(Reaffirmed, November 2009)
(Approved by the AANS Board of Directors, November 2006 and the AANS/CNS
Section on Neurotrauma and Critical Care and CNS Executive Committee, October
The number of emergency department (ED) visits in the United States continues
to increase annually. At the same time, in some parts of the country, there
is a growing shortage of specialists – including neurosurgeons – available
to treat patients with emergency medical conditions. Addressing this serious
and complex problem defies a simple resolution and will require a multi-faceted
approach that includes the regionalization of certain emergency neurosurgical
services, improved reimbursement and medical liability reform.
In order to expand the number of surgeons available to treat emergency and
trauma patients and to encourage young surgeons to pursue careers in trauma
surgery, an additional solution has been proposed – the creation of a
new subspecialty of medicine called acute care surgery. These surgeons would
perform a wider array of emergency surgeries, not just those related to general
trauma. Part of this expanded scope of practice would include neurosurgical
procedures, despite the fact that the proposed curriculum for these new practitioners
only includes one or two months of neurosurgical training.
AANS/CNS Position Statement
Optimal patient care and patient safety are best achieved when surgical diseases
affecting the nervous system are managed by neurological surgeons. Neurosurgical
procedures should therefore not be performed by practitioners in other fields.
- Neurosurgeons are the only physicians qualified to provide the full spectrum
of care to patients with neurosurgical emergencies. This is a patient safety
issue. Among these qualifications are expertise in diagnosis, decision-making,
formulation of treatment plans, initial stabilization and treatment of emergency
neurosurgical conditions, performance of neurological surgeries and other
procedures (such as insertion of intracranial pressure monitors, ventriculostomies,
application of cervical traction, etc.), critical care, postoperative care,
and long-term follow-up care. This unique range and depth of skill is acquired
throughout a neurosurgeon’s six-year residency training period and
continues to expand throughout the course of his or her time in practice.
- The majority of neurosurgical emergencies involve emergency conditions
other than trauma. Neurosurgeons receive extensive training not only in cranial
and spinal trauma, but also in other emergency conditions, including spontaneous
cerebral hemorrhages, ruptured intracranial aneurysms, stroke, hydrocephalus,
shunt malfunctions, acute brain tumor presentations, spinal cord compression,
brachial plexus injuries, peripheral nerve transections, and intracranial
and spinal infections. In neurosurgical training and practice, the same knowledge
and experience employed during the treatment of nonemergency neurosurgical
conditions is applied seamlessly to the management of emergencies, including
expertise in neurological assessment, intracranial pressure dynamics, cerebral
blood flow and metabolism, spinal stabilization, and management of seizures,
fluid and electrolyte balance, respiratory issues, infections, and nutrition.
Although other specialists may have familiarity with one or another of these
areas, no one can integrate and manage them in the context of a patient’s
overall condition as well as neurosurgeons. Published data from other countries
document the poor outcomes that result when non-neurosurgeons attempt to
perform neurotrauma procedures, leading to technically substandard operations
and major delays in definitive neurosurgical intervention.
- Appropriate care of patients with neurosurgical emergencies is labor-
and resource-intensive not only during initial assessment and stabilization,
but often for many days and weeks after injury. Interventions undertaken
during the initial management of patients with neurosurgical emergencies
require consideration of possible subsequent developments in the ensuing
days and weeks. This need to anticipate complications mandates the creation
and maintenance of a highly coordinated system involving experienced practitioners
in the various treating specialties. Specifically, it is important to note
that the practice of emergency neurological surgery requires a large complement
of appropriately trained ancillary and professional staff, to include nurses,
radiology technicians, and operative staff. With the growing shortage of
these specially trained professionals, the need for regionalization of care
is even more apparent.
- The development of a rapidly responsive, regionalized system of care may
be the best approach to treating patients with neurosurgical emergencies.
Such a system would optimize the availability of the limited supply of neurosurgeons,
nurses and costly technologies. The planned regionalized approach would eliminate
the redundancy of services and spiraling technology costs among competing
hospitals by facilitating agreements that would ensure neurosurgical emergency
coverage at key hospitals based on actual need. Not all hospitals that wish
to attract patients with neurosurgical emergencies can – nor should
they – provide the interventions, services, and resources required
for their optimal care.