Words from Stanford Neurosurgery Chairman, Gary Steinberg MD

In my four and a half decades at Stanford one of the most significant advances I’ve witnessed has been the development of imaging technologies. Our ability to see inside the body, and to penetrate not only more deeply, but to personalize images and view a patient’s unique individual anatomy, has dramatically changed how we prepare for and perform surgery. In a short time, we’ve gone from grainy, black and white 2D images to colorful and intricately detailed 3D visualizations, that have transformed how we approach surgery.

While 3D printing gained much momentum in the last 10 years, it was the rapid development of virtual reality that truly changed how even veteran neurosurgeons like myself work. The ability to see, and walk through a patient’s anatomy prior to performing surgery has truly revolutionized what it means to be a neurosurgeon. Whereas in the past we had to imagine anatomical reconstructions prior to surgery, we now practice the exact routes we will take in a virtual setting, so we can plan  how to approach a tumor or malformation while avoiding critical areas – when it’s time for the actual surgery, it’s as if we’ve already performed it before and there are no surprises. Our ability to see before surgery extends into the operating room, where we can follow our 3D imaging along with the patient’s anatomy in real time. And virtual reality hasn’t just transformed our work or how we train our neurosurgeons, it has completely changed our patients’ experience as well. We now walk our patients through the same images we use to prepare for surgery, so they are able to be completely immersed in their own anatomy prior to undergoing an operation. This ability to see such accurate and detailed compositions of their own brain reduces fear and increases confidence – patients know we have incredible visualizations and are well prepared for performing their surgery. Since opening our Neurosurgical Simulation and Virtual Reality Center in 2016, over 1,100 of our patients have benefited from virtual reality at some point during their care.

Advanced imaging isn’t just confined to the Virtual Reality Center; its use has been applied to the lab and to robots assisting in the operating room. For example, studying white matter by using innovative imaging techniques, such as High-Definition Fiber Tractography (HDFT), has facilitated a much greater understanding of brain connectivity in neurosurgery patients. Similarly, being able to visualize even the smallest microvascular compositions has meant we can perform delicate surgery on very young children more accurately and safely than ever before. Robots integrated for removal of spinal tumors and correcting deformities can depict what the human eye cannot, and can place surgical tools more safely and accurately; reducing surgery and leading to quicker recovery and less pain.

Imaging technologies alone have catapulted the field of neurosurgery easily by a decade, perhaps more. I cannot wait to see how these technologies continue to evolve our practice. It’s incredibly exciting to be a part of such rapid transformations that are making the surgeries we perform more precise, accurate, and safe. Ultimately our greatest goal as surgeons is to find the tools that permit us to perform surgery in the least invasive and most effective possible way, and advanced imaging is allowing us to do just that.

Our work is often thought-of as being restricted to the clinic, operating theater or the lab, but in fact, we spend a significant amount of our time as neurosurgeons lecturing,  teaching, and sometimes traveling elsewhere to network with other experts in our field. This past summer was no exception.

We kicked off the season with our annual Neuroscience Research Forum, bringing together faculty, residents, and students across the Stanford neurosciences community to present and discuss their latest work. We also spent the summer gathering with friends to reconnect and celebrate. We brought patients from all corners of the country together for our annual Moyamoya picnic, and hosted our first Acoustic Neuroma Association Patient Day. We spent a weekend reuniting with colleagues and families at our annual Hanbery Neurosurgical Society Meeting, and had an exhilarating adventure with our residents rafting 15 miles down the American River’s South Fork. In August we teamed up with our Stanford expert otolaryngologists/head and neck surgeons to offer our first-ever multi-day hands-on Endoscopic Endonasal Skull Base Surgery Course; which included 3D and virtual reality surgical training and anatomy sessions at a dissection lab, led by our world renowned neurosurgeons.

While summer is quickly coming to an end, our collaborations and continuous learning doesn’t stop. This Fall the Congress of Neurological Surgeons’ Annual Meeting is coming to San Francisco, and many of our faculty and residents will be participating in this 5-day inspiring and informative conference that brings together scientists and physicians from across the globe. I am particularly looking forward to taking a trip to Hong Kong in November with several of our faculty for a new Symposium sponsored by Stanford’s International Medical Services, the Chi-Li Pao Foundation and the Hong Kong Academy of Medicine – being a part of international collaborations is a highlight of my work. I am also pleased we will be sponsoring the 2019 LGBTQ+ Forum, a collaborative event focused on connections and clinical and research resources for Stanford Medicine’s LGBTQ+ community.

While our time in the clinic, operating room and in our labs is invaluable, equally important is our time spent meeting with colleagues, patients, and others in our profession, all resulting in the enrichment and advancement of our work. These experiences are a fundamental part of how we interact with our communities, and I am grateful to be at a place like Stanford that values and emphasizes the need for us to set aside time to participate in these meaningful events.

This Summer will mark the 45^th anniversary since the founding of Stanford’s resident alumni organization, the John W. Hanbery Neurosurgical Society. The society was named in honor of Dr. Hanbery, who was best known for his devotion and loyalty to Stanford’s neurosurgery residents. His legacy lives on in the more than 90 Stanford-trained neurosurgeons – myself included – who are treating patients, making discoveries at the bench, and advancing our field in ways Dr. Hanbery  never could have imagined.

The program, which is seven years long, is quite rigorous and demanding but our residents also have unique opportunities to learn from some of the world’s leading neurosurgeons and scientists, to tackle some of neurosurgery’s most complex cases, and to work in a variety of clinical settings across the Bay Area. In addition, the kind of work young neurosurgeons are doing now makes entering the field that much more compelling – it is not only growing in diversity and depth of knowledge, but there are technological advances in the field that have made training in this profession simply very cool – our residents now use 3D virtual reality, advanced imaging including vivid color displays of neural tracts, and sophisticated robots, as part of their daily work routines.

My own passion for teaching and the joy I experience from watching our residents master the skills necessary to become great neurosurgeons only continues to grow, and I am one of many Stanford faculty members who value their time training residents, as much as all the other aspects of our work. Dr. Gerald Grant, our Residency Program’s director, is an oustanding pediatric neurosurgeon-scientist who is able to expertly guide our residents through the tough balancing act of focusing on both clinical and research commitments. Dr. Michel Kliot, a nationally recognized senior peripheral nerve surgeon brings the necessary attention on physician wellness to the program, emphasizing the importance of self-care and team bonding – elements of a neurosurgery career which haven’t always been at the forefront of training, but ones we hope our residents will carry with them beyond their time at Stanford. We have built a culture where our entire faculty and staff are all dedicated to the success of our residents, and to ensuring their time here is valuable, unique, and fulfilling.

We are lucky that Stanford’s reputation and location attracts some of the top medical students in the country and our program continues to be enhanced by the talented new residents who enter the program. While we’ve consistently matched our top 5 candidates (of more than 250 applicants), this year we were particularly pleased to match our top 3! We are very excited for our new interns, Silvia Vaca, MD, Rukayat Taiwo, MD, and Daniel Lee, MD,  to begin their training and officially join our Stanford Neurosurgery family.

As a new group of residents enter, our graduating residents are moving on to the next steps in their careers. Yi-Ren Chen, MD, will be an attending neurosurgeon at Sacramento’s Dignity Health and will also stay on as an adjunct assistant professor of neurosurgery here at Stanford. Adrienne Moraff, MD, is joining the University of Missouri’s Saint Luke’s Marion Bloch Neuroscience Institute as a clinical assistant professor of open & endovascular cerebrovascular surgery. And Laura Prolo, MD, a second generation Stanford-trained neurosurgeon is going to Seattle Children’s Hospital and the University of Washington for a pediatric neurosurgery fellowship. I wish them all the very best in their future careers, they are all not just outstanding neurosurgeons but also outstanding individuals. I fully trust they are going to represent their training and our institution well in their clinical and research work, and will each become a future leader of neurosurgery in their own right.

It’s been two years since I last wrote about concussion, and with Brain Injury Awareness Month quickly approaching, it’s a good time to reflect again about the progress we’ve been making. We understand now, better than ever before, the long-term impacts that brain injury can have on brain function, and the importance of proper detection and treatment.

We were particularly excited, when this past Fall, the CDC released a major new guideline for diagnosis and management of brain injury in children. The guideline, which is the culmination of years of work by a group of experts from several disciplines – including neurosurgery, emergency medicine, sports medicine, and neurology – busts some of the myths about treatment for concussion. Most notably, in the past, it was common for doctors to prescribe long periods of isolation in a dark room as part of the recovery regiment for people with mild traumatic brain injury. We now know that is not how concussion should be treated. The new guideline also points out that imaging studies really aren’t necessary when diagnosing concussion, and emphasizes the importance of keeping athletes off the field after suffering a concussion. The goal of the guidelines is to standardize diagnosis and treatment, something we haven’t had before. In light of the new evidence, the American Academy of Pediatrics also recently updated its guidelines for treating mild brain trauma.

First author of the new CDC guideline, Dr. Angela Lumba-Brown, is also co-director of our Concussion and Brain Performance Center, where she works closely with the Center’s director, neurosurgeon Dr. Jamshid Ghajar, and director of the Stanford Children’s Health Concussion Program, and chief of pediatric neurosurgery, Dr. Gerald Grant. The three have combined forces in an effort to build one of the most cohesive concussion care programs in the country. The team is working with Vaden, Stanford’s student health center, and with Stanford Athletics, to ensure that all Stanford students are well supported and are receiving the right concussion diagnosis and treatment. In learning from successful diagnostics and treatments at Stanford’s sports medicine clinic, the team has also refined care protocols at Stanford’s Neurosciences Health Center and the Stanford Pediatrics Concussion Clinic, by adding concussion subtype evaluations, part of landmark research the team will soon publish in Neurosurgery.

In addition, the team is working closely with local high school athletes using a variety of new technologies, including CrashCourse, a novel virtual reality concussion education program, to continue to learn and enhance our understanding of concussion. And this Spring, we will be hosting our first ever Stanford Sports Concussion Summit, where our experts will present the latest advances in concussion prevention, diagnosis, and rehabilitation to physicians and the general public. If you show up early, you can catch me and former 49er Steve Young, as we discuss the transformation of concussion care in professional football over the last couple of decades.

It’s exciting to see all of the attention that concussion science and medicine are receiving, and how quickly advances in the field are moving. I’m hopeful that as we move forward we can help more people get the correct diagnosis and the appropriate treatments needed to reduce or eliminate the long-term risks associated with concussion, and to continue to improve brain health for all.