Neurosurgical Consultants: How to Select the Best Neurosurgeon for You: How To Choose A Neurosurgeon

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How to Select the
Best Neurosurgeon
for You

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Martin L. Lazar, MD, FACS, FAANS
James E. Bland, MD, FAANS

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HOW TO CHOOSE A NEUROSURGEON

"Destiny is no matter of chance. It is a matter of choice. It is not a thing to be waited for; it is a thing to be achieved."

Neurosurgeons are concerned with the diagnosis and treatment of patients with injuries or diseases of the Brain, Spine and Nerves throughout the body. Neurosurgeons provide both non-surgical and surgical care, depending on the nature of the illness or injury. Neurosurgeons are trained both as Brain and Spine Surgeons. The Nervous System (Brain, Spinal Cord and Spinal Nerves) are all housed within a dense protective bone environment (Skull and Vertebral Column). It is important to remember that ALL Skull and Spine operations are being done to protect and/or repair the Brain, Spinal Cord and/or Spinal Nerves. Only a Neurosurgeon is trained sufficiently well to manage the surgical treatment of Nervous System problems related to the interior of the Skull and Spinal Column.

Choosing any professional to assist you is, inevitably, a difficult process. Here are some tips regarding the choice of a Neurological Surgeon who will consult on your case:

How To Choose A Neurosurgeon: Qualifications of a Neurosurgeon:

Your Neurosurgeon should have passed the stringent examination to achieve Certification by the American Board of Neurological Surgery. Many Neurosurgeons have special training and expertise in specific areas of interest. The extent of their experience in these special interest areas is of immense importance to you as the patient. For example, conditions such as Skull Base Tumors, Pituitary Tumors, Acoustic Neuroma Tumors, Trigeminal and Glossopharyngeal Neuralgia, Hemifacial Spasm, Arnold-Chiari Malformation, Intracranial Aneurysms & Arteriovenous Malformations (among others) and surgical techniques such as Minimally Invasive & Endoscopic Spine and Brain Surgery, Microvascular Neurosurgery all require exceptional degrees of skill with OUTCOMES directly influenced by the EXTENT of EXPERIENCE of that Neurosurgeon. For example in the case of Pituitary Tumors this usually requires hundreds of cases as the Primary Surgeon. Similar recommendations apply for cases requiring Microvascular Decompression (MVD) for Trigeminal or Glossopharyngeal Neuralgia or Hemifacial Spasm.

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How to Choose A Neurosurgeon: What should you expect of your Neurosurgeon?

You will want a direct interaction, from the outset, with the Neurosurgeon who is consulting on your case and who will take responsibility for your Neurosurgical care. The Neurosurgeon should want to spend time getting to know you personally. That means that he/she will want to take a detailed medical history since there are circumstances unique to you that may be of major importance in your care. Filling out a questionnaire or talking to an assistant may be part of an evaluation; however, there is NO SUBSTITUTE for the detailed medical history accompanied by a highly skilled, comprehensive and focused Neurological Examination to be done by the Neurosurgical Consultant who will be your surgeon, and the one responsible for helping you to make the important choices relating to your treatment options.

Your surgeon should:

Listen carefully to your history and concerns
Conduct a detailed Neurological Examination, often focused on your specific complaint
Recommend appropriate neuroimaging studies/examinations
Review those neuroimaging studies with you
Take time to educate you about the particular Neurological Condition; this may include sharing with you printed information and/or anatomical diagrams that you can take home to review. In some situations, it is helpful to view videos of the actual operation.
Discuss the Natural History of your Neurological condition (What happens if no treatment is given.)
Review the various therapeutic options with their relative risks and limitations
Make specific recommendations for treatment

Discuss the extent of his/her personal experience and results with the treatment

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How To Choose A Neurosurgeon: Whom does your Neurosurgeon work with?

Neurosurgeons do not work in a vacuum. There should be a comprehensive care team in place. While not every member of this team will be needed for every patient, it is important for you to know the extent of experience and the skill level of the critical team members.

You will want to MAKE CERTAIN that the surgeon to whom you are referred is NOT BEING LIMITED in selecting team members or DOES NOT HAVE ACCESS TO HIGHLY SKILLED ASSISTANCE because he/she is an EMPLOYEE of a hospital or hospital affiliated practice. FREQUENTLY, this means that your CARE MAY BE SERIOUSLY COMPROMIZED and/or you may NOT HAVE ACCESS to some of the MORE ADVANCED TREATMENTS such as MINIMALLY INVASIVE SURGERY.

By way of example let me share with you how our unit works. Our Operating Room Team, at a minimum, usually consists of the Primary (Board Certified) Neurosurgeon and a Board Certified Neurosurgeon as an Assistant. There may be additional Board Certified Surgeons as needed such as Craniofacial-Plastic Surgeon, Neuro-otologic Surgeon, Neuro-ophthalmologic Surgeon, etc. Our Neurosurgical Scrub Nurse has many years and thousands of neurosurgical cases of experience. The Board Certified Neuroanesthesiologist managing your anaesthetic needs is skilled in the special anaesthetic techniques required for Neurosurgical procedures.

Figure 1: OR Photo of a Minimally Invasive Intracranial Endoscopic Operation

Dr. Lazar (right), manipulates elongated micro-instruments THROUGH the ENDOSCOPE. Dr. James Bland (Center), the Assisting Neurosurgeon, is holding the Endoscope firmly in his left hand (the Brown glove) that rests on the patient's Skull while controlling the amount of "suction" (vacuum) needed to maintain a clear visual surgical field. The Senior Neurosurgical Nurse, Ms. Christine Thomson, is holding the "micro-bipolar electrocautery" wire that Dr. Lazar is using in his right hand. The team watches a video monitor to which the ENDOSCOPE'S camera image is transmitted. (Endoscope provided by Karl Storz Endoscopy - America, Inc.)

If your personal family physician is not on staff at our hospital, we will assign a Board certified specialist in Internal Medicine for your stay in our facility. In the event that you are to go into the Neurosurgical Intensive Care Unit after surgery, a Board Certified Intensive Care Specialist will be assigned to your care during that stay. These physicians are available on a 24/7 basis for your medical needs.
Our team also includes Board Certified specialists in Diagnostic and Interventional Neuroradiology, Neurology and Neuro-oncology with all the latest technological support systems that are required for them to perform at their best.
From the time that you first contact our office you should expect to be treated with warm and friendly professional courtesy. Our office personnel are skilled in arranging for your needs. From then on you can anticipate the same level of care from each and every member of our large team of professionals. Special arrangements are available for our out-of-town and International patients. Please consult our link to International Patient Information for further useful material.

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How To Choose A Neurosurgeon: What should you expect from the Hospital Facility?

Neurosurgery is one surgical specialty that is highly reliant on advanced technology as well as dedicated facilities staffed by specially trained and qualified technicians. What follows in this section is a review of some of the types of dedicated facilities that one would expect in a hospital with a significant interest in Neurological Surgery.

A. Neuroimaging & Interventional Neuroradiology

Part of the challenge for the Neurosurgeon to achieve the best outcome possible for the patient is to identify, as accurately as possible, the precise nature and anatomical configuration of the pathological condition and its relationship to vital adjacent structures (such as blood vessels, nerves, etc.) The advances in the last several years in diagnostic and therapeutic technology have resulted in far greater accuracy and improved outcomes for Neurosurgical patients. Neuroimaging is the term applied to techniques that allow us to inspect the Brain/Skull, Spinal Cord & Nerve Roots/Spinal Column without making any incisions. (NOTE: ALL OF THIS IMPORTANT INFORMATION IS REVIEWED ON THIS WEBSITE

Figure 2A (Left): 3-D MRA (Angiogram). MRI technology combined with sophisticated computer software permits a 3 dimensional reconstruction of the Skull and blood supply to Brain.
Figure 2B (Right): 3-D reconstruction image of a child with premature closure of cranial sutures. This imagery is created using CT technology and is useful in pre-operative surgical planning for Skull Base Tumors as well as for Craniofacial Surgery.

These advanced technologies incorporate Non-invasive as well as Invasive methods. Among the Non-invasive techniques Magnetic Resonance Imaging (MRI) and Computed Axial Tomography (CAT or CT) are two of the most advanced neuroimaging systems. MRI has the capacity to evaluate "soft" tissues (Brain and Spinal Cord) in a superior manner while CT is superb for evaluating Bone Anatomy. Each technique has overlapping capabilities. Both of these technologies incorporate computer-driven capabilities that permit the investigation of the blood supply (angiography) to the Central Nervous System (CNS = Brain & Spinal Cord) as well as some ability to examine the actual FUNCTIONING of the Brain. The amalgamation of CT Scanning with Radioisotope methods (a technology called Positron Emission Tomography/CT or "PET/CT"). Occasionally your surgeon will need information from all of these technologies in order to completely evaluate the problem.

Figure 3: PET/CT Scan. This technology incorporates radioisotope imagery combined with CT Scan to render images that are useful in the evaluation of Cancer patients.

There are several INVASIVE technologies that are used as well in selected patients where the Non-invasive methods fail to give the level of information deemed necessary. Neuroradiologists use Invasive Arteriography to provide additional vital information about the Blood Supply to the Brain & Spinal Cord and/or the Tumors that affect them. Interventional Neuroradiologists use this same avenue to treat Vascular CNS problems as well as some Tumors. Myelography with Post-myelographic CT Scan is another Invasive technique that can provide invaluable information regarding certain Spine problems.

Figure 4A (Left): Cerebral Angiogram of a Right Posterior Frontal Lobe Arteriovenous Malformation (AVM). The precise anatomical configuration of the Blood Supply to and Venous "Aneurysm" (Arrow) draining the AVM is provided by "Invasive" Angiography.
Figure 4B (Right): Post-operative Angiogram of a successful treated AVM. Microvascular surgical techniques were used to remove this AVM. Two Aneurysm Clips were used to control large arterial branches feeding the AVM. Two metallic "Hemoclips" were used to control the large Venous "Aneurysm" (Arrow).

Figure 5A (Left): Cervical Spine MRI Scan of a patient with advanced Degenerative Arthritis (Spondylosis) at multiple levels. The MRI indicates a small area of Spinal Cord injury (the faint white image in the substance of the Spinal Cord at the C4, 5 level indicated by the Arrow). The MRI Scan is able to give greater details of Spinal Cord and Brain anatomy than CT.
Figure 5B (Right): Post-myelographic CT Scan (Same patient). The anatomical detail of bone, bone spurs and calcified Posterior Longitudinal Ligament is far greater on this study than on the comparable view of the MRI Scan.

B. Neurosurgical Operating Rooms

The Operating Room environment is no less dependent on advanced technology. Whether it is the very latest in Image Guidance (a type of Global Positioning System-GPS [see Figure 11B] similar in concept to that used in modern day automobiles for determining precise geographical location), intra-operative real-time imaging (MRI/CT/Ultrasound/Fluoroscopy), high level optical magnification systems (Operating Microscopes/Neuroendoscopes) or powerful ultramodern Ultrasonic Tumor Resection instruments, all these advances make for improved technical results and improved quality of life outcomes.

Figures 6A (Left) & 6B (Right): Dr. Lazar is performing a Minimally Invasive Microendoscopic Transsphenoidal removal of a Pituitary Tumor. The image of the Surgeon's maneuvers is transmitted to a Video Monitor from the Endoscope's camera allowing Dr. Lazar & Neurosurgical Nurse Chris Thomson to conduct the procedure through a tiny opening in the Skull Base. (Endoscope provided by Aesculap, Inc.)

Figure 7A (Left): Operative Photo of Neurosurgeons performing a Minimally Invasive Microsurgical Lumbar (Spine) Laminotomy. They are using a LEICA Neurosurgical Operating Microscope.
Figure 7B (Right): Operative Photo, "close-up view" of the Minimally Invasive (Medtronic-Sofamor-Danek, Inc.) tube retractor and special slender drill.

C. Intra-operative Neurophysiological Monitoring

Neurosurgeons are now able to monitor critical neurological functions during the performance of neurosurgical operations even with the patient under anesthesia. Intraoperative Evoked Response Monitoring employs electronic techniques to measure special functions such as hearing, facial muscle control, vision, eye muscle control, facial sensation, motor and sensory function in extremities, etc. These techniques are critically important for certain types of operations such as the removal of Skull Base Tumors, and Microvascular Decompression (MVD) procedures. These adjunct techniques help the Neurosurgeon to prevent injury to critical functions controlled by vital nerves that are either directly involved by a pathological process or are in contiguity with the anatomical problem and are therefore at some risk to injury. An example is the very delicate technique critical to the management of Acoustic Neuroma, removal when attempting to PRESERVE HEARING function as well as FACIAL MUSCLE control.

Figure 9A (Left): MRI Scan (Gadolinium Enhanced) of a Left Acoustic Schwannoma (Neuroma). The tumor occupies the Internal Auditory Canal (IAC) where it arises from one of the Vestibular Nerves and compresses and distorts the Cochlear Nerve (Hearing) and Facial Nerve (Facial Movement).
Figure 9B (Right): Operative Photo of the Acoustic Schwannoma (Upper Arrow) arising from A Vestibular Nerve (Lower Arrow) after the posterior bone wall of the IAC has been removed.

Figure 10A (Left): MRI Scan Post-operative resection of the Acoustic Schwannoma seen in Figure 9A. The tumor has been removed and the Cochlear and Facial Nerves have been preserved. The nerves can be seen entering the IAC on the patient's Right & Left sides.
Figure 10B (Right): Operative Photo (same patient as 9B) immediately after the Acoustic Schwannoma was removed in this HEARING CONSERVATION operation. A small surgical dissector (Arrow) is reaching over the lower lip of the IAC.

Figure 11A (Left): MRI Scan (Coronal View) Right Anterior Skull Base Meningioma (Arrows)
Figure 11B (Right): Operative Photo of an Endoscopic (Assisted) Image Guided (Arrow) Resection of this tumor through a "Keyhole" Craniotomy fashioned through a small EYEBROW incision.

We have a 30 year history of innovative utilization of Intraoperative Evoked Response Monitoring, which are electronic techniques that measure important neurological functions during Neurosurgical Operations. We work with specialists who have unique expertise with these techniques. Among these monitoring professionals are those from BIOTRONIC NEURAL MONITORING SPECIALISTS.
Information regarding this technology is available at:
Biotronic Neurophysiological Intraoperative Monitoring
emedicine: Intraoperative Neurophysiological Monitoring

D. Neurosurgical Intensive Care Unit

Critically ill Neurosurgical Pre and Post-operative patients are best managed by specially trained and certified Neurosurgical Nurses in a dedicated Neurosurgical Intensive care Unit. These units are uniquely adapted to the needs of the Neurosurgical patient and are usually supervised by a specialist in Critical Care Medicine.

Figure 12A (Left): Neuro ICU Photo. A Neurosurgical patient is being evaluated by a specially qualified Neurosurgical ICU RN.
Figure 12B (Right): Neuro ICU Photo. Neurosurgical ICU RN'S work in teams in a state-of-the art dedicated Neurosurgical Intensive care Unit. Their work is assisted by different types of high level monitoring technology.

The length of stay for any particular patient depends on several factors including the Medical and Neurological condition of the patient, the type of surgery performed, the need for "invasive" monitoring (such as arterial lines/intraventricular or lumbar subarachnoid drains) and the requirement for "isolation" to protect the patient and/or others.

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How To Choose A Neurosurgeon: Nursing Care

Neurosurgical Nursing requires a very special skill level. The American Association of Neuroscience Nurses is an organization that certifies Neurosurgical Nurses who possess special expertise to care for neurosurgical patients. A hospital that encourages and employs these highly motivated and exceptional nurses with this skill level demonstrates its commitment to the neurosurgical program in that facility.

Figure 13: Neurosurgical Nursing Staff

Our Neurosurgical Nursing Staff employs nurses skilled in the management of Neurosurgical problems and certified by the American Association of Neurosurgical Nurses.

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How To Choose A Neurosurgeon: Geography and Insurance Issues:

Getting the most competent Neurosurgeon to care for you may not be geographically convenient for you or your family. For many Brain and Spine surgery patients, the first surgical treatment is the most important one. It may well determine the quality of your existence for the rest of your life. While it may not be convenient to travel, this may be one of the most important choices that you will ever make in your life.

It is imperative to recognize that health insurance organizations are generally in the business of making a profit which frequently means limiting their financial exposure and limiting your access to higher levels of medical care.

HOW TO AVOID BEING COMPROMIZED and WHAT TO DO:

BE AWARE that the surgeon to whom you are referred may be an EMPLOYEE of a hospital or hospital affiliated practice and the REFERRAL WAS MADE PRIMARILY BECAUSE OF A COMMON EMPLOYER. FREQUENTLY, this means that you may ONLY GET A PARTIAL or LIMITED EVALUATION and NOT HAVE ACCESS to some of the MORE ADVANCED TREATMENTS such as MINIMALLY INVASIVE SURGERY.
WHAT TO DO: CONSIDER GETTING A SECOND OPINION
BE AWARE that the surgeon to whom you are referred may be an "IN-NETWORK PROVIDER" and as such may be RESTRICTED FROM OFFERING the MOST ADVANCED TREATMENTS (particularly the Minimally Invasive techniques) since the INSURANCE COMPANY WILL NOT PAY SUFFICIENTLY FOR THOSE.
WHAT TO DO: DO NOT LET THE INSURANCE COMPANY DETERMINE WHO YOUR NEUROSURGEON WILL BE and WHAT TREATMENTS HE/SHE CAN OFFER. For many patients this is a matter of FIGHTING FOR YOUR LIFE. CONSIDER GETTING A SECOND OPINION.
BE AWARE that the surgeon to whom you are referred MAY INSIST that an OPERATION BE CARRIED OUT IN A FACILITY IN WHICH HE/SHE IS AN OWNER/INVESTOR.
WHAT TO DO: ASK QUESTIONS and EVALUATE THIS POTENTIAL CONFLICT of INTEREST. FREQUENTLY these SMALL FACILITIES ARE LESS SCRUTINIZED for COMPLICATIONS, INFECTIONS and OUTCOMES.
BE AWARE that your health insurance company may ONLY PAY ONE LOW FEE SCHEDULE for a particular type of operation WHICH LIMITS WHAT YOUR NEUROSURGEON CAN DO. (Example: A "Lumbar Laminectomy" can be done "OPEN" or "MINIMALLY INVASIVELY". THERE ARE SUBSTANTIAL POTENTIAL ADVANTAGES to the MINIMALLY INVASIVE TECHNIQUE particularly when it involves both sides of the spine which is called "BILATERAL". HIGHLY SKILLED SURGEONS CAN ACTUALLY ACCOMPLISH THIS USING A ONE-SIDED or "UNILATERAL" APPROACH. "IN-NETWORK" PROVIDERS MAY NOT EVEN MENTION THIS AS AN ALTERNATIVE, EVEN IF THEY HAVE EXPERIENCE WITH THE TECHNIQUE, SINCE THEY ARE NOT PAID SUFFICIENTLY TO OFFER THIS PROCEDURE.)
WHAT TO DO: COST SHOULD NOT STAND IN YOUR WAY. You need the best, not the least expensive, Neurosurgeon available. Your Neurosurgeon and his team should be willing to work with you to make the treatment that you need available to you. Your Neurosurgeon should be willing to be your advocate before, during and after your stay in the hospital. CONSIDER GETTING A SECOND OPINION.

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How To Choose A Neurosurgeon: How Can I Be a Part of the Decision Making Process?

The concept of any form of surgery (particularly BRAIN or Spinal SURGERY) can be, for most people, quite alarming if not terrifying. So much of our very being, our personalities — our intellect, instincts, temperament, capacity for language and spatial relationships, memories, dreams — is carefully encoded within the cellular structure of our "grey matter". The prospect of any risk to alter Brain tissue in some way involves the risk of changing who we are to a greater or lesser extent. For Spine surgery patients, the recognition that the potential risks of loss (or impairment) of control of the extremities, bowel and bladder function, is obviously very worrisome.

In the event that you have a good medical reason to undergo Brain or Spine surgery, it is essential to trust the professional capabilities of your Neurosurgeon. Select one carefully. Get recommendations from physicians and/or nurses whom you know and trust. Interviewing several Neurosurgeons and asking questions can be helpful. The more you trust your physician and the more you know what to expect, the more relaxed you can be about the surgical process.

Get as much education about your condition as you can. Reviewing the material on this website is an excellent place to start. We have listed some additional reference sites relating to specific disease processes.

There is considerable information available on the Internet. Much of it is reliable. Unfortunately there is also a great deal of misinformation as well some very bad advice. This can create some real difficulties unless you have someone to guide you. A trusted personal physician who has some knowledge about the issues may be that individual. Unfortunately the process requires the time and patience of that physician. In today's medical practice environment these are rare commodities. Your Neurosurgical Consultant should be willing to take time to review your issues and to educate you.

Being informed and feeling confident that you have placed yourself in good hands can benefit your recovery process.

It is invariably true that there are choices to be made about the treatments available.

Your Neurosurgeon has a responsibility to explain a number of critical issues as explained below.

The following list suggests some reasonable expectations that you may have of the Neurosurgical Consultant.

Your Neurosurgeon should:

Make every effort to see you in a timely manner
Listen carefully to your account of your condition
Conduct a focused evaluation of your Neurological problem
Conduct appropriate investigations and then review them with you
Discuss with you the Neurosurgical condition(s) that brought you to a Neurosurgical Consultation and what will happen if it is left untreated
Provide you with educational materials relating to this condition
Explain the therapeutic alternatives available to you with their attendant risks & limitations

Make specific recommendations for treatment and discuss their experience and the expected outcome

This process requires the active participation of the patient. If you find that parts of this process are missing, then perhaps you should consider another Consultant since these are of critical importance to you.

In the end, the decisions are yours to make. It is your life, your Neurological problem and your responsibility to make the decision as to who will be responsible for your Neurosurgical care and what the treatment will be, if any.

The Surgeons and Staff at Neurosurgical Consultants are sensitive to the difficulties involved in finding the "best doctor" for your problem. We encourage you to review this entire section on How to Choose a Neurosurgeon and have prepared additional educational material on specific Neurosurgical conditions that you may download at your convenience.

Recognition

Dr. Lazar has been recognized annually by his colleagues and peers as one of the BEST DOCTORS in Dallas since the inception of this independent program in 1992 and is the ONLY NEUROSURGEON to be so recognized.

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How To Choose A Neurosurgeon: Online Information

There is a massive amount of information available online. We suggest that you start with some basic information, some of which you can download from this website.

Here are some others that we suggest:

American Association of Neurological Surgeons
American Board of Neurological Surgery
Congress of Neurological Surgeons
North American Skull Base Society
Pituitary Network Association
American Society of Neuroradiology
American Society of Interventional & Therapeutic Neuroradiology (ASITN).

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This page last edited on 9/7