Why isn't functional NS a more popular subseciality?

[Raygun77]

Seems to be a relatively lifestyle friendly option with outpatient patients who primarily have movement disorders, chronic pain or chronic epilepsy.

Seem to have generally quite good patient outcomes- spinal cord stimmies, other cranial stimmies have pretty good success rates in alleviating pain, not sure bout how well functional ns fares in curing epilepsy/movement disorders.

Seems to be pushing the barriers of technology and technique- real potential to develop devices and further the field.

The only thing left is reimbursement. Is reimbursement that low for functional NS to be less popular than say, spine or cerebrovascular, despite all the seeming pros?

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[MPMD]

I was talking to a NS here the other day about this. There is a high-up attending at one of our hospitals that focuses primarily on functional neurosurgery -- mostly in the realm of movement disorders and epilepsy, but is getting involved in neural prosthetics as well. I too think that functional sounds like a really interesting field that has a lot to offer both outcome-wise and with regards to job satisfaction.

The surgeon (the first one, not the functional guy) was saying that he wishes that he had been born 10 years later, because he believes that around the time that my residency is over, functional surgeries will be advanced enough that many academics and privates will be able to focus almost completely on the field.

He cited a few reasons why he is not as involved in functional stuff as the higher attending I mentioned. First, his research primarily has to do with cancer immunology, and because of his history in this area, he is much more likely to publish meaningful research if he operates on tumors. Second, many of the functional surgeries today involve DBS-like procedures with accuracy on the scale of a micron, necessitating very lengthy calibration surgeries that can become mind numbingly dull. This has potential to change in the near future, but for now it is a major drawback in his mind. Lastly, because he believes that significant advances are still to come in the field, the time is not really ripe to model an entire career off functional NS at this point. Come a decade from now though, when the procedures are more advanced and refined, and the patient population is more plentiful, the field will almost certainly be very popular.

Either way, I'm definitely looking to get involved in it

 

[Gozar]

Seem to have generally quite good patient outcomes- spinal cord stimmies, other cranial stimmies have pretty good success rates in alleviating pain, not sure bout how well functional ns fares in curing epilepsy/movement disorders.

Depending on the level of mapping done a patient and how disseminated the seizure onset is, the epilepsy free rate for surgery can approach 80% for pharmacologically resistant patients. If you talk to these people 6-12 months post op you will quickly realize that they are some of the most satisfied patients that you see in just about any field. Imagine going from >1 grand mal seizure/day to <1/six months.

 

[JeffLebowski]

I was talking to a NS here the other day about this. There is a high-up attending at one of our hospitals that focuses primarily on functional neurosurgery -- mostly in the realm of movement disorders and epilepsy, but is getting involved in neural prosthetics as well. I too think that functional sounds like a really interesting field that has a lot to offer both outcome-wise and with regards to job satisfaction.

The surgeon (the first one, not the functional guy) was saying that he wishes that he had been born 10 years later, because he believes that around the time that my residency is over, functional surgeries will be advanced enough that many academics and privates will be able to focus almost completely on the field.

He cited a few reasons why he is not as involved in functional stuff as the higher attending I mentioned. First, his research primarily has to do with cancer immunology, and because of his history in this area, he is much more likely to publish meaningful research if he operates on tumors. Second, many of the functional surgeries today involve DBS-like procedures with accuracy on the scale of a micron, necessitating very lengthy calibration surgeries that can become mind numbingly dull. This has potential to change in the near future, but for now it is a major drawback in his mind. Lastly, because he believes that significant advances are still to come in the field, the time is not really ripe to model an entire career off functional NS at this point. Come a decade from now though, when the procedures are more advanced and refined, and the patient population is more plentiful, the field will almost certainly be very popular.

Either way, I'm definitely looking to get involved in it

I think most of your post was pretty accurate, but I would just debate your assertion that "the time is not really ripe to model an entire career off functional NS", I think if you stay in academics you could easily be "the functional guy" at a neurosurgery program. Most residencies/academic neurosurgery departments have subspecialists who are responsible for doing most of the subspecialty work. Which means most programs have a spine guy, a vascular guy, a peds guy, a functional guy, a tumor guy, etc.

The practice environment you choose definitely impacts the extent to which you can really focus on one area, for example if you're in private practice it's much more likely you'd be a "general neurosurgeon" and do 70% spine, and a smattering of the other, usually not too complex stuff. As a functional neurosurgeon, you need a good surgery referral base from neurologists, both movement disorder specialists and epileptologists. Not to mention, if you want to do substantive epilepsy procedures you'll really need intracranial monitoring beds in an EMU. So I agree that it would be pretty difficult to be a "functional guy" if you were in private practice or in an academic program that isn't set up to see refractory movement disorders and epilepsy with referring physicians who aren't too resistant to recommend surgery.

 

[Duon89]

The initial thread talks about how 10 years later (from 2010), functional neurosurgery will become a more popular field.

I am a neurology resident going into Movement disorder, who needs functional NS to be available and placing DBS.
I want to know how popular the field is now to NS residents.

 

[mmmcdowe]

The initial thread talks about how 10 years later (from 2010), functional neurosurgery will become a more popular field.

I am a neurology resident going into Movement disorder, who needs functional NS to be available and placing DBS.
I want to know how popular the field is now to NS residents.

Still a pretty niche field

 

[chord]

It seemed to be a pretty popular answer to "what subspecialty are you interested in" for people who just applied and matched, generally with the research background to back up that claim, but obviously that distribution may change as this class goes through residency and interests change.

 

[Anti-PD1]

I'm a neurosurgery resident interested in functional neurosurgery. With MRI-guided focused ultrasound on the horizon, I think this subspecialty will remain popular.

Residency is long and brutal. Most of us go into spine and it's easy to see why. Good patient outcomes, controlled lifestyle, and higher reimbursement thanks to our ortho colleagues (don't get me started on how you get paid the same to remove a brain tumor as you do to perform an ACDF). A lot of people interested in this or that beginning NS residency end up choosing spine because of lifestyle.

Doing functional neurosurgery well requires being at an academic center, and being involved academically. Not all who are interested in the idea of functional are willing to take that route.