Neurosurgery 101

How to specialize in neurosurgery

Brian Fiani, DO, a board certified Ivy League fellowship-trained neurosurgeon, shares the details that are essential to know before pursuing a neurosurgery specialty.


Neurosurgery is a competitive field with very high standards. The challenges and demand impose significant stress, but the rewards are abundant, and the patient impact is arguably among the highest of any specialty. While osteopathic medical students may recognize the importance of the neurological system and musculoskeletal system courses, not all might realize that becoming educated academically is only half the process. Neurosurgery requires substantial surgical prowess and technical capabilities in addition to significant mental and emotional strength.

Estimates of active neurosurgeons in the United States approximate fewer than 3,700 physicians in the specialty today. In 2022, there were 117 residency programs offering 240 new residency slots.

DO representation in neurosurgery is significant, yet DOs remain a minority in the specialty. Osteopathic neurosurgeons comprise only 2% of the U.S. neurosurgery population.

In terms of peer-reviewed research, osteopathic physicians represent fewer than 1% of authorship for studies published since 1944 in the Journal of Neurosurgery (JNS) Publishing Group journals (i.e., “Journal of Neurosurgery,” “Journal of Neurosurgery: Spine” and the “Journal of Neurosurgery: Pediatrics and Neurosurgical Focus”). This may be due to medical school research funding, emphasis on research during residency training or dual-degree programs.

The numbers

In 2022, the neurosurgery specialty had a total of 379 residency applicants for 240 open spots, breaking it down to 1.58 applicants per position. Of the 272 U.S. MD senior medical students who applied, 70 did not match for a 74% match rate. The number of DO fourth-year medical student applicants was 21, of which nine matched for only a 43% match rate.

When considering attributes that help an applicant’s chance of matching into neurosurgery, one should consider research, publications, presentations, work experiences and volunteer experiences. These are quantitative evaluations that don’t take into consideration the duration of the experience or its significance. The average matched applicant had 7.6 volunteer experiences, 3.6 work experiences, 6.6 research experiences and 25.5 abstracts, presentations and publications. Board scores are also an important factor.

Post-residency fellowships are optional. Fellowships in subspecialty training offers graduating residents additional training for competitiveness and skill refinement. Often, fellowships are chosen based upon the fellowship director and institution. Fellowships that are offered include:

  • Spine
  • Neuro-oncology
  • Neurotrauma
  • Cerebrovascular
  • Functional neurosurgery
  • Pediatric neurosurgery

Neurosurgery and osteopathic medicine

Neurosurgeons are involved with history-taking, physical examination, interpretation of radiographic imaging and diagnosis of patient illness. From there, the neurosurgeon is involved in pre-operative, operative and post-operative stages of the patient’s process.

Of note, pre-operative surgical planning is a very complex stage. Osteopathic philosophies help students understand the comprehensive nature of disease and prepare them to look for other causes or sources of symptoms. Our holistic approach can and should be applied. For example, a patient might have numbness in their feet with the appearance of a herniated disc on their lumbar MRI causing bilateral neuroforaminal stenosis, but one should also see if there are confounding factors such as diabetes that could cause foot numbness if the MRI is not very impressive.

Osteopathic manipulative medicine can be applied to patients, particularly in their recovery process, given many have long hospitalizations.

Neurosurgery is a critical specialty that involves taking care of patients in traumatic, emergent and intensive care scenarios. Helping patients make miraculous recoveries and improving their quality of life is a daily blessing. The field has plenty of job opportunities and carries an extraordinary level of prestige. Such rewards come at a great cost of time and dedication. Successful applicants fully dedicate themselves to neurosurgery and typically do not place emphasis on work-life balance. The specialty requires longer hours and more irregular hours than other specialties; applicants who place a high level of importance on work-life balance may want to reconsider choosing this specialty.

Q&A on pursuing neurosurgery

For students who are interested in neurosurgery, I’m including this Q&A to answer some of the most common questions about pursuing and working in this specialty.

What is neurosurgery?

Neurosurgery is specialty that diagnoses and treats disease of the central and peripheral nervous systems. Particular emphasis is placed on the brain and spine, though more areas of focus exist. Neurosurgeons work closely with other physicians to diagnose disease and collectively guide treatment in the management and care of patients.

Can DOs be neurosurgeons?

DOs can absolutely be neurosurgeons. Both DOs and MDs are equally qualified to apply for residency positions in neurosurgery.

Why should DO students consider exploring neurosurgery as a career?

Neurosurgery is a specialty that helps patients and their families in the most extreme circumstances. Quite often, patients are coming to neurosurgeons with life-altering problems that need to be addressed. There is an immense sense of responsibility to the patient and fulfillment for a job well done.

How can students position themselves to match into neurosurgery?

Exposure to neurosurgery is the first step. Completing formal neurosurgery rotations with hospital programs that have neurosurgery residencies is the only way to determine if a student wants to pursue learning more about this demanding specialty.

Spending time working with residents and attending neurosurgeons will provide exposure to operative cases and a glimpse into the specialty. During the rotations, one can ask to participate in research that often presents during the rotations, including rare cases that can produce case reports or presentations on research projects at conferences.

Character traits are important in the selection process. Students should be respectful with a strong sense of decorum, enthusiastically engaged and be able to showcase their knowledge as appropriate. Performing well on standardized testing will be objective criteria used to help applicants position themselves well to match.

How do you address misconceptions about neurosurgeons?

There are many misconceptions about neurosurgeons. Here are a few: That we are unfriendly or stoic and lack a life outside of work. I personally try to bring a smile and laugh to every encounter. Though work is demanding, if time is managed properly there is opportunity for adventures outside the hospital. For example, I work out twice daily and run marathons.

Why are neurosurgeons important in health care?

As a neurosurgeon, I spend most of my time seeing patients or in the operating room at the hospital. Any additional time is spent reading academic publications or writing peer-reviewed journal articles.

Organized neurosurgery is important, so I hold positions on several national committees that help determine and improve how patient care is delivered. Neurosurgeons are critically important in health care to treat patients with a variety of diseases and issues. Specific to brain pathology, neurosurgeons remove brain tumors, clip aneurysms and decompress the brain from traumatic hematomas or other compressive entities.

Decompression is a core tenet in neurosurgery. Taking pressure off of the brain or spinal nerves is a frequent objective. In spine surgery, I perform decompression of the spinal cord and nerves. Sometimes patients require fusion surgeries with instrumentation consisting of screws, rods, plates or other stabilizing hardware.

Related reading:

Nephrology and osteopathic medicine: Closer than we realize

Ophthalmology: What other specialties should know

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