Picture4
[Curriculum]
[Childrens]
[Laboratory]
[Neurocritical Care]
[Parkland Chief]
[Parkland Junior]
[Neurology]
[Spine]
[Tumor]
[VA]
[Vascular Chief]
[Vascular Junior]
Zale Spine Service
 
BASIC TOPICS SECTION
 
A. NEUROANATOMY
UNIT OBJECTIVES
Demonstrate knowledge of anatomy that is pertinent to the diagnosis of diseases of  the nervous system and the practice of neurological surgery.
 
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
    Discuss the clinical presentation in anatomical terms of syndromes of the brain and its coverings including:
      epidural hematoma
      acute subdural hematoma
      chronic subdural hematoma
      subgaleal hematoma
      injury to innervation of the scalp
    Discuss the syndromes produced by mass lesions affecting the cranial nerves including:
      suprasellar lesions
      lesion of jugular foramen
      lesion of internal auditory canal
      lesions or distortion at the incisura
    Review the expected effects of stroke or mass lesion at different locations within the brain stem and cerebellum.
    List the expected effects of destructive lesions in the basal ganglia and cerebellum.
    Describe the expected effects of ischemic or destructive lesions of the white matter tracts of the cerebrum.
    Discuss the expected effect of destructive lesions of specific regions of the cerebral cortex.
    Review the clinical presentation of strokes in the distribution of the supratentorial cerebral blood vessels.
    Discuss the relationship of the spinal nerves to the vertebral level of exit.
    Diagram the structures comprising the boundaries of the spinal neural foramina.
    Discuss the clinical manifestation of injury for each of the major peripheral nerves.
    Describe the anatomy and presentation of common entrapment syndromes of peripheral nerves including:
      thoracic outlet syndrome
      carpal tunnel syndrome
      ulnar nerve entrapment syndrome at wrist and elbow
      anterior interosseous syndrome
      posterior interosseous syndrome
      meralgia paresthetica
      peroneal nerve palsy
      tarsal tunnel syndrome
    Describe the surgical exposure of common peripheral nerve entrapments including:
      carpal tunnel
      ulnar nerve at elbow
      ulnar nerve at wrist
      lateral femoral cutaneous nerve
      peroneal nerve
    Discuss the  clinical presentation and neurological deficits associated with common  lesions of and injuries to the spinal cord and nerve roots.
COMPETENCY-BASED SKILL OBJECTIVES:
    Identify at the time of surgery:
      occipital artery
      superficial temporal artery
      frontalis muscle
      pterion
      inion
      asterion
      coronal suture
      sagittal suture
      middle meningeal artery
      sagittal sinus
      transverse sinus
      foramen rotundum
      foramen ovale
      foramen spinosum
      superior orbital fissure
      jugular foramen
      internal auditory canal
      superior sagittal sinus
      sigmoid sinus
      incisura
      each cranial nerve
      each named cerebral artery and vein
      components of the brain stem
      named structures on the floor of the fourth ventricle
      Foramina of Magendie and Luschka
      cerebral peduncles
      components of the cerebellum
      cerebellar tonsils
      brachium cerebelli
      vermis
      major supratentorial gyri
      supratentorial lobes
      sylvian fissure
      central sulcus
    Identify at the time of surgery structures visible in the lateral ventricles including:
      Foramen of Monro
      fornix
      caudate
      thalamus
      choroidal fissure
      named veins
      glomus of the choroid plexus
      hippocampus
    Identify the parts of the vertebral column, spinal cord, and nerve roots at the time of surgery including:
      spinous process
      lamina
      superior facet
      inferior facet
      pedicle
      pars interarticularis
      uncovertebral joint
      neural foramen and nerve root
      nerve root ganglion
      disc space
      vertebral artery
      dorsal column and lateral column of spinal cord
      intradural afferent and efferent rootlets
 
 
B.   NEURORADIOLOGY
UNIT OBJECTIVES
Demonstrate an understanding of neuroradiological imaging and interventions as they specifically relate to neurosurgical patients.
 
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
    Identify the common carotid and vertebral circulation congenital variants on angiograms.
    Recognize intracranial aneurysms on angiograms.
    Identify and characterize intracranial vascular malformations on angiograms. Recognize:
      arteriovenous malformations
      venous angiomas
      arteriovenous fistula
      feeding vessels
      draining veins
      associated aneurysms
      degree of shunting
    Discuss the angiographic evaluation of carotid and vertebral disease.
    Review the role of MR angiography and venography in the evaluation of cerebrovascular disease, neoplasms, and trauma.
    Describe the radiological evaluation of CNS vasculitis.
    Describe the radiological evaluation of spinal vascular malformations.
    Discuss the role of myelography in the evaluation of neurosurgical patients.
    Discuss the radiological evaluation of suspected CNS and spinal infection.
    Review MR neurography.
    Describe the appearance of peripheral nerve tumors on MR scans.
    Revie the role of radionuclide scans in the evaluation of patients with suspected cranial and spinal disease.
    Discuss the use of intraperative radiographs and fluoroscopy.
    List the indications for CT- and MR-guided biopsies.
    Describe the concepts of ultrasonography.
    Review the findings of normal and abnormal neonatal cranial ultrasound.
    Review the findings of normal and abnormal carotid ultrasounds.
    Discuss the use of transcranial doppler ultrasonography in the management of  patients with subarachnoid hemorrhage, trauma, and occlusive vascular  disease
COMPETENCY-BASED SKILL OBJECTIVES:
    Demonstrate the ability to accurately interpret carotid and vertebral angiograms.
    Demonstrate the ability to accurately interpret spinal angiograms.
    Demonstrate the ability to accurately interpret spinal myelograms and post-myelogram CT scans.
    Demonstrate the ability to accurately interpret cranial and spinal CT and MR scans of nontraumatic lesions.
 
 
C. PRACTICE MANAGEMENT, LEGAL AND SOCIOECONOMIC ISSUES
UNIT OBJECTIVES
Demonstrate an understanding of the principles of practice management and the  business aspects associated with the delivery of health care.
 
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
    Discuss the ethical and moral factors associated with the practice of neurosurgery.
    Review the role of the neurosurgical leadership in the community and hospital setting.
    Explain the neurosurgeon's responsibilities in terms of health care cost containment.
    Review the features and relationships of the healthcare system including:
      treatment facilities
      third party payment systems
        Medicare
        Medicaid
        employer-provided insurance
        private insurance
      physician practice organizations
      medical equipment manufacturers
      pharmaceutical companies
    Recite the rules  and regulations of the training hospital(s) as they pertain to the  practice of neurosurgery in which the residency is performed.
    Name the institutional and social service agencies in your community and  review their role in the overall management of neurosurgical patients.
    Demonstrate a knowledge of the rules and regulations of your State Medical Board.
    Discuss the concept of informed consent.
    Discuss mandatory reporting laws.
    Discuss issues pertinent to the topic of the impaired physician.
    Name and describe the local, regional, and national neurosurgical  organizations including their purposes, roles, activities, and  interactions.
    Discuss the importance of tracking morbidity, mortality, and patient outcomes.
    Review the career options available at the completion of neurosurgical residency in detail including:
      private practice
      academic practice
      subspecialty fellowship
      research
      administration
      military
    Discuss post-residency fellowship training program availability, application process, and career usefulness.
    Describe the types and characteristics of surgical practice organizations including:
      solo practice
      group practice
        partnership
        professional association
        corporation
      academic practice
      Health Maintenance Organizations (HMO)
        Preferred Provider Organizations (PPO)
        Individual Practice Associations(IPA)
        staff model (Kaiser-Permanente type)
      Federal
        Department of Veterans Affairs
        Military
        Public Health Service
    Discuss hospital  payment systems (e.g., DRGs, per diem rates) and describe their  incentives and how they affect hospital profitability.
    Discuss the role and influence of national quality oversight and review  organizations for hospitals and health plans (JCAHO, NCQA).
    Discuss the history, changes, eligibility, funding, and problems associated with the Medicare program.
    Describe the Medicare program features, such as eligibility, funding,  administration, federal-state relationship, benefits, and payment  methods.
    Discuss federal funding of graduate medical education and how current federal  budget allocations and proposals for changes in funding affect or will  affect neurosurgical training programs.
    Discuss the significance of the following issues as they relate to the practice of neurosurgery:
      legislative/regulatory requirements
        Americans with Disabilities Act
        Clinical Laboratory Improvement Amendments (CLIA)
      Federal/professional regulatory institutions
        Health Care Financing Administration (HFCA)
        Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
        Occupational Safety and Health Administration (OSHA)
      miscellaneous
        affirmative action
        equal opportunity
        sexual harassment
    Discuss the common causes of malpractice actions and effective measures to reduce the risk of malpractice complaints.
    Describe the ways, means, and reasons physicians influence the political process at the national, state, and local level.
    Discuss the demographics of neurosurgeon distribution, numbers, workload studies, and workforce needs.
    Outline the requirements for certification by the American Board of Neurological Surgery.
    Formulate a strategy to evaluate personal and professional considerations in making a career choice.
    Appraise the importance of family involvement in making career choices, including geographic location.
COMPETENCY-BASED SKILL OBJECTIVES:
Demonstrate an ability to interact effectively, professionally, and respectfully with:
patients and their families
fellow residents
allied health care personnel
hospital staff
medical students
faculty physicians
referring physicians
Demonstrate the ability to maintain accurate and current medical records.
Discuss neurosurgical career options with:
faculty
peers
family
non-faculty neurosurgeons and other mentors
Accumulate information about post-residency career options.
Create and keep current a resume/curriculum vitae.
Record CPT codes for office visits and procedures performed on service.
Accurately document H&P and consultations according to the AMA-CPT E&M documentation guidelines.
 
 
NEUROSURGICAL CLINIC TOPICS SECTION
 
D. SURGERY OF THE PERIPHERAL NERVOUS SYSTEM
UNIT OBJECTIVES
Demonstrate an understanding of the anatomy, physiology, pathophysiology, and  presentation of peripheral nerve diseases. Demonstrate the ability to  formulate and implement a diagnostic and treatment plan for diseases of  the peripheral nerves that are amenable to surgical intervention.
 
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
    Define the peripheral nervous system versus the central nervous system.
    Discuss the major structural elements of a peripheral nerve:
      epineurium
      perineurium
      endoneurium
      axon
      fascicle
      Schwann cell
      connective tissue
      motor end plate
      sensory receptor
    Discuss the blood supply of the peripheral nerves.
    Discuss the blood-nerve barrier.
    Define axonal transport and differentiate fast from slow.
    Describe an action potential including the flow of ions.
    Describe the various nerve fibers in terms of size.
    Discuss the significance of fiber size in terms of function ( e.g., c-fiber - nociceptive).
    Discuss the various forms of action potential propagation.
    Discuss the pathophysiological response to various injuries by a nerve:
      compression
      ischemia
      metabolic
      concussive
      stretch
    Define and discuss apoptosis.
    Define Wallerian degeneration.
    Discuss nerve regeneration:
      sprouting
      nerve growth factors
      rate of growth
      remyelination
    Define neuroma:
      axonal tangle
      mechano-sensitivity
      neuroma-in-continuity
    Define and discuss the pathophysiology and clinical significance of the Tinel's sign.
    Describe the symptoms and signs of typical nerve injuries:
      entrapment syndromes
      stretch injuries
      laceration injuries
      concussive injuries
      injection injuries
    Distinguish upper versus lower motor neuron symptoms and signs in nerve injury:
      anatomical definition
      degree of atrophy
      distribution of weakness
      reflex changes
      potential for recovery
    Describe the classification of nerve injury:
      Seddon classification
      Sunderland classification
    List the major peripheral nerves of body. Describe the motor and sensory innervation of each.
    Draw the major components of the brachial plexus.
    Describe the rating scales for motor power.
    Describe the various sensory modalities and how to examine each.
    Describe the symptoms and signs of common nerve entrapments:
      carpal tunnel
      ulnar entrapment at the elbow
      lateral femoral cutaneous nerve
      peroneal at fibular head
    Define EMG and NCV.
    Describe the changes in EMG and NCV in nerve entrapment.
    Describe the nonoperative and operative treatment of entrapment syndromes.
    Define:
      coaptation
      neurorrhaphy
      neurotization
      nerve transfer
    Define the autonomic nervous system:
      differentiate sympathetic and parasympathetic
      discuss anatomic distribution
      identify the various neurotransmitters
      discuss Horner's syndrome
    Compare and contrast a peripheral nerve to a cranial nerve:
      histology
      response to injury
      root entry zone
    Describe nerve regeneration in terms of:
      specificity
      pruning of sprouts
      end to side sprouting
    Draw the complete brachial plexus.
    Discuss the lumbar plexus.
    Discuss stretch injury, missile injury and avulsion injury:
      definition
      typical etiology
      physical findings
      electrical findings
      nonoperative management
      indications for surgery
      intraoperative findings
      potential for recovery
    Describe the anatomical location of the common entrapment sites. List the various bands and arcades that produce entrapment.
    Provide a differential diagnosis for common entrapment syndromes:
      differentiate radiculopathies from entrapments
      discuss repetitive strain disorder
    Discuss uncommon entrapment neuropathies:
      Guyon's canal
      suprascapular entrapment
      radial tunnel/PIN
      median nerve in forearm/AIN
      tarsal tunnel (anterior and posterior)
      pyriformis syndrome
    Explain the use of EMG/NCV in the management of peripheral nerve disorders:
      physiology
      typical findings in neuropathy
      typical findings in nerve injury
      typical findings in nerve regeneration
    Discuss the common metabolic/inherited neuropathies.
    Discuss burn and electrical injury effects on nerves.
    Classify peripheral nerve tumors.
    Discuss the pathophysiology of NF1 and NF2.
    Discuss the timing of peripheral nerve surgery:
      laceration injury
      blunt injury
      missile injury
      iatrogenic injury
      surgical injury
      injection injury
    Discuss outcome priorities in brachial plexus surgery:
      motor versus sensory
      functional outcome- elbow flexion, shoulder abduction, etc.
    Discuss tension at the nerve repair site.
    Discuss nerve repair techniques:
      direct coaptation
      nerve graft
      nerve transfer
      donor (graft) nerves
      epineurial repair
      fascicular repair
    Describe intra-operative nerve evaluation:
      visual
      palpation
      internal neurolysis
      nerve conduction
      biopsy
    Discuss with the aid of diagrams the anatomy of the peripheral nervous system:
      common sites of entrapments
      the brachial and lumbar plexus
      innervation of the bladder
    Discuss the use of nerve grafting:
      types of fixation (suture/glue)
      types of grafts (nerve, vein, artificial)
      end to side
    Discuss entrapment syndromes:
      thoracic outlet
      double crush syndrome
      repetitive strain
    Discuss ulnar nerve decompression:
      in situ decompression
      transposition (subcutaneous/intramuscular/submuscular)
      medial epicondylectomy
    Differentiate brachial plexus injury from brachial plexitis.
    Formulate a management plan for:
      birth brachial plexus injury
      acute nerve injury (stretch/compression/laceration/injection)
      chronic nerve injury
      failed nerve decompression
      painful nerve/neuroma
    Describe the management of nerve tumors:
      imaging techniques, including MR neurography
      indications for surgery in NF1
      operative and adjuvant treatment for malignant peripheral nerve sheath tumors
      use of monitoring during tumor surgery
      fascicular dissection
    Describe adjuvant therapies in nerve injury:
      muscle and tendon transfers
      prosthesis
      joint fusion
COMPETENCY-BASED SKILL OBJECTIVES:
    Obtain a history and perform a motor and sensory examination of the peripheral nervous system.
    Based on history and physical, anatomically localize the lesion.
    Obtain appropriate ancillary tests:
      EMG/NCV
      metabolic screens
      imaging studies
    Formulate a differential diagnosis for common entrapments.
    Position and prep for common entrapment releases.
    Perform a diagnostic nerve and muscle biopsy.
    Obtain sural nerve for grafting.
    Perform pre- and postoperative care of the patient with a peripheral nerve injury.
    Evaluate a child with birth palsy.
    Position a patient for nerve surgery:
      all entrapment sites
      brachial plexus surgery
    Perform a neurolysis/decompression.
    Expose the brachial plexus.
    Manage the pain associated with nerve injury:
      use of medications
      use of rehabilitation
      use of stimulation
    Perform a consultation concerning a nerve injury.
    Discuss the risks versus benefits of a surgical repair of a given nerve injury.
    Determine the parameters confirming anticipated nerve regeneration:
      anticipated advancing Tinel's sign
      order of muscle re-innervation
    Perform a nerve decompression:
      carpal tunnel
      ulnar nerve at elbow
      peroneal nerve
    Perform a nerve repair:
      neurolysis
      internal neurolysis
      intraoperative nerve conductions
      placement and suture of nerve graft
    Excise a nerve sheath tumor.
    Expose a brachial plexus injury:
      determine possible repairs including nerve transfers
      expose the spinal accessory nerve
      expose the intercostal nerves
 
 
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 biomechanics of the craniocervical junction, cervical spine, and thoracolumbar and lumbar spine.  
    Review the biomechanics of common internal spinal fixators.
    Review the definition of spinal instability based upon the principles of Punjabi and White and other authors.  
    Recognize the radiographic signs of degenerative neoplastic, traumatic, and congenital spinal instability.
    Review the indications for, and uses, and relative effectiveness of common  spinal orthoses. Discuss the degree of segmental and regional  immobilization these orthoses provide.
    Review the indications for, and physiology of, intraoperative spinal cord  monitoring. Describe the technical aspects of intraoperative spinal cord monitoring.
    Compare and contrast indications for anterior and posterior approaches to the  cervical spine for the treatment of herniated cervical discs,  spondylosis, and instability.
    Discuss the role of corpectomy in the management of cervical disorders.
    Compare and contrast the indications for anterior cervical discectomy with and without anterior interbody fusion.
    Discuss the indications and techniques for anterior and posterior cervical spinal internal fixators.
    Explain the biology of bone healing and options for bone grafting in spinal surgery.
    Review the diagnosis and management of primary spinal tumors, spinal cord  tumors, and spinal metastatic disease including indications for dorsal  decompression, ventral decompression, and radiotherapy.
    Discuss the management principles for gunshot and other penetrating wounds to the spine.
    Review the signs, symptoms, and management options in the treatment of the adult tethered cord syndrome and syringomyelia.
    Review management principles for spontaneous and postoperative spinal infections.
    Review the management principles for intraoperative and postoperative cerebrospinal fluid leaks.
    Discuss the surgical management of intradural congenital, neoplastic, and vascular lesions.
COMPETENCY-BASED SKILL OBJECTIVES:
    Demonstrate the ability to prepare structural allografts for use in spinal surgery.
    Determine the need for postoperative inpatient or outpatient rehabilitation in patients with spinal disorders.
    Demonstrate the ability to perform a ventral exposure of the cervical spine followed by anterior cervical discectomy.
    Demonstrate the ability to perform an anterior cervical interbody arthrodesis.
    Demonstrate the ability to place anterior cervical instrumentation.
    Demonstrate the ability to perform posterior cervical decompressive laminectomy.
    Demonstrate the ability to perform posterior cervical foraminotomy with or without discectomy.
    Demonstrate the ability to perform medial and lateral approaches to a far lateral lumbar disc herniation. 
    Demonstrate appropriate surgical technique in the management of recurrent lumbar  disc herniations and recurrent lumbar stenosis.
    Demonstrate the ability to perform posterior lumbar arthrodesis with or without the use of interbody instrumentation.
    Demonstrate exposure of the cervical lateral masses, thoracic and lumbar transverse processes, and the sacral ala.  
    Demonstrate the ability to perform posterior/intertransverse arthrodesis in the cervical, thoracic and lumbar regions.
    Demonstrate the ability to perform a laminectomy with or without transpedicular decompression for tumor, infection, or trauma.
    Demonstrate techniques for spinous process arthrodesis of the subaxial cervical spine for fracture or dislocation.
    Demonstrate the ability to manage postoperative complications of spinal surgery including:
      hematoma
      infection
      spinal fluid leak
      new neurologic deficit
    Demonstrate the ability to perform a tethered cord release.

Last Updated Feb 2013