William T Couldwell is professor of neurosurgery in the Department of Neurological Surgery, University of Utah, Salt Lake City, USA. He is the current president of the American Association of Neurological Surgeons (AANS) 2013/2014. He speaks to NeuroNews about the themes for this year’s meeting, the increased use of imaging in neurosurgery, the developing role of the neurosurgeon and how the specialty is evolving
What drew you to medicine and neurosurgery in particular?
I knew that I wanted to be a physician from an early age; neurosurgery came later when I was a third year medical student. We had terrific neurosurgical mentors at McGill University and the Montréal Neurological Institute [Canada].
Who were your mentors and what wisdom did they impart to you?
Dr William Feindel, who was an advisor of mine during medical school and on my PhD advisory committee, was an inspiration, as were Dr Gilles Bertrand (chief of Neurosurgery at the Montréal Neurological Institute at the time) and Jules Hardy, a pituitary neurosurgical pioneer. During my residency, Martin Weiss, the chair of Neurosurgery at the University of Southern California [USA] was an outstanding mentor ‒ bright, fun and engaging. Takanori Fukushima was a great surgical mentor too and a brilliant surgical technician.
You are the president of the AANS 2013/2014, what are your aims for the association in 2014?
We have expanded the mission and scope of the Neurosurgical Research and Education Foundation (NREF) and have implemented this during the year. We have expanded the board structure and defined more significant goals, including funding clinical research and performing clinical trials and registry work. The Neuropoint Alliance, which is our data collection subsidiary of the AANS, enables the NREF to now engage in clinical research projects. The Neuropoint Alliance over the past two years has initiated the largest and most robust spine registry project to date for lumbar and now cervical spine surgical patients. Centres from across the country (both private practice and academic) are enrolling patients prospectively to enable quality improvement, peer comparison and to determine outcomes from a variety of spine degenerative diseases. We are now starting projects in other areas of neurosurgery, such as vascular disease and tumours. It is an extremely powerful tool.
What is the theme of the AANS meeting this year and what will the highlights of the meeting be?
The theme of the meeting this year is “expanding neurosurgery.” We are a small specialty, but we have had an outsized impact on medicine in general. We will celebrate this during the meeting and demonstrate how we can use the new opportunities that we helped create to offer new career alternatives for neurosurgeons. Examples of this include neurosurgical involvement in critical care and endovascular stroke.
You have served on many journal and book editorial boards, what three lessons did you learn from these experiences?
1) Try to be concise—this is a skill that needs to be developed and is very much appreciated by the reviewer and the readership. 2) Only consider publishing something to deliver a new message, unless you are specifically writing a review. 3) Avoid salami science (the attempt to break the work down into a minimal publishable unit). Readers know this and it will be reflected in fewer citations per article.
As professor of neurosurgery, what advice would you give to someone just starting out in the field?
This is a fantastic time to be a neurosurgeon. There is a remarkable concatenation of technology that can be applied to clinical problems. Deep brain stimulation is one such example but there are many others on the horizon, such as focused ultrasound. We have an increasing ability to intercede with diseases that afflict a large percentage of our ageing population. I am incredibly optimistic about the field.
What have you learnt over the years about patient care in neurosurgery?
I like to remind our residents and fellows that we have a tremendous impact on the lives of our patients. This tends to be minimised in our training programmes as the focus is on high volume in-patient activity and trainees do not get to know the patients and their families. This lack of out-patient follow-up is a weakness in the current training paradigm, but is a very rewarding aspect of our field that is underappreciated by the trainees and is experienced later in their career. I always enjoy receiving notes and letters of appreciation from patients from years gone by emphasising how we have changed their lives.
What innovations have changed neurosurgery in the last 10 years?
The most impact has come from the innovations in spinal surgery (including minimally invasive techniques) and endovascular surgery. The latter has made impressive strides and has changed the treatment of aneurysms globally from open surgery to the majority of cases being treated by endovascular methods. Deep brain stimulation is another innovation and is being applied to other diseases, such as to enhance memory in patients with early dementia and also with depression.
What recent publications have caught your eye?
I would not like to call out a specific publication as there are several groups internationally working on this notion. There is good preliminary experimental evidence that modulation of the vagal output can produce alterations in the immune system. Stimulation or ablation has a direct impact on the release of pro- and anti-inflammatory mediators. This has been used to direct research into general inflammatory conditions and specific inflammatory conditions of the bowel that the vagus nerve innervates. Another general condition that vagal nerve stimulation can modulate is the systemic inflammation following heat stroke. Such observations have profound implications in that it opens up a whole new paradigm on how we can influence systemic disease by modulating output of the vagus, or other nerves, yet to be identified. (Yamakawa K et al, ‘Electrical vagus nerve stimulation attenuates systemic inflammation and improves survival in a rat heatstroke model’ PLoS One 2013; 8: e56728 (Epub 12 February 2013).
How do you see the neurosurgical field developing in the future?
Increasing application of new surgical procedures to diseases not previously treated by neurosurgeons, diseases such as dementia, depression, psychiatric disorders and stroke rehabilitation.
Your research includes signal transduction and apoptosis in gliomas, pituitary tumours and meningioma, what interesting findings have come out of this research?
We are looking at new agents to slow the growth of benign tumours, such as pituitary adenomas and meningiomas. With the ageing population and increased use of imaging, these tumours are being identified with increasing frequency. For example, pituitary tumours are identified in up to 20% of the population, which is an important observation. It begs the question of what are the growth and senescence signals at play.
What are your other current areas of research?
We are using an important Utah resource, the Utah Population Data Base (UPDB), to address the questions of heritability of many neurosurgical conditions, such as aneurysms and various tumours. We have found families in the database with high frequencies of specific phenotypes (pituitary tumours, for example), which are then the focus for identifying genes that predispose to these conditions. It is a terrific resource that helped previously define the APC (adenomatous polyposis coli) and BRCA1 (breast cancer early onset) genes.
What are your interests outside of medicine?
I enjoy all that Utah has to offer. It is a great place to live and we enjoy, on a routine basis, outdoor activities such as hiking and mountain biking. Skiing (both snow and water skiing) and cycling are my passions and I have competed, in my younger days, in both cycling and snow skiing. The last major cycling race that I did was Race Across America a few years ago. I hope to do more of this following the completion of my presidential year. I also enjoy restoring vintage cars and motorcycles, which is one of my hobbies.
Professor of Neurosurgery, department of Neurological Surgery, University of Utah, Salt Lake City, USA
President 2013/2014 American Association of Neurological Surgeons
BSc combined honours; physical chemistry and biology, University of British Columbia, Vancouver, Canada; Dalhousie University, Halifax, Canada
McGill University, Montreal, Canada: MD, PhD, 1979–1984
McGill: completion of PhD (neuroimmunology/molecular biology), July 1989–June 1991
Internship and residency
Internship and residency: University of Southern California Neurosurgery Program, USA
Internship, general surgery, Los Angeles County/USC Medical Center, USA July 1984–July 1985
Resident in neurosurgery, LAC/USC Medical Center; Huntington Memorial Hospital; Childrens Hospital of Los Angeles; Norris Cancer Hospital and Research Institute, Los Angeles, USA, July 1985–June 1989
Research fellow, neuroimmunology; fellow in the surgical management of epilepsy, Montréal Neurological Institute and Hospital, McGill
University, Canada, July 1989–February 1991
Research Fellow, Neurosurgical Service, CHUV, Lausanne, Switzerland, March–July 1991
Editorial positions (selected)
Editorial board, Journal of Neurology, Neurosurgery, and Psychiatry, 2010–present
Editorial board, Journal of Neuro-Oncology, 2008–present
Co-editor, Central European Neurosurgery, 2007–present
Editorial board, Acta Neurochirurgica, 2006–present
Editor, AANS Neurosurgeon, 2005–2010
Editor, Neurosurgical Innovations section, 2004–2005
Editorial board, AANS Bulletin, 2003–2005
Editorial board, Neurosurgical Review, 2003–present
CAD-CAM based drill for skull base and craniotomy applications. U-4062-PCT. 2008