||Parkland Junior Resident Curriculum BASIC TOPICS SECTION A. NEUROANATOMYUNIT 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:
Central Nervous System
cell body dendritic process axonal process
Diagram and describe the microanatomy of the synapse. List the microglial elements and review their microanatomy:
astrocytes oligodendrocytesmicroglia 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 materpia 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.
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:
Autonomic Nervous System
cortical layerssensory 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 pathwaysanterior commissure hippocampal formation (including cytoarchitecture) amygdala limbic system
Describe the anatomy of the corpus striatum in detail including:
striatum globus pallidusclaustrum 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 nucleusmedullary 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
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 musculocutaneouslateral 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.
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. NEUROPHYSIOLOGYUNIT 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 memorysleeping 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:
D. NEURORADIOLOGYUNIT OBJECTIVES
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
Discuss the neurotransmitters GABA and glycine in detail.
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
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.
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:
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 NUTRITIONUNIT OBJECTIVES
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 fracturespneumocephalus intracranial hematomas
Recognize common pathologic conditions which may be detected by head CT including:
epidural acute subduralchronic subdural intraparenchymalintraventricular
cerebral contusions subarachnoid hemorrhage foreign bodies
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
Recognize common pathologic conditions which may be detected by head MR scans including:
epidural acute subduralchronic subdural intraparenchymalintraventricular
cerebral contusions diffuse axonal injury
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 herniationdegenerative spinal stenosis facet hypertrophy osteophyte formation foraminal stenosis degenerative spondylolisthesis degenerative scoliosisossification 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.
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 hypoalbuminemiaimpaired 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 dehydrationRecognize swallowing disorders and manage same. B. GENERAL CRITICAL CAREUNIT 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 careeye 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 bronchodilatorsdiureticsantiarrhythmicsantihypertensivesantimicrobialsanticonvulsantsDescribe 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 afterloadcontractilityReview 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/hyperthyroidismhypo/hyperparathyroidismadrenal 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:
C. INFECTIONUNIT OBJECTIVES
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.
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:
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 ISSUESUNIT OBJECTIVES
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.
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:
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 SURGERYUNIT OBJECTIVES
treatment facilities third party payment systems
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:
Medicare Medicaid employer-provided insurance private insurance
physician practice organizations medical equipment manufacturers pharmaceutical companies
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
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:
partnership professional association corporation
academic practice Health Maintenance Organizations (HMO)
Preferred Provider Organizations (PPO) Individual Practice Associations(IPA) staff model (Kaiser-Permanente type)
Department of Veterans Affairs Military Public Health Service
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.
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)
affirmative action equal opportunity sexual harassment
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:
COMPETENCY-BASED SKILL OBJECTIVES:
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 angiomascavernous 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.
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 ONCOLOGYUNIT 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:
COMPETENCY-BASED SKILL OBJECTIVES:
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.
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 CAREUNIT 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:
COMPETENCY-BASED SKILL OBJECTIVES:
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.
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 SURGERYUNIT 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