||VA Curriculum BASIC TOPICS SECTION A. NEUROANATOMYUNIT OBJECTIVES
Demonstrate knowledge of anatomy that is pertinent to the diagnosis of diseases of the nervous system and the practice of neurological surgery.
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. NEURORADIOLOGYUNIT 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 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 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 interarticularisuncovertebral 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 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 SKILL 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.
C. 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 staffmedical students faculty physicians referring physicians Demonstrate the ability to maintain accurate and current medical records. Discuss neurosurgical career options with: faculty peers family non-faculty neurosurgeons and other mentors Accumulate information about post-residency career options. Create and keep current a resume/curriculum vitae. Record CPT codes for office visits and procedures performed on service. Accurately document H&P and consultations according to the AMA-CPT E&M documentation guidelines. NEUROSURGICAL CLINIC TOPICS SECTION D. CEREBROVASCULAR SURGERYUNIT OBJECTIVES
treatment facilities third party payment systems
Recite the rules and regulations of the training hospital(s) as they pertain to the practice of neurosurgery in which the residency is performed. Name the institutional and social service agencies in your community and review their role in the overall management of neurosurgical patients. Demonstrate 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 cerebrovascular diseases, including ischemic and hemorrhagic stroke, and other diseases and malformations of intracranial, extracranial, and spinal vasculature. Demonstrate the ability to formulate and implement a diagnostic and treatment plan for cerebrovascular diseases, including medical and surgical management. COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
Recognize controversies regarding the basic neuroscience knowledge concepts mastered during junior residency. Explain the principles of ischemic neuronal protection and salvage. Review the principles of guideline development and outcome assessment related to the basic knowledge objectives achieved during junior residency. Display an understanding of the principles of hypothesis development and testing, and statistical analysis as applied to clinical research trials, as well as the critique of scientific manuscripts. Recognize areas of controversy related to management protocols in cerebrovascular patients achieved during junior residency.
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
Perform pterional craniotomy for vascular disease. Demonstrate the ability to make independent management decisions regarding ischemic and hemorrhagic stroke states. Supervise care delivered by PGY1 and junior resident physicians for cerebrovascular patients. Demonstrate efficient prioritization skills for clinical assessment of multiple simultaneous problems in the same or different patients. Display a clear sense of prioritization regarding timing and urgency of medical and surgical intervention for ischemic and hemorrhagic stroke states. Recognize the impact of systemic conditions on prioritization and timing issues. Correctly interpret and respond to changes in patient status related to systemic and neurological parameters. Implement patient-care protocols regarding perioperative management. Display independence in making decisions regarding the critical care of cerebrovascular patients. Recognize the need for reporting to senior resident and attending staff such decisions. Demonstrate the ability to obtain appropriate medical and surgical consultation. Display skills in prioritization of diagnostic interventions, including the choice and sequence of studies in the setting of ischemic and hemorrhagic states. Interpret invasive and noninvasive diagnostic imaging studies in relationship to cerebrovascular disease. Formulate preliminary and surgical planning. Perform frameless navigation procedures. Perform routine and complicated twist drill or burr-hole procedures for the drainage of the ventricular system or intracranial hematomas. Peform exposure of the cervical carotid artery for endarterectomy or proximal arterial control. Observe and assist in the performance of plaque removal and arterial closure during carotid endarterectomy. Practice microsurgical techniques in the laboratory setting. Demonstrate a mature understanding of the planning and performance of pterional craniotomy for intracranial vascular pathology. Perform pterional craniotomy with initiation of microsurgical clinical skills. Observe the microsurgical dissection of the Sylvian fissure and basal cisterns for vascular pathology. Perform the surgical approach to vascular structures via a craniotomy other than pterional. Supervise and assist junior residents in burr-hole and twist-drill procedures for ventricular access or intracranial pressure monitoring. Realize an increasingly progressive teaching responsibility to medical students, interns, and junior residents in the various educational objectives of the cerebrovascular curriculum. Supervise the junior residents in the technical performance of cerebrovascular procedures, as well as critical-care catheter procedures commensurate with their level of expertise. Organize clinical and teaching rounds and conferences, as well as the presentation of cases. Prepare topic reviews in lecture and manuscript formats, including literature summaries and reference compilations.
E. NEUROSURGICAL ONCOLOGYUNIT OBJECTIVES
Demonstrate an understanding of the anatomy, physiology, pathophysiology, and presentation of tumor-related diseases of the cranium. Demonstrate the ability to formulate and implement a diagnostic and treatment plan for tumor-related diseases of the cranium that are amenable to surgical intervention. COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
Describe appropriate postoperative management with drainage of brain abscess or cyst. Describe the appropriate surgical management and postoperative treatment of bony skull lesions. Describe the role of surgery in arachnoid cysts, infectious cysts, and tumor-related cystic lesions. Describe the adjuvant treatment of parasitic cysts. Explain the rationale and indications for various skull base approaches to the anterior, middle and posterior cranial fossae. Identify the important anatomical landmarks for each approach. Illustrate the general principles used in prophylaxis of CSF leaks employed in skull base surgery. Describe the neurosurgical management for the following tumors involving the anterior cranial fossa:
COMPETENCY-BASED SKILL OBJECTIVES:
meningioma fibrous dysplasia esthesioneuroblastomaosteoma of the frontal sinus chondroma, chordoma mucocele bony metastasis
Explain the use of the balloon occlusion test of the carotid artery, its indication for use in skull base tumor surgery, how it is performed, and how the information gained influences surgical management. Explain the surgical advantage of transposing the facial nerve during a transtemporal skull base approach. Describe the transcondylar approach, the relationship of the lower cranial nerves, and the exposure gained over a routine suboccipital craniectomy. llustrate the transpetrosal approach and the relationship of the transverse and sigmoid sinuses with skull bony landmarks such as the asterion, mastoid and inion. Describe the intradural course of the trochlear nerve, trigeminal nerve through Meckel's cave and the abducens nerve and Dorello's canal. Describe the surgical management of the frontal sinus which has been exposed during craniotomy for anterior skull base surgery. Illustrate the development and use of a frontal vascularized pericranial flap and explain its indication. Similarly, illustrate the use of a myocutaneous flap of the temporalis muscle and list the locations for application. Describe the general methods employed for embolization of tumors of the head and neck, and the indications for such procedures. Compare and contrast the methods for stereotactic radiation, including particle beam, gamma ray or linear accelerator, and the indications for each technique.
Independently determine a differential diagnosis based on the patient's history, physical examination, and radiographic studies. Position patients for craniotomy and craniectomy. Perform the opening and closing of craniotomies and craniectomies. Assist in the resection of intracranial neoplasms. Resect skull lesions. Operatively treat supra- and infratentorial brain abscess. Demonstrate the ability to manage postoperative complications including but not limited to:
F. NEUROTRAUMA AND NEUROSURGICAL CRITICAL CAREUNIT OBJECTIVES
brain edema meningitis cranial flap infection postoperative seizures
Assess the need for appropriate pre-, intra-, and postoperative monitoring. Obtain proper nonneurosurgical consultation in tumor patients. Identify patients requiring rehabilitation services. Utilize appropriate support agencies and groups for patients with intracranial neoplasms.
Demonstrate an understanding of the anatomy, physiology, pathophysiology, and presentation of traumatic injuries of the brain, spinal cord, and peripheral nervous system, including their supporting structures. Demonstrate the ability to formulate and implement appropriate diagnostic and treatment plans for traumatic injuries to the nervous system, including both surgical and nonsurgical management. COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
Describe the pathophysiology of intracranial hypertension and explain a plan for its management, including arguments for and against various treatments.
COMPETENCY-BASED SKILL OBJECTIVES:
Perform the following surgical procedures in uncomplicated cases:
craniotomy for subdural and/or epidural hematoma craniotomy for penetrating head injury craniotomy for intracerebral hematoma or contusion craniotomy for depressed skull fracture decompressive craniectomy repair/cranialization of frontal sinus fracture craniotomy/craniectomy for posterior fossa epidural, subdural, or intracerebral hematoma simple cranioplasty
Manage traumatic skull base fractures with CSF leak. Manage infections associated with open CNS injuries.
Last Updated Feb 2013