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Laboratory Curriculum 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:
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 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 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
NEUROPHYSIOLOGYUNIT OBJECTIVES
Demonstrate knowledge of physiology that is pertinent to the understanding of neurological disease. COMPETENCY-BASED KNOWLEDGE OBJECTIVES:Review the basic biology of the nerves including: synthesis and movement of proteins in the nerve membrane potential and membrane properties ion channels generation and conduction of an action potential Discuss synaptic transmission including: types of synaptic transmission transmitter release nerve-muscle transmission chemical messengers direct gated receptors second messenger linked receptors Describe the physiology of the sensory systems including: sensory receptor physiology anatomy of somatic sensory system coding of modality specific sensory information pain and analgesia cortical integration of sensory perception visual system processing of information in the retina processing of vision in the central visual pathways columnar units of visual cortex processing in the geniculate nucleus visual perception of motion and form. auditory system. Within this description review the processing of hearing in the cochlea and the central auditory pathways. olfaction and taste Discuss the physiology of the motor system including: mechanisms of muscle contraction muscle receptors, spinal reflexes spinal reflexes concerned with position brain stem reflexes controlling motion vestibular nuclei control of movement and posture red nucleus control of movement cortical control of movement cerebellar control of movement regional and cellular organization of the cerebellum functional divisions of the cerebellum the role of the cerebellum in planning movement basal ganglia the anatomy of basal ganglia pathways neural transmitters in the circuits within the basal ganglia thalamus Describe the attributes of the autonomic nervous system including both the sympathetic and parasympathetic systems. Review the physiological basis of arousal and emotion. Include within this review the:noradrenergic systems limbic system. Include within this review the physiologic basis for emotion and memorysleeping and sleep states reticular activating system Describe the higher cortical functions including: anatomy of language function of association cortex Describe the physiological basis for cerebrospinal fluid production and reabsorption. Review the physiological control of the cerebral vasculature. Discuss, in detail, the physiology of the hypothalamus and pituitary, particularly as related to endocrinology NEUROPATHOLOGYUNIT 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 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 neurocytomas medulloblastomasatypical 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:
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:
retinoblastomasocular 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.
NEUROPHARMACOLOGY UNIT OBJECTIVES
Demonstrate knowledge of pharmacology that is pertinent to the treatment of neurological disorders and diseases which affect the nervous system. COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
Review basic cellular neurotransmission. In the course of this review discuss:
the synapse membrane potentials ion pumps ion channels transmitter secretion transmitter identification
Define and discuss receptors and receptor pharmacodynamics including:
receptor classification receptor identification dose response curves agonists and antagonists receptor modulation
Discuss the neurotransmitter acetylcholine in detail. Include within the context of the discussion:
cholinergic receptor classification functional aspects of cholinergic receptors synthesis, storage, and release of acetylcholine
Discuss the catecholamine neurotransmitters (norepinephrine and dopamine) in detail. Include within the context of the discussion:
biosynthesis of catecholamines storage and release of catecholamines anatomy of catecholamine receptors adrenergic receptors dopaminergic receptors
Discuss the neurotransmitter serotonin in detail. Include within the context of the discussion:
anatomy of serotonin receptors biosynthesis, storage and release of serotonin sub-types of serotonin receptors
Discuss the neurotransmitter glutamate in detail. Include within the context of the discussion
biosynthesis, storage and release of glutamate ionotropic glutamate receptors
NMDA receptors and subunits non-NMDA receptors and subunits
metabotropic glutamate receptors
Group I metabotropic receptors and subunits Group II metabotropic receptors and subunits Group III metabotropic receptors and subunits
role in neurological disorders
Discuss the neurotransmitters GABA and glycine in detail.
synthesis, uptake, and release physiology and pharmacology clinically relevent agonists and antagonists of GABA and glycine receptors
Discuss the peptide neurotransmitters. Describe the pharmacology of each of the drugs used to treat neurological disorders.
NEURORADIOLOGYUNIT OBJECTIVES
Demonstrate an understanding of neuroradiological imaging and interventions as they specifically relate to neurosurgical patients. COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
Describe the precautions which should be taken when performing radiologic examinations. Identify the normal anatomical structures of the skull on antero-posterior, lateral, Towne, and submental vertex radiographs. List the indications for carotid and cerebral angiography. Review the potential complications to intravenous contrast agents and discuss the management of same. Identify the major arteries and veins of the neck and brain on angiograms. Describe the concepts of computerized tomographic (CT) scanning. Identify the normal anatomical structures of the scalp, skull, dura, brain, and cranial vasculature on CT scans. Describe the concepts of magnetic resonance (MR) scanning. Review the various imaging sequences which may be obtained. Identify the normal anatomical structures of the scalp, skull, dura, brain, and cranial vasculature on MR scans. Recognize common traumatic injuries which may be detected by skull radiographs including:
linear skull fractures depressed skull fractures pneumocephalus foreign bodies
Recognize common pathologic conditions which may be detected by skull radiographs including:
neoplasms fibrous dysplasia congenital bone diseases metabolic bone disorders infections
Recognize common traumatic injuries which may be detected by head CT including:
skull fracturespneumocephalus intracranial hematomas
epidural acute subduralchronic subdural intraparenchymalintraventricular
cerebral contusions subarachnoid hemorrhage foreign bodies
Recognize common pathologic conditions which may be detected by head CT including:
ischemic infarction venous infarction hydrocephalus cysts tumors cerebral edema infections congenital abnormalities infections
Recognize common traumatic injuries which may be detected by head MR scans including:
pneumocephalus intracranial hematomas
epidural acute subduralchronic subdural intraparenchymalintraventricular
cerebral contusionsdiffuse axonal injury
Recognize common pathologic conditions which may be detected by head MR scans including:
ischemic infarction venous infarction hydrocephalus cysts tumors cerebral edema vascular occlusions infections congenital abnormalities
Identify the normal anatomical structures of the craniovertebral junction on plain radiographs. Review the radiographic diagnoses of platybasia and cranial settling. Describe the plain radiographic findings of common traumatic injuries to the craniovertebral junction including:
occipital condyle fractures atlanto-occipital dislocation Jefferson fractures posterior atlas fractures dens fractures axis body fractures hangman's fracture atlas and axis facet fractures atlanto-axial rotatory dislocation
Distinguish between orthotropic and dystropic os odontoideum. Describe the common congenital abnormalities of the craniovertebral junction. Recognize common spinal congenital abnormalities on plain radiographs. Recognize common spinal traumatic injuries which may be detected by plain radiographs including:
vertebral body fractures facet fractures and dislocations posterior element fractures transverse process fractures vertebral subluxation/dislocation
Recognize common spinal degenerative conditions which may be detected by plain radiographs. Discuss the indications for CT and MR scanning of the spine in the setting of trauma. Describe the CT scan appearance of each of the traumatic spinal lesions previously listed. Describe the MR scan appearance of:
spinal ligament injury traumatic disc herniation spinal cord contusion spinal epidural hematoma
Recognize common spinal degenerative conditions which may be detected by MR including:
disc degeneration disc herniationdegenerative spinal stenosis facet hypertrophy osteophyte formation foraminal stenosis degenerative spondylolisthesis degenerative scoliosis ossification of the posterior longitudinal ligament
Identify spinal and spinal cord tumors on CT and MR scans. Discuss the indications for spinal myelography. Review the indications for spinal angiography. Discuss the use of both the radiographic contrast and radionuclide shuntogram in evaluating neurosurgical patients
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:
treatment facilities third party payment systems
Medicare Medicaid employer-provided insurance private insurance
physician practice organizations medical equipment manufacturers pharmaceutical companies
Recite the rules and regulations of the training hospital(s) as they pertain to the practice of neurosurgery in which the residency is performed. Name the institutional and social service agencies in your community and review their role in the overall management of neurosurgical patients. Demonstrate a knowledge of the rules and regulations of your State Medical Board. Discuss the concept of informed consent. Discuss mandatory reporting laws.Discuss issues pertinent to the topic of the impaired physician. Name and describe the local, regional, and national neurosurgical organizations including their purposes, roles, activities, and interactions. Discuss the importance of tracking morbidity, mortality, and patient outcomes. Review the career options available at the completion of neurosurgical residency in detail including:
private practice academic practice subspecialty fellowship research administration military
Discuss post-residency fellowship training program availability, application process, and career usefulness.Describe the types and characteristics of surgical practice organizations including:
solo practice group practice
partnership professional association corporation
academic practice Health Maintenance Organizations (HMO)
Preferred Provider Organizations (PPO) Individual Practice Associations(IPA) staff model (Kaiser-Permanente type)
Federal
Department of Veterans Affairs Military Public Health Service
Discuss hospital payment systems (e.g., DRGs, per diem rates) and describe their incentives and how they affect hospital profitability. Discuss the role and influence of national quality oversight and review organizations for hospitals and health plans (JCAHO, NCQA). Discuss the history, changes, eligibility, funding, and problems associated with the Medicare program. Describe the Medicare program features, such as eligibility, funding, administration, federal-state relationship, benefits, and payment methods. Discuss federal funding of graduate medical education and how current federal budget allocations and proposals for changes in funding affect or will affect neurosurgical training programs. Discuss the significance of the following issues as they relate to the practice of neurosurgery:
legislative/regulatory requirements
Americans with Disabilities Act Clinical Laboratory Improvement Amendments (CLIA)
Federal/professional regulatory institutions
Health Care Financing Administration (HFCA) Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Occupational Safety and Health Administration (OSHA)
miscellaneous
affirmative action equal opportunity sexual harassment
Discuss the common causes of malpractice actions and effective measures to reduce the risk of malpractice complaints. Describe the ways, means, and reasons physicians influence the political process at the national, state, and local level. Discuss the demographics of neurosurgeon distribution, numbers, workload studies, and workforce needs.Outline the requirements for certification by the American Board of Neurological Surgery. Formulate a strategy to evaluate personal and professional considerations in making a career choice. Appraise the importance of family involvement in making career choices, including geographic location.
COMPETENCY-BASED SKILL OBJECTIVES:Demonstrate an ability to interact effectively, professionally, and respectfully with: patients and their families fellow residents allied health care personnel hospital staff medical students faculty physicians referring physicians Demonstrate the ability to maintain accurate and current medical records. Discuss neurosurgical career options with: faculty peers family non-faculty neurosurgeons and other mentors Accumulate information about post-residency career options. Create and keep current a resume/curriculum vitae. Record CPT codes for office visits and procedures performed on service. Accurately document H&P and consultations according to the AMA-CPT E&M documentation guidelines. |
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Last Updated Feb 2013
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