Ask the Expert
This issue, we’re excited to bring you a new column: Ask the Expert. We hope it serves as an interesting review of questions posed within the neurosurgical community, and how physician leaders consider and ultimately look to solve these challenging issues. We hope you enjoy these perspectives, and we encourage you to submit your own questions for consideration by emailing them to firstname.lastname@example.org.
The Question: Given that Europe removed open vascular quotas from their neurosurgical training, do you think the US should continue to mandate open vascular cases (current quota is 40 cases) during neurosurgical residency? Should neurovascular training be delegated to fellowship?
The Expert Opinion: Several years ago, organized neurosurgery and thought-leaders had the foresight to embrace endovascular therapies. The growing concern at present is a reduction in “open” neurovascular procedures available to neurosurgery residents. This has been driven by several factors. Endovascular techniques and devices continue to advance treatments in the field at a rapid rate. They’ve replaced open surgical procedures for a number of intracranial and spinal vascular malformations and aneurysms. In addition, the number of neurovascular patients presenting to larger academic centers where neurosurgical residents are trained have been reduced by the growth of the availability of endovascular treatments at smaller nonacademic institutions. Often, the treating physician at the smaller facility may not be a neurosurgeon, but a neurologist or neuroradiologist with endovascular training. This has diluted the quality and quantity of vascular procedures at some major training institutions. In order to address these issues the Society of Neurological Surgeons instituted the Committee on Advanced Subspecialty Training (CAST). Program requirements and standards for enfolded and post-residency fellowships for open cerebrovascular and endovascular training were established.
However, given the rapid changes in treatment techniques, previous training standards and quotas need to be significantly modified. The previous requirement of 40 open vascular cases has not been met at many institutions. When open surgery is performed, several residents are often involved in the operation in order to enter this into their case logs. Several of the residents have little to do with the actual procedure, and were more often simply observing. At present, the American Board of Neurological Surgery is modifying the standard to include 50 open or endovascular procedures as part of the neurovascular training. This means that if the graduating chief resident did 50 endovascular cases and no open cranial vascular cases, he or she would still graduate and meet the threshold for training.
Of all physicians treating neurovascular disease, neurosurgeons represent the one subspecialty perfectly situated to lead the innovation and ongoing changes in the field. Basic endovascular techniques can easily be incorporated into a residency training program. Neurosurgical trainees often have a rapid learning curve and pick up the technical nuances of endovascular techniques quickly, as evidenced by reduction in radiation times and contrast usage over the first few weeks with diagnostic and interventional work. Patient care skills, which often have to be acquired by trainees in other subspecialties, are already part of the neurosurgery resident’s armamentarium. Required rotations on the endovascular service are being incorporated and required in many training programs.
As neurosurgery becomes more subspecialized, one could easily envision a neurosurgical resident doing a year of enfolded endovascular work as a mid-level resident, combined with senior-level training involving a more focused curriculum on open and endovascular neurovascular procedures such that upon graduation, the resident would be trained to assume a position of a comprehensive neurovascular expert in an academic or private practice setting. However, there is still a need for open vascular cases, and the resident would have to train in a program which has a high-volume open vascular practice. Currently, there are eight such CAST-accredited programs. The resident could train for a year as part of an enfolded fellowship or do it post residency. In changing training requirements, we feel it is a time for organized neurosurgery to lead, not follow.