Sustainable Neurosurgery
Sustainable Neurosurgery is ripe for development, but before we look at it more deeply, let’s discuss sustainble healthcare in general.
The World Health Organization (WHO) defines sustainable healthcare as a system that maximizes the resources available currently to provide optimal care outcomes while minimizing the effect this will have on future healthcare. Healthcare as a whole, is a significant contributor to greenhouse gas emissions, with the WHO noting that if healthcare was a country, it would be the fifth largest greenhouse gas emitter. The United Kingdom and NHS England have made significant ground in recognising this burden and planning for appropriate action; with the NHS net zero plan looking to reduce carbon emissions in NHS England by 80% by 2028 to 2032 and become entirely net-zero by 2040. Scotland, Wales and Northern Ireland also share similar targets for net-zero healthcare.
The surgical field itself has been noted to be a significant contributor to greenhouse gas emission. The green surgery report notes that surgical operations across England account for 5.7 million tonnes of emissions annually. To put this number into context, NHS England states that the total carbon emissions across the whole of English Healthcare is 24.9 million tonnes and the total carbon emissions of the entire country is 384 million tonnes.
How is climate change impacting sustainable neurosurgery?
Neurosurgery has lagged behind other specialties in addressing and researching sustainability. Only one scoping review has been produced, consisting of five papers. One paper by Talibi et al. looks at the carbon emissions per neurosurgical procedure at the University Hospitals Coventry and Warwickshire NHS Trust (UHCW). The results offer an interesting baseline for discussion:
| Operation type | Number performed | Average carbon emission per operation (Kg/case) |
|---|---|---|
| Cranial tumour | 47 | 10.92 |
| Cranial operations (non-tumour related) | 40 | 8.00 |
| Spinal fixation | 7 | 11.43 |
| Spinal operations (non-fixation) | 60 | 9.00 |
| Injections | 18 | 5.93 |
| Muscle biopsies | 4 | 6.67 |
| Peripheral nerve operations | 24 | 8.15 |
These numbers only consider the carbon emissions caused by waste directly related to the operation. Including waste indirectly related to surgery, such as municipal wastes, sharps and transport, increased the average carbon emission per neurosurgical operation to 24.5 kg. In comparison, Rizan et al. calculated the average carbon emissions of all surgical operations at 173 kg. There are some important caveats to these numbers, as this 173 average is notably raised due to particularly heavy carbon emitting surgeries such as hysterectomies which emit 814 kg or surgically treated GORD at 1375 kg. When accounting for similar scale surgeries, neurosurgical operations look like they are on the higher end of carbon emissions caused by waste.
The barriers to improving sustainable neurosurgery
It is technically impossible to know how many neurosurgical operations happen throughout the country in a year as there is no centralised database for this within the UK. It is highly probable that different theatres will have different operating techniques and different carbon emissions through waste. The Green Surgery Report identified three major domains for surgical carbon emissions; anaesthetic gas use, consumable and waste and utilities/energy use. While UHCW have provided some insight into consumable and waste emissions of neurosurgery, the other two domains remain unresearched.
Neurosurgery operating times are on average longer than most surgeries with the average operation length being 197.30±113.71 and neurosurgery being 218.45±105.66. There is no research that has looked at the carbon impact of the anaesthetic gases used in neurosurgery, and with this being the biggest carbon hotspot in surgical operations a big question mark exists on the numbers provided thus far. Additionally, the long operating times typical of neurosurgery increase energy consumption, contributing both to carbon emissions and higher financial costs. Although the carbon intensity of electricity is gradually decreasing due to renewables, it remains significant, particularly as overall demand rises with the electrification of transport and other sectors. This domain is particularly challenging, as operations will always be necessary and some electricity use is unavoidable. However, there are opportunities to improve efficiency, especially in healthcare buildings and operating theatres, where energy use for heating, ventilation, and cooling can be reduced through standby modes and other efficiency measures outside of operating hours.
What can we do?
Sustainable Quality Improvement recognises four principles for promoting sustainable healthcare: 1) prevention of ill health, 2) patient self-care, 3) lean service delivery and 4) low carbon alternatives. Thinking about these principles in turn one can begin to develop a framework for thinking about promoting carbon reduction in sustainable neurosurgery.
Prevent illness
The goal of prevention has to be at the forefront of good health education. Several great pieces of work continue to be produced promoting social healthcare opportunities to prevent disease. This is particularly relevant for conditions that often require neurosurgery, such as head injuries, which are frequently caused by road traffic collisions, falls, or sports accidents, highlighting areas where targeted prevention could reduce the need for surgical intervention. Supplementing this is work that explores further management strategies pre-surgery. Though it would be naive to suggest that this would solve the matter entirely and the carbon effects of these other management strategies would need to be assessed. Earlier and more effective treatment would likely reduce the resource-intensive management of later intervention. Social determinants of health continues to be a growing field of research with recognised problems with tobacco, obesity and other growing fields such as environmental triggers including air pollution and climate change.
Patient self-care
Empowering patients to understand their condition and its management can help them play an active role in recognising and preventing complications, as well as engaging fully in rehabilitation. Patient self-care in neurosurgery tends to align alongside prevention of ill-health and this should be the primary goal of sustainable neurosurgery. Post-op there is growing scope for empowering patients and reducing follow-up visits. Early mobilisation, where appropriate, can also help reduce complications and shorten ITU or HDU admissions, supporting both patient recovery and carbon reduction goals. There is a great psychological component to surgical recovery and patient health. Both prehabilitation and post surgical psychological recovery are expanding fields of research and clinical practice should actively recognise and integrate the value of psychological recovery alongside physical recovery.
Lean services
Streamlining NHS practice across all specialities has been at the forefront of NHS England’s thought process. With growing waiting times and prolonged in-hospital stays, there is a need to explore streamlining processes for neurosurgery. At the time of writing, there are no identified frameworks or academic papers that look at streamlining the neurosurgery field in the NHS, though there is some work that has looked at neurosurgery centres in the United States, with promising preliminary results. Opportunities for the NHS could include reducing low-value investigations or treatments, condensing appointments to minimise patient travel and administrative burden, improving the efficiency of pre-operative assessments, and strengthening communication between multidisciplinary teams and organisations to create a more coordinated pathway of care.
Low-carbon alternatives
Sustainable healthcare is a rapidly growing area of discussion in healthcare. Neurosurgery has been slow in comparison to other surgical specialities to identify the need to discuss this. The lack of research in the UK and across the globe is worryingly naive and something the healthcare sector as a whole will need to address. It would be of great value if more neurosurgical centres could perform work similar to UHCW, either directly looking at waste and carbon emission or looking at the effects of anaesthetic gases in their centres. There is also scope to explore low-carbon alternatives within sustainable neurosurgery, such as selecting lower-impact anaesthetic techniques, opting for regional or total intravenous anaesthesia where clinically appropriate, and considering the relative carbon impacts of different imaging modalities or surgical techniques when clinical outcomes are equivalent (Green Surgery Report).
The first and most vital role of healthcare is to continue to promote and educate its workers about the impact of the healthcare sector on carbon emissions. This must not be in a condescending fashion but rather a collaborative effort to recognise this challenge and our collective roles in changing this. It has to be recognised that changes cannot be made overnight and collaborative efforts will be needed; but it requires dedicated individuals to create wholesale changes.
Introducing SusQI practices to assess potentially viable waste reduction management strategies such as reducing single use plastics or reusable/refillable supplies is a great initiative for centres to try. Relevant examples include the use of reusable theatre drapes and gowns, as well as rationalising surgical instrument sets to minimise unnecessary sterilisation and waste. Further relevant case studies and information about SusQI can be found on the SusQI website.
Your next steps
There are several places to start reducing carbon emissions. The Centre for Sustainable Healthcare (CSH) runs a comprehensive course that details the basics of sustainable healthcare and then provides connections and opportunities to develop strategies further. CSH has introduced great initiatives to employ in your personal lives or in your trusts or if you have interests or ideas of your own but are unsure about where to start.
For more information about the role of the NHS at large in sustainable practice, NHS England Greener NHS is a great place to start.
By integrating even a few of these small changes into daily practice, clinicians can help transform the future of sustainable neurosurgery – creating a field that is not only clinically outstanding but also environmentally responsible and resilient. The urgency could not be clearer: if healthcare professionals do not act now to reduce our environmental impact, the resulting climate and health crises will jeopardise the very care we strive to provide.