SurgSpace / Specialties / Neurosurgery
Neurosurgery
Brain and spine: the physics of a rigid box, where pressure is the common enemy, haematomas measured against the clock, hydrocephalus drained by hydrostatics, and spinal cord compression where hours decide function for decades.
Apply it
Cases & Practice
Patients to decide on, images to interpret, and the first day on the rotation.
Patients to decide on, images to interpret, and the briefing for the first day on the rotation.
Decisions, one patient at a time
Cases
Imaging practice
Read the image, then decide
Surgical decision-making
Does this patient need surgery?
A 12 mm chronic subdural with 6 mm of midline shift in an 80-year-old: drowsy but rousable, on warfarin for AF. Burr holes or watch?
Evacuate
Symptomatic collections with shift are drained: burr holes under local or general anaesthesia, with anticoagulation reversed first. Recovery is often striking.
Observe
Thin, asymptomatic collections in patients with intact examinations: serial imaging, reversal decisions, and honest counselling about the symptoms that must trigger return.
The examination outranks the millimetres: a large collection in an intact patient can sometimes wait, a smaller one in a deteriorating patient cannot. Anticoagulation is a parallel decision with two halves, reversing it now and deciding when, if ever, it restarts.
Acute hydrocephalus on CT after a subarachnoid haemorrhage: GCS dropped from 14 to 11 over two hours. EVD tonight?
External ventricular drain now
Deteriorating consciousness with ventriculomegaly is exactly what the EVD exists for: controlled CSF diversion, measurable pressures, reversible decision.
Observe and rescan
Defensible only for stable patients with borderline imaging: a falling GCS has already voted, and waiting for a further fall is waiting for herniation.
Hydrocephalus with deterioration is a plumbing emergency, and the EVD is a bedside-adjacent fix with immediate effect. The specialty's regret archive is full of 'rescan in the morning' decisions made on falling GCS scores.
Suspected cauda equina at 2 a.m.: saddle numbness and a 600 mL post-void residual, MRI scanner an hour away. Scan tonight or first on the morning list?
MRI tonight
Established retention and saddle anaesthesia mean the syndrome may be completing: the scan tonight enables decompression at the earliest window.
First scan of the morning
Sometimes the pragmatic reality, but it must be a decision made with neurosurgery, documented, with the patient examined and the interval owned, not a default of the rota.
The evidence's honest summary: earlier decompression is better, incomplete syndromes have the most to lose, and the medicolegal graveyard of cauda equina is full of undocumented waits. The scan is cheap; the deficits are permanent.
The rotation
Your first day here
- Learn GCS properly on day one, scoring eyes, voice and motor separately: it is the specialty's currency, and 'GCS 13' means nothing without its components.
- Read the intracranial pressure module before anything else: every emergency you will see this rotation is that one idea wearing different clothes.
- Pupils are examined, not assumed: size, symmetry and reaction, documented, every time, because the blown pupil is the examination finding that mobilises a theatre.
- In any patient with a shunt, ask 'could this be the shunt?' first, and find the last well scan for comparison.
- The cauda equina questions (saddle numbness, retention, bilateral symptoms) plus a bladder scan belong in every significant back pain assessment you write.
- In theatre, watch the positioning and the planning before the incision: neurosurgery's precision is mostly decided before the knife.
Hub shaped by the Surgical Specialties Lead with the Neurosurgery reviewer (open seat). Images and videos carry their source; educational use for supervised learning, not clinical guidance.