A cry for specialists in functional neurosurgery.

Stereotactic surgery is a rapid growing field. This prolific field focuses on new technologies to improve and add precision and accuracy in all areas of neurosurgery. “Frameless Stereotactic Surgery,” which already lost the name of its stereotactic origin, now is known as “image guided surgery,” present in vascular neurosurgery, neuro-oncology surgery, spine surgery, radiosurgery, is even used for placement of shunts and drainage of hematomas. Stereotactic surgeons persist to use their precision mind to boost creativity in neurosurgery, now marching in full force in the direction of neurodegenerative and psychiatric diseases. These are fertile fields of development, representing a novel area of study and preparation. This new posed challenge demands understanding of diseases not in the realm of the knowledge of established stereotactic neurosurgeons. Do we need a new breed of neurosurgeons specialized in different neurodegenerative diseases, as we already have neurologists strictly interested in muscle disorders, headaches, epilepsy, etc., While the stereotactic surgical procedure tends to be technically less demanding than the procedures in vascular, spine, and oncologic neurosurgery, the knowledge required to manage the patients with neurodegenerative diseases is broad and foreigner to the traditionally trained neurosurgeon. As an example, surgery for Parkinson's disease requires nuances of management of medication and target choice that brought the neurologist and neurophysiologist to the operating room to help the neurosurgeon. Neurosurgeons, in certain areas of the world are turned into technicians performing a simple placement of an electrode. In some countries the absurd is taken to certain instances where the device “sales representative,” trained by the industry, comes to the operating room to tell the neurosurgeon what to do. This is inappropriate for very basic reasons. The sales persons have no medical training, does not understand anatomy related to risks of surgery, and as a rule, has no knowledge of the clinical situation of the patient. Moreover, has the conflict of interest of having the sale finalized. This situation, unacceptable in the medical field, has permeated in many of our subspecialty, including spine surgery. Stereotactic surgery requires a very dedicated specialist who understands in depth the disease being treated, as well as neuroanatomy, neurophysiology and the intricacies of the device, cell biology, nanoparticles, vectors, or chemicals being deposited in the brain. Due to the seaming easiness of the functional neurosurgical procedures, specialists of other areas have invaded the field of the functional neurosurgeons; examples in point are the implant of dorsal column stimulators and infusion delivery systems. The number of stereotactic surgeons dedicated to pain procedures has decreased immensely, while anesthesiologists have flourished in this field. Neurosurgeons led this huge area of work relegated to grabs by other specialists. The same emerges in relation to other functional neurosurgery procedures. Will the targets developed by functional neurosurgeons be relegated to other professionals that have more understanding of the diseases than the neurosurgeon, as is the case of the neurologist treating Parkinson's disease, or the psychiatrist treating obsessive-compulsive disorder? We have the history to tell us that placing surgery in the hands of untrained professionals, mainly when the number of patients suffering is pressing can be disastrous, as happened with psychosurgery in a near past. It is a fact that the neurosurgeon treating the neurodegenerative or any other functional diseases of the nervous system needs a very special training and good multidisciplinary team working skills. It is inappropriate an isolated neurosurgeon performing surgery for complex problems such as the neurodegenerative diseases pose to patients. The patients need continuation of care with specialists that unfortunately are not available in the majority of the communities in the world. These highly trained specialists are only present in large medical centers, and heavily concentrated in academic centers of excellence. How the functional neurosurgeons will solve this growing need of specialists in their field of expertise? The current trend of developing game changing procedures for neuro-system diseases cannot be relegated to specialists incapable to handle the complexity of these patients’ problems. Surgery performed without the proper indication and follow-up support leads to discredit of the method with the community. In a very near past, neurologists interested in neurodegenerative diseases believed they had to protect the patient from the neurosurgeons. This feeling is still present in many medical communities around the world. Education of the medical community outside the shield of the university tertiary centers is a must. Functional neurosurgeons will have to develop knowledge in diseases such as amyotrophic lateral sclerosis, Alzheimer's disease, major depression, morbid obesity, nervous anorexia, addiction, and schizophrenia, to name a few. How will we neurosurgeons react to the market place demanding professionals capable to handle these diseases? For example, there are over 100,000 patients already implanted with deep brain stimulation in the world, mostly for Parkinson's disease. This is less than one-third of the patients with the disease who could benefit from the procedure, not taking into consideration the upcoming applications of the technique. There is a call for well-trained stereotactic surgeons to lead the surgical treatment of patients with neurodegenerative and psychiatric diseases.