a rocket surgeon. Let's debunk the public perception myths of what it means to be a

neurosurgeon, and give it to you straight. This is the reality of neurosurgery.

Dr. Jubbal, MedSchoolInsiders.com.

Welcome to our next installment in So You Want to Be. In this series, we highlight a

specific specialty within medicine, such as neurosurgery, and help you decide if it's

a good fit for you. You can find the other specialties on our So You Want to Be playlist.

A lot of you asked for neurosurgery in our poll, so that's what we're covering here.

If you want to vote in upcoming polls to decide what future specialties we cover, make sure

you're subscribed.

If you'd like to see what being a neurosurgeon looks like, check out my second channel, Kevin

Jubbal, M.D., where I do a second series in parallel called a Day in the Life. We'll

be doing a Day in the Life of a Neurosurgeon soon and you don't want to miss it. show

footage from Daniel Choi day in the life of ortho spine surgeon where he is in the operating

room

Neurological surgery, or neurosurgery for short, is much more than just brain surgery.

The nervous system is comprised of two main components — the central nervous system,

or CNS, and the peripheral nervous system, or PNS. Try saying that one 5 times as fast

as you can. The CNS includes the brain and spinal cord, whereas the PNS includes all

other nerves within the body. Neurosurgery deals with surgical interventions of both.

There are two overarching categories to neurosurgery: 1) Elective surgery, and 2) Emergent (i.e.

non-elective) surgery. Elective surgeries take place on a non-emergent basis, and generally

involve treating conditions that are not immediately life threatening. They tend to fall into one

of three categories: Cranial surgery, spine surgery, and peripheral nerve surgery.

Cranial surgery, as it sounds, involves operating on structures within the head (i.e. the brain).

This category can be further subdivided into a few more subcategories: tumor surgery, vascular

surgery, and functional neurosurgery.

Tumors in the brain come in all shapes and sizes. They can be benign or malignant, slow

or fast growing, life threatening or not. Some tumors can be observed without ever needing

treatment, while others can be treated with radiation, but often, given the limited space

afforded by the human skull, and the sensitive nature of the brain's tissues, a neurosurgeon

is called upon to surgically resect a tumor in the brain.

Vascular neurosurgery involves treating abnormalities in blood vessels of the brain. Neurosurgeons

might treat an aneurysm on a vessel, or bypass a blockage or narrowing of a vessel, much

the same way you would do coronary bypass in the heart. Though rather than opening the

chest, of course, neurosurgeons work through a small hole in the skull.

Functional neurosurgery is the sexy stuff — the science fiction of the field. In functional

neurosurgery, the brain is viewed as one large complicated electrical circuit, and neurosurgeons

try to modulate the circuit to bring about a desired outcome. This might involve placing

electrodes within the brain to stimulate certain structures, or creating lesions with radiation,

ultrasonic energy or simple thermal ablation to effectively “turn off” structures that

might be causing a problem for a patient. Functional neurosurgery addresses pathologies

such as Parkinson's disease, tremors, and obsessive compulsive disorder, among others.

Though what's most exciting about this subset of cranial surgery is what it hopes to treat

in the future - things like chronic pain, depression, PTSD, and substance addiction.

Within spine surgery, there are a few subcategories as well: we'll call them “degenerative”,

“scoliosis”, and “tumors”.

The vast majority of spine surgery is done to treat good old fashioned wear and tear,

or degenerative disease, of the spine. As you might expect, degenerative disc disease

and osteoarthritis of the spine tend to occur in the cervical spine, or neck, and lumbar

spine, or lower back, which are the two most mobile parts of the spine. Your thoracic spine

is less mobile because of your ribs (which create additional support and limit mobility).

With these degenerative processes, the spinal cord itself or nerve roots exiting the spine

can become compressed, leading to pain and weakness. Surgeons often are required to decompress

these structures by removing certain elements of the spine. When removing these bony arthritic

spurs, or degenerated discs, the integrity of the spine can become compromised, which

can require a spinal fusion to restore stability, although the fused segment has increased rigidity.

Fusion is often achieved with rods and screws, and in some cases with disc replacement hardware.

Spine surgery also includes repair of scoliosis, whereby curvature of the spine can become

so severe as to cause pain, difficulty breathing, or other functional deficits. It's important

to note that spinal decompression surgeries and scoliosis repair can be performed by either

neurosurgeons or orthopedic surgeons. However, removal of tumors of the spinal cord is performed

exclusively by neurosurgeons. While a tumor in the liver or breast can be relatively quickly

resected, removing tumors around the spine can be quite involved, and take a long time

- even for small tumors - due to the care and precision required to leave the spinal

cord uninjured.

Peripheral neurosurgery, as the name suggests, involves operating on the peripheral nervous

system. This includes all nerves outside of the brain and spinal cord. These nerves can

sprout tumors, or become injured in an accident. In such cases, a neurosurgeon may be called

upon to remove that tumor, to reconnect severed nerves, or in some cases to connect part of

a healthy, working, nerve to a damaged nerve in the hopes that a patient can regain function

of that nerve over time.

If you're a trauma surgeon, you take shifts and handle traumas that come in on your shift.

If you're a neurosurgeon, you have to operate on your scheduled cases but also take neurosurgery

trauma call on top. It's just part of the job. This includes traumatic injuries to both

the cranium and spine. Both are very urgent.

Compared to other parts of the body, the skull is a fixed space, which results in its own

set of issues. If you bleed into your abdomen, you're concerned about exsanguination, meaning

you can bleed out and die, as your abdomen can distend to accommodate a large volume

of blood. In the cranium, however, a fixed space means that as you bleed, pressure increases,

resulting in compression of the brain. You won't ever exsanguinate as the skull is

too small, but brain bleeds are deadly due to brain herniation, meaning compression and

pushing of critical structures through the foramen magnum outside the skull. Alleviating

pressure is key, and this is done with a decompressive hemicraniectomy, meaning removing part of

the skull to create space for the brain to swell after it has been injured. The excised

segment is kept in the freezer and the neurosurgeons can put it back weeks or months later when

the brain swelling has resolved.

There are four main types of brain bleeds — epidural hematomas, subdural hematomas,

subarachnoid hemorrhages, and intraparenchymal hemorrhages. Epi- means above and -dural refers

to the dura, the outermost layer of the meninges covering the brain. Epidural hematomas are

bleeds most commonly from the middle meningeal artery in the space below the skull but above

the dura. With an arterial source, these bleed quickly, and usually result from blunt trauma

to the head. Subdural hematomas are below the dura and are more common amongst elderly

patients on blood thinners. These are venous bleeds and slower in nature, but can be equally

urgent and life threatening Subarachnoid hemorrhages result from an aneurysm rupturing, and because

it's below the arachnoid layer of the meninges, the blood fills the sulci of the brain, meaning

all the nooks and crannies, effectively coating the brain in blood, which can be toxic. Intraparenchymal

hemorrhages are bleeds within the actual tissue of the brain, and this can result from long

standing hypertension resulting in arteriosclerosis, or other reasons.

Ruptured aneurysms are usually handled by neurosurgeons, but sometimes by endovascular

surgeons or interventional radiologists. Treatment is either coil placement or placing a clip

over the aneurysm.

Intraparenchymal hemorrhages can sometimes become large enough that they need to be evacuated.

In those cases, a neurosurgeon might make an opening in the skull and work their way

down to the hematoma to evacuate as much blood as safely possible without damaging surrounding

structures.

If a patient fractures their spine, the spinal cord can become compressed, or even severed.

In such cases, it is important to relieve pressure on the spinal cord quickly. Urgent

decompression is often required, as is stabilization to reduce additional uncontrolled movement

and further injury. This is why you see C-spine collars placed on trauma patients - for stability

and to reduce the risk of additional spinal cord injuries.

To become a neurosurgeon, you'll have to complete neurosurgery residency after medical

school. Neurosurgery has the longest residency start to finish, lasting 7 years in duration..

Most residencies will include one year of dedicated research time, though not all. Show

plastic surgery at 6 years, orthopedic surgery at 5 years, general surgery at 5 years, ENT

5 years

In terms of competitiveness, neurosurgery is consistently in the top five, in most recent

years being ranked third, only behind dermatology and plastic surgery. Show points ranking of

top five with columns representing the points, the height of which is proportional to their

ranking (like bar graphs). Refer to spreadsheet and use the total points in each category

Neurosurgery candidates are top students, with very high Step 1 and Step 2 scores, generally

only a few points below the average dermatology or plastic surgery matriculants. But what

truly sets neurosurgery applicants apart is their research. The average matriculant in

2018 pumped out over 18 publications, abstracts, or presentations by the time they applied

to residency. In comparison, plastic surgery and dermatology were at 14 with orthopedic

surgery at 10. Most other specialties didn't even break 7.

Why the focus on research in neurosurgery? Neurosurgery is a highly academic field, likely

due to the fact that there is so much room to improve outcomes in patients. Residencies

want to train surgeon scientists who will advance the field. While treatment modalities

and outcomes have improved drastically in the past 20-30 years, there are several pathologies

with bleak outcomes. For example, glioblastoma multiforme, or GBM for short, had an average

prognosis of about 5 months over a century ago. Despite all the technological advancement

since, these days, even after aggressive surgery, radiation and chemotherapy, median survival

has improved to only 14-16 months

Medical students that end up applying to neurosurgery are a unique bunch and are a self-selecting

group. They take the meaning of workaholic to the next level. The award for most brutal

and rigorous residency, even amongst surgical residencies, is usually reserved for neurosurgery.

Despite the 80 hour work week restrictions enacted by the ACGME, it's not uncommon

to see neurosurgery residents exceeding these limits repeatedly. The good news is that as

an attending, the days of working 90 hour weeks are now behind you, but that won't

always be the case in residency.

After completing residency, you can practice as a general neurosurgeon, or choose to sub-specialize

further with fellowship.

Skull-base is primarily concerned with tumors that grow along the base of the skull, which

is notoriously high end real estate. It's a shrinking field, mainly because less invasive

options like radiosurgery and endovascular procedures are becoming more sophisticated

and appealing for patients, but it's still an appealing subspecialty. Those with the

best hands and stamina for 18 hour-plus surgeries go here. It's a young man's game.

Neurovascular is highly technical, dealing with aneurysms, hemorrhagic strokes, and bypassing

blockages in the brain. Call schedule is brutal, attracting those who are gluttons for punishment.

Outcomes can sometimes be particularly grim, which can take a toll over the course of one's

career. You'll need a strong stomach.

Functional and stereotactic surgery deals with modulating the electrical circuitry of

the brain. These are the nerds of the nerds, usually with PhD's after their name or computer

science backgrounds.

Spine is for the jocks and ortho bros. There's a great deal of bony work, thus requiring

a higher degree of strength and on average less finesse than other aspects of neurosurgery.

Pediatrics is for the neurosurgeons who are best at dealing with parents. A strong stomach

is prerequisite as children needing neurosurgical intervention generally don't have rosy outcomes.