Guest editorial

What can a neurosurgeon do for you?

G Fieggen, BSc, MB ChB, MSc, MD (Neurosurgery), FCS (SA), Helen and Morris Mauerberger Professor and Head of the Division of Neurosurgery, University of Cape Town

Professor Graham Fieggen graduated from the University of Cape Town and completed a postgraduate degree in neuroscience at the University of London. After working as a general practitioner in rural Canada for 18 months, he returned to Cape Town to train in neurosurgery. He was a paediatric neurosurgeon at Red Cross War Memorial Children’s Hospital for 10 years before being appointed as the Helen and Morris Mauerberger Professor and Head of the Division of Neurosurgery, University of Cape Town.

Correspondence to: G Fieggen (gfieggen@gmail.com)

This is the first time that an entire issue of this journal has been placed in the hands of neurosurgeons and I would like to begin by thanking the editor for doing so. At first glance, this may seem an odd choice for a publication aimed at primary care practitioners, but after glancing through the contents (and reading some of the articles) I hope you will agree that the invitation was not misplaced.

Neurosurgery is a relatively new specialty – apart from ancient attempts at trepanation (the earliest evidence of which hails from Africa), the birth of modern neurological surgery can be dated from a craniotomy performed by Rickman Godlee at Queen Square in 1884. What was remarkable about this case was the fact that the precise location of a patient’s lesion had been identified by a neurologist on the basis of focal signs. Despite extraordinary progress in surgical technology, and even more remarkable advances in imaging, neurosurgery remains a specialty thoroughly grounded in clinical neurology.

In the pages that follow you will find an approach to common emergencies, an overview of raised intracranial pressure (the final common pathway of so many life-threatening conditions), current thinking about cerebrovascular disorders, traumatic brain injury and cervical spine disease, as well as tips on differentiating organic from non-organic symptoms and recognising common congenital abnormalities. We also touch on areas sometimes overlooked, such as the real impact of HIV on the brain, the challenges faced by children with neurological disorders as they transition into adulthood and the upstream causes and downstream consequences of trauma, and consider the relevance of neurosurgery in the undergraduate curriculum.

We could have included a lot more about the spine (up to 80% of the daily workload of neurosurgeons in private practice), the contemporary treatment of hydrocephalus and brain tumours and the remarkable advances being made in ‘medical’ areas such as neurocritical care and functional disorders such as pain and epilepsy, but that will have to wait for another day.

Three of the themes that cut across this issue are:

• ‘Time is brain’ – many of the conditions described here can be readily diagnosed in the primary care setting and referred for early and effective management.

• No matter what amazing imaging we have available, clinical assessment is still the cornerstone of practice – the more we are able to see on an MRI scan, the more we need to remember what the patient’s actual clinical problem is.

• In the appropriate clinical context, requesting a CT or MRI scan is not an admission of defeat – in a country like ours, it is just not acceptable for a patient not to have access to a scan that is clinically indicated.

Neurosurgery lies at the cutting edge of one of the most dynamic and rapidly evolving areas of modern medicine – the clinical neurosciences. There has always been a close synergy between neurology and neurosurgery, as recently demonstrated by the integration of these two disciplines in the 2013 UCT General Practitioner Refresher Course. Wherever this specialty goes in the years ahead (catheter-based and other minimally invasive techniques, biological therapies and neuroprosthetics being just a few examples) the patients we treat will always rely on their primary care practitioner for diagnosis, referral and long-term management and together we need to build on this partnership.

So perhaps the answer to the question posed above is – more than you might have thought!