. Using the combination method of open and stereotactic surgery, intraventricular hemorrhages can potentially be evacuated successfully. Conventional surgery using image guidance technologies is also becoming common and is referred to as surgical navigation, computer-assisted surgery, navigated surgery, stereotactic navigation. Similar to a car or mobile Global Positioning System (GPS), image-guided surgery systems, like Curve Image Guided Surgery and StealthStation, use cameras or electromagnetic fields to capture and relay the patient's anatomy and the surgeon's precise movements in relation to the patient, to computer monitors in the operating room. These sophisticated computerized systems are used before and during surgery to help orient the surgeon with three-dimensional images of the patient's anatomy including the tumor. Real-time functional brain mapping has been employed to identify specific functional regions using electrocorticography (ECoG) Minimally invasive ''endoscopic surgery'' is commonly utilized by neurosurgeons when appropriate. Techniques such as endoscopic endonasal surgery are used in pituitary tumors,
craniopharyngioma A craniopharyngioma is a rare type of brain tumor derived from pituitary gland embryonic tissue that occurs most commonly in children, but also affects adults. It may present at any age, even in the prenatal and neonatal periods, but peak inciden ...
s, chordomas, and the repair of cerebrospinal fluid leaks. Ventricular endoscopy is used in the treatment of intraventricular bleeds, hydrocephalus, colloid cyst and neurocysticercosis. Endonasal endoscopy is at times carried out with neurosurgeons and ENT surgeons working together as a team. Repair of craniofacial disorders and disturbance of cerebrospinal fluid circulation is done by neurosurgeons who also occasionally team up with maxillofacial and plastic surgeons. Cranioplasty for craniosynostosis is performed by pediatric neurosurgeons with or without plastic surgeons. Neurosurgeons are involved in ''stereotactic radiosurgery'' along with radiation oncologists in
tumor A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...
and AVM treatment. Radiosurgical methods such as Gamma knife, Cyberknife and Novalis Radiosurgery are used as well. '' Endovascular neurosurgery'' utilize endovascular image guided procedures for the treatment of
aneurysm An aneurysm is an outward :wikt:bulge, bulging, likened to a bubble or balloon, caused by a localized, abnormal, weak spot on a blood vessel wall. Aneurysms may be a result of a hereditary condition or an acquired disease. Aneurysms can also b ...
s, AVMs, carotid stenosis, strokes, and spinal malformations, and vasospasms. Techniques such as
angioplasty Angioplasty, also known as balloon angioplasty and percutaneous transluminal angioplasty, is a minimally invasive procedure, minimally invasive endovascular surgery, endovascular Medical procedure, procedure used to widen narrowed or obstructe ...
, stenting, clot retrieval, embolization, and diagnostic angiography are endovascular procedures. A common procedure performed in neurosurgery is the placement of ventriculo-peritoneal shunt (VP shunt). In pediatric practice this is often implemented in cases of congenital hydrocephalus. The most common indication for this procedure in adults is normal pressure hydrocephalus (NPH). ''Neurosurgery of the spine'' covers the cervical, thoracic and lumbar spine. Some indications for spine surgery include spinal cord compression resulting from trauma, arthritis of the spinal discs, or spondylosis. In cervical cord compression, patients may have difficulty with gait, balance issues, and/or numbness and tingling in the hands or feet.
Spondylosis Spondylosis is the degeneration of the vertebral column from any cause. In the more narrow sense, it refers to spinal osteoarthritis, the age-related degeneration of the spinal column, which is the most common cause of spondylosis. The degener ...
is the condition of spinal disc degeneration and arthritis that may compress the spinal canal. This condition can often result in bone-spurring and disc herniation. Power drills and special instruments are often used to correct any compression problems of the spinal canal. Disc herniations of spinal vertebral discs are removed with special rongeurs. This procedure is known as a ''discectomy''. Generally once a disc is removed it is replaced by an implant which will create a bony fusion between vertebral bodies above and below. Instead, a mobile disc could be implanted into the disc space to maintain mobility. This is commonly used in cervical disc surgery. At times instead of disc removal a Laser discectomy could be used to decompress a nerve root. This method is mainly used for lumbar discs. ''Laminectomy'' is the removal of the lamina of the vertebrae of the spine in order to make room for the compressed nerve tissue. Surgery for chronic pain is a sub-branch of functional neurosurgery. Some of the techniques include implantation of deep brain stimulators, spinal cord stimulators, peripheral stimulators and pain pumps. Surgery of the peripheral nervous system is also possible, and includes the very common procedures of carpal tunnel decompression and peripheral nerve transposition. Numerous other types of nerve entrapment conditions and other problems with the peripheral nervous system are treated as well.


Conditions

Conditions treated by neurosurgeons include, but are not limited to: *
Meningitis Meningitis is acute or chronic inflammation of the protective membranes covering the brain and spinal cord, collectively called the meninges. The most common symptoms are fever, intense headache, vomiting and neck stiffness and occasion ...
and other central nervous system infections including abscesses * Spinal disc herniation * Cervical spinal stenosis and Lumbar spinal stenosis * Hydrocephalus * Head trauma (brain hemorrhages, skull fractures, etc.) * Spinal cord trauma * Traumatic injuries of peripheral nerves *
Tumor A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...
s of the spine,
spinal cord The spinal cord is a long, thin, tubular structure made up of nervous tissue that extends from the medulla oblongata in the lower brainstem to the lumbar region of the vertebral column (backbone) of vertebrate animals. The center of the spinal c ...
and peripheral nerves * Intracerebral hemorrhage, such as
subarachnoid hemorrhage Subarachnoid hemorrhage (SAH) is bleeding into the subarachnoid space—the area between the arachnoid (brain), arachnoid membrane and the pia mater surrounding the human brain, brain. Symptoms may include a thunderclap headache, severe heada ...
, interdepartmental, and intracellular
hemorrhage Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, ...
s * Some forms of drug-resistant epilepsy * Some forms of
movement disorder Movement disorders are clinical syndromes with either an excess of movement or a paucity of voluntary and involuntary movements, unrelated to weakness or spasticity. Movement disorders present with extrapyramidal symptoms and are caused by basa ...
s (advanced
Parkinson's disease Parkinson's disease (PD), or simply Parkinson's, is a neurodegenerative disease primarily of the central nervous system, affecting both motor system, motor and non-motor systems. Symptoms typically develop gradually and non-motor issues become ...
,
chorea Chorea, or (rarely) choreia, () is an abnormal involuntary movement disorder, characterized by quick movements of the hands or feet. It is one of a group of neurological disorders called dyskinesias. The term ''chorea'' is derived , as the move ...
)this involves the use of specially developed minimally invasive
stereotactic Stereotactic surgery is a minimally invasive form of surgery, surgical intervention that makes use of a three-dimensional coordinates, coordinate system to locate small targets inside the body and to perform on them some action such as ablation, ...
techniques (functional, stereotactic neurosurgery) such as ablative surgery and deep brain stimulation surgery * Intractable pain of
cancer Cancer is a group of diseases involving Cell growth#Disorders, abnormal cell growth with the potential to Invasion (cancer), invade or Metastasis, spread to other parts of the body. These contrast with benign tumors, which do not spread. Po ...
or trauma patients and cranial/peripheral nerve pain * Some forms of intractable psychiatric disorders * Vascular malformations (i.e., arteriovenous malformations, venous angiomas, cavernous angiomas, capillary telangectasias) of the brain and spinal cord *
Moyamoya disease Moyamoya disease is a disease in which certain arteries in the brain are constricted. Blood flow is blocked by constriction and blood clots (thrombosis). A collateral circulation develops around the blocked vessels to compensate for the blockage, ...


Recovery


Postoperative pain

Pain following brain surgery can be significant and may lengthen recovery, increase the amount of time a person stays in the hospital following surgery, and increase the risk of complications following surgery. Severe acute pain following brain surgery may also increase the risk of a person developing a chronic post-
craniotomy A craniotomy is a surgery, surgical operation in which a bone flap is temporarily removed from the Human skull, skull to access the Human brain, brain. Craniotomies are often critical operations, performed on patients who are suffering from brain ...
headache. Approaches to treating pain in adults include treatment with nonsteroidal anti‐inflammatory drugs ( NSAIDs), which have been shown to reduce pain for up to 24 hours following surgery. Low-quality evidence supports the use of the medications dexmedetomidine,
pregabalin Pregabalin, sold under the brand name Lyrica among others, is an anticonvulsant, analgesic, and anxiolytic amino acid medication used to treat epilepsy, neuropathic pain, fibromyalgia, restless legs syndrome, opioid withdrawal, generalized anx ...
or gabapentin to reduce post-operative pain. Low-quality evidence also supports scalp blocks and scalp infiltration to reduce postoperative pain. Gabapentin or
pregabalin Pregabalin, sold under the brand name Lyrica among others, is an anticonvulsant, analgesic, and anxiolytic amino acid medication used to treat epilepsy, neuropathic pain, fibromyalgia, restless legs syndrome, opioid withdrawal, generalized anx ...
may also decrease
vomiting Vomiting (also known as emesis, puking and throwing up) is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose. Vomiting can be the result of ailments like food poisoning, gastroenteritis, pre ...
and
nausea Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. It can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the throat. Over 30 d ...
following surgery, based on very low-quality medical evidence.


Notable neurosurgeons

* Harvey Cushingknown as one of the founders of modern neurosurgery. * Walter Dandyknown as one of the founders of modern neurosurgery. * Victor Horsleyknown as the first neurosurgeon. * Sofia Ionescu-Ogrezeanuknown as the first woman neurosurgeon . As a medical student at the University of Bucharest, she performed her first neurosurgical procedure in 1944, under the supervision of Dumitru Bagdasar, and saved the life of an 8-year old comatose boy with an epidural hematoma (during the WWII bombardment of Bucharest). * Hermann Schloffer invented transsphenoidal surgery in 1907. * Wilder Penfieldknown as one of the founding fathers of modern neurosurgery, and pioneer of
epilepsy Epilepsy is a group of Non-communicable disease, non-communicable Neurological disorder, neurological disorders characterized by a tendency for recurrent, unprovoked Seizure, seizures. A seizure is a sudden burst of abnormal electrical activit ...
Neurosurgery. *
Lars Leksell Lars Leksell (24 November 1907 – 12 January 1986) was a Swedish physician and professor of Neurosurgery at the Karolinska Institute in Stockholm, Sweden. He was the inventor of radiosurgery. Life and career Lars Leksell was born in Fässberg Pa ...
Swedish neurosurgeon who developed the Gamma Knife. * Wirginia Maixnerpediatric neurosurgeon at Melbourne's
Royal Children's Hospital The Royal Children's Hospital (RCH), colloquially referred to as the Royal Children's, is a major children's hospital in Parkville, Victoria, Parkville, a suburb of Melbourne, Victoria (state), Victoria, Australia. Regarded as one of the great C ...
. Primarily known for separating conjoined
Bangladesh Bangladesh, officially the People's Republic of Bangladesh, is a country in South Asia. It is the List of countries and dependencies by population, eighth-most populous country in the world and among the List of countries and dependencies by ...
i twins, Trishna and Krishna. * Saleem Abdulrauf – developed "awake" craniotomy for complex aneurysms and vascular malformations. * John R. Adler
Stanford University Leland Stanford Junior University, commonly referred to as Stanford University, is a Private university, private research university in Stanford, California, United States. It was founded in 1885 by railroad magnate Leland Stanford (the eighth ...
neurosurgeon who invented the Cyberknife. * Alim-Louis Benabidknown as one of the developers of deep brain stimulation surgery for movement disorder. *
Ben Carson Ben Solomon Carson Sr. (born September 18, 1951) is an American retired neurosurgery, neurosurgeon, academic, author, and government official who served as the 17th United States secretary of housing and urban development from 2017 to 2021. A pio ...
retired pediatric neurosurgeon from Johns Hopkins Hospital, pioneer in
hemispherectomy Hemispherectomy is a surgery that is performed by a Neurosurgery, neurosurgeon where an unhealthy Cerebral hemisphere, hemisphere of the brain is disconnected or removed. There are two types of hemispherectomy. ''Functional'' ''hemispherectomy'' ...
, and pioneer in the separation of craniopagus twins (joined at the head); former 2016 Republican Party presidential candidate, and former
United States Secretary of Housing and Urban Development The United States secretary of housing and urban development is the head of the United States Department of Housing and Urban Development, a member of the Cabinet of the United States, and thirteenth in the presidential line of succession. T ...
under the Presidency of Donald Trump. * Henry Marsh – leading English neurosurgeon and pioneer of neurosurgical advancements in Ukraine * Frank Henderson Mayfieldinvented the Mayfield skull clamp. * B. K. Misra – First neurosurgeon in the world to perform image-guided surgery for
aneurysm An aneurysm is an outward :wikt:bulge, bulging, likened to a bubble or balloon, caused by a localized, abnormal, weak spot on a blood vessel wall. Aneurysms may be a result of a hereditary condition or an acquired disease. Aneurysms can also b ...
s, first in South Asia to perform stereotactic radiosurgery, first in India to perform
awake craniotomy Awake craniotomy is a Neurosurgery, neurosurgical technique and type of craniotomy that allows a surgeon to remove a brain tumor while the patient is awake to avoid brain damage. During the surgery, the neurosurgeon performs cortical mapping to id ...
and
laparoscopic Laparoscopy () is an operation performed in the abdomen or human pelvis, pelvis using small Surgical incision, incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few ...
spine surgery. * Karin Muraszkofirst woman to occupy a chair of neurosurgery at an American medical school (
University of Michigan The University of Michigan (U-M, U of M, or Michigan) is a public university, public research university in Ann Arbor, Michigan, United States. Founded in 1817, it is the oldest institution of higher education in the state. The University of Mi ...
). * Hirotaro Narabayashia pioneer of stereotactic Neurosurgery. * Ayub K. Ommayainvented the Ommaya reservoir. * Christopher Duntsch – Former neurosurgeon who killed or maimed nearly every patient he operated on before being incarcerated. * Ludvig Puuseppknown as one of the founding fathers of modern neurosurgery, world's first professor of neurosurgery. *
Joseph Ransohoff Dr. Joseph Ransohoff, II (July 1, 1915 – January 30, 2001) was a member of the Ransohoff, Ransohoff family and a pioneer in the field of neurosurgery. In addition to training numerous neurosurgeons, his "ingenuity in adapting advanced technologi ...
known for his pioneering use of
medical imaging Medical imaging is the technique and process of imaging the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues (physiology). Medical imaging seeks to revea ...
and catheterization in neurosurgery, and for founding the first neurosurgery intensive care unit. * Majid Samiipioneer of cerebello-pontine angle tumor surgery. World Federation of Neurosurgical Societies coined a medal of honor bearing Samii's name which would be given to outstanding neurosurgeons every two years. * Juliet Sekabunga Nalwanga – Uganda's first woman neurosurgeon. * Robert Wheeler Rand along with
Theodore Kurze Theodore may refer to: Places * Theodore, Australian Capital Territory, Australia * Theodore, Queensland, Australia * Theodore, Saskatchewan, Canada * Theodore, Alabama, United States * Theodore Reservoir, in Saskatchewan People * Theodore (give ...
, MD was among the first to introduce the surgical microscope into neurosurgical procedures in 1957 and published first textbook on Microneurosurgery in 1969. * Robert J. White – Established the Vatican's Commission on Biomedical Ethics in 1981 after his appointment to the Pontifical Academy of Sciences and was famous for his head transplants on living monkeys. * Gazi Yaşargilknown as the father of microneurosurgery.


Bioethics in neurosurgery

Neurosurgery is a part of practical
medicine Medicine is the science and Praxis (process), practice of caring for patients, managing the Medical diagnosis, diagnosis, prognosis, Preventive medicine, prevention, therapy, treatment, Palliative care, palliation of their injury or disease, ...
and the only specialty that involves invasive intervention in the activity of the living brain. The brain ensures the structural and functional integrity of the body and the implementation of all the main life processes of the body. Therefore, neurosurgery faces a wide range of bioethical issues and a significant selection of the latest treatment technologies. Neurosurgery has the following applied scientific and ethical problems: * Ethical and legal aspects of
clinical research Clinical research is a branch of medical research that involves people and aims to determine the effectiveness (efficacy) and safety of medications, devices, diagnostic products, and treatment regimens intended for improving human health. The ...
; * Αxiological deficit due to professional deformation and professional burnout; * Limited access to expensive medical services; * The industry-specific problem of "
medical error A medical error is a preventable adverse effect of care (" iatrogenesis"), whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, ...
" due to the complexity of neurosurgical pathologies and the huge number of possible technologies and tools for their treatment; * Controversial bioethical and legal issues of surgery for the treatment of psychiatric diseases; * Bioethical discussions regarding the instrumentation of
reconstructive surgery Reconstructive surgery is surgery performed to restore normal appearance and function to body parts malformed by a disease or medical condition. Description Reconstructive surgery is a term with training, clinical, and reimbursement implicat ...
, through the use of experimental technologies; * Debatable bioethical issues of improving human brain activity with the help of artificial implants, for instance neurocomponents (artificial impulse quasi-
neuron A neuron (American English), neurone (British English), or nerve cell, is an membrane potential#Cell excitability, excitable cell (biology), cell that fires electric signals called action potentials across a neural network (biology), neural net ...
s); * Cyborgization in
transhumanism Transhumanism is a philosophical and intellectual movement that advocates the human enhancement, enhancement of the human condition by developing and making widely available new and future technologies that can greatly enhance longevity, cogni ...
meaning; * Ethical issue of
standardization Standardization (American English) or standardisation (British English) is the process of implementing and developing technical standards based on the consensus of different parties that include firms, users, interest groups, standards organiza ...
of research protocols for testing neuroengineering means of nerve tissue regeneration in order to improve the
implementation Implementation is the realization of an application, execution of a plan, idea, scientific modelling, model, design, specification, Standardization, standard, algorithm, policy, or the Management, administration or management of a process or Goal ...
of experimental research results in
clinical practice ''Clinical Practice'' is a bimonthly peer-reviewed open access medical journal. It covers good clinical practice and health care. The journal was established in 2004 as ''Therapy'' by Future Drugs Ltd, obtaining its current name in 2012 when it wa ...
.


See also

* * * * * *


References

{{Authority control Surgical specialties