Have there been any big new developments in neurosurgery? Not so much. The truly big steps happened 50 to 60 years ago, when safe anaesthesia and the ability to anticoagulate patients let us operate on the heart without the blood vessels clogging. That changed surgery completely.
The biggest shift since then has been in vascular procedures. Rather than opening the body and cutting into a vessel, we can now thread catheters through a blood vessel in the wrist or groin, guided by an X-ray machine, and treat almost anything that involves a blood vessel that way. It’s revolutionised that part of medicine.
The brain and spine are different. We haven’t got a safe way to work like that here, so we’re still performing procedures much like the ones we did 30, 40, even 60 years ago. Strip it back, and there are really only two spinal operations: take the pressure off the spinal cord or nerves, or fuse bones together. Almost everything else is a version or combination of those two, with a few rarities such as disc replacement or spinal cord stimulators for severe chronic pain.
What keeps improving is how well and how safely we do it. The more we can see inside without exposing the area, the less normal tissue we disturb. In the days before MRI, we were never quite sure what was down there. Now a scan gives us such an accurate map that I can plan exactly where to go and what to remove before I make a single cut.
So we perform the same operations through far smaller incisions. Our finest tools, the rongeurs and drills, are already about 1 millimetre across, and there’s a limit to how small the opening can be, because you still have to get the instruments in safely. Go any smaller, and you’re operating blind, and in the brain or spine, there’s no margin for error. If a structure is damaged, it can’t be repaired. I think we’re close to the limit of what the human hand can do, unless we bring robots into it.
