By S. Alan Hoffer, MD, FAANS
Associate Professor, Case Western Reserve University School of Medicine
One of the most significant advances in neurosurgery education in recent years has been the endorsement of fellowships enfolded into residency training. The Society of Neurological Surgeons Committee on Advanced Subspecialty Training (CAST) accredits fellowship programs in many neurosurgical subspecialities. Most recently, CAST announced the opening of fellowships in the field of Neurotrauma. Historically, advanced training in the field of neurotrauma and critical care, a specialty reflecting the AANS/CNS Joint Section on Neurotrauma and Critical Care, highlighted the overlap between these two fields, namely the operative and ICU care of patients with severe traumatic neurological injuries. As the field of neurocritical care developed into its own specialty, fellowship training evolved to keep pace. Currently there are almost 30 CAST-accredited Neurocritical Care Fellowships. These programs have been successful in training neurosurgical neurointensivists and expanding the footprint of neurosurgeons in the greater critical care landscape. This is a welcome development for neurosurgery. Graduating fellows are expected to be competent in the treatment of a wide variety of neurological diseases in addition to traumatic injuries. They must also treat patients with ischemic stroke, seizure, neuromuscular disease, autoimmune disease, CNS infections and the wide variety of systemic complications that accompany these conditions.
By necessity however, comprehensive training in critical care mandates a significant investment of time outside the traditional surgical responsibilities for neurosurgery trainees. In fact, the program guidelines for CAST Neurocritical Care fellowships specifically state that, “fellows should not routinely be engaged in operative care of patients beyond intensive care procedures.” As such, advanced operative management of cranial and spinal injuries was not given a place in this paradigm. Similarly, the evaluation and treatment of neurological injuries not severe enough to warrant ICU admission were not addressed.
While some neurosurgeons may choose to become neurointensivists, others are specifically interested in the field of neurotrauma. These individuals may go on to become the neurotrauma specialist in a multispecialty department or practice, be the leader of neurotrauma at a trauma center or establish an acute-care neurosurgery practice. To meet the needs of these individuals, SNS-CAST has developed a separate fellowship specifically for neurotrauma. The new CAST Neurotrauma Fellowship is a 12-month training experience that can be completed either during or after neurosurgery residency. Like most of the CAST fellowships, residents may not enter into the fellowship until after they have completed their chief resident year. While there is some overlap with the curriculum of the Neurocritical Care Fellowship, namely ICU rotations that focus on brain and spinal cord injury, the Neurotrauma Fellowship has several unique components. Most notable among these is a mandatory operative experience for the treatment of spinal and cranial trauma. Other differences include experiences in injury prevention, concussion/mild TBI and neuro-rehabilitation after injury. Understanding the important role neurosurgeons play in the delivery of trauma care overall, an emphasis is placed on the organizational and administrative aspects of a neurotrauma program.
As the practice of medicine has evolved, the field of neurosurgery has changed with it, meeting the needs of both patients and practitioners. For more information regarding the Neurotrauma Fellowship and other CAST Fellowships, please visit the CAST website at https://sns-cast.org/.