Baclofen: Applications and how it works

Mr Sanj Bassi explains to us all about Baclofen pumps and what they can be used to treat.


As neurosurgeons we see a wide variety of patients with differing symptoms and diagnoses. In my practice I often see individuals with conditions such a cerebral palsy and increased spasticity. Spasticity can be quite disabling and have a significant impact on quality of life.


Anything that causes damage to part of the brain can increase spasticity such as cerebral palsy, stroke, head injury and multiple sclerosis. Increased spasticity causes the muscles to go into spasm which can be extremely painful and quite distressing for the individual. Left untreated the increased muscle spasms can have a considerable impact on daily activities including walking and using arms and legs.

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 In the treatment of these individuals there may be the option of implanting an intra-thecal Baclofen pump which delivers a drug directly to the fluid around the brain and spine. This drug is known as Baclofen. Baclofen is a relative of Diazepam and works as a muscle relaxant. In fact, it is known as a Gaba (neurotransmitter) agonist which provides negative (inhibitory) impulses to the muscles thus relaxing them.

Baclofen can be taken by mouth however only a small amount of the drug will go into the brain and spine and therefore oral Baclofen has quite limited benefits. If the dose of Baclofen is increased enough to improve the spasticity significantly, patients unfortunately suffer many side effects of the drug such as sleepiness and drowsiness.

Since 1998 it has been possible to deliver Baclofen directly into the brain and spine at a dose that is 1000 times less than that taken by mouth. This tiny dose of Baclofen is very effective in relieving spasticity and has none of the side effects of the oral version of the drug.


 The drug is delivered through a small pump which is the size of an iPhone 5. This pump is implanted in the fat of the tummy and a small tube (about the thickness of a pencil lead) is run from the pump into the spine. The operation to implant these is quite straightforward. The pump is then programmed by Bluetooth to deliver the drug continuously to the brain and spine thus improving the spasticity. The dosage can be changed and increased using the Bluetooth device.

The pump usually holds enough drug for about 4 months of treatment and then has to be refilled with the drug using a small needle. The refilling of the pump is probably very similar to having blood taken. These pumps have a limited battery life and usually need to be changed every 8 years.

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.

What is a pars defect?

Mr Nick Thomas explains about pars defects for us.

A pars defect is a condition affecting the lumbar (lower) spine. It affects an area of bone called the pars interarticularis. The pars interarticularis is a small segment of bone which joins the facet joints at the back of the spine. A pars defect means that the lower and upper portion of the vertebrae (spine bones) can become separated during repeated stress and strain. This can happen on one side (unilateral) or both sides (bilateral) of the spine. Although often asymptomatic it is the most common cause of lower back pain in adolescents (with the majority of cases being in 10 -15 year olds). The most common area of the spine this affects is the lower or lumbar spine specifically L5-S1 and L4-5.

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A pars defect is present it can lead to development of other conditions such as stress fractures or spondylolisthesis. Sometimes the upper vertebra slips forward relative to the lower one – this is referred to as spondylolisthesis. Neurological deficits are relatively rare with the most common symptoms being back pain and leg pain which limits the activity level of the patients.


Causes of a pars defect:

The break in the bone occurs due to undue pressure on the pars interarticularis which can be linked to activities which cause repeated stress and strain. These may include (but not limited to):

  • Gymnastics, athletics, diving due to hyperextension and/or extreme twisting.

  • Weight lifting, wrestling, tennis, dancing due to repetitive, forceful movements.

  • Pars defects can also be linked to degenerative changes in the spinal discs and facet joints, which occurs with age.


Treatments for pars defects:

If the pars defect is present without spondylolisthesis and neurological symptoms then rest, immobilisation of the area and time can heal the defect. Rest and proper healing are vital prior to returning to sport and other activities. Physical therapies can help with speeding up the recovery and can include back strengthening exercises and gradual return to sport.

If there is a spondylolisthesis, neurological symptoms and pain with the pars defect the treatment plan can be a little different. Whilst pain medications and physical therapies as well as exercises to gradually return to sport can help some may not heal or could have resulting neurological problems. These cases may require surgical intervention which include a decompression (to release and free up the nerves being compressed by the slippage) and spinal fusion (to stabilise the spine whilst the bone heals).


This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.

What are vertebral compression fractures?

Mr David Bell explains all about vertebral compression fractures, who gets them and how to go about treating them.

Vertebral compression fractures occur when the weight bearing, block-like part of the vertebra (spine bone) becomes compressed or squashed. These occur most commonly in the lumbar (lower spine) but can happen anywhere in the spine.

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How do we get vertebral compression fractures?

There are three possible causes of a vertebral compression fracture:

·      Osteoporotic: Osteoporosis is a disease of the bone causing reduced bone density. This may increase the chance of sustaining a vertebral compression fracture without trauma. The risk of osteoporosis and therefore vertebral compression fractures increases in women post-menopause.

·      Trauma: Usually the force needed to cause a vertebral compression fracture is fairly high. These often occur as a result of a fall from a height, landing feet first or road traffic accidents.

·      Pathological: Fractures occur as a result of pre-existing disease such as metastatic cancer but also other conditions such as osteomyelitis (infection of the bone) or Paget’s disease.


How do you know if you have a vertebral compression fracture?


There are a few possible symptoms of vertebral compression fractures which can include:

  • Pain – especially in the lower back.

  • Numbness, tingling and weakness – this can occur if the bony fragments from the fracture cause compression of the nerves at the fracture level.

  • Incontinence or urinary retention – this can occur if fracture fragments press on the spinal cord.

Vertebral compression fractures are diagnosed through imaging of the spine to look at the bones which may include and x-ray, CT scan or MRI scan.


How are vertebral compression fractures treated?

There are several treatment options for vertebral compression fractures:

  • Back brace

  • Rest and ice

  • Pain relief – including non-steroidal anti-inflammatories, muscle relaxants

  • Exercise – when signed off by the doctor to prevent further osteoporosis and strengthen the muscles in the back.

If the conservative treatments do not have the desired effect or the fracture is causing neural problems there are surgical options.

  • Kyphoplasty: A kyphoplasty is a minimally invasive procedure which aims to reduce or stop the pain caused by micro-movement in vertebrae often linked to a fracture. During a kyphoplasty the spine is accessed from the back via a small keyhole incision through with the surgeon passes a narrow tube. Positioning of the tube is confirmed and guided by x-ray images. The tube creates a pathway from the skin to the damaged vertebral body via the pedicle (part of the vertebra linking the front to the back). The surgeon inserts a special balloon through the tube into the vertebra and gently inflates it. As the balloon inflates it compacts the soft bone to create a void inside the vertebra. It may also partially restore the height of the vertebral body. The surgeon removes the balloon and injects a cement-like material into the void via the tube. The cement-like material (polymethylmethacrylate) hardens quickly once injected to stabilise the bone.

  • Vertebroplasty: A vertebroplasty is a minimally invasive procedure which aims to reduce or stop the pain caused by micro-movement in vertebrae often linked to a fracture. During a vertebroplasty the spine is accessed from the back via a small keyhole incision through with the surgeon passes a narrow tube. Positioning of the tube is confirmed and guided by x-ray images. The tube creates a pathway from the skin to the damaged vertebral body via the pedicle (part of the vertebra linking the front to the back). The surgeon removes the balloon and injects a cement-like material into the void via the tube. The cement-like material (polymethylmethacrylate) hardens quickly once injected to stabilise the bone.

  • Decompression to relieve pressure on the spinal cord by removing some bone from the back of the spine.

How to prevent vertebral compression fractures?

Many vertebral compression fractures are a result of osteoporosis therefore if the osteoporosis is prevented the risk of fracture is also reduced. So, how do we go about this?

  • Balanced diet with plenty of Calcium and vitamin D

  • Exercise particularly weight bearing exercise to help keep bone strength high

  • Quit smoking

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.


Deciphering the alphabet soup that is spinal fusion surgery!


One of our complex spine experts, Mr Irfan Malik, explains to us all about spinal fusion surgery and what all the acronyms mean.

What is a PLIF, what is a TLIF, what is an ALIF? What are all of these different spinal fusion options that are out there for patients? You can read about one then another but they all sort of sound and look the same, so what do they mean?

Spinal fusion is an operation to make two of the segments of the spine become one, to fuse the segments. The spine is made up of:

  • Bones which provide support

  • Discs which act as shock absorbers between the bones

  • Ligaments which hold it all together

  • Muscles which provide movement.

As we age, or sometimes through trauma, the discs become degenerative and start to cause a problem in the spine. This can result in back pain although this is usually accompanied by pain down the legs like sciatic pain and if this progresses it can result in a lack of or reduction in function in the lower limbs, so this could be a foot drop or could just be weakness in the legs but whichever one of these it is, it will need to be treated.

So how do we go about doing that?

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In the simplest way it could be a decompression which is just removing part of the bones at the back of the spine to free up the spinal cord and the nerves which is being affected. When a nerve becomes trapped or compressed, it can result in leg pain, weakness or numbness. If this progresses further sometimes more bone needs to be removed than a simple decompression which can cause the spine to become unstable. If this is the case the surgeon may have to add extra instrumentation into the spine to hold it in place whilst the bones grow and it becomes stable again. So this is where the PLIF, TLIF and ALIF comes in to play.

What is a PLIF, TLIF and ALIF?

A PLIF is a Posterior Lumbar Interbody Fusion. The easiest way to understand this is to break it down by each word and what happens in the procedure. The surgeon will approach the lower spine (lumbar) from the back (posterior), remove the disc (that is the interbody part – i.e. between the vertebral bodies) and replace it with a cage or a spacer to restore the disc height and allow space for the nerves to move again and be free. The fusion aspect comes from putting a screw in the level above and below the affected disc and holding them together in order to keep everything stable until the bones have grown around the edge and formed one spinal segment rather than two - the fusion part of the operation.  This can be encouraged by putting bone graft down in the lateral gutters or edges of the spine bones to encourage bone to grow more quickly whilst the screws are holding it steady.

A TLIF is just a different approach to the same operation. Instead of being called a posterior lumbar interbody fusion it is called a transforaminal lumbar interbody fusion. This means that the disc is usually accessed via one side (usually about 2 or 3 centimetres from the midline of the back rather than directly from the back) and is often accompanied with minimally invasive techniques meaning the operation is carried out through small stab incisions like keyhole surgery.

An ALIF on the other hand is an anterior lumbar interbody fusion where the disc spaces are approached through the anterior aspect (stomach) and a larger spacer is placed in to the disc space once the disc is removed. This is often accompanied with minimally invasive posterior fixation, from the back of the patient, as well.

The final option is an XLIF which is an extreme lateral lumbar interbody fusion. This is where the patient is placed on their side and the disc space is accessed directly from the side of the patient, past the iliac crest and on to the spine from the side. Again, this is often accompanied by screws in the back to hold everything in place until the fusion takes place.

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Recovery times vary from fusion to fusion and from patient to patient. It is hard to say exactly when a patient will fully recover but we usually expect patients to be going home within a couple days of surgery and to be getting back to normal activities within six weeks, but again this varies from patient to patient.

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.



ACDF? What is it and what does it mean?

We asked Mr Bell all about what happens when you get pain, tingling and weakness in your arms and hands, what it means and how to treat it.

What does ACDF mean?


ACDF stands for Anterior Cervical Discectomy and Fusion. To break it down - anterior refers to the front, cervical being the neck region of the spine, discectomy means cutting out the disc and fusion, joining two bones together. This is fusion surgery after removing the disc from the front of the neck (ACDF).


Why do people have ACDF surgery?

ACDF is usually in relation to radicular pain which is radiating from the neck, down the arms and in to the fingers. It is when one or more nerves in the neck are affected by a bulging or herniated disc and the disc is compressing the nerves to cause pain, weakness, tingling or numbness down the arms in to the fingers.


During surgery what actually happens?

An incision will be made in the front of the neck and the muscles, trachea (wind pipe), oesophagus (food pipe) and any other tissues in front of the spine will be moved to one side so the surgeon can see the spine bones and the discs. The offending level is then identified using X-ray guidance and the disc at that level is removed – this is the discectomy part of the operation. In place of the disc, a spacer or cage is put in which is filled with bone graft to encourage bone to grow from the level above to the level below, forming one motion segment – that is the fusion part of the operation.


In terms of recovery, patients tend to go home within a couple of days of the operation and recovery time is usually in the region of four weeks. There may be some stiffness immediately following the operation but this should ease up through keeping mobile and doing some exercises prescribed by the physio.

Postoperatively, patients will wake up in the recovery area and will be taken to the ward to be looked after for a couple of days before they return home. Sometimes hoarseness and sore throat or difficulty swallowing may occur in some patients but these symptoms should not continue for long.

Within a few days the patient should be able to return to daily activities without any strenuous activity and walking is encouraged with short distances building up. Using proper lifting techniques, good posture and an appropriate exercise programme whilst maintaining a healthy weight will all help with a speedy and successful recovery.

As with all surgery, this does carry risks and these should be discussed at length with your consultant prior to any decision.

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.

What is Trigeminal Neuralgia and why do you get it?

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Trigeminal neuralgia is a condition where the patient suffers excruciating pain in one side of the face.  The pain has been compared to electricity, or being stabbed in the face with a hot poker or a knife. Patients invariably say it is the worst pain they have ever experienced.  It is usually triggered by eating, soft touch, brushing teeth, shaving and cold wind blowing on the face.  It affects women slightly more frequently than men and usually starts between the ages of 40 and 70.  Patients often think the cause of their pain is dental and may sometimes have teeth extracted or treated without improving their symptoms.

Trigeminal neuralgia is mostly managed well with medication such as carbamazepine or oxcarbazepine, or indeed several others. However, these medications can have side effects including sleepiness, difficulty concentrating, forgetfulness or feeling off balance.

A significant group of patients will, however, find that their dose will need to be increased as time progresses.  When the medication becomes ineffective, or the side effects are so pronounced that the patient is unable to perform daily tasks then the patient may wish to consider other treatments such as surgery or radiotherapy. The aim of these further treatments is to try and keep the patient pain-free for as long a period as possible.

The surgical procedure is called a microvascular decompression.  This involves making a small hole in the skull behind the ear and lifting an artery off the trigeminal nerve. This has traditionally been performed using a microscope, but at London Neurosurgery Partnership we use an endoscope. An endoscope is a long thin cord with a light and camera on the end. This allows for a much smaller incision to be used and the procedure to be minimally invasive. Surgery is performed under general anaesthetic and usually lasts about 2 hours. Patients are generally in hospital for 2 to 5 days after surgery. The risks of surgery are potentially serious but fortunately rare. Seventy percent of people with a correct diagnosis of trigeminal neuralgia who undergo a microvascular decompression are pain-free 10 years after surgery.

Alternative methods of treatment include one of the percutaneous techniques; glycerol injection, radiofrequency rhizotomy or balloon compression. These involve passing a needle into the cheek and though a small hole in the base of the skull onto the trigeminal nerve. X-rays are used to guide the needle and are performed under sedation or general anaesthetic. These procedures work on the premise of deliberately damaging the trigeminal nerve to disrupt the pain signals.

  • Glycerol injections: Glycerol (performed at LNP) is then injected around the nerve. More than ninety percent of patients with trigeminal neuralgia will experience relief of their pain with a few days of the procedure. Most patients will wake up with numbness in the face but this gradually improves. 
  • Radiofrequency rhizotomy: The needle is used to apply heat to the trigeminal nerve.
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There is, however, a recurrence of pain in about 50% of patients over three years and for this reason the procedure is recommended in patients who are frail or may otherwise not tolerate the microvascular decompression. The injection can be repeated but is less likely to be effective and complications are slightly more common. The risks of the injection include persistent facial numbness, weakness of the jaw, infection/meningitis, injury to an artery resulting in a bleed or stroke, reactivation of herpes infection, anaesthesia dolorosa (a very painful and numb face which is very difficult to treat).

Finally, there is the option of radiotherapy to the nerve, called gamma knife. Like the percutaneous techniques, this is also a destructive procedure. Performed as a day case, a frame is fitted to the patient’s head and a very focused beam of radiation is targeted at the trigeminal nerve. This does not, therefore, involve any incisions or surgery to the head. There is a 30-40% recurrence rate of 3 to 4 years after the procedure. This is a useful treatment for patients with serious medical problems who might not be suitable for a microvascular decompression.

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.


Chiari Malformations: What are they and why do they occur?

We asked Mr Sanj Bassi, London Neurosurgery Partnership’s Chiari expert, to explain a bit about Chiari malformations, the different types as well as how and why they happen.

Chiari malformation refers to a condition in which some of the brain tissue (namely the cerebellar tonsils, cerebellum, brain stem and/or part of the fourth ventricle) extends into the spinal canal. This can happen when the skull is unusually small or misshapen so the brain tissue is pushed downwards into the spinal canal.

The concern is that the abnormal positioning of the brain can lead to a blockage of signals from the brain to the body or a build-up of cerebrospinal fluid in the brain or spinal cord. There may also be pressure of the brain on the spinal cord and brain stem leading to neurological problems. That said, many people with a Chiari malformation have no signs or symptoms so the condition goes unnoticed without need of treatment. The increased use of imaging tests has led to more frequent diagnosis, even without symptoms. However, symptoms can occur depending on type and severity of the Chiari malformation.

The Chiari malformation can be divided into three types, with Chiari I and II being the most common, although some doctors will include a fourth type within the classification:

Chiari I:

  • Although often asymptomatic, if these become apparent it is usually in late childhood/early adulthood.
  • Symptoms include an impulse headache (associated with increased brain pressure especially after coughing or sneezing), balance and vision problems, and if associated with a spinal cyst (syringomyelia) can cause poor hand coordination, difficulty walking and difficulty swallowing (syringobulbia).
  • These occur when a part of the back of the skull is too small or is deformed causing the brain to become cramped. Therefore, the lower part of the brain (cerebellar tonsils) are pushed into the upper part of the spinal canal.

Chiari II: 

  • This type often presents at birth and is always related to an open myelomeningocele/spina bifida (the backbone and spinal canal do not close properly prior to birth). A greater proportion of the brain extends into the spinal canal than in a Chiari I.
  • Symptoms can include changes in breathing, feeding/swallowing problems, quick downward eye movements and arm weakness.

Chiari III:

  • This is one of the more severe but also rare forms of Chiari where a portion of the back part of the brain protrudes through an opening in the skull called an encephalocele. Chiari III can be associated with neurological problems and is usually diagnosed at birth or in pregnancy.

How do you treat a Chiari malformation?

The treatment of Chiari malformation varies depending on the type and symptoms.

Asymptomatic Chiaris will likely be treated with nothing other than monitoring with regular examinations, follow ups and MRI scans.

Symptomatic Chiaris will usually be treated surgically. The aim of surgery is to stop the progression of symptoms and anatomical changes whilst hopefully having some positive impact on symptoms.

With a symptomatic Chiari I it is important to always treat the hydrocephalus first (often with a shunt – see hydrocephalus post). Following this a posterior fossa decompression may be done to remove a small amount of bone from the back of the skull to give the brain more space. In some cases, the surgeon may also remove a small section of bone from the top of the spine to give the spinal cord more room. Sometimes the covering of the brain and spinal cord (dura) may be thinned to allow the brain and spinal cord more space. These options would all be discussed but the aim of these procedures is to free the brain and spinal cord of compression.

It is important to note that there are risks and complications as with all surgery and it is imperative to discuss these with your consultant when deciding if surgery is the best option.

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.



What is a ‘slipped disc’?

A ‘slipped’ disc is a term we hear all too frequently but what does it actually mean?

Mr Ranjeev Bhangoo explains to us what exactly this means and how it might be treated.


The spine is made up of small bones called vertebrae. These stack on top of each other separated by intervertebral discs. The bones form a column or canal through which the spinal cord runs, these bones protect the spinal cord. The spinal discs act as shock absorbers and are made up of a tough fibrous outer layer (called annulus fibrosus) and a gelatinous inner core (nucleus pulposus).

The term slipped disc is used interchangeably with bulging disc, herniated disc, disc protrusion and prolapsed disc but there is not one single correct phrase. If anything, the term slipped disc can be a bit misleading as the disc itself doesn’t move rather some of the inner gel-like material can leak out if the outer layer develops a crack. So how does this happen? Most discs are well hydrated and the outer layer securely encases the inner gel. However, as discs get older and degenerate they become less hydrated, flatter and the outer layer can become more brittle. This means that it is more likely to let some of the inner gel leak out. This leakage can press on nearby nerves and irritate them causing symptoms such as pain in one of the legs – sciatic type symptoms.

So how is this treated?

There are several options for treatment and we start with the most conservative avoiding surgical intervention unless absolutely necessary. Usually the symptoms will settle down on their own within a few weeks. During this time, it is important to remain active, returning to work and normal daily activities.

Should the symptoms not settle then it is reasonable to consider medication in the form of Non-Steroidal Anti-inflammatory Drugs or neuropathic agents. If symptoms still do not settle down referral to a group exercise programme sometimes combined with a psychological programme can be very effective.

If all non-surgical treatment has proved ineffective or there is motor deficit such as weakness or numbness surgical options would include:

·      Injections

·      Radiofrequency ablation

·      Discectomy

·      Microdiscectomy

·      Laminectomy

·      Foraminotomy

·      Endoscopic discectomy 

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.

How do spinal injections work?

Why would you have a spinal injection?

Mr Richard Selway talks us through the different types and uses of spinal injections.

There are two types of spinal injections which we use:

·      To principally treat back pain

·      To principally diagnose and treat sciatic pain

Back pain injections

Usually back pain will originate from the facet joints. These are the joints at each segment in the back of the spine which articulate to allow the spine to flex, extend and bend as well as providing stability. These can become painful if they become ‘worn out’, arthritic or due to mechanical stress. This type of back pain is often characterised by pain being worse in the mornings or after a long period of sitting down, the back will feel very stiff. Long term this is treated with exercise, building core strength (including the Alexander Technique for optimum balance and posture), physical therapies as well as yoga and pilates.

Sometimes patients cannot tolerate these treatments due to the pain and in these circumstances facet joint injections can offer pain relief to give a window of opportunity to allow the patient to complete these treatments. In some cases, the back pain can return rapidly and repeatedly but the injections continue to provide relief. In these cases, patients can be considered for facet joint denervation. This is a slightly more invasive technique targeting the same area but for a longer lasting effect.


Injections for sciatica

These are generally called perineural injections, nerve root injections or transforaminal epidural injections. As a general rule these are given to patients with specific symptoms – pain down one leg linked to irritation of one nerve root commonly known as sciatic pain.

Often these injections can also be used for diagnostic purposes if there is any doubt from the MRI scan which nerve root is responsible for the pain. These injections are also useful to help alleviate severe pain to allow the patient to complete other treatments such as physiotherapy which may work long term to treat the sciatic pain but currently the patient is unable to do so due to the pain. Injections are a useful tool when trying to avoid open surgery but it is always worth noting nothing works for everyone so it is always a good idea to discuss all options with your consultant before making a final decision.

Spinal epidural injections can on occasion be used when multiple nerve roots are involved in the source of the pain. Again it is important to discuss this with your consultant.


This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.

What is hydrocephalus?

Hydrocephalus in its most literal sense means water on the brain. It affects 1-1.5% of the population. The brain and spinal cord are surrounded by cerebrospinal fluid (CSF). This fluid acts as a shock absorber, protecting the brain and spinal cord, as well as supplying nutrients to the brain. There are cavities in the brain called ventricles which also contain CSF.

An adult brain produces approximately 500ml of CSF per day but the brain only has capacity for about 125ml. The fluid is in a constant cycle of production, circulation and reabsorption into the blood. Usually, the brain keeps the balance of production and reabsorption of fluid so that there is a constant amount of fluid around the brain and spinal cord. Anything that disrupts this balance can cause too much fluid to be around the brain and this is known as hydrocephalus.

Hydrocephalus generally occurs if any one of the follow happens:

  • Too much fluid is produced
  • The circulation of fluid is blocked
  • Not enough fluid is reabsorbed

What causes hydrocephalus? There are several possible causes including:

  • Congenital – the child was born with hydrocephalus. This includes Chiari I and II malformation, Spina Bifida (often children with Spina Bifida will develop hydrocephalus), Dandy Walker Syndrome, aqueduct stenosis, rare X-linked disorders.
  • Acquired – develop after birth as a result of other factors including bleeding on the brain (linked with prematurity and intraventricular haemorrhage), tumours (colloid cyst, posterior fossa tumour, spinal tumour), infection (often as a consequence of meningitis).

Investigation and diagnosis: During the antenatal period the diagnosis can be made from an ultrasound scan of the baby whilst still in the womb. In all other patients a CT scan is mandatory and most patients will also have an MRI scan of the brain and spine.

Symptoms: The symptoms are partially linked to age:

  • In young children and babies, the child’s head may enlarge more so than the face, they may be irritable with poor head control, the veins on the scalp may be enlarged and they may develop the sun-setting sign (eyes tend to be looking downwards).
  • Older children and adults may develop a headache, nausea, vomiting and may become drowsy.
  • How can we treat hydrocephalus? If left untreated hydrocephalus can cause the child’s head to enlarge, the pressure on the brain to build up, it will interfere with development and may even, in severe cases, result in permanent brain damage. The treatment does depend on the cause of the hydrocephalus. For example, if it is caused by a brain tumour blocking the ventricles containing the CSF then removing the tumour may be the best treatment.

However, most patients with symptomatic hydrocephalus require a CSF diversion procedure. There are two options here; to reroute the fluid from the head to another body part or reroute to fluid flow in the brain.

  • Shunts: A shunt diverts fluid from the brain to another area of the body. Most commonly a tube is inserted into the ventricle this then attaches to a valve and runs into the abdomen. When the fluid volume in the brain increases the valve opens and fluid drains away, leaving the brain at normal pressure. There are different types of shunt available.
  • Endoscopic third ventriculostomy: In some (but not all) cases fluid can be rerouted within the brain without need for a shunt. During this procedure a new hole is made within the ventricle to bypass the obstruction causing the hydrocephalus and allow the free flowing of fluid around the brain. Whilst only certain patients are suitable for the procedure the general consensus is that third ventriculostomy has revolutionised the treatment of hydrocephalus for these patients.

As with any surgical procedure these do carry risks and it is always important to discuss these prior to any decisions.

Hydrocephalus is a relatively common and often complex problem to treat with treatments constantly improving with technological developments. The best management is, generally, with a team who specialise in the treatment of hydrocephalus.

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.

What is sciatica and why do you get sciatic pain?


Sciatica refers to a pain which radiates from the lower spine, through the buttocks and down the legs. This pain can range from fairly mild pain to excruciating debilitating pain. The medical term for sciatica is lumbar radiculopathy. It is a very common condition – most people have an 80-90% chance of experiencing back pain in their lifetime, 2-3% of these patients will go on to experience sciatica.

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Sciatic pain is due to irritation and/or compression of the sciatic nerve. The sciatic nerve is the largest nerve in the human body and runs from the lower spine on both sides of the body through the buttocks and into the back of the thighs. It travels all the way down to the foot and connects the spinal cord with the leg and foot muscles.


What are the symptoms of sciatica?

  • Very different from general back pain
  • Often described by patients as one of the worst pains imaginable
  • Most people find it hard to get comfortable in a position for more than 10 minutes
  • Pain radiating from the lower back running down the back of the leg (although sometimes pain is felt on the front of the leg as well)
  • Tingling and numbness
  • If patients have pain in both legs, weakness in legs or feet or a change in bladder and bowel function they should seek urgent neurosurgical opinion

What causes sciatica?

  • Sciatica is due to compression or irritation of the sciatic nerve
  • It often occurs when a disc in the spine “slips” and presses on the sciatic nerve
  • The disc usually slips to one side or the other pressing on the sciatic nerve as it exits the spinal canal

 How do we treat sciatica?

  • Initial conservative management is reasonable and can include:
    • Pain killers
    • Maintaining good posture
    • Maintaining acceptable weight
    • Exercises
  • Persistent sciatica may warrant surgical intervention following an MRI scan and examination. Surgery would involve removing the offending disc pressing on the sciatic nerve.

Medical studies have shown that 75-80% of patients are free of leg pain after surgery and 65-70% remain pain free after 5 years. Tingling and numbness may improve but is less likely to fully resolve.


This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.

Neurosurgical societies: Why do we have them?

What is SBNS? Why you might want to choose a surgeon who is a member?

Mr Bassi talks us through why these societies exist.


-   SBNS is the Society of British Neurological Surgeons. It is one of the oldest neurosurgical societies, being founded in 1926.

-   The aim of the organisation is the advancement of neurosurgery for the public benefit. This can be achieved through:

  • Improving education, knowledge and training among surgeons and other medical practitioners.
  • Advancing expertise, knowledge and understanding of neurosurgery for the relief of the suffering associated with neurological disorders.
  • Holding scientific meetings of the society to discuss publications arising from the work of its members.
  • Carrying out research to advance knowledge in the world of neurosurgery
  • Fostering professional relationships amongst neurosurgeons.

-   SBNS provides a forum where the neurosurgeons have a voice in an attempt to have some say in health policy, the future of neurosurgery, standardisation of teaching and training and setting of standards of care.

-   Much of the work has been based on patient safety and sustainability of practice. The SBNS is a vehicle where ideas can be floated, cases can be discussed and research undertaken for the communal good of enhancing British neurosurgery. **

Spine surgery: General aspects and considerations

-   Mr Gullan, our most senior spine surgeon, explains to us what London Neurosurgery Partnership’s patients can expect when undergoing spine surgery.

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Most spinal surgery is undertaken for the following reasons:

  • Patients have symptoms that have failed to settle on their own with help from simpler treatments such as painkillers, anti-inflammatory medications, physiotherapy and possibly injection procedures.
  • Severe symptoms or evidence the nerves in the lumbar spine are being damaged and need to be freed from being trapped and compressed.
  • There is a significant mechanical problem in the spine structure that needs surgical correction.

-   It is important to always remember that any surgery may result in complications or other problems and these have to be weighed up against the overall benefits of the procedure. This is something that you will usually discuss with your family, perhaps close friends, therapists, nurses and the surgeons treating you. It’s always wise to seek advice from your GP as well if you have any worries.

-   Almost all lumbar spinal surgery is undertaken under general anaesthetic, nearly always with the patient being gently turned, once they are anaesthetised, so they are face down to give access to the spine. Risks of full general anaesthetic vary from patient to patient because of variable medical health, age and fitness. Most patients today will have some form of pre-assessment by the surgical and anaesthetic team. It is obviously important to alert your surgeon and his team if you have any background ill-health that could potentially jeopardise your well-being.

-   The most important thing to remember is that the proposed surgery is being offered to try and help you. It is not a panacea cure for all aches and pains. Surgery inevitably carries some risk, but thankfully in modern practice this is usually very low indeed. The associated risks for your surgery can be found on the British Association of Spinal Surgeon’s website

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-   On a cautionary note it is sensible to be careful of relying too much on information so readily available on the internet. This is not always refereed well and may be misleading. Also, the information may not really be of relevance to the condition you suffer and can cause confusion. However, there is much available on the internet and some of this can be very helpful for patients if they wish to use this phenomenal information resource. Usually, the best person to speak to if you have any concerns or questions is your consultant. 

-   Surgery doesn’t always help and this is very disappointing for patients. However, it is not common that the surgery actually makes the condition “worse” but the operation discomfort and disruption are of course inevitable. 

-   When treating “pain” it is vital to understand that our perception of pain in our conscious mind is incredibly complex and influenced by numerous factors. Pain is a important sensation to protect us from injuring ourselves and our brain is capable of modifying our perception of this information instantly at any moment. Nerve cells in the brain like being activated and connecting with each other. They then seem to strengthen their connections by a process often called “Neural Plasticity” so that the connections and pathways become more efficient and quicker. This is why “Practice makes Perfect” when we learn things. Unfortunately nerve cells involved in the pain pathways will do exactly the same thing! As a result, the more one concentrates on the pain or leaves the stimulus untreated the more likely the pain pathways involved in the brain will become “perfected” and harder to reverse. Luckily with lack of practice these pathways may tend to lower their prominence and activity in our brain and the pain syndrome will begin to fade.


-   In consenting to go ahead with an operation it is essential you appreciate why it is being done, the potential benefits and risks and that it is in the end your decision. If you are uneasy or uncomfortable to proceed try and resolve this before coming into hospital for the operation. Luckily most procedures are not “absolutely essential” but being done to try and improve the quality of your life, frequently to try and reduce or get rid of miserable pain. This is obviously different to the situation where terrible consequences may occur, such as progressive neurological disability and paralysis, if the operation isn’t done. Don’t be frightened to ask for help in trying to feel reassured as much as possible that you are making the right decision before you go ahead.

-   Everyone accepts that patients can be terribly nervous about an operation, especially under general anaesthetic and on their spine! However, over anxiety may be quite easily overcome if you ask your team or GP to help and naturally it would be odd for anyone not to be at all nervous of an operation on their spine. Remember spinal surgery has helped thousands and thousands of patients over the years and saved many from awful pain and disability. The number of patients who have unfortunately been seriously damaged by operative interventions is thankfully extremely low and rare. Spinal surgical teams are always trying to improve techniques and operative care to try and keep any events to an absolute minimum, but we all know there is no such thing as “never” in medicine, or indeed life itself.

-   In some circumstances it may be wise to consider asking for a second opinion before proceeding and this can be helpful for patients and their immediate family. Decision making can be difficult at the best of times and surgeons frequently ask advice and help from their colleagues when dealing with complex cases where clinical issues or options of operative technique are difficult.

-   If you decide to proceed with spinal surgery all of us in the London Neurosurgery Partnership want your operation to go smoothly, calmly and without complication. Hopefully it will be a great success and help you significantly.

-   Learn more about the treatments London Neurosurgery Partnership offer here and learn more about the consultants at the next lecture the are speaking at 

What is functional neurosurgery?

What is functional neurosurgery? Professor Ashkan talks us through what functional neurosurgery means and how it works.

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-   We asked Professor Ashkan what it means to be part of the fascinating world of functional neurosurgery.

-   So, what is functional neurosurgery?! Traditionally surgery has been a process whereby you change the structure of the body for example if you have appendicitis you remove the appendix, if you have a very worn out spinal disc you take out the disc, you fuse it – ultimately, you’re altering the morphology or the anatomy of the thing you are performing surgery on to fix it.

-   But functional surgery is fundamentally different because you aren’t changing the structure of tissues. Instead you are trying to change the way they work – the function of the tissues. So, it is essentially using surgical techniques whereby you alter the functioning of the body. If you think about it functional surgery is a little more like medicine than surgery. If you take a drug you don’t alter the structure of the body but you do alter its function. For example, if you have thyroid problem you can take a drug and it corrects the abnormal function of that part of the body. If you think about it functional surgery sits at the borderline between traditional structural changing surgery and medicine. We are using surgical techniques to change function. So, you modulate the human function, brain or nervous tissue using electricity rather than chemicals – which is how the drugs work. It is a fundamentally different way of doing things than standard surgery.

-   In the context of functional neurosurgery, we use surgical techniques to correct the function of neural tissue – the nerve tissue. This could be changing the function of the brain which is the ultimate neural structure, changing the function of the spinal cord, the cranial nerves and the peripheral nerves. We can do all of those within the context of functional neurosurgery. An example of this could be Deep Brain Stimulation. This is a technique where we use electricity to change the function of the brain. Spinal cord stimulation is another example where you use electricity but this time to alter the function of the spinal cord. Occipital nerve stimulation uses electricity to change the functioning of the occipital nerve. There is also dorsal ganglion (a bundle of nerves) stimulation among many others.

-   These stimulations use electricity to change the function of the nerves and tissues to reduce pain, correct abnormal function and alter the behaviour of these tissues. This involves placing electrodes into the tissues and a battery into the body. These batteries generate electricity to deliver different types and intensities of electricity by altering the current, the voltage, the pulse width or the frequency. The clever bit here is the battery that can be programmed to deliver all sorts of different combinations of electricity to alter and correct function. The electrodes transmit this electricity to the point of interest in the brain, the spinal cord and the nerves.

- We hope this article gave you a little insight into the exciting world of functional neurosurgery.

-   Get to know Professor Ashkan a bit better and learn about his career to date.  and


What is an MDT and why do we need them?

What is a multidisciplinary team (MDT) and why do we use them?

Professor Ashkan explains all about MDTs and why they are so important to the medical world.

-   We are increasingly living in a world where not everyone can know everything. The body of knowledge and information available is growing. Therefore, no single person can know everything about everything! Because of that in the world of surgery, particularly something as complex as neurosurgery, we are becoming more and more subspecialised. This means that we are master of a specific area but not necessarily of the totality of any branch of medicine.

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-   As a result of this we need to work with our other colleagues who are the masters of their fields. This enables us to address all the needs of patients. For example, one of the fields I work in is neuro-oncology. The patients I see need a combination of treatments – it may be surgery, it may be radiotherapy, it may be chemotherapy or palliative care. These patients also have a wide range of investigations. These may be radiological, surgical or pathological to name but a few. As you can see I have already mentioned a number of specialist fields that these patients will need. So, to start we will need a surgeon, an oncologist, neuro-oncologist, radiologist, radiation-oncologist, pathologist, palliative care specialist, neurologist and that’s just the start. Almost all of these patients will need rehabilitation care as well so we would also need a physiotherapist, rehabilitation specialist, I could go on. What you can see though is the vast amount of knowledge needed to treat and look after these patients. Obviously, no one person can be the expert in all of these areas and it cannot be handled by just one person. Therefore, we bring together groups of these people who are the experts in their field meaning that the patient gets the holistic, complete, best quality care package for their treatment. These are called multidisciplinary teams (MDTs).

-   Another good example of the use of an MDT would be a spine MDT. Both complex and simple spine patients have a large number of considerations when it comes to how to best look after them and treat their symptoms. For some surgery might be the best solution whilst others non-operative management might be the most successful treatment pathway for them. Within a spine MDT we would normally see physiotherapists and pain specialist, spine surgeons, neurologists and radiologists to name just a few. Patients are discussed within the group to look at the best options for the patient – is it non-operative pain management, is surgery going to give them the best outcome, how is the rehabilitation going to be delivered? All these questions are answered with the patient’s needs at the forefront of discussion. A comprehensive spine MDT will have access to a psychologist because pain (like back pain and neck pain) will have consequences on the psychological wellbeing of the patient. Sometimes the pain can be made worse or the recovery reduced if the psychology of a patient is not optimized. So, this group meets to ensure every patient is offered the highest quality, holistic treatment pathway. 

Get to know the London Neurosurgery Partnership a little better...

Meet the consultants behind London Neurosurgery Partnership

London Neurosurgery Partnership comprises of 11 highly skilled surgeons, each an expert in their chosen field. Most have had wide reaching careers to date, both across the UK and internationally, leading to some pretty interesting lives behind the brains! We took 5 minutes out of each surgeon’s day to catch up with the men behind the scrubs!

Meet Ranj Bhangoo the secret pastry chef!

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-   What was the defining moment you decided to be a doctor? It was at the age of 5 when I saw a brain in the museum I decided at the moment I wanted to be a brain surgeon.

-   What do you enjoy most about being a neurosurgeon?  Working with a team of highly motivated colleagues to help patients and families with uncommon and often difficult to treat conditions that affect the most complex structure that we know of in the Universe

-   What is one fact that very few people know about you? When I was at medical school I co-founded a Classical Music Society that has gone on to become the largest festival of Indian Classical music outside of India, held annually at the Southbank

-   Outside of being a surgeon, what are you best at? Making pastry!

-   Who, within the field of Healthcare do you admire most? Anton Chekov, marrying medicine and literature with over a hundred physician characters in his literary career.

-   Away from all of this, how do you relax and switch off from the working day? Spending time with my family.


Get to know Richard Selway the marathon running chess player!

-    What was the defining moment you decided to be a doctor? My father was a GP and totally dedicated to his practice.  It was he who alerted me to the remarkable world of biological sciences and their application to the real human being. Once at medical school I realised that brain and spine functions were an area of immense interest where practical advances were achievable and treatments were always going to be specific to a specific person and problem.  No two brains or spines are the same so no two treatments will be identical.

-   What is one fact that very few people know about you? I was in the UK Archery Team and in 1986 was 7th in the World Championships.  I was first reserve for the Seoul Olympics in 1988.  Medicine took up too much of my training time and I had to give up once I qualified as a doctor but was team manager for the Barcelona Olympics in 1992. 

-   Surgery aside, what are you best at? Outside medicine, I’m a strong chess player.  Representing Kent in their first team and just short of Master level – but working on it. I run competitively, as a member of Beckenham Running Club; my fastest Marathon was 3hr 5 Minutes. 

-    Who, within the field of healthcare, do you admire most? Most admired doctor is Ignaz Semmelweiss – a Hungarian doctor who first promoted the concept of hand-washing to reduce infection.  It was not a popular idea at the time and many doctors regarded it as beneath their dignity to be told to wash their hands. However his persistence resulted in a massive reduction in infection and led on to Lister’s work on antisepsis.  I really care about infection in my patients and have made it a particular area of interest.  I have gradually changed my operative technique and preparations over the years to address all areas I can think of to reduce risk.  Semmelweiss reminds us that attention to detail and to apparently minor aspects can make a huge difference.

-   Outside of all of this, how do you relax and switch off from the working day? A game of chess or out for a run usually!


Meet Richard Gullan our resident golf pro!

-   What was the defining moment you decided to be a doctor? No single defining moment, but had a strong hankering to be a surgeon from mid-teens. Later realised that to be a good surgeon you have to be technically excellent but also a really good "doctor" in the most general sense. Those two qualities combined make the best surgeon.

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-   What do you enjoy most about being a neurosurgeon?  The work and range of surgery involved, from bold tissue handling to absolutely detailed microsurgery. Treating patients and the fact they entrust us to operate on their brain or spinal cord is a huge honour and great privilege.

-   What is one fact that very few people know about you? I am completely hopeless at cooking and have no knowledge of how to work washing machines and dishwashers. Can do by hand though and am excellent at drying up! Actually, I think too many people know this!

-   Outside of being a surgeon, what are you best at? Playing the violin and missing short putts.

-   Who, within the field of healthcare, do you admire most? Edward Jenner - saved more lives than any other single human being in the history of humankind.

-   How do you relax and switch off from the working day? Being happy at home and with family and friends, especially my incredibly tolerant wife, without whom I would starve!


Meet Chris Chandler – the one who can cook!

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-   What was the defining moment you decided to be a doctor?  Watching open heart surgery at The Health Pavillion at Expo 67 in Montreal. 

-   Outside of all of this, how do you relax and switch off from the working day? Getting some good music on and cooking up a storm!


Get to know the poet Christos Tolias

-   What was the defining moment you decided to be a doctor? In school I was fascinated by biology. Seeing closely a brilliant local doctor, who cared and spent time with his patients, was one of my first triggers.

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-   What do you enjoy most about being a neurosurgeon? The ability to approach areas of the human body that are very challenging to treat and achieving, against all odds, results. We admit patients that are in a coma and it always moves me when they return in clinic months later to tell me how grateful they are. Finally, the site of the human brain is still awe inspiring to me. I also relish the challenge of mastering the art.

-   What is one fact that very few people know about you? I write poetry

-   Outside of surgery, what are you best at? Husband, uncle, friend… I can do DIY and cook as well!

-   Who, within the field of healthcare, do you admire most? Those individuals who achieve their goals and remain humble and realistic. Some senior Neurosurgeons come to mind

-   Away of all of this, how do you relax and switch off from the working day? Spending time with my family, jogging is a passion, reading and watching movies. Also love long walks and playing with my dog, Oscar.


Irfan Malik

-   What was the defining moment you decided to be a doctor? I have wanted to be a doctor for as long as I can remember!

-   What do you enjoy most about being a neurosurgeon? The ability to really make a difference to patient’s lives. When the come to my clinic with crippling pain or unable to walk and I can help to change that makes me love this job.

-   What is one fact that very few people know about you? I used to be quite a good spin bowler!

-   Surgery aside, what are you best at? I love playing cricket but I don’t know if I’m that good at it!

-    How do you relax and switch off from the working day? I love walking, I go to the Scottish Highlands with my family – the scenery is so beautiful.


Meet David Bell – the karaoke star!

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-   What was the defining moment you decided to be a doctor? When my father’s business partner died of pancreatic cancer aged 43.

-   What do you enjoy most about being a neurosurgeon? The interaction with patients, the complexity and the variety of our work.

-   What is one fact that very few people know about you? I enjoy karaoke from the Great American Songbook!

-   Outside of being a surgeon, what are you best at? Golf

-   Who, within the field of healthcare, do you admire most? Atul Gawande, author and surgeon.

-   How do you relax and switch off from the working day? Time in the countryside with my wife and children.


Get to know Sinan Barazi

-   What was the defining moment you decided to be a doctor? When my dad told me that I wasn’t allowed to do PPE at Oxford, I had to do medicine – a very good choice in the end!

-   What do you enjoy most about being a neurosurgeon? The diversity of pathology and treatment options. Also, my colleagues who are much more friends than colleagues.

-   What is one fact that very few people know about you? I actually have lots of hair - I just choose the shave my head!!

-   Who, within the field of healthcare, do you admire most? I mostly admire the healthcare workers who work way beyond their contracted hours, who don’t make a big deal of it and who are unfortunately not given the recognition they deserve.

-   Outside of all of this, how do you relax and switch off from the working day? I run, cycle, read history and hang out with my kids!


Meet Sanj Bassi – 80’s music fanatic!

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-   What was the defining moment you decided to be a doctor? I spent quite a lot of time in hospital as a child. Seeing how the doctors worked and how they had an impact on their patients’ lives meant that I knew from about age 6 onwards that’s what I wanted to do too.

-   What do you enjoy most about being a neurosurgeon? The patient contact and interaction.

-   What is one fact that very few people know about you? I have encyclopaedic knowledge of 80’s music, particularly new romantic.

-   Outside of surgery, what are you best at? Losing in the annual Bassi family downhill skiing race to my four sons – even the 10 year old beats me now!

-   Who, within the field of Healthcare do you admire most? Vets – the greatest skill is to diagnose and treat animals who cannot vocalise their problems - one day it’s a parrot, next day it’s a dog!

-   How do you relax and switch off from the working day? Enjoyment of music including playing some tunes on the saxophone!


The piano playing salsa dancer - Professor Ashkan!

-   What was the defining moment you decided to be a doctor? Aged 5 when learned about how doctors could relieve pain and suffering from a family friend who then was a trainee doctor.

-   What do you enjoy most about being a neurosurgeon? It is a privilege to have the trust of others to place in my hand their most precious self, namely their mind and brain.

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-   What is one fact that very few people know about you? I did a music degree and diploma alongside my medical training!

-   Surgery aside, what are you best at? Music – listening to it, playing it and dancing to it!

-   Who, within the field of Healthcare do you admire most? Professor AL Benabid, the father of modern neuromodulation surgery. I had the honour of doing my fellowship with him almost 15 years ago before he retired from clinical practice in France. He is an amazing man who should be on course for a Nobel prize, a true human being and a gentleman.

-   Outside of all of this, how do you relax and switch off from the working day? I don't! Neurosurgery is my life and hobby so I don’t really see it as work!


Introducing Nick Thomas!

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-   What was the defining moment you decided to be a doctor? It was my father’s strong influence, he was a GP. I never ever considered any other profession from the age of 8.

-   What do you enjoy most about being a neurosurgeon? It’s always challenging and I learn every day. It is one of the best professions to teach oneself humility and humanity.

-   What is one fact that very few people know about you? I very much enjoy fly fishing.

-   Outside of being a surgeon, what are you best at? A family man and loyal friend.

-   Who, within the field of Healthcare do you admire most? I admire my colleagues who are constantly around to help. The job can be demanding so cohesive and collaborative work is crucial.

-   Outside of all of this, how do you relax and switch off from the working day? I enjoy time with family, friends, good conversations, good food and a nice glass of wine!


-   Want to get to know the London Neurosurgery Partnership better? Join us at a lecture that they will be speaking at next…

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