30 years of neurosurgery at the University Hospital Brno: "We prefer to learn from successes rather than from mistakes."

The Department of Neurosurgery of the Brno University Hospital and Faculty of Medicine of Masaryk University celebrates thirty years since its foundation. For more than half of this time, it has been managed by Professor Martin Smrčka, who in 2005 succeeded his father, Vladimír Smrčka, who was the head for the previous nine years. In addition, Martin Smrčka has served as President of the Czech Neurosurgical Society for the past four years and is still active as a trainer and lecturer at the Faculty of Medicine of Masaryk University. So who else to go to if you want to look back at the history of neurosurgery in Brno and uncover the challenges that lie ahead in the upcoming years?

15 Dec 2022

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What was the form of neurosurgical practice before an independent clinic was established at the Brno University Hospital in the early 1990s?
In the field of general surgery, neurosurgery began to be cultivated in our country as early as the 1920s, although the brain surgeries performed at that time did not have great results. In Brno, a separate department was established on the platform of the surgical clinic in 1949 at St. Anne's, under the direction of Professor Jan Navrátil. However, the doctors did not have the necessary anaesthesia methods or substances to reduce brain swelling, and so it happened that the brain would prolapse out of the head during operations, and the results were not satisfactory. The high mortality rate frustrated Professor Navrátil so much that he turned to cardiac surgery and became head of the cardiac surgery clinic in Vienna. The very first neurosurgical clinics as we know them today, i.e. with training of medical students, were established at the end of the 1950s in Hradec Králové and Prague. Both of their heads - Professor Petr and Professor Kunc - drew their know-how from America at that time, which is strange, that they were able to do this so soon after the war period.

You are known to have followed in your father's career footsteps. Do you think you would make the same decision today when choosing a field of study and a career path, taking into account, for example, the difficulty, prestige or perspective?
Not only neurosurgery, but medicine as such, had great prestige in the 1970s and 1980s. I believe that it still has it today, even though the economic opportunities are diametrically different and people are freer to pursue their careers. However, for us then, it was primarily the prestige, because there was no business and those who wanted to pursue something more demanding were offered medicine. My father was, of course, a role model for me, and although brain surgery fascinated me, I was not sure I would be able to pursue neurosurgery. And would I choose the field now? I can't rule out choosing something else. My sons were in that decision-making phase recently, and I sense that young people around me are seeing success in other fields. Not to mention that the big attraction today is money, so it's no longer just about the prestige that comes with medicine.

Why did you have doubts about whether you could do neurosurgery? I have seen a few students in my area who went to medical school with the vision of becoming a neurosurgeon, but gave up because of the difficulty of the field...
Thanks to my father, I knew how demanding the field was, but I wasn't sure if I would have any inhibitions, whether intellectually, manually or otherwise. I had a general respect for the human body. Not that I was a shy medic, on the contrary, I used to be very active in the autopsy room. But the living human body is a liability for a young doctor. So I went from the simple to the more complex, and through surgery in Ivančice, where I gained some confidence, I got further.

"We are trying to promote the creation of neurorehabilitation units where prospective patients after head injuries would get a chance."


Double-digit risk

Can the complexity of the neurosurgical field be quantified?
For me, it is essential to look at the riskiness of the procedures performed. Even in neurosurgery we have simple procedures such as carpal tunnel syndrome operations. You don't kill a person, at worst you damage them, but it's still just a hand in quotes. But when you take more complex brain surgeries, there's a whole range of damage that can be done to the patient, right up to those that end in death. In neurosurgery, there are a number of such high-risk surgical procedures. The quantification of such risk, which is now quite sophisticated, comes into consideration. And there is a difference if you go in for a procedure with a one per cent risk of mortality or one that has a 20 per cent risk. But whether we want it or not, we have to accept it, explain it to the patient and the family and carry out the operation, because otherwise the risk of death would be even higher. This makes us quite different from other disciplines, which do not think in this way because they do not even take death into account.

How motivating is it when patients come to thank you for saving their lives?
Of course, this encourages one to continue working. But it's also a bit relative, because with less risky procedures there are more people who could perform them and you just sort of fall into them. It is true that the more difficult the procedure, the fewer doctors can perform it, and in such cases I am particularly pleased - and take it more personally - when the patient can be saved. They say you should learn from mistakes, but in neurosurgery, mistakes are too expensive. We prefer to try to learn from successes.

To turn the question around - how demotivating can it be when a procedure goes wrong and you lose the patient?
If you want to run a workplace that claims to be up to scratch, you have to be able to face up to mistakes. For us, a failure is generally a patient we can't bring back to health, or yes, one who dies. But you have to identify each time whether it was a mistake or a natural course. If we find that we have made a mistake, we must find a way not to repeat it. This is the kind of learning from mistakes that we don't like to make, but if it comes to that, there is nothing else for us to do. When we analyze that we didn't make a mistake but still fail, it's good for us but still frustrating because we don't know what to do differently in the future. Unfortunately, there are more of these situations than those where we make mistakes, and I personally find them extremely frustrating. Although in absolute numbers they are relatively rare cases and the incidence of mortality in elective procedures is actually very low, almost zero.

Are they also declining due to advances in technology and new knowledge?
Definitely yes. But it is not just about failures in the form of neurological damage or impaired mobility or speech. Recently, care has also been taken to ensure that the patient's psychological state is not altered after the operation, so that his cognitive functions, his perception, memory, intellect and other things are not altered, which we did not pay much attention to in the past in the field, because for us it was essential to save the patient so that he was able to walk and talk.

„Bez technologií jako je ,CéTéčko‘ nebo magnetická rezonance se zákroky po úrazech hlavy řešily často v podstatě metodou pokusu omylu.“

New technologies, better diagnostics

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So, do you see the growing importance of interdisciplinarity in your field as well?
Yes. If you want a patient to have the same - or even better - psyche after cancer surgery as before, you need a battery of tests. You need a psychologist, a speech therapist, and other specialists from disciplines we haven't worked with before in neurosurgery. For conscious surgery, these specialties are even needed in the operating room.

Wasn't that the case in the past?
Nor could it be, because the necessary technology was not there. Consider that the first "CT" was installed in Brno in 1982. Thanks to it, the entire organisation of care for neurosurgical patients was dramatically transformed. And the first magnetic resonance imaging, which today is taken for granted, has been in Brno even since the 1990s... Without these technologies, for example, interventions after head injuries were often solved essentially by trial and error, when the only identifier of the injury was, for example, an enlarged pupil. My father often describes how he used to be called from Znojmo or Vyškov, where he used to go for such injuries. A dilated pupil is already a sign of a very late stage of the development of intracranial hypertension, when the patient has little chance of being saved. Now that we have imaging methods and, since the 1990s, an air ambulance service, we can also develop psychological care and other aspects.

What other milestones have helped move neurosurgery forward in recent years?
At the turn of the 1980s and 1990s, neurosurgery was still mainly performed macroscopically. The microscope came to Brno only when our then newly established department was being equipped in the ninety-second year. But it is one thing to have a microscope and another to be able to operate with it. And with all due respect to our predecessors, they didn't know how to do it because there was no one to teach them. That was waiting for us. That's why my generation, then in their thirties, who are now in charge of most neurosurgical departments around the country, travelled the world - because we could - and watched how microsurgery was done. This opened up a whole new world for us! In fact, I admire our predecessors for being able to operate on anything without a microscope, just a light from the ceiling.

Today, the clinic performs about two thousand operations a year. How have these numbers evolved over the years?
Before 1992, higher hundreds of performances were performed in Brno - eight or nine hundred. But then the neurosurgical department on Pekařská Street was divided into two, and while the department at St. Anne's remained, the clinic (with medical training) was established in new premises in Bohunice. When my father, who had been the head of the department at St. Anne's until then, became the head of the department in Bohunice in 1996, the number of operations began to increase, to the point that when I took up the post in 2005, there were up to 2700 operations a year. Unfortunately, then the FN Brno reconstructed its operating theatres and we were left with two instead of three. Initially, it was only temporary, but that temporary nature continues to this day, so we are not able to get over 2000 operations. We can't do more than that in two theatres, so we have started doing fewer of the simpler procedures like carpals or discs, and more of the more difficult brain or spinal procedures. But we still want and need a third OR.

How has the portfolio of interventions you perform changed, for example, in relation to prevention?
Nowadays, there is much better diagnostics of oncological diseases, so we have expanded our portfolio of brain tumour surgeries, which we deal with as a priority. We are also developing vascular neurosurgery and aneurysm surgery, which is also part of better diagnostics, and I would say that we have no competition in this area in the region. The most challenging procedures in the field then include spinal canal surgery.

"Today, we can also develop psychological care and other aspects in neurosurgery. "

Defend and develop

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In November, the annual congress of the Czech Neurosurgical Society took place, and this year you are handing over its leadership to your successor. What were the main topics of the congress? What are the main current challenges of neurosurgery?
The field is developing quite dynamically, I personally perceive a significant change in the field of oncology, when we realized that some types of tumours, especially the more malignant ones, we are not able to solve independently and we cannot do without the help of some specialities that we had no idea about before. Recently, we have seen a trend towards the development of molecular biology and genetics, which we cannot do without if we are to add more years to patients' lives. Therefore this is another shift towards interdisciplinarity and a little wake-up call for us because we have to force ourselves to understand at least a little bit about the theory behind these processes. And it will be a small revolution if the current young neurosurgeons are educated in molecular biology and genetics to be good partners to their colleagues in these fields.

When you were elected president of the Czech Neurosurgical Society four years ago, you said in an interview for MF DNES that although it was possible to establish independent neurosurgery, it is a never-ending story because "someone will come along again who will declare that neurosurgery is redundant". Has such a person emerged?
I will remind you that my comment was about education, where we have managed to defend neurosurgery as a basic strain of education. I believe that we have managed to consolidate it with further decrees so that hopefully it will not be moved again. Unfortunately, there are other predators trying to take a bite out of our field. For example, we are trying to define competencies with the newly formed spondylo-surgical society, which deals with spinal surgery, when we take the position that spinal surgery has long belonged to the portfolio of neurosurgery. This society has declared itself as our superstructure and would like to decide which spinal operations are performed and where. We are trying to work together because, paradoxically, many of its representatives are neurosurgeons - later specialising in spondylo-surgery - even though they now represent our fifth column. There are more such overlaps, and we must continue to defend our field and its boundaries. On the other hand, there are challenges such as neurorehabilitation, which is a speciality that has not been nurtured for a long time, and to which we have begun to attach importance because it involves some of our patients whom we have nowhere to place today. Often these are young people after head injuries and brain surgeries who will stay with us for a few weeks, but then they might need a few more weeks of rehabilitation somewhere. But there's nowhere that can provide them with such care at an ICU.

So this is one of the challenges facing your successor at the head of the Czech Neurosurgical Society, Professor Sameš?
Yes, during my tenure we have already established an acute neurorehabilitation section where we are advocating for the creation of acute neurorehabilitation units that would be part of hospitals where neurosurgery is located. They would give a chance to promising young patients after head injuries, who would be helped not only by physiotherapists but also by psychologists, speech therapists and others to ultimately get out of bed and get back to life. And neurorehabilitation is precisely the field that is not tearing neurosurgery apart, but rather developing it.

How does the cooperation with the Faculty of Medicine of Masaryk University work from your point of view? Does it generate enough students and enough prospective ones?
The cooperation with the faculty is very good. Whether with Professor Repko at the Dean's Office, with Professor Kašpárek at the Science and Research Department, with Vice-Dean Zdeněk Kala or within the Simulation Centre with Vice-Dean Štourač. I cannot praise the cooperation in terms of substance enough. However, I see a big problem in the scope of teaching, and I have been saying this for years, that not enough attention is paid to teaching neurosurgery. The medics have nowhere to learn about it when they are with us for basically three days and now we have hopefully carved out another day in the Simulation Centre. It used to be two and a half days. I understand that all specialities want space for their field, but I think neurosurgery deserves to have medics spend at least five working days with us throughout their studies. I think that is the minimum, and I believe that if we reach that, medics will become more aware of neurosurgery and maybe then they won't get so frustrated with it that they give up the dream of becoming a neurosurgeon.

"I admire our predecessors for being able to operate on anything without a microscope, just a light from the ceiling. "


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