"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.
William Jennings Bryan (1860-1925)
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:
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,
Acoustic Neuroma Tumors,
Intracranial Aneurysms &
(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
Glossopharyngeal Neuralgia or
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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:
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- Listen carefully to your history and concerns
- Conduct a detailed Neurological Examination, often focused on your
- 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
- Make specific recommendations for treatment
- Discuss the extent of his/her personal experience and results with the
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
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.|
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,
Neuro-oncology with all the
latest technological support systems that are required for them to perform at
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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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.
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
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
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
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.
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
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
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.
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
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
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
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
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.
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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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
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
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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
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
- 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
before, during and after your stay in the hospital. CONSIDER GETTING A SECOND
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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
Your Neurosurgeon has a responsibility to explain a number of critical issues as
The following list suggests some reasonable expectations that you may
have of the Neurosurgical Consultant.
Your Neurosurgeon should:
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.
- 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
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,
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.
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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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.
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