The specialty first developed through the treatment of cranial trauma
and intracranial mass lesions. Successive advances in microsurgical techniques,
non-invasive imaging, neuro-anaesthesia, intensive care, image-guided surgery,
and the introduction of sophisticated radio-oncological and interventional treatments have greatly enhanced and widened the scope of effective treatments.
Head and spinal injuries remain a leading source of mortality and disability, and as such most neurosurgical units are an essential component of local major trauma centres. Overall, emergency and urgent activity comprises some 50% of the caseload of a neurosurgical unit, indicative of the uniquely high acuity of neurosurgical patients.
General neurosurgery is typically taken to embrace spinal, trauma, oncology, CSF diversion (i.e. hydrocephalus), posterior fossa and peripheral nerve surgery. Most neurosurgeons will cover these cases on call but may refer on subsequently. New consultants are typically appointed with a subspecialty interest (following a fellowship), the major of which comprise:
- Neuro-oncology: biopsy and resection of tumours of the spine and the brain, which may be primary or secondary. This may also comprise pituitary surgery which is predominantly performed endoscopically via the nose and sphenoid sinus.
- Neurovascular Surgery: management of aneurysms and other vascular malformations either emergently following subarachnoid haemorrhage or electively if incidental findings.
- Skull Base Surgery: the treatment of (predominantly) tumours of the clivus, dorsum sellae, cerebello-pontine angle, around the 3rd ventricle and parasellar area. Procedures are frequently undertaken jointly with ENT.
- Spinal Surgery: the largest specialty (up to 50% of caseload in some centres) deals with a great number and range of degenerative pathologies; decompressing the spinal cord and nerve roots both electively and emergently via laminectomies, discectomies and foraminotomies, as well as spinal trauma where instrumentation is also often necessary. There is considerable overlap with spinal orthopaedics.
- Traumatology: encompasses the critical care and surgical management of intracranial injuries (subdural, extradural and intracerebral haematomas), diffuse axonal injury, skull fractures etc.
- Functional Neurosurgery: covers the surgical treatment of chronic pain, movement disorders, neuropsychiatric disorders and epilepsy.
- Paediatric neurosurgery: almost a completely separate specialty, although covers similar pathology to adults as well as the development abnormalities seen in children.
Neurosurgery’s focus on a physiological system, rather than an anatomic area, brings great operative variety as well as neurology and critical care components. A typical elective theatre list may contain a broad range of cases such as a cervical discectomy, craniotomy and carpal tunnel release, affording wide operative experience to the junior surgical trainee who will also benefit non-operatively from caring for some of the sickest surgical patients.