Picture4
[Curriculum]
[Childrens]
[Laboratory]
[Neurocritical Care]
[Parkland Chief]
[Parkland Junior]
[Neurology]
[Spine]
[Tumor]
[VA]
[Vascular Chief]
[Vascular Junior]
Zale Tumor 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.  NEUROPATHOLOGY
UNIT OBJECTIVES
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 System
Describe 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
hydromyelia
diastematomyelia and diplomyelia
syringomyelia and syringobulbia
Chiari I malformation
Chiari II malformation
Dandy-Walker malformation
arachnoid cysts
porencephaly
aqueductal 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
subependymomas
choroid plexus tumors
colloid cysts
gliomatosis cerebri
gangliocytomas and gangliogliomas
dysembryoplastic neuroepithelial neoplasms
central neurocytomas
medulloblastomas
atypical 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
hemangioblastomas
lipomas
primary central nervous system lymphomas
metastatic carcinomas including leptomeningeal carcinomatosis
teratomas
dermoids 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:
      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
Pituitary and Pineal
    Describe the gross and histopathological features of the following pituitary conditions:
      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
Skull and Spine (including intervertebral discs)
    Describe the gross and histopathological features of the following disorders of the skull:
      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
Eye and Orbit
    Describe the gross and histopathological features of the following ocular lesions:
      retinoblastomas
      ocular melanomas
    Describe the gross and histopathological features of the following orbital lesions:
      optic nerve gliomas
      optic nerve meningiomas
      orbital lymphomas and pseudotumors
      orbital metastases
Miscellaneous
    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.   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 SKILLS 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.
 
 
D. PRACTICE MANAGEMENT, LEGAL AND SOCIOECONOMIC ISSUES
UNIT OBJECTIVES
Demonstrate an understanding of the principles of practice management and the  business aspects associated with the delivery of health care.
 
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
    Discuss the ethical and moral factors associated with the practice of neurosurgery.
    Review the role of the neurosurgical leadership in the community and hospital setting.
    Explain the neurosurgeon's responsibilities in terms of health care cost containment.
    Review the features and relationships of the healthcare system including:
      treatment facilities
      third party payment systems
        Medicare
        Medicaid
        employer-provided insurance
        private insurance
      physician practice organizations
      medical equipment manufacturers
      pharmaceutical companies
    Recite the rules  and regulations of the training hospital(s) as they pertain to the  practice of neurosurgery in which the residency is performed.
    Name the institutional and social service agencies in your community and  review their role in the overall management of neurosurgical patients.
    Demonstrate 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 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 ONCOLOGY
UNIT OBJECTIVES
Demonstrate an understanding of the anatomy, physiology, pathophysiology, and  presentation of tumor-related diseases of the cranium. Demonstrate the  ability to formulate and implement a diagnostic and treatment plan for  tumor-related diseases of the cranium that are amenable to surgical  intervention.
 
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
    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.   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 MANAGEMENT
UNIT 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.   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:
      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.  
    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.  
    discuss in detail the evaluation and management of a patient selected for radiofrequency lesioning of the facets.  
    Discuss the alternatives to radiofrequency lesioning, with particular emphasis  on the potential surgical remedies including decompression,  instrumentation, and fusion.
COMPETENCY-BASED SKILL OBJECTIVES:
    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.  
    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.  
    Assess patients for appriateness of local anesthetic block(s).
    Perform simple superficial blocks with supervision and assist in complicated procedures. Following such procedures:
      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
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.
    Recognize and  execute intelligent treatment choices for different pain syndromes  including nociceptive, neuropathic, and cancer pain.  
    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.  
    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:
      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.
 
 
H. STEREOTACTIC AND FUNCTIONAL NEUROSURGERY
UNT OBJECTIVES
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:
      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.
COMPETENCY-BASED SKILL OBJECTIVES:
    Perform radiosurgery dose-planning.
    Perform stereotactic craniotomies.

Last Updated Feb 2013