Picture4
[Curriculum]
[Childrens]
[Laboratory]
[Neurocritical Care]
[Parkland Chief]
[Parkland Junior]
[Neurology]
[Spine]
[Tumor]
[VA]
[Vascular Chief]
[Vascular Junior]
Parkland Junior Resident 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.
 
General
    Review the  embryological development of the brain, cerebellum, brain stem, glial  elements, spinal cord, conus medullaris, cauda equina, sympathetic and  parasympathetic systems and the peripheral nervous system.
    Discuss the embryologic development of the skull, craniovertebral junction, and spine.
    Describe and differentiate the different types of neurons.
    Discuss the microanatomy of the neuron including the:
      cell body
      dendritic process
      axonal process
    Diagram and describe the microanatomy of the synapse.
    List the microglial elements and review their microanatomy:
      astrocytes
      oligodendrocytes
      microglia
      ependyma
      choroid epithelium
    Diagram and  describe in detail the carotid and vertebral arteries and their branches which provide blood supply to the face, scalp, skull, meninges, brain,  brain stem, cerebellum, and rostral spinal cord.
    Discuss in detail the arterial blood supply to the spinal cord. Include in the  discussion the spinal and radicular arteries and the concept of  watershed ischemia.
    Identify and review the venous drainage of the central nervous system.
    List and identify the bones of the skull.
    Describe each of the sutures of the skull.
    Identify each named foramen of the skull and list its contents.
    Describe the anatomy of the meninges including the:
      dura mater
      arachnoid mater
      pia mater
    Describe the anatomy of the dura including the falx cerebri and tentorium.
    Review the layers of the scalp and discuss its innervation.
    Diagram the cerebral ventricles.
    Discuss the major arachnoid cisterns.
    Review the anatomy of the arachnoid villi.
    Discuss the anatomic correlates pertinent to the production, flow, and reabsorption of cerebrospinal fluid.
    Identify and describe the gross anatomy of the spine including:
      atlas
      axis
      subaxial cervical vertebrae
      thoracic vertebrae
      lumbar vertebrae
      sacrum
      coccyx
      intervertebral disc complex
      supporting ligaments of the spine
    List the muscles related to the skull and spine.
    Describe the gross anatomy of the neck.
    Discuss the anatomical basis for the blood-brain barrier in detail.
Central Nervous System
    Describe the gross anatomy of the brain, brain stem, cerebellum, cranial nerves, and spinal cord in detail.
    Describe the anatomy of the cerebral cortex in detail including:
      cortical layers
      sensory areas
      motor areas
      prefrontal cortex
      fiber tracts
      calcarine cortex
    Describe the anatomy of the olfactory pathways, hippocampal formation and amygdala in detail including:
      rhinencephalon
      olfactory pathways
      anterior commissure
      hippocampal formation (including cytoarchitecture)
      amygdala
      limbic system
    Describe the anatomy of the corpus striatum in detail including:
      striatum
      globus pallidus
      claustrum
      subthalamic region
      striatal afferent and efferent connections
      pallidal afferent and efferent connections
      pallidofugal fiber systems
    Describe the anatomy of the hypothalmus and pituitary in detail including:
      cytoarchitecture of the hypothalmus
      afferent and efferent connections of the hypothalmus
      supraoptic nuclei and tracts
      hypophysial portal system
      anatomy of the pituitary stalk
      anterior and posterior pituitary
      cellular organization of the anterior pituitary
      hormonally active cells of the hypothalmus and pituitary
    Describe the anatomy of the diencephalon in detail including:
      midbrain-dienencephalon junction
      caudal diencephalon
      epithalamus
      thalamus (including nuclei)
      thalamic radiations
      internal capsule
      visual pathways
    Describe the anatomy of the cerebellum in detail including:
      cerebellar cortex including organization
      deep cerebellar nuclei
      cerebellar connections
      cerebellar peduncles
    Describe the anatomy of the mesencephalon in detail including:
      superior colliculus
      inferior colliculus
      pretectal region
      posterior commissure
      mesencephalic nuclei
      oculomotor nerve
      tegmentum
      mesencephalic reticular formation
      substantia nigra
      crus cerebri
      ascending and descending tracts
    Describe the anatomy of the pons in detail including:
      vestibulocochlear nerve
      facial nerve
      abducens nerve
      trigeminal nerve
      ascending and descending tracts
    Describe the anatomy of the medulla in detail including:
      olivary nucleus
      medullary reticular formation
      cranial nerves of the medulla
      ascending and descending tracts
    Review the  location and connections of each cranial nerve nuclei. Trace the course  of each cranial nerve from nucleus to end organ termination.
    Describe the external topography and landmarks of the fourth ventricle.
    Describe the anatomy of the spinal cord in detail including:
      nuclei and cell groups
      cytoacrchitectural lamination (Rexed laminae)
      somatic and visceral efferent neurons
      posterior horn neurons
      descending tracts
      ascending tracts
      upper and lower motor neurons
      somatotopic organization
Autonomic Nervous System
    Distinguish pre- and postganglionic neurons.
    Describe the sympathetic nervous system.
    Describe the parasympathitic nervous system.
    Review the visceral afferent fibers.
    Describe the structure of the autonomic ganglia.
    Discuss the central autonomic pathways.
Peripheral Nervous System
    Differentiate between segmental and peripheral innervation.
    Diagram the anatomy of the spinal nerve root.
    Diagram and discuss the cervical, brachial, and lumbosacral plexi.
    Outline the anatomy of the major peripheral nerves of the upper and lower extremity including:
      axillary
      suprascapular
      median
      ulnar
      radial
      long thoracic
      musculocutaneous
      lateral femoral cutaneous
      femoral
      obturator
      sciatic
      saphenous
      peroneal
      tibial
    Describe the microanatomy of the peripheral nerves in detail.
    Explain the difference between myelinated and unmyelinated nerves.
    Review the anatomy of the Schwann cell.
    List the peripheral afferent receptors and describe the anatomy of each.
    Segregate peripheral neurons by size and explain the rationale for such a classification scheme.
Muscle
    Explain the concept of the motor unit.
    Describe the anatomy of the motor end plate.
    Describe the microscopic anatomy of striated and smooth muscle.
    Discuss the subcellular components of muscle.
 
 
B.  NEUROPHYSIOLOGY
UNIT OBJECTIVES
Demonstrate knowledge of physiology that is pertinent to the understanding of neurological disease.
 
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
Review the basic biology of the nerves including:
synthesis and movement of proteins in the nerve
membrane potential and membrane properties
ion channels
generation and conduction of an action potential
Discuss synaptic transmission including:
types of synaptic transmission
transmitter release
nerve-muscle transmission
chemical messengers
direct gated receptors
second messenger linked receptors
Describe the physiology of the sensory systems including:
sensory receptor physiology
anatomy of somatic sensory system
coding of modality specific sensory information
pain and analgesia
cortical integration of sensory perception
visual system
processing of information in the retina
processing of vision in the central visual pathways
columnar units of visual cortex
processing in the geniculate nucleus
visual perception of motion and form.
auditory system. Within this description review the processing of hearing in the cochlea and the central auditory pathways.
olfaction and taste
Discuss the physiology of the motor system including:
mechanisms of muscle contraction
muscle receptors, spinal reflexes
spinal reflexes concerned with position
brain stem reflexes controlling motion
vestibular nuclei control of movement and posture
red nucleus control of movement
cortical control of movement
cerebellar control of movement
regional and cellular organization of the cerebellum
functional divisions of the cerebellum
the role of the cerebellum in planning movement
basal ganglia
the anatomy of basal ganglia pathways
neural transmitters in the circuits within the basal ganglia
thalamus
Describe the attributes of the autonomic nervous system including both the sympathetic and parasympathetic systems.
Review the physiological basis of arousal and emotion. Include within this review the:
noradrenergic systems
limbic system. Include within this review the physiologic basis for emotion and memory
sleeping and sleep states
reticular activating system
Describe the higher cortical functions including:
anatomy of language
function of association cortex
Describe the physiological basis for cerebrospinal fluid production and reabsorption.
Review the physiological control of the cerebral vasculature.
Discuss, in detail, the physiology of the hypothalamus and pituitary, particularly as related to endocrinology.
 
 
C.  NEUROPHARMACOLOGY
UNIT OBJECTIVES
Demonstrate knowledge of pharmacology that is pertinent to the treatment of  neurological disorders and diseases which affect the nervous system.
 
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
    Review basic cellular neurotransmission. In the course of this review discuss:
      the synapse
      membrane potentials
      ion pumps
      ion channels
      transmitter secretion
      transmitter identification
    Define and discuss receptors and receptor pharmacodynamics including:
      receptor classification
      receptor identification
      dose response curves
      agonists and antagonists
      receptor modulation
    Discuss the neurotransmitter acetylcholine in detail. Include within the context of the discussion:
      cholinergic receptor classification
      functional aspects of cholinergic receptors
      synthesis, storage, and release of acetylcholine
    Discuss the  catecholamine neurotransmitters (norepinephrine and dopamine) in detail. Include within the context of the discussion:
      biosynthesis of catecholamines
      storage and release of catecholamines
      anatomy of catecholamine receptors
      adrenergic receptors
      dopaminergic receptors
    Discuss the neurotransmitter serotonin in detail. Include within the context of the discussion:
      anatomy of serotonin receptors
      biosynthesis, storage and release of serotonin
      sub-types of serotonin receptors
    Discuss the neurotransmitter glutamate in detail. Include within the context of the discussion
      biosynthesis, storage and release of glutamate
      ionotropic glutamate receptors
        NMDA receptors and subunits
        non-NMDA receptors and subunits
      metabotropic glutamate receptors
        Group I metabotropic receptors and subunits
        Group II metabotropic receptors and subunits
        Group III metabotropic receptors and subunits
      role in neurological disorders
    Discuss the neurotransmitters GABA and glycine in detail.
      synthesis, uptake, and release
      physiology and pharmacology
      clinically relevent agonists and antagonists of GABA and glycine receptors
    Discuss the peptide neurotransmitters.
    Describe the pharmacology of each of the drugs used to treat neurological disorders.
 
 
D.  NEURORADIOLOGY
UNIT OBJECTIVES
Demonstrate an understanding of neuroradiological imaging and interventions as they specifically relate to neurosurgical patients.
 
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
    Describe the precautions which should be taken when performing radiologic examinations.
    Identify the normal anatomical structures of the skull on antero-posterior, lateral, Towne, and submental vertex radiographs.
    List the indications for carotid and cerebral angiography.
    Review the potential complications to intravenous contrast agents and discuss the management of same.
    Identify the major arteries and veins of the neck and brain on angiograms.
    Describe the concepts of computerized tomographic (CT) scanning.
    Identify the normal anatomical structures of the scalp, skull, dura, brain, and cranial vasculature on CT scans.
    Describe the concepts of magnetic resonance (MR) scanning. Review the various imaging sequences which may be obtained.
    Identify the normal anatomical structures of the scalp, skull, dura, brain, and cranial vasculature on MR scans.
    Recognize common traumatic injuries which may be detected by skull radiographs including:
      linear skull fractures
      depressed skull fractures
      pneumocephalus
      foreign bodies
    Recognize common pathologic conditions which may be detected by skull radiographs including:
      neoplasms
      fibrous dysplasia
      congenital bone diseases
      metabolic bone disorders
      infections
    Recognize common traumatic injuries which may be detected by head CT including:
      skull fractures
      pneumocephalus
      intracranial hematomas
        epidural
        acute subdural
        chronic subdural
        intraparenchymal
        intraventricular
      cerebral contusions
      subarachnoid hemorrhage
      foreign bodies
    Recognize common pathologic conditions which may be detected by head CT including:
      ischemic infarction
      venous infarction
      hydrocephalus
      cysts
      tumors
      cerebral edema
      infections
      congenital abnormalities
      infections
    Recognize common traumatic injuries which may be detected by head MR scans including:
      pneumocephalus
      intracranial hematomas
        epidural
        acute subdural
        chronic subdural
        intraparenchymal
        intraventricular
      cerebral contusions
      diffuse axonal injury
    Recognize common pathologic conditions which may be detected by head MR scans including:
      ischemic infarction
      venous infarction
      hydrocephalus
      cysts
      tumors
      cerebral edema
      vascular occlusions
      infections
      congenital abnormalities
    Identify the normal anatomical structures of the craniovertebral junction on plain radiographs.
    Review the radiographic diagnoses of platybasia and cranial settling.
    Describe the plain radiographic findings of common traumatic injuries to the craniovertebral junction including:
      occipital condyle fractures
      atlanto-occipital dislocation
      Jefferson fractures
      posterior atlas fractures
      dens fractures
      axis body fractures
      hangman's fracture
      atlas and axis facet fractures
      atlanto-axial rotatory dislocation
    Distinguish between orthotropic and dystropic os odontoideum.
    Describe the common congenital abnormalities of the craniovertebral junction.
    Recognize common spinal congenital abnormalities on plain radiographs.
    Recognize common spinal traumatic injuries which may be detected by plain radiographs including:
      vertebral body fractures
      facet fractures and dislocations
      posterior element fractures
      transverse process fractures
      vertebral subluxation/dislocation
    Recognize common spinal degenerative conditions which may be detected by plain radiographs.
    Discuss the indications for CT and MR scanning of the spine in the setting of trauma.
    Describe the CT scan appearance of each of the traumatic spinal lesions previously listed.
    Describe the MR scan appearance of:
      spinal ligament injury
      traumatic disc herniation
      spinal cord contusion
      spinal epidural hematoma
    Recognize common spinal degenerative conditions which may be detected by MR including:
      disc degeneration
      disc herniation
      degenerative spinal stenosis
      facet hypertrophy
      osteophyte formation
      foraminal stenosis
      degenerative spondylolisthesis
      degenerative scoliosis
      ossification of the posterior longitudinal ligament
    Identify spinal and spinal cord tumors on CT and MR scans.
    Discuss the indications for spinal myelography.
    Review the indications for spinal angiography.
Discuss the use of both the radiographic contrast and radionuclide shuntogram in evaluating neurosurgical patients
 
COMPETENCY-BASED SKILL OBJECTIVES:
Order appropriate radiological evaluations in a timely fashion.
Complete radiological requisitions properly.
Demonstrate the ability to accurately interpret the radiographic studies of trauma patients
 
 
GENERAL CLINICAL TOPICS SECTION
 
A.  FLUIDS, ELECTROLYTES, AND NUTRITION
UNIT OBJECTIVES
Demonstrate an understanding of normal and pathologic fluid and electrolyte  homeostasis. Demonstrate an ability to maintain normal electrolyte  balance. Demonstrate an understanding of the basics of nutritional  management in neurosurgical patients.
 
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
Discuss the normal distribution of intracellular and extracellular fluid and electrolytes including:
sodium and water distribution and metabolism
clinical assessment of water and sodium balance and the concept of osmolality
normal maintenance requirements
management of pathologic conditions such as diabetes insipidus and the syndrome of inappropriate antidiuretic hormone secretion
cerebral salt wasting
Review the potential implications of diuresis and fluid restriction on water and electrolyte balance.
Briefly review the potential clinical implications of calcium, phosphorous, and magnesium excesses and deficiencies and the treatment of same.
Review the criteria for nutritional assessment including:
history of significant weight loss
hypoalbuminemia
impaired immune response including diminished total lymphocyte count and anergy
physical signs of malnutrition
Briefly describe the metabolic responses to starvation and stress.
Describe and contrast the indications, contraindications, complications, and benefits of enteral and parenteral nutrition.
Analyze the implications of specific nutritional deficiencies as they relate to neurological and neurosurgical diseases.
Briefly review swallowing disorders.
Describe the common changes of metabolism and nutritional requirements of trauma patients and their evaluation.
 
COMPETENCY-BASED SKILL OBJECTIVES:
Demonstrate an ability to manage the fluid and electrolyte requirements of  neonatal, pediatric, and adult neurosurgical patients.
Demonstrate the ability to place central venous catheters.
Demonstrate the ability to place enteral feeding tubes.
Demonstrate an ability to prescribe appropriate parenteral and enteral nutrition.
Recognize and treat the complications of parenteral and enteral feeding including:
line sepsis
glucose intolerance
diarrhea
dehydration
Recognize swallowing disorders and manage same.
 
 
B.  GENERAL CRITICAL CARE
UNIT OBJECTIVES
Demonstrate an ability to triage neurosurgical patients to and from a critical care setting. Demonstrate a knowledge of and the ability to manage  neurosurgical patients in the critical care setting.
 
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
Define the adult and pediatric patient which would be best served in a  critical care setting; include both medical and neurosurgical issues  within the context of this discussion.
Review general medical issues pertinent to the management of neurosurgical patients in a critical care setting including:
prophylaxis of gastrointestinal hemorrhage
prophylaxis of pulmonary morbidity
prophylaxis, diagnosis, and treatment of venous thrombosis and pulmonary embolism
skin care
eye care
physical therapy to maintain strength and joint range of motion
universal precautions
workup and treatment of sepsis
Describe the indications and pharmacokinetics for medications commonly used in  the management of critically ill neurosurgical patients including:
vasoactive drugs
ionotropic drugs
bronchodilators
diuretics
antiarrhythmics
antihypertensives
antimicrobials
anticonvulsants
Describe the clinical presentation, evaluation, and treatment of infections  which commonly occur in critical care neurosurgical patients.
Review the indications for intubation including:
loss of patient airway
respiratory insufficiency
inability to protect airway
Discuss commonly used pulmonary values including:
measured pulmonary functions
rate
minute ventilation
spontaneous tidal volume
forced vital capacity (FVC)
functional residual capacity (FRC)
maximum ventilatory volume (MVV)
ventilator modes and settings
pressure versus volume ventilation
continuous positive airway pressure (CPAP)
intermittent positive airway pressure (IPAP)
pressure support
assist control
intermittent mandatory ventilation (IMV)
positive end expiratory pressure (PEEP)
rate
tidal volume
Review the indications for weaning patients from ventilatory support. Describe the methods by which this is accomplished and the general pulmonary  parameters a patient must demonstrate prior to extubation.
Discuss the medications used to improve pulmonary function.
Briefly review the following cardiac function parameters:
preload
afterload
contractility
Review the indications for implementing the following monitoring devices.  Briefly describe how the information obtained is utilized to optimize  patient management:
arterial catheters
central venous catheters
Swan-Ganz catheters
pulse oximetry
electrocardiographic monitoring
end-tidal CO2 monitors
List the signs of acute myocardial ischemia and briefly discuss the emergent treatment of this condition.
Review the impact of renal insufficiency as it pertains to the management of neurosurgical patients.
Briefly discuss the diagnosis and management of acute renal insufficiency.
Describe the diagnosis and management of an ileus. List the differential diagnosis for an ileus.
review the diagnosis and management principles of the following endocrine disorders:
hypo/hyperthyroidism
hypo/hyperparathyroidism
adrenal cortical excess and deficiency
diabetes mellitus
diabetes insipidus
Review the medical and legal definitions of brain death.
Discuss moral and ethical issues pertaining to critically ill neurosurgical patients including:
patient or family requests to withhold or withdraw treatment
organ donation.
Summarize the physiology of hydrogen ion production and excretion.
Briefly discuss acute and chronic buffering systems.
Discuss metabolic acidosis and alkalosis.
Discuss respiratory acidosis and alkalosis.
Review the effects of acid-base disturbances on the central nervous system and intracranial pressure.
 
COMPETENCY-BASED SKILL OBJECTIVES:
    Obtain ACLS and ATLS certification.
    Demonstrate the ability to perform an initial evaluation and management of critically ill neurosurgical patients.
    Perform the following procedures:
      orotracheal intubation
      nasogastric intubation
      bladder intubation
    Serve on a trauma team.
    Demonstrate an ability to manage neurosurgical patients in a critical care setting.
    Diagnose and treat acid-base abnormalities in neurosurgical patients.
    Demonstrate an understanding of the management of complex acid-base disturbances in the critical care setting.  
 
 
C.  INFECTION
UNIT OBJECTIVES
Demonstrate an understanding of the factors related to the acquisition, diagnosis,  and treatment of infections as they pertain to neurosurgical patients.  Describe the typical presentation and treatment of common neurosurgical  infections. Review the methods used to minimize infectious complications in neurosurgical patients. Demonstrate an understanding of the  techniques to minimize the risk of spread of viral infections, including hepatitis and human immunodeficiency virus (HIV).
 
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
    List the common organisms responsible for meningitis in an age related fashion.
    List the common CNS infections and describe the populations which are most at risk for each.
    List the common opportunistic CNS infections and describe the populations which are most at risk for each.
    Describe in detail the clinical and pathological symptoms and findings associated with CNS infections.
    Discuss the radiological evaluation of patients with suspected and known CNS infections.
    Review the indications for alerting individuals at risk for infections based  on exposure to a patient with a known CNS infectious process.
    Review each major class of antimicrobial drugs:
      describe the potential of resistance to each drug
      list the potential complications of each agent
      review the serological monitoring of each antimicrobial agent including the  need for monitoring renal, hepatic, and hemopoietic function
      indicate which drugs will traverse the blood-brain barrier and which will not
      demonstrate a knowledge of the pharmacokinetics of each antimicrobial agent
      describe the potential complications of each antimicrobial drug and explain how to monitor for and detect same
      review the rationale for monitoring drug levels and list the therapeutic  levels of antimicrobials commonly used to treat neurosurgical infections
    Discuss the advantages and disadvantages of treatment of CNS infections with corticosteroids.
    Review the role of anticonvulsant therapy in the management of CNS infections.
    List the universal precautions for prevention of infection as they pertain  to health care workers in general and neurosurgeons in particular.
    Discuss the role of hand washing as the most important method of preventing infection.
    Describe the role of the clinical epidemiologist in tracking infectious disease  incidence and potential sources of infection within the hospital and  community setting.
    Review the mode of transmission, diagnosis, and treatment of non-CNS  infections which may commonly arise in neurosurgical patients such as:
      respiratory infections
      urinary tract infections
      wound infections
    Review the prevention, diagnosis and management of sepsis.
    List the common sources of a postoperative fever.
    Describe the workup for a febrile patient.
    Discuss the use of prophylactic antibiotics.
    Review the symptoms, clinical evaluation and management of patients with shunt infections.
    Discuss prion disease and precautions to be taken when it is suspected.
COMPETENCY-BASED SKILL OBJECTIVES:
Demonstrate the ability to use universal precautions.
Demonstrate the ability to use sterile technique.
Appropriately diagnose and treat non-CNS infections in neurosurgical patients.
Appropriately diagnose and treat CNS infections in neurosurgical patients.
 
 
D.  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 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 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
 
A.  CEREBROVASCULAR SURGERY
UNIT OBJECTIVES
Demonstrate an understanding of the anatomy, physiology, pathophysiology and  presentation of cerebrovascular diseases, including ischemic and  hemorrhagic stroke, and other diseases and malformations of  intracranial, extracranial, and spinal vasculature. Demonstrate the  ability to formulate and implement a diagnostic and treatment plan for  cerebrovascular diseases, including medical and surgical management.
 
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
    Describe the anatomy of the extracranial and intracranial vessels, including the carotid, vertebral, and spinal arteries.
    Describe the location of key perforating arteries involving the anterior and  posterior circulation, their target distribution, and the consequence of occlusion or injury.
    Review the anatomy of the venous circulation as it pertains to the central nervous system.
    Identify the classic syndromes of vessel occlusion of the following:
      internal carotid artery
      middle cerebral artery
      anterior cerebral artery
      recurrent artery of Heubner
      anterior choroidal artery
      vertebral artery
      posterior inferior cerebellar artery (PICA)
      lower and upper basilar trunk
    Identify the classic brain stem ischemic syndromes.
    Explain the concepts of cerebral blood flow, cerebral autoregulation  (hemodynamic and metabolic), ischemic thresholds, intracranial pressure, and cerebral perfusion pressure. Describe the impact of intracranial  hypertension with and without mass lesion on cerebral blood flow.
    Recognize the common causes of brain ischemic states including:
      cardiac embolism
      embolism from proximal vasculature
      large vessel occlusion
      intracranial conducting vessel occlusion
      small vessel disease
    Associate computed tomography (CT) and magnetic resonance (MR) evidence of ischemic injury with likely anatomic substrate.
    Describe the epidemiology, physiology, and underlying pathophysiology of  ischemic brain injury, including concepts of critical therapeutic  window.
    Recognize the common causes of intracranial and intraspinal hemorrhage including:
      aneurysmal disease
      vascular malformations
      hypertension
      vasculopathies
      degenerative diseases
      hemorrhagic arterial infarction
      venous infarction.
    Relate typical imaging characteristics of central nervous system hemorrhagic lesions to probable causes.
    Categorize common causes of intracranial hemorrhage, subarachnoid hemorrhage, and ischemic stroke.
    Explain the principles of fluid and electrolyte resuscitation and maintenance,  respiratory physiology, cardiac physiology, and nutritional physiology,  as applied to the neurological patient following ischemic or hemorrhagic stroke. Integrate this knowledge with the specific issues of the  perioperative period.
    Recognize the need for laboratory evaluation for systemic illness.
    List the appropriate diagnostic neuro-imaging studies utilized to evaluate ischemic and hemorrhagic stroke.
    Recognize the typical clinical course of patients with ischemic and hemorrhagic  stroke, including peak risk intervals for edema, vasospasm, re-bleeding, etc.
    Identify the periods of high vulnerability to systemic complications of  cerebrovascular illness, including deep venous thrombosis, pulmonary  embolism, bacterial pneumonia, aspiration, congestive heart failure,  etc.
    Explain the principles of augmentation of cerebral blood flow during cerebral vasospasm.
    Discuss the principles and indications for medical, endovascular, and surgical  interventions for ischemic and hemorrhagic stroke.
    Relate the principles of timing of medical, endovascular, and surgical intervention in these same disease states.
    Explain the principles, indications for, and complications of barbiturate coma.
    Recognize the principles and interpretation of normal and common abnormal  findings on skull, chest, and abdominal x-rays in the Critical Care  Unit.
    Describe the fundamentals of CT scanning, including the typical appearance of  acute, subacute, and chronic blood, calcification, ventricular anatomy,  and mass effect.
    Describe the typical CT appearance of hemorrhagic and ischemic stroke. Provide a detailed explanation for the typical delay between the onset of stroke  and appearance of confirmatory CT findings.
    Explain the fundamentals of MR imaging. Distinguish between normal and abnormal findings within the realm of cerebrovascular disease. Recognize the  classic MR appearance of:
      arteriovenous malformations
      venous angiomas
      cavernous malformations
      aneurysms
    List the  indications for non-invasive vascular imaging, including ultrasound,  magnetic resonance angiography (MRA), and CT angiography. Recite the  limitations of non-invasive studies.
    Describe the practical application of commonly employed non-invasive studies,  such as transcranial Doppler, in the setting of cerebral vasospasm.  
    List the indications for catheter angiography. Interpret the findings of  angiography in ischemic and hemorrhagic cerebrovascular conditions.  Identify the key segments of the internal carotid artery including the  upper cervical, petrous, cavernous, and supraclinoid components.
    Recite the principles of localizing focal intracranial and spinal vascular  pathology by the use of traditional topographic measurements and the  application of stereotactic guidance.
    Describe the surgical anatomy and the principles of exposure of the cervical carotid artery.
    Describe the principles of pterional craniotomy, including scalp and bony  anatomy, as well as the anatomy of the sphenoid ridge.
    Explain the principles of cerebrovascular surgery detailed in the previous  objectives to medical students and allied health personnel during  conferences.
 
COMPETENCY-BASED SKILL OBJECTIVES:
    Perform a comprehensive neurological history and clinical examination.
    Perform a comprehensive systemic evaluation.
    Adapt comprehensive evaluation to specific pertinent positives and negatives with regard to ischemic and hemorrhagic stroke.
    Demonstrate an understanding of urgency and the ability to prioritize during  emergent aspects of hemorrhagic and ischemic disease states.
    Demonstrate the ability to manage cardiac and pulmonary complications following  cerebrovascular illness and therapy, and review the need for specialty  and subspecialty consultations.
    Apply the principles of perioperative care following common endovascular and  surgical procedures directed at cerebrovascular disease.
    Demonstrate the ability to be vigilant in the clinical detection of subtle  neurological change during the acute and subacute phases of illness.
    Demonstrate the ability to place an arterial catheter, central venous catheter, and pulmonary artery catheter. Perform placement of a ventricular catheter  via a burr hole or twist-drill craniostomy.
    Perform lumbar puncture and cerebrospinal fluid (CSF) reservoir tapping.
    Define the proper placement of a craniotomy flap in the planned surgical  evacuation of hematoma. This should be performed using both  topographical as well as stereotactic-assisted navigation techniques.
    Assist in the opening, exposure, and closure of cervical carotid procedures.
    Assist during pterional craniotomy for vascular disease.
    Assist in the performance of intracranial hematoma evacuation.
    Demonstrate the ability to keep accurate and timely records.
 
B.  NEUROSURGICAL ONCOLOGY
UNIT OBJECTIVES
Demonstrate an understanding of the anatomy, physiology, pathophysiology, and  presentation of tumor-related diseases of the cranium. Demonstrate the  ability to formulate and implement a diagnostic and treatment plan for  tumor-related diseases of the cranium that are amenable to surgical  intervention.
 
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
    Summarize the epidemiology, incidence, and risk factors for intracranial neoplasms.
    Summarize the tenets of tumor biology including genetic factors and biochemical  processes associated with invasion. Describe the natural history of  intracranial neoplasms.
    List a differential diagnosis of lesions requiring biopsy and describe their pathophysiology.
    List the various types of bone tumors involving the calvarium.
    Describe and differentiate:
      astrocytomas, including the accepted World Health Organization (WHO) grading scheme
      gliomas other than astrocytomas
      metastatic tumors, including location and common origins
      infectious, granulomatous, and cystic lesions that may present in a tumor-like manner
    Define the cell or origin of meningioma, its common intracranial locations, and the expected presentation for each location.
    Define the embryological origin of arachnoid cysts and their natural history;  list the etiologies of other cystic lesions of the brain, including  tumoral and infectious.
    Describe the anatomic location, cell of origin, clinical presentation, age at  presentation, and natural history of common intrinsic posterior fossa  neoplasms, including cerebellar astrocytoma, medulloblastoma, and  ependymoma.
    Describe the anatomy of the posterior fossa and the relation of the cranial nerves to the brain stem and skull.
    Illustrate the relationship of the facial, vestibular, and cochlear components of  the acoustic nerve at the internal auditory meatus.
    Describe the various tumors that may arise in the cerebellopontine angle (CPA).
    Describe the management of a patient with a brain abscess, including the role of stereotactic drainage or open drainage.
    Explain the medical workup of a patient with a diagnosed brain abscess.
    Specify the follow-up and evaluation of the patient with a brain abscess following surgical treatment.
    Describe the embryological origin of craniopharyngioma. List the common locations of the tumor.
    Describe the common presentations of pituitary tumors, the cell of origin, and endocrinopathies associated with:
      null cell adenomas
      somatotrophic adenomas
      prolactinomas
      corticotrophic secreting adenomas
      thyrotrophic-secreting adenoma
    Define the medical management of the secreting pituitary tumors. Explain the role of surgery in each of the tumors above.
    Describe the etiology of fibrous dysplasia, its presentation and general  management. List the indications for surgery for benign tumors of bone  at the base of the skull, and potential adjuvant therapy.
    List the tumors that may be routinely approached through a transtemporal route.
    Describe the indications for use of lumbar spinal drainage in skull base  surgery, and its implementation. List all complications associated with  continuous lumbar spinal drainage.
    Illustrate the general principles of stereotaxis and the underlying localization  techniques used in the presently used frame-based and frameless systems.
 
COMPETENCY-BASED SKILL OBJECTIVES:
    Perform a complete history and physical examination on patients with intracranial neoplasms.
    Review appropriate radiographic studies with a radiologist and formulate a  differential diagnosis for patients with intracranial neoplasms.
    Prepare patients for cranial tumor surgery.
    Understand the positioning of patients for craniotomy and craniectomy.
    Assist in the opening and closing of craniotomies and craniectomies for neoplasms.
    Place lumbar drains.
    Demonstrate the ability to open and close scalp incisions.
    Perform ventriculostomies.
    Demonstrate proper postoperative wound care.
 
C.  NEUROTRAUMA AND NEUROSURGICAL CRITICAL CARE
UNIT OBJECTIVES
Demonstrate an understanding of the anatomy, physiology, pathophysiology, and  presentation of traumatic injuries of the brain, spinal cord, and  peripheral nervous system, including their supporting structures.  Demonstrate the ability to formulate and implement appropriate  diagnostic and treatment plans for traumatic injuries to the nervous  system, including both surgical and nonsurgical management.
 
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
    Describe the systematic assessment of polytrauma patients.
    Rank management priorities in polytrauma patients appropriately.
    Discuss principles of resuscitation of polytrauma patients including  appropriate fluid resuscitation, and explain the anticipated effects of  shock and resuscitation on fluid shifts and on electrolyte balance.
    Name an initial choice for intravenous fluids for a newly admitted Intensive Care Unit (ICU) patients with the following diagnoses and explain  changes in that choice based upon specific changes in the patient's  diagnosis, clinical condition, electrolyte and volume status:
      head injury
      stroke
      tumor
      infection
      hydrocephalic
    Propose  appropriate initial ventilator settings for patients with different  types of common neurosurgical conditions and explain changes in that  choice based upon specific changes in the patient's metabolic or  pulmonary status.
    List the mechanisms of action and potential complications of commonly used pressors and hypotensive agents.
    Discuss indications, pharmacologic mechanism, duration of action, and effect on the neurologic examination for sedative, paralytic, and analgesic  agents commonly used in the ICU.
    Explain the indications, advantages, and risks for various hemodynamic  monitoring tools (e.g., pulmonary artery catheters, indwelling arterial  lines) used in critically ill patients.
    Discuss the pathophysiology and management of coagulopathy after head injury.
    Describe basic principles of nutritional management in neurosurgical critical care.
    Explain the treatment of posttraumatic seizures.
    Outline basic principles of ICU management of patients with spinal cord injury.
    name the major structures supplied by the major vessels of the brain and spinal cord.
    Discuss the evaluation, treatment, and prognosis of subarachnoid hemorrhage, both traumatic and spontaneous.
    Explain the pathophysiology and treatment of cerebral vasospasm.
    Formulate a diagnostic and treatment plan for patients with cerebral ischemia.
    Explain the evaluation and management of birth-related intracranial hemorrhage, spinal cord injury, and brachial plexus injury.
    Describe a systematic approach to the examination of the peripheral nervous system.
    Describe the basic principles of management of peripheral nerve injuries.
    List principles of rehabilitation of different types of neurosurgical patients.
    Define brain death and discuss methods of making such a diagnosis.
    Describe the pathophysiology of electrical injuries to the nervous system and review treatment of same.
COMPETENCY-BASED SKILL OBJECTIVES:
    Perform and document pertinent history, physical findings, and radiologic findings in a polytrauma patient.
    Differentiate central from peripheral nervous system injuries.
    Insert intravascular monitoring devices for use in the hemodynamic management  of critically ill patients, including central venous lines, pulmonary  artery catheters, and arterial catheters.
    Insert intracranial pressure monitoring devices, including ventriculostomy  catheters and electronic (fiberoptic or miniaturized strain gauge)  devices.
    Perform twist-drill or burr-hole drainage of subdural fluid collections.
    Decide appropriately which patients require emergency craniotomy and other procedures.
    Position patients appropriately for procedures/surgery and begin emergency  procedures if more experienced neurosurgeons have not yet arrived.
    Assist with opening and closure of craniotomies.
    Perform elective tracheotomies and be able to perform emergency tracheotomies.
    Be able to intubate patients in both emergency and elective situations.
 
G.  SPINAL SURGERY
UNIT OBJECTIVES
Demonstrate an understanding of the anatomy, physiology, pathophysiology, and  presentation of disorders of the spine, its connecting ligaments, the  spinal cord, the cauda equina, and the spinal roots.  Demonstrate the  ability to formulate and implement a diagnostic and treatment plan for  diseases of the spine, its connecting ligaments, the spinal cord, the  cauda equina, and the spinal roots that are amenable to surgical  intervention.
 
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
    Review the anatomy of the craniocervical junction, cervical, thoracic, and lumbar spine, sacrum, and pelvis.
    Interpret plain and dynamic radiographs, bone scans, myelograms, computerized  tomographic (CT) scans, and magnetic resonance (MR) scans of patients  with spinal disorders.
    Review the signs, symptoms, and pathophysiology of common syndromes of  degenerative spinal disorders: radiculopathy, myelopathy, instability,  and neurogenic claudication.
    Identify the common syndromes of spinal cord injury, including complete  transverse injury, anterior cord injury, Brown-Sequard injury, central  cord injury, cruciate paralysis, syringomyelia, conus syndrome, and  sacral sparing. Describe the pathophysiology of spinal cord injury.
    Describe the cauda equina syndrome.
    Recite the differential diagnosis of cervical, thoracic, and lumbar pain.
    Discuss the indications for cervical, thoracic, and lumbar discectomy.
    Identify non-surgical spinal cord syndromes including amyotrophic lateral  sclerosis, demyelinating conditions, and combined systems disease.
    Review the initial management of spine and spinal cord injured patients  including immobilization, traction, reduction, appropriate radiographic  studies, and medical management.
    Classify fractures, dislocations, and ligament injuries of the craniocervical  region, subaxial cervical spine, thoracic, thoracolumbar junction,  lumbar, and sacral spine. Describe the mechanism of injury and classify  the injuries as stable or unstable. Review the indications for surgical  management.
    Discuss briefly the concept of grading schemes for spinal cord injury and myelopathy.
COMPETENCY-BASED SKILL OBJECTIVES:
    Perform a complete history and physical examination on patients with spinal disorders.
    Interpret plain x-rays, dynamic x-rays, myelograms, CT scans and MR scans of patients with spinal disorders.  
    Prepare patients for spinal surgery, including proper positioning, protection  to pressure points, and placement of indicated arterial and central  venous catheters, indwelling urinary catheters and anti-embolism  devices.  
    Perform lumbar punctures and placement of lumbar drains.
    Demonstrate the ability to place and manage cranial traction devices for reduction  and immobilization of the unstable cervical spine.
    Demonstrate the ability to place and manage a halo vest, including indications for placement and criteria for removal.
    Demonstrate the ability to properly place the Mayfield head holder and other headrests.
    Demonstrate the ability to harvest autologous bone graft from the calvarium, rib,  fibula, and anterior or posterior iliac crest.
    Perform dorsal exposure of the spinous processes, laminae, and facets of the cervical, thoracic, and lumbar spine.  
    Demonstrate the ability to close dorsal, ventral, and lateral spinal incisions.
    Demonstrate proper postoperative wound care.
    Demonstrate appropriate postoperative management of patients who have undergone spinal procedures.
    Demonstrate the ability to perform, with supervision, a lumbar decompressive laminectomy for spinal stenosis.
    Demonstrate the ability to excise, with supervision, a herniated lumbar disc.
    Demonstrate the appropiate use of the operating microscope.

Last Updated Feb 2013