||Zale Tumor Service 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. COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
Discuss the clinical presentation in anatomical terms of syndromes of the brain and its coverings including:
COMPETENCY-BASED SKILL OBJECTIVES:
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.
Identify at the time of surgery:
B. NEUROPATHOLOGYUNIT OBJECTIVES
occipital artery superficial temporal artery frontalis muscle pterion inion asterion coronal suture sagittal suturemiddle meningeal artery sagittal sinus transverse sinus foramen rotundum foramen ovale foramen spinosum superior orbital fissure jugular forameninternal auditory canal superior sagittal sinus sigmoid sinus incisura each cranial nerveeach 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 fissurecentral 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 processlamina 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
Demonstrate knowledge of neuropathology that is pertinent to the diagnosis of diseases of the nervous system and practice of neurological surgery. COMPETENCY-BASED KNOWLEDGE OBJECTIVES:General Neuropathology Describe the techniques available for examination of surgical specimens from central nervous system, peripheral nervous system, skeletal muscle, pineal and pituitary. Review the use of standard chromatic, histochemical and selected immunohistochemical stains employed in the evaluation of surgical specimens from the central nervous system, peripheral nervous system, skeletal muscle, pineal and pituitary. List the techniques available for morphological examination of cerebrospinal fluid and the abnormalities observed in cerebrospinal fluid from patients with meningeal carcinomatosis, meningeal lymphomatosis, pyogenic meningitis and aseptic meningitis. Central Nervous SystemDescribe the gross and histopathological features and, when applicable, the genetic basis of the following congenital and perinatal disorders: encephaloceles and cranial meningoceles myelomeningoceles and meningoceles hydromyeliadiastematomyelia and diplomyelia syringomyelia and syringobulbia Chiari I malformation Chiari II malformation Dandy-Walker malformation arachnoid cysts porencephalyaqueductal stenosis subependymal germinal matrix hemorrhages posthemorrhagic hydrocephalus periventricular leukomalacia (white matter infarcts) Describe the gross and histopathological features and characteristics of the causative agents of the following infectious diseases: cranial and spinal epidural abscesses cranial and spinal subdural abscesses pyogenic bacterial meningitis and ventriculitis brain abscesses tuberculous meningitis and tuberculomas central nervous system sarcoidosis central nervous system cryptococcosis central nervous system mucormycosis central nervous system toxoplasmosis central nervous system cysticercosis Herpes simplex encephalitis central nervous system HIV infections central nervous system cytomegalovirus infection Describe the gross and histopathological features of the following vascular lesions: acute, subacute, and remote infarcts border zone and watershed infarcts manifestations of embolic infarcts including those secondary to atheromatous embolization and embolization from extracoporeal pumps vasculitis including temporal arteritis, primary central nervous system vasculitis, granulomatous angiitis, and Wegener's granulomatosis moyamoya hypertensive intracerebral hemorrhages lobar intracerebral hemorrhages amyloid angiopathy malformations including arteriovenous malformations, cavernous angiomas, venous angioma and capillary telangiectases Vein of Galen "aneurysms" saccular aneurysms infectious ("mycotic") aneurysms giant aneurysms traumatic and dissecting aneurysms venous and dural sinus occlusive disease vascular malformations of the spinal cord spinal cord infarcts Describe the gross and histopathological features of the following traumatic lesions: skull fractures entrance and exit gunshot wounds of the skull gunshot wounds of the brain including internal ricochet epidural hematomas acute subdural hematomas chronic subdural hematomas recent and remote cerebral contusions traumatic intraparenchymal hemorrhages diffuse axonal injury traumatic cranial nerve injuries spinal cord injuries cerebral herniation syndromes fat embolization central nervous system trauma in infancy central nervous system radiation injuries manifestations of prior surgical intervention Describe the gross and histopathological features and, when applicable, the metabolic basis for the following intoxications and deficiency states: hypoxic-anoxic encephalopathy carbon monoxide intoxication ethanol intoxication alcoholic cerebellar degeneration central pontine myelinolysis CNS complications of diagnostic agents including contrast material CNS complications of antimicrobial therapy CNS complications of antineoplastic therapy CNS complications of "street drugs" Wernicke's encephalopathy and thiamine deficiency Subacute combined degeneration and B12 deficiency Describe the gross and histopathological features of the following demyelinating diseases: multiple sclerosis progressive multifocal leukoencephalopathy HIV vacuolar myelopathy postinfectious encephalomyelitis Describe the gross and histopathological features and the metabolic basis for the following leukodystrophies: adrenoleukodystrophy and adrenomyeloneuropathy Krabbe's disease metachromatic leukodystrophy Describe the gross and histopathological features and, when applicable, the genetic basis for the following dementias and degenerations: Alzheimer's disease including familial forms vascular dementia including Binswanger's disease and cerebral autosomal dominant arteriopathy (CADASIL) Pick's disease other fronto-temporal dementias Creutzfeldt-Jacob disease and other prion diseases Parkinson's disease diffuse Lewy body disease Huntington's disease amyotrophic lateral sclerosis paraneoplastic degenerative diseases Describe the gross and histopathological features and, when applicable, the biochemical and genetic basis for the following metabolic diseases: Wilson's disease Tay Sachs disease and other GM-2 gangliosidoses neuronal ceroid-lipofuscinoses hepatic encephalopathy Reye's syndrome stopathological features and, when applicable, the grading criteria for the following central nervous system neoplasms: diffuse fibrillary astrocytomas gemistocytic astrocytomas anaplastic astrocytomas glioblastoma multiforme including giant cell glioblastoma and gliosarcomas pilocytic astrocytomas including cerebellar, diencephalic, dorsal exophytic pontine, and cerebral pilocytic astrocytomas subependymal giant cell astrocytomas pleomorphic xanthoastrocytoma oligodendrogliomas including anaplastic oligodendrogliomas and mixed oligoastrocytomas ependymomas including myxopapillary ependymomas subependymomaschoroid plexus tumors colloid cysts gliomatosis cerebri gangliocytomas and gangliogliomas dysembryoplastic neuroepithelial neoplasms central neurocytomasmedulloblastomasatypical teratoid/rhabdoid tumors primitive neuroectodermal tumors and cerebral neuroblastomas olfactory neuroblastoma spinal paragangliomas meningiomas including meningothelial (syncytial) fibrous, transitional, psammomatous, angiomatous, and papillary meningiomas anaplastic and malignant meningiomas meningeal hemangiopericytomas other meningeal mesenchymal tumors meningeal melanomatosis and melanomas hemangioblastomaslipomas primary central nervous system lymphomas metastatic carcinomas including leptomeningeal carcinomatosis teratomasdermoids and epidermoids schwannomas including acoustic neurinomas or vestibular schwannomas, schwannomas of other cranial nerves, and spinal root schwannomas Describe the gross and histopathological features and the genetic basis for the following tumor syndromes: Neurofibromatosis type 1 Neurofibromatosis type 2 von Hippel-Lindau syndrome Tuberous sclerosis Cowden syndrome Turcot syndrome Peripheral Nervous System
Describe the gross and histopathological features and, when applicable, the genetic and biochemical basis for the following disorders of peripheral nerves:
Pituitary and Pineal
compressive and traumatic neuropathies leprosy diabetic and uremic neuropathy Charcot-Marie-Tooth disease Guillain-Barre syndrome sympathetic dystrophy
Describe the gross and histopathological features of the following neoplastic and tumorous disorders of peripheral nerves:
peripheral schwannoma neurofibromas malignant peripheral nerve sheath tumors spinal root and peripheral nerve root cysts
Describe the gross and histopathological features of the following pituitary conditions:
Skull and Spine (including intervertebral discs)
pituitary adenomas including null cell adenomas, growth hormone secreting adenomas, prolactin secreting adenomas, ACTH secreting adenomas, and oncocytomas craniopharyngiomas including adamantinomatous and squamopapillary craniopharyngiomas Rathke pouch (cleft) cysts pituitary involvement by metastatic neoplasms lymphocytic hypophysitis pituitary infarcts including pituitary "apoplexy" pituitary lesions resulting from closed head trauma empty sella syndromes
Describe the gross and histopathological features of the following lesions of the pineal:
germinomas teratomas and embryonal carcinomas pineoblastomas and pineocytomas metastatic carcinoma
Describe the gross and histopathological features of the following disorders of the skull:
Eye and Orbit
dermoids and epidermoids hemangiomas osteomas chordomas solitary and multifocal eosinophilic granuloma Paget's disease including secondary osteosarcoma metastatic carcinomas plasmacytoma including myeloma
Describe the gross and histopathological features of the following disorders of the spine and intervertebral discs:
herniated intervertebral discs pyrophosphate disease including involvement of ligamentum flavum tumoral calcinosis hemangiomas chordomas eosinophilic granulomas metastatic carcinomas including epidural metastases plasmacytoma including myeloma lymphomas primary bone tumors spinal osteomyelitis including tuberculous and fungal spinal osteomyelitis
Describe the gross and histopathological features of the following ocular lesions:
Describe the gross and histopathological features of the following orbital lesions:
optic nerve gliomas optic nerve meningiomas orbital lymphomas and pseudotumors orbital metastases
List the gross and histopathological features found in temporal lobectomy and cerebral hemispherectomy specimens removed during epilepsy surgery. Review the gross, histopathological, and cytopathological features that can be observed in shunt revision specimens. Describe the gross, histopathological, and cytopathological features that can be observed with indwelling pump and intrathecal catheter specimens. Cite the techniques for examination of foreign objects removed from the nervous system and the need for documentation of chain of custody when of potential legal significance. Describe the histopathological features of myotonic dystrophy and central core myopathy and list the potential implications of these diseases with regard to adverse anesthetic reactions including development of malignant hyperthermia.
C. Â Â NEURORADIOLOGYUNIT 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:
COMPETENCY-BASED SKILLS OBJECTIVES:
arteriovenous malformations venous angiomasarteriovenous fistula feeding vesselsdraining 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
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.
D.Â PRACTICE MANAGEMENT, LEGAL AND SOCIOECONOMIC ISSUESUNIT 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:
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. E. NEUROSURGICAL ONCOLOGYUNIT 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 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:
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 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:
Describe the indications for transcranial orbitotomy and list the lesions which require this approach. Discuss the surgical management and postoperative treatment of astrocytomas, gliomas other than astrocytomas, metastatic brain tumors, infectious granulomas, and cystic lesions presenting in a tumor-like manner. Review the role of radiotherapy, chemotherapy, and other adjunctive treatments of these neoplasms. Describe the role of surgery for intracranial meningioma, and the relation between the surgical option and location of tumor. Discuss adjuvant treatments of meningioma and their efficacy. Discuss the surgical treatment of common intrinsic posterior fossa neoplasms, including cerebellar astrocytoma, medulloblastoma, and ependymoma including the role of ventricular drainage, and surveillance imaging. Present adjuvant treatment options and outcomes for the various posterior fossa intrinsic tumors. Address the surgical goals of treatment, complications of surgical treatment, and adjuvant therapy for posterior fossa meningioma. List and illustrate the various approaches for removal of a vestibular schwannoma, and the rationale and indication for each approach. Describe the role of stereotactic radiosurgery and microsurgery in the management of vestibular schwannoma. List the various approaches to the midline clivus and review the indications for each approach. Outline the surgical and medical management of tumors of the clivus and midline skull base. Explain the management goal for a patient with craniopharyngioma, and the risks of surgical treatment and conservative treatment. Describe the various surgical approaches used to resect craniopharyngiomas and the options for adjuvant treatment, including radiotherapy and chemotherapy (systemic and local). Illustrate the transnasal-transphenoidal approach and its indications. Define the options for treatment of recurrent pituitary tumors of all types (including medical management). Describe the risks of the approach and the management of the complication of CSF leak. Illustrate the various skull base approaches to the anterior, middle and posterior cranial fossae in detail, explaining the key anatomical landmarks and strict indications for the approach. Â List the complications relevant to each approach and the management of each complication. List a differential diagnosis of orbital tumors, their usual location within the orbit, medical and surgical management of the tumor and the approach used to remove the tumor if indicated. List the various tumors and their location in which an orbitocranial approach may be indicated for their removal. Compare and contrast the exposure offered by the pre-and postauricular infratemporal approach, and the indications for each approach. Illustrate transposition of the facial nerve during a transtemporal skull base approach. Describe the location of meningiomas intracranially which are amenable to preoperative embolization.
COMPETENCY-BASED SKILL OBJECTIVES:
Demonstrate the capability to function independently in all phases of management of patients with intracranial neoplasms. Perform resection of supra- and infratentorial intra-axial and extra-axial neoplasms. Perform resection of pituitary lesions. Perform or serve as first assistant for skull base procedures. Oversee the pre- and postoperative management of patients with intracranial neoplasms. Assume teaching responsibilities for junior residents as assigned. Assume responsibility for managing the pyschosocial aspects of intracranial neoplasms.
D. PAIN MANAGEMENTUNIT OBJECTIVES
Illustrate an understanding of the anatomical and physiological substrates of pain and pain disorders. Demonstrate an ability to formulate and execute diagnostic and therapeutic plans for management of pain and disorders giving rise to pain. COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
Describe the anatomy and physiology of nociception within the peripheral and central nervous system. Differentiate the basic categories of pain syndromes:
acute chronic nociceptive neuropathic (including complex regional pain syndromes) myofascial cancer-related postoperative
Explain the concept of pain as a biopsychosocial disorder. Discuss the role of rehabilitation in pain management. Describe methods for assessing pain in pediatric patients. Discuss ethical standards in pain management and research. Discuss methods of assessing outcomes of pain treatment and describe common assessment tools. Describe a typical history of a patient with trigeminal neuralgia, trigeminal neuropathic pain, and atypical facial pain. Diagram the anatomy of the following: trigeminal nerve divisions (ophthalmic, maxillary and mandibular nerves), foramen ovale, Meckel's cave, trigeminal (gasserian) ganglion, cistern of Meckel's cave, retrogasserian root, descending tract and nuclei, nervus intermedius, glossopharyngeal nerve. Illustrate the appropriate medical management of patients with trigeminal neuralgia, trigeminal neuropathic pain, and atypical facial pain. Discuss the potential complications of percutaneous procedures for trigeminal neuralgia. Describe the brain stem anatomy and physiology of the spinothalamic and trigeminothalamic systems. Describe the anatomy of the primary sensory cortex (S1), Rolandic fissure, and the relationship of S1 to the primary motor cortex. Describe the functional anatomy of the following thalamic nuclei: ventral posterolateral (VPL), ventralis caudalis externus (Vce), ventral posteromedial (VPM), and ventralis caudalis internus (Vci). Review the functional anatomy of the medial thalamic nuclei (e.g., n. parafascicularis). Identify the primary indications for spinal cord stimulation, peripheral nerve stimulation, and intraspinal (epidural, intrathecal) drug infusion therapy. Diagram the spine anatomy pertinent to SCS and intraspinal drug administration, including the spinous process/interspinal ligament/spinous process complex, ligamentum flavum and dorsal epidural space. Review the different degrees of angulation of the spinous processes at various spine levels in the cervical and thoracic area. Diagram the spinal cord anatomy pertinent to spinal ablative procedures for pain management. Recognize complications arising from implantation of pulse generators/receivers and infusion pumps. Describe the anatomy of the major peripheral nerves, brachial plexus, and lumbosacral plexus. Describe the anatomy of the sympathetic nervous system and explain its role in pain. List the common mechanisms of peripheral nerve injury and describe the changes which occur in an injured nerve at both the microscopic and macroscopic level. Explain the theories of pain generation in peripheral nerve injury. Describe the pharmacology of local anesthetic agents (e.g., lidocaine, procaine, tetracaine, bupivacaine) and the use of epinephrine with local anesthetic agents. Discuss the indications for peripheral neural blockade. Â Explain the principles of blocking procedures including the techniques and expected outcomes. Cite the complications of peripheral neural blockade (including anaphylaxis, neural injury, intravascular or intrathecal administration). List the alternatives to temporary blockade including neurolytic blocks, ablative neurosurgical procedures, augmentative neurosurgical procedures, alternative traditional pain management procedures, and alternative medicine approaches. Review the indications for radiofrequency facet rhizolysis. Discuss the anatomy and biomechanics of the facet complex with emphasis on bone, cartilage, fibrous capsule, synovial fluid, and innervation of this structure.
Name and differentiate the major classes of medications that are used commonly for pain treatment (opioids, non-steroidals and acetaminophen, antidepressants, anticonvulsants). Review the psychosocial issues that may influence a pain disorder and describe the role of behavioral interventions in pain management. Explain the rationale for multidisciplinary management of pain disorders. Contrast impairment and disability. Explain the basis of chemical, balloon compression, and radiofrequency neurolysis in the treatment of trigeminal neuralgia. Relate subcortical and brain stem sites that appear to be involved in the modulation of nociception to targets for deep brain stimulation (DBS) for pain control. Explain how central neurostimulation (cortical, subcortical) is thought to produce analgesia. Explain the role of ablative brain and brain stem procedures, (e.g., cingulotomy, mesencephalic tractotomy, trigeminal tractotomy) in the management of chronic benign pain and cancer pain. Discuss the possible complications of subcortical and brain stem ablative procedures for deafferentation pain. List the primary indications for the following spinal ablative lesions: dorsal root entry zone lesion, open and percutaneous anterolateral cordotomy, myelotomy. Discuss spinal cord stimulation (SCS), including types of stimulation systems and electrodes available, basic techniques of insertion of percutaneous and plate electrodes, the rationale and goals of intraoperative SCS testing (paresthesia coverage of painful area, avoidance of undesirable stimulation), the rationale and techniques for trialing SCS, and advantages and disadvantages of different sites of implantation of SCS pulse generator/receiver. Explain the key aspects of intraspinal drug administration, including the pharmacology of intraspinal drugs, the various types of infusion systems available, the rationale for trialing intraspinal drug infusions, basic techniques for insertion of intrathecal and epidural catheters, and the proper location for infusion pump implantation. Discuss the role of neuroectomy and neurolysis for pain control in nerve injury and compare alternative techniques for pain control. Describe the anatomy of the dorsal root ganglion, the bony anatomy of the nerve root foramen and the location of the ganglion within that foramen. Discuss indications for ganglionectomy and describe long-term outcome from ganglionectomy with emphasis on pain recurrence and deafferentation. Describe the indications for peripheral nerve stimulation and contrast to spinal cord stimulation. Describe indications for ablative peripheral neurolysis. Review the pharmacology and histopathologic effects of neurolytic agents (e.g., phenol, glycerine/glycerol, chlorcreosol, absolute alcohol, ammonium chloride/sulfate). Discuss basic principles of ablative neurolytic procedures in terms of technique, expected outcomes, and complications including neural injury, injury to surrounding soft tissue, inadvertent intravascular or intrathecal administration. Describe the alternatives to neurolysis, including temporary anesthetic blocks, ablative neurosurgical procedures, augmentative procedures, alternative traditional pain management procedures, and alternative medicine approaches. Describe the principles of radiofrequency lesioning. Include in the discussion the following topics:
probe thermocouple and thermistor time intensity of heat isotherm fields
Discuss basic principles of radiofrequency facet rhizolysis and list the equipment utilized, technique employed, expected outcomes, and complications (including damage to other nerve root branches, potential for spinal instability, inadvertent damage to radicular artery, CSF leak, and spinal cord injury). Compare the alternatives to radiofrequency lesioning:
local anesthetic facet blocks epidural injections neurolytic facet blocks ablative neurosurgical procedures augmentative neurosurgical procedures alternative traditional pain management procedures alternative medicine approaches surgical intervention such as instrumentation and fusion
Distinguish the indications for surgical and non-surgical treatment of pain. Construct a management strategy relating to application of percutaneous trigeminal neurolytic procedures, retrogasserian rhizotomy, and microvascular decompression in the care of patients with trigeminal neuralgia. Describe and contrast the approaches to the cerebellopontine angle for microvascular decompression or rhizotomy of the trigeminal and glossopharyngeal nerves. Identify the various target spine levels for spinal cord stimulation according to the pain topography (simple and complex). Identify the various intraspinal structures based on their responses to mechanical and electrical stimulation (dura mater, lateral canal wall, dorsal columns, dorsal roots, ventral roots, motor neurons). Compare the different methods of intraspinal drug administration (epidural, intrathecal, tunneled catheter, implanted infusion system). Describe the techniques for trialing intraspinal drugs. Compare the pharmacodynamics of different drugs delivered intrathecally (e.g., hydrophilic vs. lipophilic). Describe the possible complications of spinal cord stimulation electrode or spinal catheter insertion and their evaluation and treatment:
COMPETENCY-BASED SKILL OBJECTIVES:
paralysis nerve root damage electrode or catheter migration electrode or catheter breakage epidural hematoma cerebrospinal fluid leak
Describe the common drug side effects associated with intraspinal analgesic administration. Describe the correct placement of lesions for DREZ, cordotomy, and myelotomy, including lesion depth and structures affected. Discuss the possible neurological sequellae of spinal ablative procedures with both correct and incorrect lesion placement, with anatomical correlates.Describe the role of DREZ lesioning in the overall management of the patient with deafferentation pain. Describe the techniques for exposure of the major peripheral nerves. Demonstrate knowledge of basic principles of nerve grafting, including regeneration, graft length considerations, and use of allograft donor nerves. Describe the role and outcomes of ganglionectomy in the management of various pain syndromes, contrasting it with augmentative techniques. Discuss in detail the surgical technique of ganglionectomy. Â Describe percutaneous methods of gangliolysis. Explain the effects of blocking agents at the membrane and synaptic cleft, and the biochemistry and histology of neurotoxicity. Explain the histologic effects of neurolytic agents at the membrane level and display a comprehensive level of understanding with regard to toxicity. Describe the histologic effects of radiofrequency lesioning. Â discuss in detail the evaluation and management of a patient selected for radiofrequency lesioning of the facets. Â Discuss the alternatives to radiofrequency lesioning, with particular emphasis on the potential surgical remedies including decompression, instrumentation, and fusion.
Obtain a pertinent history and perform an appropriate physical examination for a patient with a primary complaint of pain. Formulate and implement treatment plans for simple pain syndromes (e.g., acute postoperative pain, acute low back pain). Evaluate and diagnose a patient with trigeminal neuralgia, trigeminal neuropathic pain, and atypical facial pain. Assist with radiofrequency, glycerol or balloon compression neurolysis of the trigeminal nerve in patients with trigeminal neuralgia. Assist with surgical exploration of the trigeminal nerve, nervus intermedius, or glossopharyngeal nerve for MVD or rhizotomy. Illustrate appropriate patient selection for spinal ablative or augmentative procedures for pain management. Locate the spinal epidural space and place a percutaneous spinal cord stimulation electrode with supervision. Â Assist with implantation of a plate electrode for spinal cord stimulation. Insert with supervision a spinal catheter for drug administration. Implant with supervision a spinal cord stimulation system pulse generator/receiver and extension wire. Implant with supervision an intraspinal drug infusion pump. Assist with spinal ablative procedure for pain management (cordotomy, myelotomy, DREZ). For peripheral nerve repair, neurectomy, and neurolysis perform, record, and report complete patient evaluation and assessment, including comprehensive neuromuscular examination of affected nerve distribution. Evaluate electrodiagnostic studies pertaining to peripheral nerve injury. Recognize and treat the potential complications of peripheral nerve repair, neurectomy, and neurolysis including hematoma formation, infection, and local wound problems. Assist in surgical treatment of peripheral nerves. Assist with implantation of a peripheral nerve stimulation system. Perform, record, and report complete patient evaluation and assessment for dorsal root ganglionectomy.Recognize and treat the potential complications of dorsal root ganglionectomy including cerebrospinal fluid leak, infection, and local wound problems.Assist in foraminotomy and exposure of dorsal root ganglion. Â Assess patients for appriateness of local anesthetic block(s). Perform simple superficial blocks with supervision and assist in complicated procedures. Following such procedures:
Formulate and implement an appropriate treatment program for complicated pain syndromes (e.g., chronic back pain, "failed back surgery syndrome"). Assess the need for multidisciplinary management of pain disorders. Demonstrate appropriate management of psychosocial factors complicating a pain disorder. Employ the Hartel technique to perform radiofrequency, glycerol or balloon compression neurolysis of the trigeminal nerve in patients with trigeminal neuralgia. Implant a plate electrode. Demonstrate appropriate methods for trialing spinal cord stimulation and intraspinal drug administration systems. Implant a peripheral nerve stimulation system. Assess patient for appropriateness of radiofrequency facet blocks. Perform radiofrequency facet blocks with supervision. Following the performance of such procedures: assess outcome of facet blocks recognize and treat complications record and monitor effects of facet blocks over a specified time interval assess need for repeat facet blocks Diagnose and formulate appropriate treatment plans for sympathetically-maintained pain. Diagnose and formulate an appropriate treatment plan for a patient with occipital neuralgia.
assess outcome of nerve block recognize and treat complications record and monitor effects of block over a specified time interval assess need for repeat blocks
Assess patient for appropriateness of ablative neurolysis. Perform simple superficial neurolysis with supervision and assist in complicated procedures. Following ablative neurolysis:
assess outcome of procedure recognize and treat complications record and monitor effects of neurolysis over a specified time interval assess need for repeat procedures
Recognize and execute intelligent treatment choices for different pain syndromes including nociceptive, neuropathic, and cancer pain. Â Demonstrate appropriate use of each of the major classes of medications in common use for treating pain. Demonstrate appropriate selection of patients for surgical treatment of pain disorders. Perform microvascular decompression and rhizotomy of the trigeminal nerve and glossopharyngeal nerves. Assist a junior resident in performing a percutaneous ablative procedure for trigeminal neuralgia. Formulate and implement an appropriate treatment plan for management of pain using spinal ablative and augmentative techniques according to pain etiology, pain topography, and status of spinal column (e.g. previous surgery at implant level, scoliosis, stenosis, etc.). Select and implant an appropriate SCS system, recognizing how to modify electrode insertion technique and location based upon intraoperative responses. Implant a plate electrode in a patient with previous spinal surgery at the same level. Demonstrate proficiency with maintenance and programming of spinal drug administration systems and spinal cord stimulation systems. Recognize and evaluate malfunctions of SCS and intraspinal drug administration systems. Perform surgical revision of SCS and intraspinal drug administration systems. Demonstrate proficiency in identification and lesioning of the dorsal root entry zone, even in cases of nerve root avulsion. Demonstrate proficiency in performing myelotomy and cordotomy. Expose major peripheral nerves and perform closure of extremity incision for peripheral neurectomy/neurolysis. Demonstrate proficiency in neurolysis and nerve grafting techniques. Plan and execute surgical approaches to injuries of the major peripheral nerves. Plan a peripheral nerve reconstruction including exposure, preparation of donor site, and nerve graft. Demonstrate proficiency in technique of ganglion resection. Â Incorporate ganglionectomy as one part of an integrated approach to the patient with intractable pain. Display appropriate patient selection for local anesthetic blocks. Perform simple superficial blocks with minimal supervision. Relative to these blocks perform the following:
H.Â STEREOTACTIC AND FUNCTIONAL NEUROSURGERYUNT OBJECTIVES
assess outcome of block recognize and treat complications maintain detailed records of effects of block and follow-up assess need for repeat blocks
Provide information regarding alternatives for failed nerve block. Perform complicated nerve block procedures with direct supervision. Recognize and treat the complications of these procedures. Display appropriate patient selection for ablative peripheral neurolysis. Perform simple neurolytic procedures with minimal supervision. Relative to these procedures perform the following:
assess outcome of the procedure recognize and treat complications maintain detailed records of effects of neurolysis and follow-up assess need for repeat neurolysis
Provide information regarding alternatives for failed neurolysis. Perform complicated neurolytic procedures with direct supervision. Display appropriate patient selection for radiofrequency facet rhizolysis. Perform simple facet blocks with minimal supervision. Relative to these procedures perform the following:
assess outcome of the procedure recognize and treat complications maintain detailed records of effects of facet blocks and follow-up assess need for repeat facet blocks
Provide information regarding alternatives for failed facet blocks. Perform complicated facet blocks with direct supervision. Perform sympathectomy.
Define neurosurgical stereotactic procedures and recognize their proper application. Describe the appropriate anatomy, physiology, and presentation of patients that are candidates for stereotactic procedures. COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
Discuss the considerations of stereotactic frame placement in regard to target localization and purpose of procedure (biopsy, craniotomy, functional, radiosurgery). Describe the direct and indirect basal ganglion-thalamocortical motor pathways. Define and distinguish each of the following entities:
tremor rigidity dystonia chorea athetosis
Describe the pathophysiology of Parkinson's disease and cerebellar tremor. Explain the primary symptoms treated by ventro-lateral (VL) thalamotomy pallidotomy. Discuss the advantages and disadvantages of stereotactic biopsy compared to open biopsy procedures. Discuss the differential diagnosis of a newly discovered ring-enhancing intracranial mass. Discuss the differential diagnosis of a newly discovered non-enhancing intracranial mass. Define different seizure types (partial, partial-complex, generalized, etc). Define medically intractable epilepsy. Describe the anatomy of the mesial temporal lobe. Define brachytherapy. Define conventional care for patients with high-grade gliomas. Review the limitations of conventional care for patients with high-grade gliomas. Describe the anatomy of the trigeminal nuclei, root, ganglion and divisions. Define typical trigeminal neuralgia, atypical trigeminal neuralgia, and trigeminal neuropathy. Explain the potential causes for trigeminal neuralgia. Define stereotactic radiosurgery.Explain the differences between radiosurgery and radiation therapy. List the potential indications for radiosurgery. List the reported complications of radiosurgery. Compare advantages and disadvantages of frame-based or frameless stereotactic craniotomies to non-stereotactic craniotomies.
Describe factors guiding the choice of neuroimaging (CT, MRI, angiography) for stereotactic procedures. Explain the rationale for various MRI sequences used for tumor localization and functional procedures. Discuss the benefits and limitations of frame-based stereotactic procedures. Discuss patient selection for VL thalamotomy and pallidotomy. Discuss the advantages and disadvantages of ablative procedures. List the potential complications of VL thalamotomy, pallidotomy, and bilateral thalamotomies or pallidotomies. Discuss technical considerations to minimize the potential for an intracranial hemorrhage after a stereotactic biopsy. Discuss technical considerations to minimize the potential for a non-diagnostic stereotactic biopsy. Describe the appropriate trajectories to biopsy a lesion in the pineal region, midbrain, pons, and medulla. Compare the advantages and disadvantages of radiosurgery and surgical resection for tumors and vascular malformations.
Identify the microelectrode recordings of the thalamus and globus pallidus. Identify the primary indications for medial thalamotomy and cingulotomy. Describe the evaluation of a patient with medically intractable epilepsy. Discuss the indications for placement of depth electrodes. Describe the surgical treatment of epilepsy in detail. Discuss the theoretical advantages of brachytherapy over external beam radiation therapy. Describe the most common complications of brachytherapy and their treatment. Explain the effect of patient selection on the reported results of brachytherapy for high-grade gliomas.Describe the methods used to localize and percutaneously penetrate the foramen ovale. List the potential advantages and disadvantages for the following trigeminal rhizotomy procedures:
COMPETENCY-BASED SKILL OBJECTIVES:
glycerol radiofrequency balloon compression
Discuss the dose-volume relationships for radiation-related complications after radiosurgery. Discuss potential sources of inaccuracy for stereotactic procedures. Discuss advantages and disadvantages of deep brain stimulation compared to ablative techniques.
Perform radiosurgery dose-planning. Perform stereotactic craniotomies.
Last Updated Feb 2013