NEUROSURGERY CURRICULUM

This rotation introduces the first-year neurosurgery resident to the management of neurosurgical patients in the critical care and perioperative environments. It is at this time the resident is evaluated with respect to progression of responsibility from direct supervision to indirect supervision (with direct supervision available). The rotation also focuses on the principles of pathophysiology and treatment of major central nervous system injury, including brain, spinal cord, and spinal column. This rotation is the resident's introduction to academic neurosurgery and the associated enterprises of interdisciplinary care (systems-based practice), outcomes tracking and reporting (practice-based learning), technological and management advances, and the role of the neurosurgeon in these advances.

Trauma neurosurgery is a critical and fundamental aspect of neurosurgical care and training. Traumatic brain injury is an acute surgical problem requiring rapid assessment, aggressive treatment, and an intimate knowledge of the physiology, anatomy, and critical care of the nervous system and all other organ systems, which are often also affected in the traumatized patient.

The care of trauma patients also involves communicating with family members experiencing a dramatic, unexpected, and profoundly disruptive life event. The junior resident plays an important role, with attending surgeon participation and supervision, in the intensive communication needs of these families, providing an opportunity to learn and practice critical professionalism and communication skills.

This rotation also introduces the first-year neurosurgery resident to the inpatient management of neurosurgical patients as well as to the principles of basic neurosurgical procedures including craniotomy and straightforward approaches to the spine. The rotation focuses on the complex, interdisciplinary environment of hospital-based, modern neurosurgical practice. Thus, the junior resident is instructed in principles of systems-based practice, including the management of neurosurgical patients, and working on care teams involving mid-level providers (NPs and PAs). The junior resident also learns the principles of longitudinal care, discharge planning and outpatient communication and the recognition and management of late neurosurgical complications.

Operative experience is directed towards basic neurosurgical procedures such as simple craniotomy, posterior (dorsal) approaches to the (principally lumbar) spine and CSF diversion procedures.

The junior resident will be responsible for the basic functions of the neurosurgical ICU and ward service and urgent daytime neurosurgery consultation in the emergency department and hospital. The chief resident will supervise the junior resident and report directly to attending surgeons.

The junior resident will assess neurosurgical patients and will organize this data for presentation to the chief resident and attending during morning rounds and to the resident and call team during afternoon rounds. The junior resident will report to the chief resident and neurosurgery attendings.

The main teaching hospitals during the PGY-2 year are OUMC, OCH, and the VA hospital. The junior resident will gain an exposure to outpatient management of neurosurgical and spine patients and will attend the Department of Neurosurgery teaching conferences. The junior resident will perform ICU-based neurosurgical procedures (see above) with initial supervision under the departmental procedures certification policy, and then independently with back-up from senior residents and faculty. The junior resident will also participate (with appropriate back-up coverage for the ICU) in trauma and other emergency procedures (hematoma evacuation, decompressive craniotomy, etc.) on ICU patients.

The junior resident will also be expected to perform clinically driven, case-based study (i.e. performing literature searches on topics relevant to active patients in the ICU).

The junior resident will observe, participate in and, as appropriate, perform family updates, care discussions, end-of-life discussions, brain death evaluations and organ donation referrals (within institutional guidelines regarding brain death and conflict of interest).

The neurosurgical attending makes daily rounds with the junior resident, if available.

• Describe the anatomy of the brain, spine, peripheral nerves, and the bony coverings of each.
• Describe the physiology of normal brain and normal vasculature.
• Describe the pathophysiology of TBI.
• Describe auto regulation of cerebral blood flow and what occurs to auto regulation in TBI.
• Describe the definition of mild, moderate, and severe brain injury and identify the individual components and scores of the Glasgow Coma Scale and Glasgow Outcome Scale.
• Describe what neuro-monitoring techniques are available for TBI patients and articulate normal and critical values of monitored parameters and the associated path physiology of their deregulation.
• List and describe the major patterns of spinal injury.What mechanisms of injury and spinal column injury are most associated with each? What is the prognosis for recovery for each?
• Describe the difference between complete and incomplete spinal injury and the prognosis of neurologic recovery for each.
• Describe the pathways for clearance of the spine.
• Describe the appropriate use of paralytics/sedatives/vasopressors in severe TBI.
• Describe the pathophysiology of craniocervical injuries in adults.
• Describe the pathophysiology of sub-axial spinal column and cord injuries in adults.
• Describe the diagnosis of CSF leak after trauma, cranial surgery, spinal surgery.
• Describe the management of status epilepticus.
• Describe the anatomy of the brain, spine, peripheral nerves, and the bony coverings of each.
• Describe the anatomy of the brachial plexus and major peripheral nerves and their common sites of injury.
• Describe surgical techniques for continuous intrathecal infusion of morphine for chronic pain.
• Describe complications of intrathecal drug delivery and their management, including device infection, overdose and withdrawal, and catheter granuloma formation.
• Describe the pathophysiology of entrapment neuropathy.
• Describe clinical risk factors for entrapment neuropathy and how they affect prognosis after surgery, as well as conditions mimicking entrapment neuropathy.
• Describe the pathophysiology of spondylosis, including secondary radiculopathy and myelopathy.
• List and describe the inflammatory arthritides which may involve the spine, and their radiographic, clinical, and serological diagnostic considerations.
• List the complications of dorsal approaches to the spine for spondylotic disease and describe the 'failed back syndrome'.
• Describe barriers in communication that may exist in interdisciplinary teams consisting of physicians, nurse practitioners and physicians' assistants.
• Describe JACHO patient safety standards regarding proper patient identification, medication order writing, surgical site preparation (including hair removal), peri-operative antibiotic administration, and pre-procedural site identification pause.
• Discuss appropriate medical and surgical management of TBI.
• Discuss the management including ICU care, bracing, and surgery for spinal cord and column injury, and clearance of the spine.
• Discuss appropriate post-traumatic and peri-operative narcotic orders.
• Describe the principles of medical and surgical management of spinal cord injuries.
• Write appropriate ICU admission and post-op orders appropriate for ICU pts.
• Demonstrate the proper performance of a complete and a targeted neurological examination in
• TBI
• Spinal cord injury
• Sub-arachnoid hemorrhage
• Posterior fossa surgery
• Hemispheric surgery
• Metabolic disorder/intoxication/delirium tremens
• MRI brain and spine
• Spine radiographs
• Cine MRI CSF flow study
• MRA/MRV
• CT brain and spine
• angiography and CTA
• Status epilepticus
• Cerebral herniation & acute intracranial hemorrhage
• CNS infection
• Unstable spine
• Severe metabolic abnormality
• Severe CSF shunt malfunction
• Cerebral vasospasm
• Demonstrate the ability to evaluate patients for CSF shunt infection and/or failure
• Demonstrate the ability to evaluate neurotrauma patients.
• Demonstrate effective participation in clinic.
• Demonstrate the ability to perform basic bedside and ICU procedures:
• CSF shunt tap
• ICP monitor
• Ventriculostomy
• Lumbar puncture/Lumbar drain placement
• Arterial line placement
• Central venous access placement
• Endotracheal intubation
• Demonstrate appropriate work-up of post-operative fever in neurosurgical patients with or without history of intradural procedure.
• Write effective ward management orders for cranial and spinal adult neurosurgery patients.
• Demonstrate the ability to efficiently transfer patient to critical care setting and/or operating room in response to critical change in condition, including writing appropriate care orders for new setting.
• Write appropriate pain management orders including PCA orders for peri-operative and chronic pain patients.
• Implement effective fluid and diet management orders and manage feeding tube and vascular access issues (with appropriate surgical consultation as needed).
• Demonstrate the ability to assist with basic neurosurgical operations with attending supervision:
• Lumbar laminectomy
• Lumbar laminotomy/discectomy
• Cervical decompressive laminectomy
• CSF shunt (ventricular and lumbar)
• Carpal tunnel release
• Ulnar nerve release
• Spinal cord stimulation
• Intrathecal catheter/pump
• Radiosurgery
• Straightforward craniotomy

• Attend rounds in timely fashion
• Pre-round on ICU patients and present timely, accurate data to team
• Participate in discussion of ethical dilemmas related to care delivery, consent, and life support in severely injured patients and participate in ethics board discussion of any service patient during rotation.
• Interact effectively with mid-level providers and discharge planners
• Maintain professional rapport and comportment with patient families, nurses, other physician teams and other hospital personnel.
• Prepare for scheduled operative cases by reviewing patient records and films, reading about the pathophysiology and presentation of the patient’s disease process, and reviewing details and technique of the planned surgical procedure
• Demonstrate care and compassion for neurosurgical patients and their families
• Accurately self-report fatigue in situations that may compromise safety and/or patient care
• Describe conflicts of interest that may arise from industry sponsorship of hospital-based educational activities.
• Demonstrate respect for patients and colleagues from diverse cultural, ethnic and religious backgrounds
• Demonstrate honesty in all professional interactions
• Provide consultation to the ED and other services in timely fashion and/or arrange for back-up consultation if unavailable
• Demonstrate dress, grooming and comportment consistent with institutional guidelines and earning confidence and respect from supervisors, peers, and patient families
• Comply with all GME and Departmental regulations regarding duty hour restrictions and report personal schedule in timely and accurate fashion 

• Communicate patient information, care plans and prognostic information effectively with the families of injured patients
• Communicate the plan for co-managed neurotrauma patients with peers on the surgical trauma service
• Communicate clearly and promptly with consulting services
• Communicate expectations and care plans to the interns and medical students working on the service
• Manage and cooperate with the nursing and support staff to obtain the best care for patients while building teamwork, responsibility, and enthusiasm
• Communicate effectively with other members of the neurosurgery team
• Describe barriers to communication that may exist in interdisciplinary teams consisting of physicians, nurse practitioners, and physician assistants. 

• Keep a database of all patients.
• Daily teaching rounds with the attending when available.
• Participate in the patient/family consent process.
• Report all morbidity for review and discussion at M & M conference.
• Review and modify ward based policies as needed with supervision from chief resident and faculty.
• Maintain current and accurate information for patient handoff sheet.

• Describe the nature of complex interdisciplinary team management in neurotrauma.

• Manage communication with the ICU and trauma surgery teams regarding co-care patients, manage communication with midlevel providers, consultants.
• Interact with neurosurgical nurse practitioners, PAs, physical therapists, and social workers in planning longitudinal care of neurosurgery patients.
• Participate in effective discharge planning with hospital personnel.
• Demonstrate effective interaction with peri-operative nursing and anesthesia personnel in delivering effective OR environment care:
• Pre-operative antibiotic administration
• Surgical site preparation
• Surgical site and patient identification
• Modification of anesthetic technique for operative requirements (for example, electrophysiological monitoring or testing)
• Availability of blood products, if appropriate      
• Review and correction of coagulation, cardiac, pulmonary, and other risk factors prior to operative procedures