The training and experience of individual surgeons is a factor that must be considered on a case-by-case basis when deciding whether to perform a neurosurgical intervention in an austere environment. In some cases a prolonged evacuation may be preferred over intervention by an untrained surgeon, while in other cases, such as with host national casualties, evacuation is not an option and the deployed care available is the only option.

Since neurosurgical training is not standard training for the majority of general surgeons, the following recommendations have been established to allow general surgeons to better prepare for austere surgical missions. The main purpose is to establish a guideline that, per expert opinion, optimizes the benefit: risk ratio for injured patients cared for in the forward deployed, resource limited environment.

Recommendations for non-neurosurgeons to perform cranial procedures for specific clinical indications in austere environments include:

- Board certified/eligible general or head and neck surgeon.
- Participation in at least 10 cranial procedures supervised by a neurosurgeon. At least 1 of these procedures should occur within 1 year of scheduled deployment.
- Completed a cranial simulator course prior to deployment run by a board certified/board eligible neurosurgeon (i.e., Emergency War Surgery Course or ASSET+).

Training recommendations do not constitute a credentialing requirement. Individual surgeons may perform cranial procedures when the clinical situation, available resources, and analysis of the risks and benefits of both surgical and medical management favor surgical intervention.

In cases where a surgeon has not completed the recommended training, the risk of neurosurgical intervention may outweigh the benefit and medical management may be preferred.

For context and perspective, the minimum number of trauma craniotomies required to graduate a neurosurgical resident trainee is 40. The committee of subject matter experts suggest 10 for non-neurosurgeons in an effort to balance forward requirements with the necessary competency given the current training environment.

*Recommendations based on Consensus opinion American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Committee of Military Neurosurgeons, meeting 24 Apr 2017.*