Day in the life of a neurosurgeon SHO?

Sub-dural bleeds. Neonatal neurosurgery wards. Ventricular-peritoneal stents. These are just a few of the things a neurosurgeon can expect to tackle on the job on a daily basis. From traumatic car crashes to chronic subdural haemorrhages, the acute to the chronic,

neurosurgery is all about problem-solving, quick thinking and applying a rapid and logical clinical approach to patients in often time pressured situations.

Figure 1

With a myriad of scans and surgical options at their disposal, neurosurgeons are submerged in a fast paced and dynamic field. Shadowing a neurosurgery SHO for one day, the range of patient cases I saw in as little as eight hours was breath-taking. On the 9am ward rounds, for example, we encountered contorsions (intracerebral bleeds), suspected TIAs (transient ischaemic attacks) and unexplainable brain abscesses. We saw babies, children, the elderly. A true cross section of society. Each patient with their own family, own history, own background, but all in hospital.

We managed patient observations, watched a laminectomy (an operation where the lamina of the vertebrae are removed), organised prescriptions, administered intrathecal antibiotics and assessed CT scans. It was also holistic. For example, when we saw a patient presenting with a spinal metastasis and systemic cancer symptoms, or the small premature boy who developed an abdominal infection which threatened the integrity of his brain-abdominal stent.

It’s hard to imagine just how incredible the field is, and almost impossible to convey the excitement and shear range of patient cases. Here a description of a patient case might come in handy.

The patient – let’s call them x - was happy and healthy. They loved their life and haven’t been to the doctor in ages. They eat healthily, and whilst they might be a bit overweight, have no other health complaints. But then one day when they are playing football with their granddaughter their right arm goes numb, and they can’t talk. What do they do? Luckily it’s soon over. They can forget about their “funny turn” – or can they really? One week later they are in hospital having a CT scan. The next day they have been told they had a subdural haemorrhage, but luckily they won’t need any further surgery.

So what’s a subdural haemorrhage? It’s basically a bleed between the skull and the surface of the brain. It can be chronic or acute and you can also have bleeds in other areas of the brain, between the different layers covering the brain and spinal cord such as an extradural or subarachnoid haemorrhage. Like most problems in neurosurgery, the problem of an intracranial bleed can be best understood according to a simple principle known as the Monro-Kellie doctrine. Named after Monro (a Scottish doctor) and Kellie, the hypothesis posits that as the skull is a “rigid box” containing brain, blood and CSF, if any of these components increase in volume, they must either push another component out or increase the pressure inside the head (intracranial pressure). The risk here is that the pressure in the brain will become so great that it will cause the uncus of the temporal lobe to herniate. As it herniates, it presses against the midbrain and causes stretching of the penetrating branches of the basilar artery. If these rupture, the patient duffers from a Duret haemorrhage which can be fatal. Equally if the foramen magnum herniates, vital structures such as the medulla can be compressed resulting in circulatory collapse and death.

Other pathologies which cause similar effects include tumors and edema. Initially, there is a little compliance of the brain and so the mass is tolerated, but eventually the intracranial pressure will rise to such an extent that it will cause the brain to displace. In neurosurgery the focus is on managing a patient to reduce this risk. Luckily X is now better: he is recuperating in hospital, had his high blood pressure treated and lost a stone in weight. He says that having the funny turn saved his life, otherwise he would never have been diagnosed. Neurosurgery is an amazing job, tough, demanding and time consuming – but it’s also about literally saving patients lives every day,managing complex set of neurological problems and the results are well worth it.

References:

Figure 1:

(https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwjP5bGrxofXAhUMJ8AKHZ-kCRoQjRwIBw&url=https%3A%2F%2Fmyhealth.alberta.ca%2FAlberta%2FPages%2Facquired-brain-injury.aspx&psig=AOvVaw0u8mWj8br8yd2t7ls0UEO0&ust=1508875749174633)