Haines, Stephen J. MD*; Rockswold, Gaylan L. MD, PhD*,‡; Maxwell, Robert E. MD, PhD*,§
In 1937, Owen Wangensteen, MD, PhD, the fabled head of the Department of Surgery at the University of Minnesota, recognized the special nature of neurosurgery and officially created the Division of Neurosurgery in the Department of Surgery. He appointed William T. Peyton, MD, as head of the division (Figure 1). Dr Peyton trained in surgery at the University of Minnesota where he also received a PhD degree in anatomy. He had done a fellowship in neurology and showed more interest in surgical diseases of the head, neck, and brain than other members of the faculty.
The first residents in neurosurgery were accepted in 1940. Dr Peyton retired from his position as Head of Neurosurgery in 1960. Dr Lyle French (Figure 2) was appointed Head of the Division, charged by Dr Wangensteen to build on the foundation created by Dr Peyton to create an outstanding academic neurosurgery department of national and international reputation.
GROWTH TO NATIONAL PROMINENCE
The birth, adolescence, and early youth of the Department were parented by 3 superb chairmen with markedly different personalities and styles of leadership and mentorship. The history of the Division and then Department of Neurosurgery at the University of Minnesota from its founding in 1937 until 1985 was thoroughly documented by Shelley Chou1 (Figure 3) and will not be repeated in detail here.
These were years of growth, enthusiasm, and tremendous energy. The faculty was small and home grown, and everyone was expected to be comfortable and competent doing things the “Minnesota Way.” Residents expected their training to be challenging and arduous and were not disappointed. Teaching conferences were held in the evenings and on Saturday mornings, and it was understood that all residents and faculty would attend. Journal Club was held Thursday evenings at the home of Dr French or Dr Chou.
A strong emphasis on developing academic neurosurgeons encouraged residents with academic career aspirations to extend their training with graduate courses in the basic sciences and an extra 2 or 3 years in the laboratory to carry out publishable original research and write and defend their theses. These efforts resulted in substantial contributions to the practice of neurosurgery. Dr French and his resident, Joseph Galicich (who would go on to head Neurosurgery at Memorial Sloan-Kettering Cancer Center), introduced the use of dexamethasone for the treatment of cerebral edema surrounding brain tumors.2 Some of the first transthoracic repairs of complex spinal deformity and fracture were developed by Shelley Chou as part of a complex multidisciplinary team effort.3 There were important contributions to the early development of radioisotope brain scanning,4 cerebrovascular surgery,5 and epilepsy surgery.6 The basic science that led George Allen to the introduction of nimodopine for the treatment of cerebral vasospasm was done in the laboratories of the University of Minnesota.7 Seminal contributions to the understanding of brain death resulted in Dr Chou's appointment to the President's Commission on Brain Death.8
Based on work done in the laboratories and clinics at the University of Minnesota, Jim Story, Don Long, Jim Ausman, and Fernando Diaz went on to distinguished careers as academic department leaders. Neurosurgery in South Korea benefitted greatly from the training of 2 chairmen of neurosurgery at Seoul National University (Bo Sung Sim and Kil Soo Choi) and 1 at Korea University (Jeong Wha Chu).
Leadership was also emphasized. Dr Peyton served on the American Board of Neurological Surgery, and Drs French and Chou served as President of the American Association of Neurological Surgeons (AANS) and several other neurosurgical organizations. Many graduates who entered the practice of neurosurgery became leaders of the best practices in their communities.
CHANGE AND CHALLENGE
Dr Chou announced his intention to step down as Department Head in 1988, and a national search commenced. This culminated in the appointment of Roberto C. Heros, MD (Figure 4), as the fourth Chairman of the Department of Neurosurgery. Dr Chou handed to Dr Heros a department with a strong record of producing academic neurosurgeons and leaders of community neurosurgery (Table 1), presidents of national neurosurgical societies (Table 2), and many professors and leaders of some of the finest private practices of neurosurgery in the country. Dr Heros, as the first Department Head not trained in Minnesota, brought an interesting, different, and dynamic dimension to the Department. He fit the need for a leader of an outstanding neurosurgical department with a strong history of excellent resident training, growing research programs, and an outstanding cerebrovascular surgeon created by Dr Chou's retirement.
The early years under Dr Heros were years of excitement and growth. He fostered the development of subspecialty practice. He concentrated in cerebrovascular disease, Steve Haines in cranial base surgery, Ed Seljeskog and Steve Haines in pediatric neurosurgery, and Bob Maxwell in stereotactic and functional neurosurgery and epilepsy. Walter Hall was recruited from Pittsburgh to develop surgical neuro-oncology. The research labs expanded with Walter Low, PhD, joining Tim Ebner, MD, PhD, at the University and Gaylan Rockswold establishing a long-term National Institutes of Health (NIH)–funded research program in the use of hyperbaric oxygen in the treatment of traumatic brain injury at Hennepin County Medical Center.9
The Department at this time had a number of advantages. There was a brand new university hospital with state-of-the-art intraoperative angiography and stereotactic surgery equipment. Although Dr French and Dr Chou had retired from their active positions, they remained very influential. In this time of growth and excitement and with these advantages, the Department expanded. Dennis Wen was hired to run the VA Medical Center. Deepak Awasti joined the faculty from David Kline's department at Louisiana State University, bringing broad expertise in microneurosurgery and specific expertise in complex peripheral nerve surgery. Paul Camarata, currently the Chairman of Neurological Surgery at the University of Kansas, joined the faculty as the second cerebrovascular surgeon. Bill Ganz joined the faculty serving at St. Paul Ramsey Medical Center, and Setti Rengachary was recruited both for his expertise with the neurosurgical literature and to fill out the spinal neurosurgery and peripheral nerve surgery programs.
These were also very challenging times. Minnesota had been at the forefront of managed care from the beginning. Enrollment in health maintenance organizations in Minnesota had reached 50% by 1990. Hospital admission rates decreased through the 1970s and 1980s and were substantially below those that Dr Heros was used to in Boston. The late 1980s and early 1990s saw a marked consolidation and merger of health maintenance organizations and hospital systems and significant downward pressure on reimbursement. The environment is well summarized by Christianson et al10: “UMHC is also reassessing its traditional role in the Twin Cities health care market.”
In 1993, University of Minnesota Hospitals and Clinics formed a corporate structure that brought the clinical faculty and hospital together to contract with integrated service networks (ISNs) and to negotiate with health insurance plans. According to the President of the University of Minnesota Health System, “Not to join (an ISN) could mean being left without a patient base in the competitive Minnesota health care environment. At the same time, we won't be an exclusive partner. Our mission makes it imperative that we be available to any Minnesotan who needs us.”10
One effect on the Department was that many patients were excluded from coverage at the University Hospital. The Department responded by expanding coverage to several other hospitals and health care systems throughout the region. This had several negative effects. Faculty surgeons found their time split between hospitals and clinics many miles apart. The new hospitals were not part of the residency training program. The end result was that the enlarged practice required significantly greater faculty effort to manage and did not add significantly to the base for resident teaching. These factors limited the growth of the core academic faculty and the residency training program.
Meanwhile, at the Medical School, trouble was brewing. It is perhaps best summarized in a brief paragraph from an article in the Minneapolis Star Tribune (March 24, 2011). “In 1995, a Federal Grand Jury indicted Dr John Najarian, a renowned transplant surgeon, on charges of fraud, theft and tax evasion relating to the illegal sale of ALG, an experimental anti-rejection drug. Although the Food & Drug Administration never approved ALG, the school's surgery department, which Najarian chaired, sold $80 million dollars' worth of ALG throughout the 1970s and 1980s with much of that money benefitting the University. A jury acquitted Najarian the following year, but the damage was done. The school paid $32 million dollar in fines and the National Institutes of Health placed severe restrictions on the University's freedom to use research money.”
These events resulted in the sale of the University Hospital and Clinics to the Fairview Health System. The re-engineering of the Medical School that followed was associated with a significant decline in NIH funding and ranking.11
Despite all of this, the program continued to recruit excellent residents. Thirty-five percent of those who graduated or matriculated in the decade of the 1990s had their first post-residency or fellowship position in an academic institution. Research thrived. NIH funding continued, and early work in magnetic resonance imaging (MRI)-guided deep brain stimulation for Parkinson's disease was carried out by Maxwell.12 The principles and concepts of evidence-based medicine applied to neurosurgery achieved national prominence.13 There were continuing contributions in neurosurgical infectious disease.14
Fundamental discoveries in motor cortical and cerebellar neurophysiology came from the Ebner lab,15,16 and the development of targeted immunotoxin therapy for primary brain tumors continued, which led to 3 Preuss Awards from the Tumor Section of the American Association of Neurological Surgeons for resident work in this area.17 There was strong involvement of the Department in organized neurosurgery. Bob Maxwell was President of the Society of University Neurosurgeons from 1993 to 1994, Ed Seljeskog was President of the American Association of Neurological Surgeons from 1994 to 1995, and Steve Haines was President of the Congress of Neurological Surgeons from 1995 to 1996.
The pressures were great, however. There was turnover in leadership at the Vice President and Dean levels in the Medical School. Dr Chou served as interim Dean of the Medical School from 1993 to 1995. In response to the many challenges, Dr Heros prepared a detailed plan for University-community engagement designed to increase access for patients to the advanced services of the faculty. This plan was not accepted by the Medical School administration. Ultimately, Dr Heros was recruited by the University of Miami in 1995, where his natural affiliation with the Cuban community has led to a very satisfying career as Co-chairman of the Department of Neurosurgery at the Miller School of Medicine.
A number of the faculty members left the Department, some for private practice, Setti Rengachary for a faculty position at Wayne State University, Steve Haines to be Chairman of Neurological Surgery at the Medical University of South Carolina, and Tim Ebner to become the head of the newly formed Department of Neuroscience at the University of Minnesota in October 1998. Don Erickson retired, and Ed Seljeskog entered the private practice of neurosurgery in Rapid City, South Dakota.
Robert Maxwell (Figure 5), who had been Chief of the University Hospital Medical Staff for the previous 4 years, was then appointed Head of the Department of Neurosurgery by Dean Alfred Michael with full awareness by both parties of the daunting challenges that lay ahead for the Department and Medical School. Several residents were hired to faculty positions: Eric Flores and Alejandro Mendez at the VA Medical Center, Eric Nussbaum to do cerebrovascular and cranial base surgery, and Leslie Sebring-Nussbaum for spinal neurosurgery. Cornelius Lam was recruited to head Pediatric Neurosurgery.
During these years, the faculty retained a focus on specific areas of clinical interest in investigation. Bob Maxwell studied the efficacy of corpus callosum section for the control of partial complex epilepsy with secondary generalization and the utility of real-time guided MRI resection of brain lesions to control medically intractable seizures. He was also the first to use concomitant real-time MRI and electrophysiological guidance during the placement of deep brain stimulating electrodes for the management of movement disorders. Walter Hall used functional MRI brain mapping and real-time MRI tumor resections to enhance the thoroughness of brain tumor resection with reduced morbidity.18 They also conducted spine surgery stimulation sessions for the residents. Gaylan Rockswold continued his nationally recognized NIH-funded basic and clinical research on brain injury including studies on the response of the injured brain to hyperbaric oxygenation. The entire faculty retained a strong emphasis on resident education. Of 34 residents who matriculated or graduated during this time period, 11 (32%) had their first post-residency or post-fellowship position in an academic institution.
However, despite hard work and total dedication to the Department's welfare, by 2003, the faculty had decreased to 3 clinical neurosurgeons at the University: Bob Maxwell, Walter Hall, and Cornelius Lam. Gaylan Rockswold, Tom Bergman, and Walter Galicich covered the service at Hennepin County Medical Center. Walter Bailey, who had recently retired from practice in St. Paul, was helping with the VA Medical Center, and Walter Low continued running the neurosurgical laboratories.
STABILITY, GROWTH, AND EXCELLENCE
After a national search, Stephen Haines (Figure 6) was recruited to return from the Medical University of South Carolina to assume the position of Department Head in December 2003. Since that time, by focusing on excellence in patient care and education informed by discovery, we have developed a healthy, strong, growing department of surgeon scientists.
The current faculty (9 members at the University and VA Medical Center, 3 at Hennepin County, and 1 PhD) maintain a dynamic set of clinical programs covering all significant subspecialties of neurosurgery. There is an important focus on highly collaborative interdisciplinary programs such as spinal surgery, cranial base surgery, brain tumors, stereotactic and functional neurosurgery, pediatric neurosurgery, and cerebrovascular surgery. Although the majority of faculty teaching and research programs are based at the University of Minnesota Medical Center, the Hennepin County Medical Center and Minneapolis VA Medical Center are vital components of the clinical, teaching, and research programs. The Department's home is the Mayo Memorial Building (Figure 7). The current state of the Department's programs is best accessed through the Department's Website http://www.neurosurgery.umn.edu.
The Department remains focused on providing an outstanding educational program for training the next generation of neurosurgeons. In the face of the challenges previously described, the Department has steadily maintained an average graduation of 2 residents per year, with approximately one third entering academic practice on completion of residency or fellowship. Despite access to approximately 4500 neurosurgical cases per year in the 7 hospitals that the practice serves, we continue to concentrate resident education in the core training hospitals. We believe that the quality of training is more important than the quantity of cases. The training provides a great diversity of cases from simple to complex. The Department has a long history of being the first in the Twin Cities to introduce new techniques and to train its residents to carry them out and thereby diffuse them rapidly into the community. We participated as a development site for the Milestones Development Project of the Society of Neurological Surgeons and the Residency Review Committee of the Accreditation Council for Graduate Medical Education. Resident interest in additional academic training is increasing with recent graduates obtaining PhD and Master's degrees. A large variety of basic and clinical research opportunities are available, and the residency training program is structured to allow for extra dedicated research time in the fourth and fifth years of training.
Research labs, originally in the basement of the library, were energized by moving on to the first floor of the University's Biomedical Discovery District buildings, now named the McGuire Translational Research Facility (Figure 8). In the early part of the 21st century, the research programs of the Department concentrated on neural stem cells in the Low laboratory, traumatic brain injury in the Rockswold laboratory, and targeted immunotoxin therapy for brain tumors in the Hall laboratory. Building on the strength of the Stem Cell Institute at the University of Minnesota and the ongoing work in neural stem cells in the Low laboratory,19 2 of our faculty focus on stem cell–mediated recovery from neurological injury: Ann Parr studies cellular therapies for regeneration after spinal cord injury and Andrew Grande studies stem cell–mediated recovery after stroke.
Cornelius Lam's laboratory studies the cerebrospinal fluid absorption system of the arachnoid granulation with the goal of bioengineering a replacement for arachnoid villi.20 Matthew Hunt conducts collaborative research on immunotherapy and blood-brain disruption therapy of brain tumors. He is part of a team that includes Elizabeth Pluhar, DVM, that studies vaccine therapy of naturally occurring gliomas and meningiomas in dogs.21
Dr Rockswold's clinical studies in hyperbaric oxygen therapy in traumatic brain injury continue.22 Walter Low has been principal investigator on an NIH training grant in the neuro-biology of disease.
The Department of Neurosurgery at the University of Minnesota is a vibrant, thriving center for state-of-the-art clinical neurosurgical care, excellent resident education, and promising research. We have a storied past and have always maintained excellence in clinical neurosurgical training. Changes in the regulatory environment of medical and research practice challenge the practice of academic neurosurgery. Although we now must do 2 to 3 times the volume of clinical practice that was necessary to maintain the Department in the 1960s and 1970s and the regulatory burden no longer allows us to go from bench to bedside in a day, as was done during those years of fertile innovation, the Department has grown in the size, depth, and breadth of its clinical programs. By constant focus on the missions of excellence in patient care, resident education, and discovery, we were able to maintain the core of the program through difficult times and are now building on the strength of the past to create a vibrant future.
The authors have no personal financial or institutional interest in any of the drugs, materials, or devices described in this article.
The authors acknowledge the help of Susan Whaley and Susan Julson in preparing the manuscript.
1. Chou SN. Neurosurgery at the University of Minnesota 1937-1985. Minn Med. 1985;68(7):505–511.
2. Galicich JH, French LA, Melby JC. Use of dexamethasone in treatment of cerebral edema associated with brain tumors. J Lancet. 1961;81:46–53.
3. Flesch JR, Leider LL, Erickson DL, Chou SN, Bradford DS. Harrington instrumentation and spine fusion for unstable fractures and fracture-dislocations of the thoracic and lumbar spine. J Bone Joint Surg Am. 1977;59(2):143–153.
4. Peyton WT, Moore GE, French LA, Chou SN. Localization of intracranial lesions by radioactive isotopes. J Neurosurg. 1952;9(5):432–442.
5. French LA, Zarling ME, Schultz EA. Management of aneurysms of the anterior communicating artery. J Neurosurg. 1962;19:870–876.
6. French LA, Johnson DR, Brown IA, Van Bergen FB. Cerebral hemispherectomy for control of intractable convulsive seizures. J Neurosurg. 1955;12(2):154–164.
7. Allen GS, Gross CJ. Cerebral arterial spasm. Part 7: in vitro effects of alpha adrenergic agents on canine arteries from six anatomical sites and six blocking agents on serotonin-induced contractions of the canine basilar artery. Surg Neurol. 1976;6(2):63–70.
8. Mohandas A, Chou SN. Brain death. A clinical and pathological study. J Neurosurg. 1971;35(2):211–218.
9. Rockswold GL, Ford SE, Anderson DC, Bergman TA, Sherman RE. Results of a prospective randomized trial for treatment of severely brain-injured patients with hyperbaric oxygen. J Neurosurg. 1992;76(6):929–934.
10. Christianson J, Dowd B, Kralewski J, Hayes S, Wisner C. Managed care in the Twin Cities: what can we learn? Health Aff (Millwood). 1995;14(2):114–130.
11. Glazer RI, Miller RF, Kaslow HR. How not to reform a medical school. Academe: Bulletin of the AAUP. 1999;85:44–46.
12. Chu RM, Tummala RP, Kucharczyk J, Truwit CL, Maxwell RE. Minimally invasive procedures. Interventional MR image-guided functional neurosurgery. Neuroimaging Clin N Am. 2001;11(4):715–725.
13. Haines SJ, Walters BC. Evidence-based Neurosurgery: An Introduction. New York, NY: Thieme; 2006.
14. Haines SJ, Hall WA. Infections in Neurologic Surgery. Philadelphia, PA: W.B. Saunders; 1992.
15. Ojakangas CL, Ebner TJ. Purkinje cell complex and simple spike changes during a voluntary arm movement learning task in the monkey. J Neurophysiol. 1992;68(6):2222–2236.
16. Fu QG, Flament D, Coltz JD, Ebner TJ. Temporal encoding of movement kinematics in the discharge of primate primary motor and premotor neurons. J Neurophysiol. 1995;73(2):836–854.
17. Rustamzadeh E, Low WC, Vallera DA, Hall WA. Immunotoxin therapy for CNS tumor. J Neurooncol. 2003;64(1-2):101–116.
18. Hall WA, Truwit CL. Intraoperative MR-guided neurosurgery. J Magn Reson Imaging JMRI. 2008;27(2):368–375.
19. Burns TC, Verfaillie CM, Low WC. Stem cells for ischemic brain injury: a critical review. J Comp Neurol. 2009;515(1):125–144.
20. Lam CH, Hansen EA, Janson C, Bryan A, Hubel A. The characterization of arachnoid cell transport II: paracellular transport and blood-cerebrospinal fluid barrier formation. Neuroscience. 2012;222:228–238.
21. Andersen BM, Pluhar GE, Seiler CE, et al.. Vaccination for invasive canine meningioma induces in situ production of antibodies capable of antibody-dependent cell-mediated cytotoxicity. Cancer res. 2013;73(10):2987–2997.
22. Rockswold SB, Rockswold GL, Zaun DA, et al.. A prospective, randomized clinical trial to compare the effect of hyperbaric to normobaric hyperoxia on cerebral metabolism, intracranial pressure, and oxygen toxicity in severe traumatic brain injury. J Neurosurg. 2010;112(5):1080–1094.
An exciting and very interesting article about the history of the neurosurgery program at the University of Minnesota and its contributions to the field. It nicely describes the great strengths and significant struggles throughout its long history. This program experienced (and survived) great challenges from managed care—a good read for programs currently struggling with this issue.
D. Cory Adamson
Durham, North Carolina
This paper is interesting and extremely well written. The details regarding the rise and fall of the faculty numbers and the effect of external affairs on the Department are useful reflections of the course of neurosurgery in general as well as for specifics of the Minnesota program. The photos included are well done. We all profit from revisiting past triumphs and travails, and applying the lessons learned to current challenges.
Ann Marie Flannery