Neurosurgeons and Neurotrauma: Standing Front and Center

Jamie S. Ullman, MD

There is never an end to the work that we, as neurosurgeons, must do to improve the care of our patients, advocate for injury prevention, and devise innovative ways of treating neurotrauma to achieve the best outcomes possible. Through ongoing collaboration and research, we can truly and monumentally affect and minimize the impact of neurotrauma. To do this, we must be front and center of this effort.

There is a disturbing trend toward neurosurgeons abdicating their role in the management of acute traumatic brain injury (TBI), allowing other specialties, such as Acute Care Surgery, to advocate for protocols that exclude neurosurgeons from consulting upon and treating patients with mild traumatic brain injury (mTBI). Gaps in neurosurgery interest will result in many TBI patients finding themselves in the exclusive care of non-experts. General surgery residencies no longer require exposure to clinical neurosurgery except for what is likely encountered during trauma rotations. The American Association for the Surgery of Trauma (AAST) Acute Care Surgery Fellowship does not include direct neurosurgical experience in its curriculum. With this in mind, the section took a stance against a recent publication in JAMA Surgery advocating a hospital head injury management protocol that permitted acute care surgery to evaluate and treat mild TBI patients with “trivial” intracranial hemorrhage without the need of neurosurgery input.1 What was not clear in this protocol was how these patients were to be followed up and by whom. It is the position of organized neurosurgery that TBI management is a cooperative effort among the various disciplines, including trauma surgery. Trauma and other neurosurgical emergencies are at the very core of what we do. Our extensive training makes neurosurgery best suited to manage acute TBI because our three-dimensional perceptions go beyond what is presented at face value. It is true that neurosurgeons cannot be in all places at once; we are clearly a relatively rare commodity. Some of our colleagues, however, have fostered the use of teleradiology and telemedicine to facilitate the management of patients at facilities without neurosurgical services. Such practices can help keep our involvement strong.

In contradistinction, there is an exciting trend in neurosurgery toward increased interest in neurocritical care. The American Board of Neurological Surgery has developed its first subspecialty certificate in neurocritical care culminating its inaugural examination in March 2016. With increasing numbers of the Society of Neurological Surgeons Committee on Advanced Subspecialty Training (CAST)-accredited neurocritical care fellowships, we will see more neurosurgeons advancing in this direction.

Sadly, though, many neurosurgeons have long since abdicated their role in the management of concussion. Many primary care providers such as pediatricians and internists, as well as physical therapists and other providers, have filled in this gap. No doubt, it is important for primary care providers, coaches, and the public to recognize signs of concussion, ways to prevent them, and to be familiar with appropriate treatment and return to activity protocols. Even though a few neurosurgeons have achieved prominence in mTBI research, all neurosurgeons should take the lead and play an active role in educating stakeholders in these aspects of concussion. Sitting at the helm of the National Football League’s Head Neck and Spine Committee, our colleagues are currently providing organizational experience in the clinical and investigative evaluation of concussion. They are also standing on the sidelines during games to assess potentially injured players. ThinkFirst, neurosurgery’s own injury-prevention organization, has added concussion education and prevention as a priority. The section’s Sports Injury Committee, led by Julian Bailes and Tanvir Choudhri, has worked with the CNS and AANS in keeping us in the foreground of mTBI policy and education.

The section holds strong on its commitment to improve trauma care by fostering collaborations with the American College of Surgeons (ACS) Committee on Trauma (COT) and other organizations, such as the Neurocritical Care Society and Brain Trauma Foundation. Through the leadership of Geoffrey Manley, past section chair, a TBI best practices document was developed for the ACS Trauma Quality Improvement Program (TQIP). Additionally, we are involved in international outreach through our new international committee, chaired by Andres Rubiano. We are pleased to have supported a noble effort, initiated by Indian American neurosurgeons, to work with government officials to establish guidelines for a neurotrauma care system in India. We are also assisting in educational efforts in Latin America. We are looking forward to working with the World Federation of Neurosurgical Societies (WFNS) and President-Elect Franco Servadei, a noted neurotraumatologist, along with the Foundation for International Education in Neurological Surgery (FIENS), and the World Health Organization (WHO), in important efforts to increase international neurotrauma awareness and intervention.

Through a strong connection with the Brain Trauma Foundation (BTF), key section members, led by BTF Committee Chair Greg Hawryluk, have co-authored the new fourth edition of Guidelines for the Management of Severe Traumatic Brain Injury. After its publication, we will work with the BTF on the Living Guidelines initiative which will provide, at the very least, annual updates. This ongoing effort will facilitate the reporting of new evidence to guide practice in a timelier fashion. The section remains involved in reviewing evidence-based guidelines through representation on the AANS/CNS Joint Guidelines Committee. The section’s guidelines committee, chaired by Patti Raksin, reviews other consensus documents related to trauma and critical care for the purposes of recommending CNS and AANS endorsement.

Knowing the importance of neurosurgery to trauma centers throughout the United States, neurosurgeons are steadfast in their commitment to uphold the vigorous requirements set forth by the ACS COT. The section also has the duty to provide CME credit to help fulfill the ACS educational requirements. Our education committee, chaired by David Okonkwo, and annual meeting subcommittee chair, Craig Rabb, have provided meaningful trauma-related content for the CNS and AANS Annual Meetings. In addition, we have solidified our relationship with the National Neurotrauma Society (NNS) and look forward to collaborating with them on their 2016 Annual Symposium, held June 26—29, in Lexington, Kentucky. The section’s sessions will be held on June 26, 2016, and were devised by our superb scientific program subcommittee, chaired by Uzma Samadani. We encourage all of our members to attend these and other sessions offered at the NNS Symposium. Attendance could easily provide a neurosurgeon with more than the required 16 annual CME credits. To register, visit neurotraumasociety.org. Additionally, we are happy to announce our partnership with the International Neurotrauma Society (INTS) and the NNS for the INTS Biennial Meeting in Toronto, Canada, August 11–16, 2018.

The Trauma Section has also had a long-standing commitment to resident research by offering the DePuy Synthes awards for craniofacial and spinal injury. In addition, Codman has supported a yearly neurotrauma fellowship that funds a top-selected research proposal culminating in a presentation at the AANS one year later. Our first Ethicon Resident Research Awards were presented to outstanding projects in spine and head injury, and were presented at the 2015 NNS meeting. Our awards committee, led by Eve Tsai, has tirelessly pursued the maintenance and expansion of our awards and lectureship offerings.

The section, with industry support, continues to offer three outstanding lectureships: The Charles Tator Honorary Lectureship on Spinal Injury research, the J. Douglas Miller Lectureship, and the Anthony Marmarou Memorial Lectureship. Recent honorees have included Charles Tator, Raj Narayan, Ross Bullock, Peter Hutchinson, Nino Stocchetti, Barth Green, Susan Harkema, and Jamshid Ghajar. We continue to support neurotrauma research, lectureships, and other initiatives through the generosity of our membership. Recently, through the hard work of Membership Chair Martina Stippler, the section sent out requests for contributions, either through a direct contribution to the section or through the Neurosurgery Research and Education Foundation’s (NREF) Honor Your Neurosurgical Mentor fund. A fund has also been established to honor Drs. Charles Tator and Anthony Marmarou. There is abundant room for all members to honor a colleague, mentor, or ourselves by funding research awards and lectureships through these mechanisms.

My tenure as chair came to a close on May 2. I want to thank officers and voting members Daniel Michael, Julian Bailes, Geoffrey Manley, Sharon Webb, and Rocco Armonda, for their dedication and wisdom. Special mention must go to our special advisor, Michael Fehlings, for his counsel and encouragement, and for providing opportunities for involvement. The section is fortunate to have an executive committee of more than 30 hardworking individuals. I want to personally thank all of them for contributing much of their time and effort in the past two years. The section also congratulates our past chairs—Alex Valadka for his election as AANS President for 2016–17, and Shelly Timmons for her appointment as chair of the AANS/CNS Washington Committee. The chair’s gavel has been passed to Daniel Michael, with Julian Bailes serving as chair-elect, and David Okonkwo as secretary/treasurer. We congratulate Patti Raksin and Odette Harris for their elections as members-at-large. Each of these individuals has a wealth of experience in clinical management, research, and leadership that will continue to strengthen the section and its scope. We encourage everyone interested in assisting and leading our efforts to join the Trauma Section.

The AANS/CNS Section on Neurotrauma and Critical Care exists to advise, advocate, and educate regarding issues pertaining to its title. We want to help reinforce and restore neurosurgery’s position at the forefront of all neurotrauma management, from concussion to severe TBI; from spinal column injury to spinal cord injury. As neurosurgeons, our unique and intensive training makes us most suitable for this task, granting each and every one of us leadership in this endeavor—so let us all stand front and center for neurotrauma.

1 Ullman J, Timmons S, Valadka A. Neurosurgeons’ Critical Role in Managing Traumatic Brain Injury. JAMA Surg. 2016: Feb: 151(2):199-200