Picture4
[Curriculum]
[Childrens]
[Laboratory]
[Neurocritical Care]
[Parkland Chief]
[Parkland Junior]
[Neurology]
[Spine]
[Tumor]
[VA]
[Vascular Chief]
[Vascular Junior]
Children’s Curriculum
 
BASIC TOPICS SECTION
 
A. NEUROANATOMY
UNIT OBJECTIVES
Demonstrate knowledge of anatomy that is pertinent to the diagnosis of diseases of the nervous system and the practice of neurological surgery.
 
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
    Discuss the clinical presentation in anatomical terms of syndromes of the brain and its coverings including:
      epidural hematoma
      acute subdural hematoma
      chronic subdural hematoma
      subgaleal hematoma
      injury to innervation of the scalp
    Discuss the syndromes produced by mass lesions affecting the cranial nerves including:
      suprasellar lesions
      lesion of jugular foramen
      lesion of internal auditory canal
      lesions or distortion at the incisura
    Review the expected effects of stroke or mass lesion at different locations within the brain stem and cerebellum.
    List the expected effects of destructive lesions in the basal ganglia and cerebellum.
    Describe the expected effects of ischemic or destructive lesions of the white matter tracts of the cerebrum.
    Discuss the expected effect of destructive lesions of specific regions of the cerebral cortex.
    Review the clinical presentation of strokes in the distribution of the supratentorial cerebral blood vessels.
    Discuss the relationship of the spinal nerves to the vertebral level of exit.
    Diagram the structures comprising the boundaries of the spinal neural foramina.
    Discuss the clinical manifestation of injury for each of the major peripheral nerves.
    Describe the anatomy and presentation of common entrapment syndromes of peripheral nerves including:
      thoracic outlet syndrome
      carpal tunnel syndrome
      ulnar nerve entrapment syndrome at wrist and elbow
      anterior interosseous syndrome
      posterior interosseous syndrome
      meralgia paresthetica
      peroneal nerve palsy
      tarsal tunnel syndrome
    Describe the surgical exposure of common peripheral nerve entrapments including:
      carpal tunnel
      ulnar nerve at elbow
      ulnar nerve at wrist
      lateral femoral cutaneous nerve
      peroneal nerve
    Discuss the clinical presentation and neurological deficits associated with common lesions of and injuries to the spinal cord and nerve roots.
COMPETENCY-BASED SKILL OBJECTIVES:
    Identify at the time of surgery:
      occipital artery
      superficial temporal artery
      frontalis muscle
      pterion
      inion
      asterion
      coronal suture
      sagittal suture
      middle meningeal artery
      sagittal sinus
      transverse sinus
      foramen rotundum
      foramen ovale
      foramen spinosum
      superior orbital fissure
      jugular foramen
      internal auditory canal
      superior sagittal sinus
      sigmoid sinus
      incisura
      each cranial nerve
      each named cerebral artery and vein
      components of the brain stem
      named structures on the floor of the fourth ventricle
      Foramina of Magendie and Luschka
      cerebral peduncles
      components of the cerebellum
      cerebellar tonsils
      brachium cerebelli
      vermis
      major supratentorial gyri
      supratentorial lobes
      sylvian fissure
      central sulcus
    Identify at the time of surgery structures visible in the lateral ventricles including:
      Foramen of Monro
      fornix
      caudate
      thalamus
      choroidal fissure
      named veins
      glomus of the choroid plexus
      hippocampus
    Identify the parts of the vertebral column, spinal cord, and nerve roots at the time of surgery including:
      spinous process
      lamina
      superior facet
      inferior facet
      pedicle
      pars interarticularis
      uncovertebral joint
      neural foramen and nerve root
      nerve root ganglion
      disc space
      vertebral artery
      dorsal column and lateral column of spinal cord
      intradural afferent and efferent rootlets
 
 
B.   NEURORADIOLOGY
UNIT OBJECTIVES
Demonstrate an understanding of neuroradiological imaging and interventions as they specifically relate to neurosurgical patients.
 
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
Identify the common carotid and vertebral circulation congenital variants on angiograms.
    Recognize intracranial aneurysms on angiograms.
    Identify and characterize intracranial vascular malformations on angiograms. Recognize:
      arteriovenous malformations
      venous angiomas
      arteriovenous fistula
      feeding vessels
      draining veins
      associated aneurysms
      degree of shunting
    Discuss the angiographic evaluation of carotid and vertebral disease.
    Review the role of MR angiography and venography in the evaluation of cerebrovascular disease, neoplasms, and trauma.
    Describe the radiological evaluation of CNS vasculitis.
    Describe the radiological evaluation of spinal vascular malformations.
    Discuss the role of myelography in the evaluation of neurosurgical patients.
    Discuss the radiological evaluation of suspected CNS and spinal infection.
    Review MR neurography.
    Describe the appearance of peripheral nerve tumors on MR scans.
    Revie the role of radionuclide scans in the evaluation of patients with suspected cranial and spinal disease.
    Discuss the use of intraperative radiographs and fluoroscopy.
    List the indications for CT- and MR-guided biopsies.
    Describe the concepts of ultrasonography.
    Review the findings of normal and abnormal neonatal cranial ultrasound.
    Review the findings of normal and abnormal carotid ultrasounds.
    Discuss the use of transcranial doppler ultrasonography in the management of patients with subarachnoid hemorrhage, trauma, and occlusive vascular disease
COMPETENCY-BASED SKILL OBJECTIVES:
    Demonstrate the ability to accurately interpret carotid and vertebral angiograms.
    Demonstrate the ability to accurately interpret spinal angiograms.
    Demonstrate the ability to accurately interpret spinal myelograms and post-myelogram CT scans.
    Demonstrate the ability to accurately interpret cranial and spinal CT and MR scans of nontraumatic lesions.
 
 
C. PRACTICE MANAGEMENT, LEGAL AND SOCIOECONOMIC ISSUES
UNIT OBJECTIVES
Demonstrate an understanding of the principles of practice management and the business aspects associated with the delivery of health care.
 
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
    Discuss the ethical and moral factors associated with the practice of neurosurgery.
    Review the role of the neurosurgical leadership in the community and hospital setting.
    Explain the neurosurgeon's responsibilities in terms of health care cost containment.
    Review the features and relationships of the healthcare system including:
      treatment facilities
      third party payment systems
        Medicare
        Medicaid
        employer-provided insurance
        private insurance
      physician practice organizations
      medical equipment manufacturers
      pharmaceutical companies
    Recite the rules and regulations of the training hospital(s) as they pertain to the practice of neurosurgery in which the residency is performed.
    Name the institutional and social service agencies in your community and review their role in the overall management of neurosurgical patients.
    Demonstrate a knowledge of the rules and regulations of your State Medical Board.
    Discuss the concept of informed consent.
    Discuss mandatory reporting laws.
    Discuss issues pertinent to the topic of the impaired physician.
    Name and describe the local, regional, and national neurosurgical organizations including their purposes, roles, activities, and interactions.
    Discuss the importance of tracking morbidity, mortality, and patient outcomes.
    Review the career options available at the completion of neurosurgical residency in detail including:
      private practice
      academic practice
      subspecialty fellowship
      research
      administration
      military
    Discuss post-residency fellowship training program availability, application process, and career usefulness.
    Describe the types and characteristics of surgical practice organizations including:
      solo practice
      group practice
        partnership
        professional association
        corporation
      academic practice
      Health Maintenance Organizations (HMO)
        Preferred Provider Organizations (PPO)
        Individual Practice Associations(IPA)
        staff model (Kaiser-Permanente type)
      Federal
        Department of Veterans Affairs
        Military
        Public Health Service
    Discuss hospital payment systems (e.g., DRGs, per diem rates) and describe their incentives and how they affect hospital profitability.
    Discuss the role and influence of national quality oversight and review organizations for hospitals and health plans (JCAHO, NCQA).
    Discuss the history, changes, eligibility, funding, and problems associated with the Medicare program.
    Describe the Medicare program features, such as eligibility, funding, administration, federal-state relationship, benefits, and payment methods.
    Discuss federal funding of graduate medical education and how current federal budget allocations and proposals for changes in funding affect or will affect neurosurgical training programs.
    Discuss the significance of the following issues as they relate to the practice of neurosurgery:
      legislative/regulatory requirements
        Americans with Disabilities Act
        Clinical Laboratory Improvement Amendments (CLIA)
      Federal/professional regulatory institutions
        Health Care Financing Administration (HFCA)
        Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
        Occupational Safety and Health Administration (OSHA)
      miscellaneous
        affirmative action
        equal opportunity
        sexual harassment
    Discuss the common causes of malpractice actions and effective measures to reduce the risk of malpractice complaints.
    Describe the ways, means, and reasons physicians influence the political process at the national, state, and local level.
    Discuss the demographics of neurosurgeon distribution, numbers, workload studies, and workforce needs.
    Outline the requirements for certification by the American Board of Neurological Surgery.
    Formulate a strategy to evaluate personal and professional considerations in making a career choice.
    Appraise the importance of family involvement in making career choices, including geographic location.
COMPETENCY-BASED SKILL OBJECTIVES:
Demonstrate an ability to interact effectively, professionally, and respectfully with:
patients and their families
fellow residents
allied health care personnel
hospital staff
medical students
faculty physicians
referring physicians
Demonstrate the ability to maintain accurate and current medical records.
Discuss neurosurgical career options with:
faculty
peers
family
non-faculty neurosurgeons and other mentors
Accumulate information about post-residency career options.
Create and keep current a resume/curriculum vitae.
Record CPT codes for office visits and procedures performed on service.
Accurately document H&P and consultations according to the AMA-CPT E&M documentation guidelines.
 
 
 
NEUROSURGICAL CLINIC TOPICS SECTION
 
D. PEDIATRIC NEUROSURGERY
UNIT OBJECTIVES
Demonstrate an understanding of the anatomy, physiology, pathophysiology, and presentation of diseases in children which a neurosurgeon may be called upon to diagnose and treat. Demonstrate the ability to formulate and implement a diagnostic and treatment plan for these diseases.
 
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
Myelomeningocele and its Variants, Meningocele, Encephalocele, Chiari Malformations, Occult Spinal Dysraphism, Split Cord Anomalies, Segmentation Anomalies, Craniofacial Syndromes and Phakomatosis
    Review the embryology of the central nervous system (CNS) and its supporting structures.
    List the abnormalities a neurosurgeon may treat which are congenital/developmental in nature and classify them with respect to their embryology defect.
    Describe the incidence, epidemiology and inheritance patterns.
    State other disorders associated with this set of diseases.
    Describe the anatomic and pathophysiologic parameters which distinguish amongst these diseases.
    Develop a diagnostic treatment plan along with prognostication of outcome with optimal management.
    List disorders which may be referred for neurosurgical care but do not require surgery.
    Display current knowledge of the molecular basis for these diseases where known.
    Describe the expected outcome if treatment is not undertaken.
Hydrocephalus and Other Disorders of CSF Circulation
Describe the normal physiology of CSF.
Delineate the different etiologies of hydrocephalus and their relative incidence.
Explain how to differentiate between CSF collections which require treatment and those which do not.
Indicate the various treatment options for the management of hydrocephalus.
Distinguish between treatment options for hydrocephalus with normal CSF and contaminated (e.g. infection, blood) CSF.
List the complications associated with each treatment option for hydrocephalus and the diagnosis and treatment of same.
Differentiate between low-pressure and high-pressure hydrocephalus.
Describe the presentation and diagnostic approach to a patient with suspected shunt malfunction.
Define how the diagnosis of hydrocephalus is made.
List nonsurgical diseases which may be mistaken for hydrocephalus but require treatment different than surgery.
Review the causes of cerebral atrophy.
 
Neoplasia
    Delineate the differences between pediatric and adult tumors.
    List the common tumor types occurring in children and their typical location.
    Describe the changing tumor type and location based upon age.
    Identify lesions which require biopsy as part of the treatment/diagnostic plan.
    Describe the typical presentations of tumors.
    Describe appropriate evaluation for patients suspected of having a tumor.
    Classify tumor types as to degree of malignancy, role of surgical vs. nonsurgical therapy, and outcomes of optimal treatment.
    Discuss the possible complications associated with specific tumor types.
    Describe the pertinent anatomy for surgical treatment of midline or hemispheric cerebellar tumors and hemispheric cerebral tumors.
    Discuss appropriate preoperative management of patients with tumors.
    Compare the role of biopsy, subtotal resection and total resection in the management of tumors.
    List possible complications of the treatment options, their diagnostic evaluation and treatment.
Infection
    Describe the presentations of a shunt infection.
    List the indications for ventricular lumbar and subarachnoid CSF sampling.
    List the common organisms seen in shunt infections.
    Describe treatment plans for shunt infection.
    List risk factors and risks of shunt infection and the proper diagnostic protocol to establish the presence of a shunt infection.
    Describe common presentations of intracranial and intraspinal suppuration.
    List host risk factors which are associated with CNS infections.
    Describe appropriate diagnostic protocol to establish the presence of CNS infection.
    Discuss the timeliness and utility of surgical therapy for the treatment of CNS infection both shunt-related and non-shunt-related.
Other
    Delineate the various types of spasticity and movement disorders seen in children.
    List seizure types.
    Describe surgical lesions which may be related to seizures.
    Describe surgical and non-surgical treatment options regarding the alleviation of spasticity in children.
    Discuss the pathophysiology of craniosynostosis.
Cerebrovascular
    Delineate the possible causes of an atraumatic intracerebral or subarachnoid hemorrhage.
    Delineate the possible causes of cerebral infarction/ischemia.
    Discuss the common locations of arteriovenous shunts and their presentation, evaluation, and treatment (includes dural AVM).
    Discuss the embryology of the cerebral and spinal vasculature and its possible role in vascular anomalies in children.
    Describe the common locations and types of aneurysms seen in children and how they differ from those seen in adults.
    List the possible presentations of Vein of Galen aneurysms, their diagnosis and management.
    List the possible causes of aneurysms in children which are not congenital in nature.
    Describe the pathophysiology, treatment, and outcome of intraventricular hemorrhage in the neonate.
Trauma
    List the appropriate diagnostic tests to evaluate a children who has sustained multisystem trauma.
    Describe the Glasgow Coma Scale and its use.
    List the salient historical and exam features which lead one to the diagnosis of non-accidental trauma.
    Discuss the management of the cervical spine in a child who is comatose.
    Describe the anatomy of the child's spine which causes the epidemiology of spinal cord injury to differ from adults.
    Describe the common injuries seen as a result of birth trauma and discuss their diagnosis and management.
    Describe the use of antibiotics and anticonvulsants in CNS trauma.
    Review the evaluation and management of a child who has sustained a head injury with loss of consciousness but is now awake.
    Discuss the management of depressed skull fractures, both open and closed.
    Describe the diagnosis and management of spinal column injury.
    Discuss the diagnosis and management of spinal cord injury without radiologic abnormality (SCIWORA).
    Describe the intracranial pressure (ICP) compliance curve and discuss its utility in the management of head injury.
    List the parameters needed to decide on letting an athlete who has sustained a CNS injury return to activity.
    Discuss the concept of "brain death", its diagnosis and role in organ donation.
    Discuss the importance and interplay between ICP and cerebral perfusion pressure (CPP) in the management of head and spinal cord injury.
    Define the concept of "secondary injury".
    Discuss the role of invasive monitoring in all its forms in closed head injury (CHI).
Myelomeningocele and its Variants, Meningocele, Encephalocele, Chiari Malformations, Occult Spinal Dysraphism, Split Cord Anomalies, Segmentation Anomalies, Craniofacial Syndromes and Phakomatosis
    Enumerate the indications for surgery, surgical options and expected outcomes for each disease entity.
    Explain the indications for and utility of intraoperative monitoring.
    Describe appropriate timing of intervention and its rationale.
    Describe the pathophysiology and presentation of the tethered cord syndrome.
Hydrocephalus and Other Disorders of CSF Circulation
    Describe normal ICP dynamics and their relation to establishing a differential diagnosis of CSF flow disturbance.
    Define "slit ventricle system" and how it is diagnosed and treated.
    Define "brain compliance" and relate how that can affect ventricular size.
    List indications for and describe technique of accessing a shunt for CSF samples.
    List disease states which are commonly associated with hydrocephalus.
Neoplasia
    Discuss the differential diagnosis and evaluation of tumors located in the following areas:
      suprasellar
      pineal region
      intraventricular
    Discuss the treatment/diagnostic options for tumors in each location listed in #1 including surgical approaches.
    Describe the appropriate evaluation and treatment of patients with neoplastic processes associated with:
      neurofibromatosis
      tuberous sclerosis
      von Hippel Lindau
    Discuss the appropriate use of skull base approaches for specific tumor locations.
    List tumors which will require adjunctive therapy and describe those therapies and potential complications thereof.  
    Discuss the global management of tumoral hydrocephalus.
    Cite the long-term outcome and complications for treatment of the common cerebellar and supratentorial hemispheric tumors.
Infection
    Compare the differing patterns of infection as seen in immune-compromised patients to those with a functioning immune system.
    Discuss the sequelae of CNS infection, both shunt-related and non-shunt-related.
    List all acceptable treatment options for CNS infection with the pros and cons of each plan.
    Demonstrate an understanding of the different etiologies for subdural and epidural empyema and brain abscess and differing treatments thereof.
    Provide a complete differential diagnosis in regard to infectious disease for ring enhancing brain lesions.  
    Discuss the role of osteomyelitis in CNS infection.
    Differentiate radiographically between infection and tumor of bone.
Other
    Discuss variance in the surgical management of tumoral vs non-tumoral seizure foci.
    Discuss surgical options, indications and outcome for non-lesional approaches (e.g., callosotomy).
    Discuss various surgical options for the management of spasticity.
    Discuss preoperative evaluation and planning for seizure treatment.
    Discuss preoperative evaluation and planning for treatment of spasticity and postoperative management.
Cerebrovascular
    Describe the nomenclature for congenital vascular anomalies and what, if any, role inheritance plays.
    Describe the pathology, risk factors, diagnosis and treatment of moyamoya in children.
    List the phakomatoses which have vascular anomalies associated with them and their treatment.
Trauma
    Discuss the role of apoptosis in brain and spinal cord injury.
    Compare the utility of epidural, subdural, parenchymal, and intraventricular ICP monitoring.
    Differentiate between retinal hemorrhages and Terson's syndrome.
    Describe the role of electrophysiological monitoring in the management and prognostication of the CNS injured patient.
    Discuss the evidence for and role of steroid therapy in CNS injury.
    Discuss the prognosis and management of penetrating injuries to the brain and spine.
    Discuss the management of CSF leaks after head injury.
    Describe the diagnosis and treatment of a traumatic leptomeningeal cyst.
Myelomeningocele and its Variants, Meningocele, Encephalocele, Chiari Malformations, Occult Spinal Dysraphism, Split Cord Anomalies, Segmentation Anomalies, Craniofacial Syndromes and Phakomatosis
    Differentiate between the use of rigid and non-rigid skeletal fixation in the appropriate surgical setting for this group of disorders.
    Explain the rationale for surgical treatment of a symptomatic disease.
Hydrocephalus and Other Disorders of CSF Circulation
    Discuss the utility of expansion craniotomy in the treatment of hydrocephalus.
    Differentiate between ventriculomegaly, compensated hydrocephalus, and pseudotumor cerebri.
    Describe the pertinent anatomy of the ventricular system and prepontine cisterns.
    Describe the role of venous outflow obstruction in hydrocephalus.
Neoplasia
    Describe the pertinent surgical anatomy for approaches to tumors in the following locations:
      suprasellar
      pineal region
      intraventricular
    Discuss the role of endoscopic third ventriculostomy in management of tumoral hydrocephalus.
    Cite the long-term outcome and complications of all treatment options for tumors arising in the following locations:
      suprasellar
      pineal region
      intraventricular
    Discuss the utility of preoperative embolization and/or chemotherapy in the surgical management of specific tumors.
    Discuss the role of stereotactic radiosurgery in the management of selected tumors.
    Describe the presentations of hypothalamic hamartomas and the role of surgery in management.
    Describe options for CNS monitoring during surgical therapy and their efficacy.
    Discuss options for treatment and expected outcomes for recurrent tumors.
Infection
    Describe in detail the differential diagnosis, evolution and treatment options of an immune-compromised patient with a ring enhancing brain lesion.
    List the important aspects of the patient's history which may lead one to entertain the diagnosis of CNS infection, both shunt-related and non-shunt-related.
    List diagnostic tools, other than CSF culture, which are utilized to diagnose a shunt infection.
Cerebrovascular
    List the locations for traumatic vascular lesions and their risk factors, diagnosis, and treatment.
    Discuss management options and controversies in the treatment of vascular disease in children.
Trauma
    Discuss the potential complications and evaluation of comatose patients with skull base fractures.
    Discuss the utility of lumbar drains and expansion craniectomy and the removal of frontal or temporal lobe in the management of refractory elevated ICP.
    Describe the approaches to the management of traumatic ICH and its supporting data, both surgical and non-surgical.  
    List the vascular and endocrine complications seen after head injury.
    Discuss the long-term management of a child who has sustained CNS trauma including rehabilitation and neuro-cognitive issues.
    Discuss the management of peripheral nerve injuries in a child.
COMPETENCY-BASED SKILL OBJECTIVES:
    Perform complete history, physical examination and assessment on newborns, infants, and children.
    Interpret results of the physical examination, laboratory and radiological studies to arrive at a differential diagnosis.
    Perform subdural, intraventricular and lumbar punctures in children.
    Perform a shunt tap.
    Perform a twist drill or burr hole for subdural, parenchymal, or ventricular access or as part of a craniotomy.  
    Perform a craniotomy or craniectomy for evacuation of subdural or epidural lesion.
    Perform a craniectomy as part of skull biopsy.
    Perform craniotomy for elevation of depressed skull fracture.
    Place a ventriculoperitoneal, jugular, or pleural shunt.
    Revise a ventriculoperitoneal, jugular, or pleural shunt.
    Perform a cranioplasty with artificial material or homologous material.
    Perform a laminectomy in a patient with normal spinal anatomy.
    Position a patient for intracranial or intraspinal surgery.
    Demonstrate an ability to open and close cranial and spinal wounds to include dural opening and repair.
    Complete a sagittal synostectomy.  
    Close an open spinal or cranial neural tube defect.
    Repair an intracranial encephalocele.
    Perform the opening for a complex craniofacial repair.
    Perform the exposure for supratentorial and infratentorial lesions (excluding pineal, suprasellar and intraventricular locations).
    Perform the exposure for spinal exploration in a patient with abnormal spinal anatomy or reoperation.
    Evacuate an intraparenchymal hematoma.
    Accomplish endoscopic third ventriculostomy in uncomplicated settings.
    Apply and utilize frameless or framed stereotactic modalities for lesion location and shunt placement.
    Accomplish repair of a Chiari malformation.
    Accomplish an uncomplicated detethering procedure.
    Perform a cranial vault expansion.  
    Perform placement of baclofen type pumps.
    Perform spinal fusion without instrumentation.
    Apply a vagal nerve stimulator.
    Perform exposure for suprasellar, pineal and intraventricular lesion (including orbito-frontal, transcallosal and supracerebellar).
    Remove uncomplicated posterior fossa and supratentorial lesions.
    Repair complex tethered cords (e.g. lipomyelomeningocele, retethering, and diastematomyelia).
    Accomplish exposure for intradural spinal neoplasms.
    Utilize an endoscope to communicate trapped CSF spaces.
    Remove intracranial vascular malformation less than 3 cm in size and in non-eloquent brain.
    Perform placement of grids for seizure monitoring.
    Perform rhizotomy for spasticity.  
    Perform temporal lobectomy in an uncomplicated patient.
    Perform stereotactic biopsy of supratentorial lesion.
    Perform spinal fusion utilizing instrumentation.
    Accomplish endoscopic third ventriculostomy in uncomplicated settings.
    Assist with complex craniofacial surgery.
    Assist with a vascular procedure for moyamoya disease.

Last Updated Feb 2013