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The care of neurotrauma patients has historically fallen upon neurosurgeons. As technology and knowledge of neurophysiology advanced, training programs provided neurosurgical residents with intensive care experiences that prepared them to “captain” the team addressing neurologic injury. Simultaneously, other specialists, most notably anesthesiologists, trauma surgeons, and pulmonologists, developed an intense interest in critical care medicine, including the management of neurosurgical patients. This became most evident in the polytrauma patient, in whom the various specialties had overlapping interests. In many centers, a cooperative team approach emerged, encompassing several specialists providing expertise directed toward their particular organ systems.

The question as to whether a patient fares better when admitted to an NTICU as opposed to a general ICU or other setting is not easily answered. The question implies that all NTICUs are comparable in terms of available services and the expertise and interests of their staffs. Ghajar et al1 surveyed the care of comatose, head-injured patients in a pool of over 600 trauma centers, 34% of which had designated NTICUs, and found disturbing variability in the management of these patients. Even in some NTICUs directed by neurosurgeons, there was a reluctance to utilize ICP monitoring routinely, as well as a reliance on such therapies as excessive hyperventilation and high-dose steroids, which have been shown to be detrimental or ineffective in the treatment of severely head-injured patients. Jeevaratnam and Menon² and McKeating et al³ reported a similar experience in the United Kingdom and proposed the establishment of guidelines to be adopted by all ICUs caring for head-injured patients.

Evidence supporting improved outcomes from care in an NTICU has been offered by Warme et al,⁴ who looked retrospectively at the outcomes of two groups of severely head-injured patients treated at the same institution before and after the establishment of an NTICU. The number of good outcomes increased dramatically in the latter group. A second study out of Sweden by Nordstrom et al⁵ arrived at a similar conclusion. Hyman et al,⁶ looking at the experience at Vanderbilt, suggested that treatment in a neurosurgical intensive care unit resulted in improved patient care as well as outcome. It must be remembered that these data are retrospective and anecdotal, but they do suggest that patients may indeed benefit from treatment in a specialized neurosurgical intensive care unit if that facility adheres to accepted standards of patient care. Simply calling a unit an “NTICU” offers little advantage to patients if they are not being appropriately mon-itored and treated.

The role of neurosurgeons in the management of neurotrauma patients has been the subject of much recent debate.^7–10 During the last decade, neurosurgeons have, with disturbing frequency, willingly abdicated their role in neurotrauma care to intensivists, trauma surgeons, and in some instances to nurse practitioners and physician assistants. This has led to a sounding of alarms throughout organized neurosurgery and has prompted other specialists to question the necessity of neurosurgeons in the care of traumatic brain injury.^11–18 Arecent survey of members of the American Association for the Surgery of Trauma highlighted the perception that neurosurgeons are providing inadequate care for victims of trauma.¹⁷ Respondents emphasized the resistance of neurosurgeons to participate in the management of patients without “surgical” lesions and their reluctance to insert ICP monitors in comatose patients.

The reasons for neurosurgical “nonparticipation” are diverse. Invariably, surveys reveal a high degree of anxiety regarding exposure to malpractice actions by emergency room patients despite the fact that the few studies investigating this issue fail to substantiate this concern.^19,20 The frequency of less-than-perfect outcomes despite neurosurgeons’ best efforts and the impact of the unpredictability and inconvenience of trauma on their schedules also contribute to neurosurgeons’ reluctance. Most important, however, is the dismal reimbursement most surgeons realize for their many efforts. These factors have conspired to create acritical shortage of neurotrauma manpower in many communities, leading to the closure of many trauma centers and obligating trauma surgeons to identify alternative means of appropriately caring for neurologically injured patients.

Some reports suggest that general surgeons and trauma surgeons can be trained to perform emergency craniotomies and drill burr holes for intracranial hematomas.12,15,16,18 Although the majority of these recommendations relate to practices in rural settings where neurosurgical expertise is geographically distant, the time is coming when trauma surgeons will seek similar privileges in more suburban and urban locales where neurosurgeons are practicing but are resistant to providing the necessary care to neurotrauma patients.

Havill and Sleigh¹² reported that the mortality rates of patients treated in their tertiary referral trauma center without neurosurgical specialists compared favorably with those of other adult series of TBI patients. Visvanathan¹⁸ detailed the outcomes of head-injured patients, both surgical and nonsurgical, managed on a general surgery service and advocated more extensive neurosurgical training for the general surgical staff. The implications of these and other studies are that management of severe head injury is not beyond the realm of a general or trauma surgeon with additional training and that outcomes in such scenarios could be expected to approach those in the neurosurgical literature.^15,16