Establishing Reconstructive Neurosurgery as a Subspecialty

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Paralyzing injuries are frequently neglected in current medical care, a group of neurosurgeons contends in Neurosurgical Focus. They urge the formal recognition of reconstructive neurosurgery as a new subspecialty and the creation of multidisciplinary “paralysis centers,” modeled on cancer centers.

Justin Brown, MD, Director of the Mass General Paralysis Center, and colleagues, including Bob S. Carter, MD, PhD, Chief of Neurosurgery at Massachusetts General Hospital, note that candidates for reconstructive neurosurgery now include those with peripheral nerve and brachial plexus injury, stroke, spinal cord injury, traumatic brain injury and multiple other paralyzing disorders of both upper and lower motor neuron sources. Interventions that can promote functional recovery in these conditions include nerve grafting and nerve transfers, tendon transfers, free functional muscle transplants and, for spasticity, selective peripheral neurotomies and even tendon lengthening. Occasionally, bony fusion can fixate a limb or digit in a more functional position. These procedures form the basis of a robust reconstructive neurosurgery repertoire that also comprises the rapidly expanding options in functional neurosurgery.

Dr. Brown and his co-authors predict a specialist in reconstructive neurosurgery would receive enough cases from a single hospital to fully occupy a surgical practice with cases entirely focused upon function restoration. For example, each year there are more than 600,000 new strokes in the U.S., and about 480,000 result in some degree of hemiparesis that is amenable to surgical correction. Additionally, there are 1.7 million new traumatic brain injuries each year, of which 15% result in hemiparesis and 6% result in quadriparesis, representing another 350,000 surgical candidates, 11,000 new spinal cord injuries, not to mention the numerous peripheral nerve injuries of various sources.

The authors acknowledge that neurosurgeons overlap with orthopedic surgeons and plastic and reconstructive surgeons in their ability to provide functional restoration of paralyzing disorders. Still, they believe that neurosurgeons are critically positioned to manage such disorders. For one thing, neurosurgeons best understand the pathologies that result in paralysis and paresis. Therefore they can best determine whether the original pathology has been adequately addressed, what the future concerns may be and whether reconstruction is advisable and, if so, what the timing should be. In addition, neurosurgeons are uniquely positioned to adopt more proximal interventions, such as nerve root reimplantation and contralateral nerve root transfer via the prevertebral route.

The authors emphasize, though, that specialists in reconstructive neurosurgery would not always work independently of orthopedic and plastic surgeons. To the contrary, they urge the establishment of paralysis centers, where all surgeons could consult on a case. Specialists in physical medicine and rehabilitation, physical and occupational therapy, neurophysiology, neurology, radiology and orthotics would also contribute. The centers would have expertise in all sources of paralysis and all treatments, as opposed to the current tendency for centers to focus on a subset of procedures, a body region or a pathology type.

The authors expect that full development of reconstructive neurosurgery as a new subspecialty will facilitate the introduction of novel procedures currently in clinical trials, such as neuroprosthetics and intraparenchymal injection of stem cells.

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