Field of work

Neurological disorders are disorders that affect the central nervous system (brain, brainstem and cerebellum), the peripheral nervous system (peripheral nerves – cranial nerves included), or the autonomic nervous system (parts of which are located in both central and peripheral nervous system). Neurologists also diagnose and treat some conditions in the musculoskeletal system.

Major conditions include:

* headache disorders such as migraine, cluster headache and tension headache
* epilepsy and seizure disorders
* neurodegenerative disorders, including Alzheimer’s disease, Parkinson’s disease, Lou Gehrig’s disease and ataxia.
* cerebrovascular disease, such as transient ischemic attacks, and strokes (ischemic or hemorrhagic)
* sleep disorders
* cerebral palsy
* infections of the brain (encephalitis), brain meninges (meningitis), spinal cord (myelitis)
* infections of the peripheral nervous system, such as botulism
* neoplasms – tumors of the brain and its meninges (brain tumors), spinal cord tumors, tumors of the peripheral nerves (neuroma)
* movement disorders such as Parkinson’s disease, chorea, hemiballismus, tic disorder, and Gilles de la Tourette syndrome
* demyelinating diseases of the central nervous system, such as multiple sclerosis, and of the peripheral nervous system, such as Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy (CIDP)
* spinal cord disorders – tumors, infections, trauma, malformations (e.g., myelocele, meningomyelocele, tethered cord)
* disorders of peripheral nerves, muscle (myopathy) and neuromuscular junctions
* traumatic injuries to the brain, spinal cord and peripheral nerves
* altered mental status, encephalopathy, stupor and coma
* Speech and language disorders

Educational Requirements

A neurologist’s educational background and medical training varies with the country of training. Typically it includes a medical degree, and some years of postgraduate training, often 3-5 years. In the US, neurologists follow the standard pattern with an undergraduate degree, four years of medical school, a one-year internship and three years of specialized training. Many neurologists also have additional training or interest in one area of neurology such as stroke, epilepsy or movement disorders.

Testing Examinations

During a neurological examination, the neurologist reviews the patient’s health history with special attention to the current condition. The patient then takes a neurological exam. Typically, the exam tests vision, strength, coordination, reflexes and sensation. This information helps the neurologist determine if the problem is in the nervous system. Further tests may be needed to confirm a diagnosis or find a specific treatment.

Clinical tasks

General caseload

Neurologists are responsible for the diagnosis, treatment, and management of all the above conditions. When surgical intervention is required, the neurologist may refer the patient to a neurosurgeon, an interventional neuroradiologist, or a neurointerventionalist. In some countries, additional legal responsibilities of a neurologist may include making a finding of brain death when it is suspected that a patient is deceased. Neurologists frequently care for people with hereditary (genetic) diseases when the major manifestations are neurological, as is frequently the case. Lumbar punctures are frequently performed by neurologists. Other neurologists may develop an interest in particular subfields, such as movement disorders, headaches, epilepsy, sleep disorders, multiple sclerosis or neuromuscular diseases.

The core neurological diseases that are the primary domain of neurologists are:

* demyelinating diseases of the central nervous system.
* the epilepsies
* headache and migraine
* movement disorders
* polyneuropathies
* spinal cord disorders
* genetic diseases with a primarily neurologic manifestation

Overlapping areas

There is some overlap with other specialties, varying from country to country and even within a local geographic area. Most stroke patients are seen only by specialists in internal medicine. Whether stroke patients should be seen primarily by neurologists is contested. Acute head trauma is most often treated by neurosurgeons, whereas sequela of head trauma may be treated by neurologists or specialists in rehabilitation medicine. Some cases of nervous system infectious diseases are treated by infectious disease specialists. Most cases of headache are diagnosed and treated primarily by general practitioners, at least the less severe cases. Similarly, most cases of sciatica and other mechanical radiculopathies are treated by general practitioners, though they may be referred to neurologists or a surgeon (neurosurgeons or orthopedic surgeons). Sleep disorders are also treated by pulmonologists. Cerebral palsy is initially treated by pediatricians, but care may be transferred to an adult neurologist after the patient reaches a certain age.

Relationship to clinical neurophysiology

In some countries, e.g. USA and Germany, neurologists may specialize in clinical neurophysiology, the field responsible for EEG, nerve conduction studies, EMG and evoked potentials. In other countries, this is an autonomous specialty (e.g. United Kingdom, Sweden).

Overlap with psychiatry

Although many mental illnesses are believed to be neurological disorders affecting the central nervous system, traditionally they are classified separately, and treated by psychiatrists. In a 2002 review article in the American Journal of Psychiatry, Professor Joseph B. Martin, Dean of Harvard Medical School and a neurologist by training, wrote that ‘the separation of the two categories is arbitrary, often influenced by beliefs rather than proven scientific observations. And the fact that the brain and mind are one makes the separation artificial anyway.’ (Martin JB. The integration of neurology, psychiatry and neuroscience in the 21st century. Am J Psychiatry 2002; 159:695-704)

There are strong indications that neuro-chemical mechanisms play an important role in the development of, for instance, bipolar disorder and schizophrenia. As well, ‘neurological’ diseases often have ‘psychiatric’ manifestations, such as post-stroke depression, depression and dementia associated with Parkinson’s disease, mood and cognitive dysfunctions in Alzheimer’s disease, to name a few. Hence, there is no sharp distinction between neurology and psychiatry on a biological basis – this distinction has mainly practical reasons and strong historical roots (such as the dominance of Freud’s psychoanalytic theory in psychiatric thinking in the first three quarters of the 20th century – which has since then been largely replaced by the focus on neurosciences – aided by the tremendous advances in genetics and neuroimaging recently.)

Most diseases affecting the kidney are not limited to the organ itself, but are systemic disorders. Nephrology concerns itself with the diagnosis of kidney disease and its treatment (medication, dialysis), and follow-up of renal transplant patients. Additionally, most nephrologists consider themselves to be expert in the care of electrolyte disorders and hypertension. Given that most renal conditions are chronic, nephrologists “grow with their patients”.

Patients are referred to nephrology specialists for various different reasons, such as :

* Acute renal failure, a sudden loss of renal function
* Chronic renal failure; another doctor has detected symptoms of declining renal function, often a rise in creatinine.
* Hematuria (blood loss in the urine)
* Proteinuria the loss of protein especially albumin in the urine
* Kidney stones
* Cancer of the kidney, mostly renal cell carcinoma but this is usually the domain of the urologist
* Chronic or recurrent urinary tract infections
* Hypertension that has failed to respond to multiple forms of anti-hypertensive medication or could have a secondary cause
* Electrolyte disorders or acid/base imbalance

Urologists are surgical specialists of the urinary tract. They are involved in renal diseases that might be amenable to surgery:

* Diseases of the Bladder and prostate such as malignancy, stones, or obstruction of the urinary tract.

Diagnosis

As with the rest of medicine, important clues as to the cause of any symptom are gained in the history and physical examination.

Laboratory tests are almost always aimed at: urea, creatinine, electrolytes, and urinalysis– which is frequently the key test in suggesting a diagnosis.

More specialized tests can be ordered to discover or link certain systemic diseases to kidney failure such as hepatitis b or hepatitis c, lupus serologies, paraproteinemias such as amyloidosis or multiple myeloma or various other systemic diseases that lead to kidney failure. Collection of a 24-hour sample of urine can give valuable information on the filtering capacity of the kidney and the amount of protein loss in some forms of kidney disease. However, 24-hour urine samples have recently, in the setting of chronic renal disease, been replaced by spot urine ratio of protein and creatinine.

Other tests often performed by nephrologists are:

* Renal biopsy, to obtain a tissue diagnosis of a disorder when the exact nature or stage remains uncertain.;
* Ultrasound scanning of the urinary tract and occasionally examining the renal blood vessels;
* CT scanning when mass lesions are suspected or to help diagnosis nephrolithiasis;
* Scintigraphy (nuclear medicine) for accurate measurement of renal function (rarely done), diagnosis of renal artery disease, or ‘split function’ of each kidney;
* Angiography or Magnetic resonance imaging angiography when the blood vessels might be affected

Therapy

Many kidney diseases are treated with medication, such as steroids, DMARDs (disease-modifying antirheumatic drugs), antihypertensives (many kidney diseases feature hypertension). Often erythropoietin and vitamin D treatment is required to replace these two hormones, the production of which stagnates in chronic renal disease.

When symptoms of renal failure become too severe, dialysis might be required. Please refer to dialysis for a comprehensive account of this treatment.

If patients proceed to renal transplant, nephrologist often monitor the immunosuppressive regimen and the infections that can occur at this stage.