Grand Rounds 11 10

The past, present and future of neurosurgery at Saint Louis Univer-sity are sitting comfortably on sleek black and chrome furniture on the fifth floor of SLU Hospital. They have a great view of the medical school across the street and an even greater view of the future of their department.

In July, the division of neurosur-gery was restructured as a depart-ment — a move its leaders say will elevate the neurosurgery program beyond its already outstanding international reputation.

Sitting on the left of the leather couch is Kenneth R. Smith Jr., M.D., professor emeritus of surgery. He became the School of Medicine’s first full-time neurosurgery faculty member when he arrived in 1966. Smith is recognized not only as a world-class surgeon but as the director who established SLU as a leader in neurosurgery research and education.

On his right is one of Smith’s recruits: Richard D. Bucholz, M.D., professor, vice chairman of research for the department of neurosurgery and holder of the K.R. Smith Endowed Chair in Neurosurgery. Bucholz is an internationally renowned innova-tor who, among other accomplishments, invented the Stealth

Station™, a device now widely used to make cranial and spinal surgery safer and less invasive.

Sitting between Smith and Bucholz is Saleem Abdulrauf, M.D. (’91), professor and chairman of the new depart-ment. Abdulrauf is vice presi-dent of the Congress of Neu-rological Surgeons, secretary of the North American Skull Base Society and secretary general of the World Federa-tion of Skull Base Societies. Abdulrauf developed a high blood-flow brain bypass tech-nique that is less invasive and keeps more blood flowing in the brain than previous bypass surgeries for brain tumors and aneurysms.

Getting these three sur-geons together in the same

room at the same time can be a scheduling challenge, but they came together in Ab-dulrauf ’s office to discuss something about which they are passionate — the restructur-ing of neurosurgery. They talked about why it was necessary and why now.

smith: When Vallee Willman, M.D. (’51) was chair of the department of surgery, I really had no desire to be out on my own. The department of surgery was one of the

most powerful departments within the University for many years, and I was happy to be a part of that. But then we started to get more faculty and more programs. (During the past 18 months, the division of neurosurgery has added six new full-time faculty members and opened the Center for Cerebrovascular and Skull Base Surgery, which brings together specialists from neurosur-gery, neurology, head and neck surgery, and radiology to treat patients from around the world who have complicated brain tumors and aneurysms.) And other medical schools were starting the trend toward neurosurgery as a department. I realized being a department was an important step toward maintaining SLU’s importance as a neurosurgery center.

Abdulrauf: Ninety percent of neurosurgery programs in the United States are departments now, and I think it’s because neurosurgery has transformed significantly as a specialty. It was really close to surgery in the ’60s and ’70s, but neurosurgery has become so sub-specialized that its relationship to departments of surgery throughout the country is no longer there. Even our residencies are completely separate. We also hit a critical thresh-old when it comes to faculty. A majority of departments in the United States have between five and 12 faculty members. We’re at nine, and we have plans to expand by next July. More impor-tantly, having departmental status allows us to define our own

mission — to create and execute many of our initiatives. So it was multiple factors that came together to facilitate this change: our size, the trends in neurosurgery and our desire to define for ourselves where we want to be down the road.

smith: As a department, we can negotiate our own way when dealing with the hospital. We can make commitments and deci-sions without all the layers. And we have a dean who was recep-tive to the idea of our restructuring.

Abdulrauf: Absolutely. That was critical and so was the support of University President Lawrence Biondi, S.J. He saw what we were accomplishing and what we’re hoping to accomplish over the next five years, and he gave us his full backing.

Bucholz: In building upon the idea that neurosurgery has diverged from surgery, I was just taking a resident through seg-mentation of a brain stem and a brain tumor using a computer mouse to sculpt a dose of radiation so as to prevent damage to surrounding structures. It’s a fact now that in neurosurgery, dexterity with a mouse in many instances is almost as important as dexterity with a scalpel or another instrument. I think the use of technology is the critical thing that has made it important for neurosurgery to split off from surgery. Not only are our techniques different, but our education is different. What we use on a day-to-day basis to achieve our surgical goals is completely different than other surgical specialties use on a routine basis; and furthermore, many of those technological advances have been created here at the University.

smith: I would agree with that. And Dr. Bucholz has been instrumental in developing many of these technological break-throughs, such as computer-guided surgery and imaging and magnetoencephalography. All of these things are entirely sepa-rate from the regular surgery department.

What impact will the change from division to department have on faculty and recruitment of faculty?

Abdulrauf: In the short time we’ve been a separate depart-ment, I’ve noticed a tremendous improvement in the morale of our faculty, residents and fellows. We now have quite a bit of autonomy for what we want to do. We can pursue our goals of research and teaching with leaders who understand what neuro-surgery needs. As for recruitment, I think departmental status is a very important factor. It changes the game for us. Potential faculty can see we have a vision and the resources to pursue it. There are certain things we take care of very well here, trauma for example. This is a trauma hospital, so head injury is a big area for us. And Dr. Bucholz is involved in a large government-funded trial looking at head injury in both civilian and military populations. Stroke is another big one, and we work closely with the department of neurology. These are local and regional disease processes. We also take care of complex diseases, such as skull-base tumors and complex aneurysms. These cases are relatively rare, and few centers in the country can provide care. For that reason, we would like to have a much larger population base, basically the entire United States. And over the next five years, we’re looking at making ourselves a treatment center not just for patients in the United States but for patients from other countries as well. That kind of strategic initiative requires vision and resources, and we have the leadership to do this. Faculty members recognize this.

Bucholz: It also goes for medical school. There’s intense competition for the best and brightest in medical school, and there’s a tendency for certain medical students to go into areas that are less demanding than surgery. I think it’s important to demonstrate that neurosurgery is not only a commitment in terms of duration of training but also a commitment to a life of research and a life of actual fascination with the nervous system. By becoming a department, I think the University is making a commitment to the neurosciences that will be reflected in get-ting the best possible students to go into the neurosciences and, hopefully, into neurosurgery.

What changes will departmental status have on research endeavors? Bucholz: Just as Dr. Abdulrauf indicated that neurosurgery

is expanding its traditional domains, we also are expanding in areas that hardly would be considered neurosurgical at all. We’ve already pioneered many new ways of doing deep-brain stimula-tion for Parkinson’s disease, and we’re doing our first case to treat obsessive compulsive disorder with neurostimulation. This gets into the whole area of neuromodulation, which is quite an exciting frontier in neurosurgery. I travelled to Bosnia recently to do the first procedure to stimulate the vagus nerve to look at inflammatory disease and mitigating its effects on rheumatoid arthritis. Neurosurgery is expanding into an area where any type of possible connection to the brain in terms of disease or mitigation of disease can be pursued so that we can actu-ally change the brain’s parameters and treat various conditions. So the component of research is extremely important in that neurosurgery is reinventing itself literally on a yearly basis. What we consider to be neurosurgical disease now will be completely different from what we’ll think of possible neurosurgical disease in the future.

Abdulrauf: I’d like to add that we’ve been very involved in neurosurgical education in the United States and throughout the world. Expanding that is part of our strategic plan. We’re known nationally and internationally for our state-of-the-art Practi-cal Anatomy and Surgical Education Center (PASE). Senior residents from throughout the country come here once a year for training, and starting next year residents from Europe will be coming over. We’re also planning to have a program that incor-porates multiple continents sending their graduating residents here to spend a few days with our faculty and our cutting-edge technology. By contributing to the education of neurosurgeons in the United States and abroad, we will have a lasting effect on the well-being of patients we would never see otherwise. That means a lot.

smith: I think Paul H. Young, M.D. (’75) (clinical professor of neurosurgery and founder of the PASE program) has been essential in building our practical anatomy workshops. All of the world’s leading neurosurgeons have been coming here to teach because nowhere else can they find this kind of lab or facilities. Paul Young will be playing a much larger role in training residents and taking our residents to Saint Anthony’s Medical Center.

Abdulrauf: I don’t think we can calculate all the positives this change to departmental status will have on us and our field. We’re all just very proud of what we’ve done already and what we’re about to do. We look forward to tremendous growth across the board, and we appreciate the University and medical school for allowing us to carry out our initiatives and strategic plan.

Neurosurgery reorganizes

and redefines its mission

Brain Trust

Abdulrauf

Bucholz

smith