1. Neurologic surgery specializes in primarily surgical management
of central, peripheral, and autonomic nervous system disorders.
2. Although clinical examination is paramount, neurosurgical diagnosis
and treatment are aided largely by a variety of modalities, such
as magnetic resonance imaging and intracranial pressure monitoring.
3. The common treatment goals for traumatic brain and spinal injury
are aimed at preventing secondary insults of hypoxia and hypotension.
4. Aneurysmal subarachnoid hemorrhage remains one of the most morbid
and intensive neurosurgical diseases. Endovascular therapy is a
growing technology that allows for safer securing of ruptured aneurysms.
5. Brain tumors can arise from primary or metastatic tissues. Treatment
typically involves resection, followed by radiation and/or
chemotherapy, depending on the type and grade of tumor.
6. Degenerative spine disease affects mainly the cervical and lumbar
regions. Narrowing of the canal in the cervical spine may cause
myelopathy or radiculopathy, while narrowing in the lumbar spine
results in radiculopathy, neurogenic claudication, or cauda equina
7. Spinal instrumentation is used for surgical stabilization of
many types of spinal instability, including traumatic, infectious,
oncologic, and degenerative.
8. Infection of the nervous system is a serious and prevalent medical
problem. Operative management is indicated for most conditions in
which there is symptomatic compression of neural structures.
9. Functional neurosurgery via device implantation is a rapidly
evolving discipline that has already become the standard of care
in treating medically refractory Parkinson’s disease and
essential tremor. A wider variety of deep brain stimulation targets
will treat additional neuropsychiatric diseases.
10. Stereotactic radiosurgery is a powerful treatment option for
intracranial disease, whether it is primary or adjunct. Gamma knife
surgery can be used to treat tumors, vascular malformations, and
Neurologic surgery is a discipline of medicine and the specialty
of surgery that provides the operative and nonoperative management (i.e.,
prevention, diagnosis, evaluation, treatment, critical care, and rehabilitation)
of disorders of the central, peripheral, and autonomic nervous systems
(ANSs). This includes their supporting structures and vascular supply;
the evaluation and treatment of pathologic processes that modify
the function or activity of the nervous system, including the hypophysis;
and the operative and nonoperative management of pain. Such disorders
include those of the brain, meninges, skull and skull base, and
their blood supply, including surgical and endovascular treatment
of disorders of the intracranial and extracranial vasculature supplying
the brain and spinal cord; disorders of the pituitary gland; disorders
of the spinal cord, meninges, and vertebral column, including those
that may require treatment by fusion, instrumentation, or endovascular
techniques; and disorders of the cranial and spinal nerves throughout their
An accurate history is the first step toward neurologic diagnosis.
A history of trauma or of neurologic symptoms is of obvious interest, but
general constitutional symptoms are also important. Neurologic disease
may have systemic effects, while diseases of other systems may affect
neurologic function. The patient’s general medical ability to
withstand the physiologic stress of anesthesia and surgery should be
understood. A detailed history from the patient and/or
family, along with a reliable physical examination, will clarify
An understanding of neuroanatomy is the foundation of comprehensive
neurologic examination and diagnosis. Salient features will be considered,
from cephalad to caudad. The cerebral hemispheres (or telencephalon)
consist of the cerebral cortex, underlying white matter, the basal
ganglia, hippocampus, and amygdala. The cerebral cortex is the most
recently evolved part of the nervous system. Its functions are mapped
to discrete anatomic areas. The frontal areas are involved in executive
function, decision making, and restraint of emotions. The motor
strip, or precentral gyrus, is the most posterior component of the
frontal lobes, and is arranged along a homunculus with the head
inferior and lateral to the lower extremities superiorly and medially.
The motor speech area (Broca’s area) lies in the left posterior
inferior frontal lobe in almost all right-handed people and in up
to 90% of left-handed people. The parietal lobe lies between
the central sulcus anteriorly and the occipital lobe posteriorly.
The postcentral gyrus is the sensory strip, also arranged along a
homunculus. The rest of the parietal lobe is involved with awareness
of one’s body in space and relative to the immediate environment,
body orientation, and spatial relationships. The occipital lobes
are most posterior. The visual cortex is arrayed along the apposing
medial surfaces of the occipital lobes. The left occipital lobe
receives and integrates data from the left half of each retina.
A left occipital lesion would therefore result in inability to see
objects right of center. The temporal lobes lie below the sylvian
fissures. The hippocampus, amygdala, and lower optic radiations
(Meyer’s loops) are important components of the temporal
lobe and are involved in memory, emotion, and visual pathways, respectively. The
receptive speech area (Wernicke’s area) lies in the area
of the posterior superior temporal lobe and the inferior parietal
lobe, usually on the left. The basal ganglia include the caudate,
putamen, and the globus pallidus. Basal ganglia structures are involved
with modulation of movement via inhibition of motor pathways.
Lying deep to the cerebral hemispheres is the diencephalon, which includes
the thalamus and hypothalamus. The thalamus is a key processor and
relay circuit for most motor and sensory information going to or
coming from the cortex. The hypothalamus, at the base of the brain,
is a key regulator of homeostasis, via the autonomic and neuroendocrine
The brain stem consists of the midbrain (mesencephalon), pons (metencephalon),
and medulla (myelencephalon). Longitudinal fibers run through the
brain stem, carrying motor and sensory information between the cerebral
hemispheres and the spinal cord. The corticospinal tract is the
major motor tract, while the medial lemniscus and the spinothalamic
tracts are the major sensory tracts. The nuclei of cranial nerves
III through XII are also located within the brain stem. These ...