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The Alksne Era

In 1971, the newly formed University of California, San Diego (UC San Diego) appointed Dr. John Alksne as Division Chief of Neurosurgery, launching the San Diego's only academic neurosurgery program. The academic program at UC San Diego has grown tremendously in the past five decades under the guidance of three chairs: Dr. Alksne, Dr. Lawrence Marshall, and Dr. Bob Carter. Neurosurgery at UC San Diego has been, and continues to be, home to innovative and pioneering research and is home to many well respected neurosurgeons and neurosurgical trainees. In this manuscript, a brief overview history of the Department is presented, which characterizes the tradition of service to the citizens of San Diego and the efforts of past and present faculty to push the frontiers of neurosurgical care.

 

The history of UC San Diego Neurosurgery is closely intertwined with the development of UC San Diego as a major public research institution and with the emergence of La Jolla as one of the nation's leading biotechnology clusters. Roger Revelle, the major force behind the formation of UC San Diego, described an early vision of UCSD as "something like" a publicly supported Caltech, with a great emphasis on science and research. Early recruits to the new University in 1960 including scientic luminaries such as Harold Urey, Nobel laureate in physics from the University of Chicago and David Bonner, a renowned geneticist from Yale set the tone of building a faculty that placed research at the pinnacle of academic endeavor. Thus, the undergraduate and graduate programs at the University of California, San Diego were founded on a rich scientic heritage that persists to this day.

Simultaneous with the University's founding, in 1960 the Salk Institute was gifted 27 acres adjacent to UCSD overlooking the Pacic Ocean. The Salk Institute, opened its doors in 1963 to become one of the nation's renowned institutes of research in the neurosciences and neurological disorders, genetics, and cancer biology. In the years ahead, both the Sanford Burnham Prebys Institute (1979) and the Scripps Research Institute (1980) consolidated operations on the Torrey Pines 'mesa' to create an internationally prominent nucleus of biologic research in La Jolla. It was in this scientic ferment, that the UC San Diego School of Medicine was founded in 1968 and in 1971 created a nascent Division of Neurosurgery.

The formal beginning of neurosurgery at UC San Diego began with the recruitment of Dr. John Alksne in 1971. Dr. Alksne received his medical degree and neurosurgical training at the University of Washington. Prior to arriving in San Diego, from 1964 to 1967, he served as Chief of Neurosurgery at Harbor General Hospital at UCLA. He also served as Professor and Chair of Neurological Surgery at the Medical College of Virginia from 1967 to 1971. His research on the stereotactic thrombosis of intracranial aneurysms, as well as the treatment andetiology for vasospasm was at the forefront of Dr. Alksne's clinical and laboratory research during his early years in San Diego. Some of his earliest work focused on using iron acrylics for the stereotactic thrombosis of surgically inaccessible intracranial aneurysms.  In hindsight, this research was pivotal because it foreshadowed the idea that aneurysms could be treated via alterations in flow dynamics as an alternative to microsurgical reconstruction, which is the basis behind modern endovascular coiling techniques.

Alksne later became well known for his clinical expertise in cranial nerve compression disorders.  Alksne's early task was to build both a faculty and a residency; he recruited two surgeon scientists as the rst faculty: Dr. Hoisang 'Ben' U from UCSF and Dr. Lawrence Marshall from Penn. In the model of a surgeon scientist that influences the Department today, U focused on cerebrovascular disease and basic science; he worked closely with colleagues in neuroanethesia including John Drummond to improve the safety of surgically resection of complex deeply seated arteriovenous malformations. Laboratory work included early papers discussing the role of EGFR ampli cation in glioblastoma and the development of gene therapy initiatives was Manuel Barbawho had been an early community advocate of establishing a formal training program to meet the neurosurgical needs of the San Diego community.

In order to meet the growing demands of the division, a formal neurosurgery residency was created. Dr. David Barba, whose father Manuel Barba was one of the fi rst neurosurgeons in San Diego, was selected as the fi rst resident of the program in 1980. Barba and Alksne's first paper together in 1984 on trigeminal neuralgia highlights the strong tradition of faculty/resident mentorship that is a hallmark of the UC San Diego program today. Barba spent a year as a research fellow at the National Institute of Neurological Disorders and Stroke (NINDS) working on the use of interleukins and thymidine-kinase mediated killing of brain tumors.[8] before returning to UCSD as a faculty member to develop the functional neurosurgery program.

After twenty five years as Division Chief, Dr. Alksne was tapped to lead larger academic initiatives within the institution. He was appointed dean of the UC San Diego School of Medicine in 1992, and was named Vice Chancellor for Health Sciences in 1994. Because of his new responsibilities he stepped down as Chief of the Division of Neurosurgery in 1994.

One specifi c initiative in the Alksne years that was an integral part of the educational program was the development of an integrated clinical and teaching program with the Kaiser San Diego hospital system. Initially, UC San Diego neurosurgeons provided the neurosurgical coverage to the Kaiser Permanente group. The Kaiser Permanente group later developed a fully independent division of neurosurgery, however, resident rotations and joint appointments of the Kaiser neurosurgery as voluntary faculty at the University has been an ongoing result of Dr. Alksne's early work.

 

The Marshall Era

 In 1995, Dr. Lawrence Marshall succeeded Dr. Alksne as Division Chief as Alksne became Dean of the medical school. Dr. Marshall had been initially recruited as an adult and pediatric brain tumor specialist from Philadelphia. Dr. Marshall received his medical degree from the University of Michigan. He completed his neurosurgical training at the University of Pennsylvania and spent a year as a research fellow at the Institute of Neurological Sciences in Glasgow, Scotland. He then went on to complete a fellowship in pediatric neurosurgery at the Children's Hospital of Philadelphia. Marshall led a major expansion in the research infrastructure of the Division,much of it focusing on developing a bench to beside laboratory at Hillcrest hospital, where UCSD's level 1 trauma center was situated. Several grants awarded to UC San Diego in the late 1970s paved the way for the designation as a comprehensive head injury program. This designation opened the door for numerous clinical trials on the treatment of traumatic brain injury. Additionally, UC San Diego was recognized as one of four centers in the country involved in the National Traumatic Coma Data Bank.   Information obtained from the data bank led to ground breaking discoveries in the categorization and treatment of traumatic brain injury. Along the same lines, under the guidance of Dr. Marshall, UC San Diego became one of the centers for the National Acute Spinal Cord Injury study. Many of the breakthroughs in medical and surgical management of traumatic brain injury were based on papers published from UC San Diego under Marshall's leadership with signicant inuence in larger literature. (Marshall's work has been cited over 27,000 times in the literature). The Marshall CT classication has become a staple of neurosurgical practice, and has been adopted extensively in the literature as a means of grading head injury

Marshall's pioneering work in intracranial pressure monitoring and the use of medical therapy for reducing intracranial pressure has been instrumental in our understanding of TBI. Many of the strategies developed at UC San Diego to manage complicated intracranial hypertension are still in use today. For example, work done in the 1970s by Dr. Marshall using barbiturate coma for severe head injury is utilized throughout the world in the management of patients with poorly controlled intracranial hypertension. Dr. Marshall was also one of the key investigators of the National Acute Spinal Cord Injury Study. Although controversial, work looking at methylprednisolone compared to naloxone or tirilazad mesylate has helped a generation of investigators think about spinal cord injury, and its treatment in new and exciting ways.

In addition to Dr. Marshall's clinical and research efforts he also became chairman of the Executive Committee of Clinical Practice, Associate Dean of Clinical Aairs in 1986, and CEO of the UC San Diego Medical Group in 1986, as well as Executive Director of UC San Diego's managed health care plan.

The Division expanded substantially during Marshall's tenure as Division chief. One focus was in the domain of spinal neurosurgery. William Taylor, who trained with Dr. Paul McCormick at Columbia in spine surgery led the development of a major initiative in minimally invasive spine surgery with a focus on lateral approaches. Taylor worked closely with the San Diego biotech environment to bring several innovations related to intraprocedural neurological monitoring to clinical use. In the domain of spinal neurosurgery, Marshall also recruited Dr. Joseph Ciacci, who had a special interest in complex spinal reconstruction for traumatic and degenerative diseases. Ciacci later teamed with scientists at the Sanford Stem Cell Initiative, collaborative joint venture between Salk, UCSD, the Sanford Burnham, and the TSRI to develop UCSD's rst phase one clinical trial in the country for the direct injection of stem cells into adult patients with chronic spinal cord injury.  In 2009, after 15 years of service as Division Chief, Marshall elected to step down and a national search for a new neurosurgery Chair was undertaken, led by Dr. Mark Talamini, Chair of the Department of Surgery and David Brenner, Medical School Dean.

 

The Carter Era

Dr. Bob Carter was recruited from Massachusetts General Hospital and Harvard Medical School to UC San Diego. Dr. Carter received his MD and PhD degrees from Johns Hopkins School of Medicine and Public Health. His neurosurgical training was completed at Massachusetts General Hospital. He remained on faculty at Harvard and MGH until coming to San Diego in 2010. Dr. Carter had published extensively in the academic literature on the topics of gene therapy and CAR T-cells as treatment for glioblastoma and outcomes research in cerebrovascular and cranial neurosurgery. His work on exosomes, nano-sized vesicles secreted by glioblastoma cells, has re-shaped the development of diagnostic biomarkers for brain cancer patients. Carter's background as both a scientist and surgeon were uniquely suited to the UC San Diego environment.

An early task for Carter was to prepare the Division to become an Department. Historically, the neurosurgery service had been a Division in the Department of Surgery. This worked well for many years but the time was ripe for change with the planned expansion the Neurosurgery service line.  Carter's task initially was to grow the service and prepare for this change. It was clear the recruitment of new faculty would be important in several of the clinical domains. Neurosurgical oncology, neurovascular clinical care, and neurocritical care were early needs. In rapid order, new faculty including Doctors Clark Chen and Justin Brown, Dr. Alexander Khalessi, and Dr. Andrew Nguyen were recruited with the goal of expanding the faculty.  Each new faculty member has made major programmatic contributions to building towards a new department.

Additional recruits including Drs. Scott Olson, Jeffrey Pannell, Howard Tung, David Gonda, Sharona Ben Haim, and Pamela Jones have now come on board as the service has continued to expand to a faculty of 23.  Drs. Ben-Haim and Jones have the distinction of joining the Department as the first two women on the faculty of the Department of Neurosurgery. 

The creation of Jacobs Medical Center afforded the Department an opportunity to envision the 'operating rooms' of the future. In 2010, as Carter was arriving to be the Chair, the plans for Jacobs Medical Center were on the verge of being developed. An intraoperative MRI scanner was to be included in the plans. Carter worked closely with Carlos D'Amato, project architect, to describe the types of surgical procedures of the future, those that would be guided by real time image based information in both the MRI and CT modalities. With Amato's ability to translate the Neurosurgery team's vision into architectural reality, plans were soon drawn up. This suite will consist of an intraoperative 3.0T MRI that runs on a ceiling mounted rail between two ORs, with a 'garage' at the center that can be used for diagnostic imaging when the magnet is not in use for a surgery. Across a shared control room, two additional ORs are congured on either side of 64-slice mobile CT housed in another garage.

With the opening of the Jacobs Medical Center in November 2016, a new state of the art operating environment to train the next generation of neurosurgeons at UC San Diego is now available.  The Department continues to view the training of leaders in Neurosurgery as a core value, while bringing the best of Neurosurgical care to the citizens of San Diego.