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 personal Youtube 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.
What is Neurosurgery?
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, the 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 Nerve Surgery
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.
How to Become a Neurosurgeon
To become a neurosurgeon, you’ll have to complete a 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.
In terms of competitiveness, neurosurgery is consistently in the top five, in most recent years being ranked third, only behind dermatology and plastic surgery. 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 workweek 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.
Subspecialties within Neurosurgery
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 Ph.D.’s after their name or computer science background.
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 a prerequisite as children needing neurosurgical intervention generally don’t have rosy outcomes.
Peripheral nerve is perhaps the smallest subspecialty within neurosurgery, partly because it’s not exclusive to neurosurgeons (you can get there through orthopedics or plastic surgery). It’s for surgeons who enjoy operating all over the body, since the peripheral nervous system exists everywhere outside of the brain and spinal cord.
Surgical neuro-oncology tends to attract surgeons with an interest in tumor biology. These surgeons may spend up to half of their time in the research lab, studying additional methods for tumor treatment beyond simple surgical resection. This is because a large subset of brain tumors don’t respond to just surgical resection (like GBM).
Trauma/neurocritical care is for those surgeons who wish to focus on the multi-disciplinary treatment of patients with traumatic neurological injuries. Beyond performing life-saving surgeries, these folks are interested in the longer-term post-operative recovery process for patients suffering from TBI, spinal cord injury, aneurysm rupture or hemorrhagic stroke.
What You’ll Love About Neurosurgery
As a neurosurgeon, you’ll be working on arguably the most fascinating and mysterious organ of the body — the brain. Psychiatrists and neurologists deal with the brain as well but in a non-surgical capacity. You’ll get to touch, change, and augment the central nervous system right in front of you, in real-time.
It’s a highly innovative field, particularly the subspecialty of functional neurosurgery, where the line is blurred between what is you and what is hardware. It raises questions about free will, consciousness, and other questions that are bound to keep you up late at night.
Only a few specialties truly save people’s lives. Neurosurgery is one of them. At a moment’s notice, you may be called in and rush to the hospital to save someone’s life. While the surgeries may become routine, the feeling of saving someone’s life never will. Trauma and emergency medicine are some other specialties that share this aspect.
Neurological surgery is a highly academic field, satisfying even the most intellectually curious. You’ll be surrounded by driven and truly impressive colleagues cut from the same cloth. To quote my neurosurgery friend, “not to say we’re better than everyone, but we are.” He’s joking of course, but only a little.
As a doctor, you normally need to choose between honing surgical expertise and foregoing medical management, or vice versa. That’s one thing I didn’t enjoy about plastic surgery. I wasn’t managing patients medically so much, just more so surgically. As a neurosurgeon, you’ll be handling the medical side of things quite intensively — titrating sedatives to adjust for intracranial pressure abnormalities, adjusting ventilator settings, and reading EEG’s to see if someone is seizing. You won’t quite be a cardiothoracic surgeon, who are the most badass in terms of medical management while being surgeons, but you won’t miss the medical side of medicine.
In medical school, I rotated on orthopedic surgery, plastic surgery, and neurosurgery, the three specialties I was considering most seriously. One thing I loved about neurosurgery was the personalities. Some of the funniest and coolest surgeons I worked with were neurosurgeons. This isn’t uncommon. The field is very humbling, and despite the stereotype, neurosurgeons are faced daily with the reality that they are not god. You can’t take yourself too seriously and you’ll need to learn to laugh at yourself, otherwise, you won’t last.
What You Won’t Love About Neurosurgery
There were two main factors that pushed me away from neurosurgery, despite my love for neuroscience and fascination with the brain. First, think about the types of patients that need neurosurgical intervention. They’re very sick and can often have poor outcomes. Many of your patients will succumb to immense suffering or death. That may not sound so bad right now, but day after day, year after year, that sort of heaviness will weigh on you.
The other thing that pushed me away from neurosurgery was learning that it wasn’t as precise and meticulous as I would have expected brain surgery to be. Certain aspects are highly precise, like skull-base, but much of neurosurgery is surprisingly crude and more similar to orthopedic surgery than something like plastic surgery.
But wait, there’s more. Neurosurgeons face one of the most challenging lifestyles of any specialty, even beyond residency. That’s because, in addition to scheduled cases, you’ll need to take neurosurgery trauma call. In medicine, we say that neurosurgeons make the most money, but don’t have any time to enjoy it. The median salary is $680,000 per year, and they’re consistently number 1 or number 2 in terms of highest-paid specialty, duking it out with orthopedic spine surgeons.
The field is 92% men. While not as bad as orthopedic surgery, it’s one of the most male-dominated specialties, although that is slowly changing.
The neurosurgeon stereotype comes with good and bad. For online dating apps, it’s great, but beyond that, the stereotype is difficult to deal with in the hospital. Others expect you to have a god complex, to be an asshole, egotistical, emotionless, or even sociopathic.
Should You Become a Neurosurgeon?
At this point, you’ll know whether or not neurosurgery is right for you. It’s a highly self-selecting group of people. Obviously, you need to enjoy the practice of surgery and have a deep intellectual curiosity for the brain and mind.
But beyond that, you need to really want it more than anything else. You’ll need incredible stamina to endure a brutal 7-year residency and continue to work challenging and unpredictable hours as an attending.
The stakes are high, and there’s a consistently high sphincter tone and level of vigilance. That’s because, so often, patients with neurological injuries can be incredibly hard to monitor. A patient in acute organ failure, mid-heart-attack, or exsanguinating during trauma can be hard to ignore. But in neurosurgery, potentially devastating neurological complications – such as a stroke or a brain bleed – can occur with scary subtlety. Being on top of the ball is a must.
If you’re all about that, you’ll certainly get the excitement and rush from the unpredictability of trauma. You’ll also get the highly technical aspect of something like plastic surgery. If you take deep pride in your work and have perfectionistic tendencies, neurosurgery may be a good fit.