CARILION CLINIC NEUROSURGERY

MEDICAL STUDENT ROTATION OPTIONS

INTRODUCTION TO CARILION CLINIC

NEUROSURGERY

WE WANT YOU!!

If you want to step into the world of high-energy, high-motivation, medicine, if you

want to care for some of the most critically ill and in-need patients in any hospital, if

you want to live on the “cutting edge” of the interface between technology and

medical care- we have the rotation for you! Neurosurgery is the most dynamic and

most rapidly evolving specialty in medicine. A rotation with us offers a medical

student a vision into the future, but also allows him or her to experience some of the

most ancient and most captivating components of being a physician- the thoughtful

and empathetic care for the most critically ill. Neurosurgery takes exceptional

technical abilities, stamina, and “front-line” intelligence, but also tremendous

patience, empathy, resilience, kindness, communicative skills, and most of all caring.

Carilion Clinic Neurosurgery is a bustling, full service, residency training program

featuring an exceptionally busy and complex operative palette, an active clinical and

bench research effort, and a rigorous but fun academic schedule. The Carilion Clinic

Neurosurgery team of attending surgeons, neurosurgical residents, and specialized

physician assistants invite and encourage medical students to spend some time on

our high-energy service. We truly believe the experience will enhance the education

of all students whether they plan to enter the neurosciences or not. We can assure

the interested student an experience of fast-paced clinical action, profound patient

interactions, extensive pathophysiology discourse, and an abundance of research

and hands-on operative opportunities. We believe that we can demystify much of

the world of neuroscience with real-life clinical, anatomic, and pathologic examples

of a multitude of neurological disorders and diseases.

DON’T JUST READ ABOUT IT!!

On our service, you will become facile with radiology of the brain and spine. You will

learn how to execute an exquisite neurological exam. You will greatly broaden your

differential diagnosis of neurological disorders. You will witness first-hand literally

dozens of abnormal neurologic exams and radiographic studies EVERY DAY. You

wont just read about disorders and discuss them in sterile classrooms- you will

experience them FIRST HAND! You will be on the front lines of acute care-

participating daily in LIFE AND DEATH DECISION MAKING! Furthermore, you will

regularly consider ethical issues and socioeconomic questions that you have never

dreamed of before.

Besides all this- we are fun! We are “the good guys!” The Carilion Clinic

Neurosurgery team is packed with high energy, high-performance, congenial,

fascinating (and humble) individuals who all hold patient care paramount, but also

know how to not take themselves too seriously. The end result is a dynamic,

exciting, fast-paced, wide-open, and often thrilling experience of laughter,

compassion, blood, sweat, and certainly tears. There is no other medical experience

like it.

COME JOIN US!!

THE TYPICAL WORK WEEK ON

NEUROSURGERY

The work week at Carilion Clinic Neurosurgery is varied and can be adapted to the

interests of the individual medical student. Generally team members begin each day

with “rounds” on intensive care unit patients and then floor patients. Several

members split off to go to the operating room while others head to the outpatient

clinics. Surgeries are conducted every day but are generally limited on Tuesdays. On

Tuesdays the resident team participates in an attending-supervised clinic in the

morning. In the afternoon, the entire team meets for academic sessions. The

academic sessions begin in the ICU with traditional “grand rounds” where selected

inpatients are visited and focused upon. The team extensively evaluates each

patient’s history and physical exam, and then discusses the multiple permutations of

the patient’s disorder in a challenging, Socratic, manner. The team then moves to

classrooms and addresses a variety of neuroscience related topics ranging from

research, to operative nuances, to physiology, to pathology, to ethical and

socioeconomic issues. Teaching methods such as student and resident prepared

lectures, Jeopardy-style intra-service competitions, quiz sessions, role-playing,

demonstrations, guest lecturers, pre-op conferences, literature reviews, surgical

nuance discussions, round table ethics discussions, and more are routinely

employed. The days can be rather long, starting at 0600 and going until the work is

done, but the fast-pace action assures that the time goes extraordinarily quickly.

ROTATION OPTIONS

“TRACKS”

You can participate in a variety of rotation “tracks” during your time with us.

Rotations can also be customized to the academic needs and desires of the

individual student. 2 and 4 week rotations are routinely offered.

Neurosurgical Sub-Internship STRONGLY SUGGESTED FOR THOSE STUDENTS CONSIDERING A CAREER IN

NEUROSURGERY, NEUROLOGY, NEURORADIOLOGY OR INTERVENTIONAL

NEURORADIOLOGY! This track is the most demanding and rigorous offered by the

Carilion Clinic Neurosurgery team. In this rotation the medical student acts

essentially as a neurosurgical intern. They are assigned a palette of inpatients with

whom they care for and follow throughout the patients’ hospitalizations. They will

spend a sizable amount of time in the ICU’s, on the floors, and in the operating room.

They will write regular notes and will interact intimately with patients and their

families. They will take neurosurgical call with a resident one in every four nights.

They will participate in Resident Clinic every Tuesday morning. They will gain an

appreciation of the full gamut of neurosurgical issues encountered in a busy

academic/clinic practice. They will acquire skills in inpatient and outpatient

neurosurgical evaluation, the neurologic exam, surgical tissue manipulation,

neurological critical care, neuroradiology, patient and family interaction, and much

more.

Research Track Students on the research track work predominately on on-going projects of the

team although we are open to initiating novel proposed projects). They will still

participate in Tuesday afternoon academic sessions and will always be welcome on

rounds and in the operating room. Students will work with a faculty mentor and a

resident mentor/partner. Skills will be built in study design, literature search, data

accumulation, synthesis. They will share authorship of finished research projects

with team members (posters, presentations, papers).

Outpatient Clinic Track Students will spend the majority of their rotation evaluating Neurosurgery and

Spine Center outpatients. They will develop an exceptional acumen in neurological

history taking, exam, differential diagnosis, synthesis, and treatment planning. They

will learn how to efficiently move a number of patients through a clinic. They will

develop patient interaction skills. They will develop a strong background in

neuroradiologic evaluation. They will gain an in-depth appreciation for the

evaluation and management of spinal disorders and also various brain and

peripheral nerve disorders. They will partner with attending neurosurgeons and

residents each day. They will independently evaluate each of their patients, review

the patient’s studies, and formulate a diagnosis and treatment plan prior to

discussing with their neurosurgical partners. Students will be encouraged to follow

their patients through their entire neurosurgical experience including inpatient care

and surgery. Students will participate in Tuesday afternoon academic sessions and

will always be welcome on rounds and in the operating room.

Neurological ICU Track Students will spend the majority of their rotation working with neurosurgical

patients admitted to the various Carilion Clinic intensive care units. Students will

work side by side with the neurosurgical “hospitalist” and neurosurgical-ICU

resident on some of the most critically ill and medically challenging patients in the

hospital. Routinely they will encounter patients suffering from multiple trauma,

severe head injury, strokes, hemorrhages, spinal cord injuries, brain tumors, spinal

cord tumors, central nervous system infections, neurologic disease with significant

medical co-morbidities, and much more. They will develop skills and acumen in

management of critical neurologic disease. They will develop a strong background

in abnormal brain and spine radiology. They will witness daily a host of abnormal

neurological exams and will correlate them with neuroanatomy and neuroradiology.

They will gain experience in procedures such as central line placement, a-line

placement, ventriculostoy placement, lumbar punctures, and more. They will be

responsible for writing inpatient notes, histories and physicals and consultations.

Students will participate in Tuesday afternoon academic sessions and will always

be welcome on rounds and in the operating room.

Complex Spine Track Students on this rotation will partner with the Director of Complex Neurosurgical

Spine Surgery, Dr. Nicholas Qandah. They will go through the work week “joined at

the hip” with Dr. Qandah. Dr Qandah is a lightening bolt-energized surgeon and an

exceptional teacher. The days will be action-packed and moving at the speed of light.

The experience will include about 40% of the week in the neurosurgery and/or

Spine Center clinic, and 60% in the operating room and inpatient floors. The student

will gain a deep appreciation for the evaluation and management of degenerative

spinal disorders, radiculopathy, myelopathy, spinal column tumors, spinal column

fracture, spinal column deformity, chronic spinal pain, scoliosis, and more. Surgical

experiences will include the opening and closing of large spinal wounds, pedicle

screw placement, laminectomy, fusion, kyphoplasty, and more. Students will

participate in Tuesday afternoon academic sessions and will always be welcome on

rounds and in the operating room.

Pediatric Neurosurgery Track In this rotation, students will work closely with two pediatric neurosurgery oriented

attending surgeons (Dr. Lisa Apfel and Gary Simonds). Dr. Apfel will be the principle

surgeon on this rotation. She is known for her tremendous work rate and her

fantastic bedside manner. Students on this rotation will not only learn the nuts and

bults of pediatric neurosurgery but will also gain a deep appreciation for how to

relate to critically ill children and their families. This will involve both outpatient

clinic work and inpatient evaluations and surgeries. Students will experience

patients with disorders such as hydrocephalus, spina bifida, tethered spinal cord,

head trauma, spine trauma, brain tumors, non-accidental trauma, chiari

malformation, skull masses, craniofacial synostosis and deformity, and more. The

pediatric volume of the service is variable and a healthy mix of adult neurosurgery

may be mixed into the rotation. Students will participate in Tuesday afternoon

academic sessions and will always be welcome on rounds and in the operating

room.

Operating Room Only Track For the surgery hound! In this track, students will spend the vast majority of their

time in the operating room. They will participate in the daily operating schedule.

They will be expected to evaluate the patients and their radiographs in the pre-op

area and then discuss the choice and execution of procedures with attending

surgeons and residents involved in the procedure. They can anticipate the

development of skills in sterile technique, prepping and draping, operative

positioning, opening and closing of surgical wounds, control of bleeding, tying,

suturing, drain placement, burr hole placement, pedicle screw insertion,

laminectomy, ventricular catheter placement, lumbar catheter placement,

craniotomy, bone drilling, and more. They will develop an appreciation for the

fragility of the nervous system and will develop skills in the delicate manipulation of

such tissues. Students will participate in Tuesday afternoon academic sessions and

will always be welcome on rounds and in the operating room.

Night Call Track For the night owls! Much can be learned about the nitty gritty of any

medical/surgical specialty by experiencing its facets and demands during the “off-

hours.” Much happens “on-call” in neurosurgery. For example, 50% of all trauma

consults to neurosurgery come in after midnight at our institution. On this rotation,

the student would work four 12 hour shifts a week at night. They would partner

with the on-call resident and attending surgeon. They would see all emergency

room and hospital consultations during these hours. They would attend all urgent

inpatient issues on the floors and in the ICU’s. They would accompany patients to

the operating room when needed. The experience would not be for the faint of heart

but would be exceptional in breadth and intensity. Students would come out of the

rotation with a strong familiarity with urgent neurological situations. They would

develop a strong acumen for urgent neurological care. They would develop a strong

background in neuroradiology and emergent neurosurgical procedures. Students

will participate in Tuesday afternoon academic sessions and will always be welcome

on rounds and in the operating room.

Consult Service Track Students on this rotation would spend the majority of their time performing

emergency room and inpatient neurosurgical consultations. They would partner

with the neurosurgical “hospitalist” and “floor” resident. They would perform a full

evaluation of 8 to 12 patients a day. They would perform a full history and physical,

order and evaluate appropriate radiological studies, develop a differential diagnosis,

generate a treatment plan and present all of the preceding to their

attending/resident partners for each patient seen. They will routinely document all

their work in the medical record. Through this rotation the student would be

exposed to a huge breadth of neurological disorders from the most mundane to the

most complex. They would sharpen their neurological exam to an exquisite point.

They would develop a strong background in neuroradiology. They would learn skills

in patient and family discourse. Students will participate in Tuesday afternoon

academic sessions and will always be welcome on rounds and in the operating

room.

Ultra-Short Track IF YOU ONLY HAVE A DAY OR TWO, OR EVEN JUST AN HOUR OR TWO….

Carilion Clinic Neurosurgery welcomes all medical students to spend time with us

under any conditions. If a 2 or more week rotation is untenable, we are open to

weekend visits, or half-day visits in the clinic, on the wards, or in the operating

room. We believe that any time spent experiencing neurosurgery is invaluable and

we will find ways of accommodating every interested student. So please come join

us- even just for an hour here and there.

PREREQUISITES

The only prerequisite that we insist upon is a hunger for learning, we will take care

of the rest!

ROTATION REQUIREMENTS

We expect you to come “loaded for bear,” to be energized and interested and on

your toes.

We expect you to flood us with questions and challenges. You will get it back in

spades!

We ask that you dress nicely and professionally out of respect for our critically ill

patients and their families.

We expect appropriate professional decorum in all practice settings, for the same

reason as above.

We expect you to be a self-starter and to be proactive in your education (although

we will work ourselves to death to support you in your endeavors).

We expect you to speak up if you are not getting what you want out of the rotation.

We expect you to evaluate us and the rotation, openly and honestly, at the end of

your time with us.

We expect you to read about the cases you experience daily (see book list below).

We will ask you to prepare ONE HALF-HOUR LECTURE for Academic Tuesdays

during a one month rotation. This is completely optional for those rotating for less

than a month.

You will take a short ORAL EXAM at the end of the rotation based on the track you

chose and the patients you encountered.

On all but the Night Call Track, we will ask you to take some NEUROSURGERY CALL.

We believe that this is an invaluable experience. For those doing the Neurosurgery

Sub-internship this call will be ONE IN FOUR. For all other rotations it will be ONE

IN SIX.

GOALS Our goal for medical student rotations on our service is to begin to break down the walls of mystique and befuddlement that all to often exists between practicing physicians and disorders of the nervous system. We want our students to begin to feel familiar and comfortable evaluating and managing such disorders. We want our students to gain an appreciation for how disorders of the nervous system insinuate themselves into virtually all medical situations, and how so many other medical disorders affect the health and function nervous system. We also desire, teach, and emphasize emphatically, a methodology of organized thought, and critical thinking, when approaching disorders of the nervous system. We also want to develop an appreciation for the skill, empathy, clarity, affability, confidence, and care, that is required to talk with and relate to neurosurgical patients and their families. For all rotating, we hope to affect an appreciation for the decision making, critical thought, non-surgical considerations, preparation, pre- post- and intra-operative judgment, and the extensive postoperative care that goes into every neurosurgical patient. For those with a surgical bent, we hope to bestow some rudimentary operative skills, an appreciation for the fragility and intricacy of the nervous system, and a sense of exquisite delicacy in the operative manipulation of nervous system tissues. More than anything though, we want our students to be as awe-struck and humbled by the elegance and grandeur of the central nervous system as we are, and to truly enjoy the care of those unfortunate enough to be afflicted with disorders of the brain, spinal cord, spine, and peripheral nerves.

OBJECTIVES By the end of your time with us we expect that you would be able to: Perform an exquisitely thorough yet focused neurologic exam. Interpret routine radiographic studies of the brain and spine including x-rays, MRIs, angiograms, myelograms, CT scans, CTAs, MRAs, MRVs, etc. Recognize the radiographic characteristics of common disorders of the nervous system and spinal column. Generate a thoughtful, well-reasoned, and reasonable differential diagnosis for patients presenting with neurologic disorders.

Communicate comfortably, rationally, and with clarity issues relating to disorders of the spine and nervous system and their evaluation and management. Evaluate comfortably a patient in the emergency room or hospital floor with an acute neurologic disorder. Discuss cogently the basic neuroanatomy behind a patient’s neurological deficits. Discuss cogently the physiology and pathologic process involved in a patient’s neurological disorder. Discuss the indications, risks, benefits, outcomes, and alternatives to the surgical treatment of various common neurological and spinal disorders. Relay clinical information clearly and succinctly to neurosurgical patients and their families. Be familiar with the management of seizures. Be familiar with the management of increased intracranial pressure. Be familiar with the evaluation and treatment options in the care of low back pain, radiculopathy, and neck pain. Be able to recognize a cauda equine syndrome and a profound myelopathy. Be familiar with the determination of instability of spinal column fractures. Be familiar with the signs of brain herniation. Recognize the symptoms and signs of an aneurysmal rupture. Recognize the signs and symptoms of a stroke, and of meningitis. Know how to evaluate for a ventriculo-peritoneal shunt failure. Manage several critically ill patients at a time. Discuss the ethical and socio-economic implications of your patient’s illness.

GRADING Grading for the rotation will be based on performance on rounds and in academic sessions (70%), a 30 minute presentation on an Academic Tuesday (20%), and upon an oral examination (10%). A final grade will be assigned to the medical student and will be discussed on the last day or two of the rotation in a bi-directional manner (don’t worry- we are push-overs in the grading department!). We will insist on students returning the favor by grading the rotation and offering a critique on how to improve it.

KEY PLAYERS Various members of the neurosurgery team can be critical in your acquisition of a superb learning experience. All members of the team will bend over backwards to assist an interested and motivated student.

Gary Simonds MD

Chief and Program Director Expertise in microneurosurgery (aneurysms, tumors) Where the buck ultimately stops! Contact me any time with any concern! 540-529-4276 grsimonds@carilionclinic.org Nicholas Qandah DO Assistant Program Director Director of Complex Neurosurgical Spine An exceptional teacher and high-voltage surgeon. Expertise in the most complicated spinal disorders. Zev Elisa MD Neurosurgical Director of Medical Student Rotations First stop for educational questions and concerns. A fountain of literature knowledge. A master of clinical critical thinking. Expertise in Pituitaty Surgery, Cyberknife Radiosurgery, and Head Injury. Jonathon McNeal DO Chief Resident in Neurosurgery In his sixth year of neurosurgical training- he better be pretty good by now! Will help students get settled into the practice and aligned with residents and physician assistants on the team. Knows every corner of the system and how to get things done. Rhea Jordan Graduate Medical Education Coordinator Able to square away “nuts and bolts” and mechanics of your rotation. Darla Summers Neurosurgery Practice Manager Go-to person with any and all general neurosurgical issues. 540-526-1357 Lisa Apfel MD Director of Pediatric Neurosurgery Mentor for students particularly interested in the pediatric track. High energy, extremely busy surgeon.

Great teacher. Known for her exceptional bedside manner. John Fraser MD Highly experienced neurosurgeon in all areas of the specialty. Vast knowledge base of clinical neurosurgery. Fabulous mentor for rotating students. Rod Dunker MD Director of Neurosurgical Research A surgeon of vast experience and knowledge. A bastion of critical thought and analytic prowess. A fantastic mentor for the interested student.

TEXTS You will be provided with (lent) the two texts needed for this rotation.

Handbook of Neurosurgery is the go-to resource for beat to beat care of neurosurgical patients. It has everything! But there is limited discussion about any one thing. Before you discuss a case with your attending surgeon- always take a look first at “Greenburg.” Essential Neurosurgery offers a more narrative overview of the specialty. But is nice and short! A whole array of more in depth texts will be available in the system’s and the program’s libraries. We will also direct you to on-line resources.

CASES YOU WILL SEE The breadth of pathology encountered by the Carilion Clinic Neurosurgery team is staggering. A complete list would take pages. Below are listed some of the typical and not so routine cases cared for in the past year on our service. Anterior communicating aneurysm Posterior communicating Aneurysm Basilar tip aneurysm Mycotic Aneurysm Pericallosal artery aneyrsm Carotid trunk aneurysms Basilar trunk aneurysm Middle cerebral artery aneurysms Multiple aneurysms Carotid bifurcation aneurysm Superior hypophyseal Aneurysm Grades I, II, III, IV astrocytomas Pineal region Tumors Pituitary tumors Pituitary apoplexy Craniopharyngiomas Olfactory meningiomas Medial sphenoid wing meningiomas Cerebello pontine angle meningiomas Acoustic neuromas

Oligodendrogliomas Neurocytomas Colloid Cysts Petrous apex meningiomas Convexity meningiomas Hemangioblastomas Brainstem tumors Brainstem cavenromas Hemispheric Cavernomas Metastases to all parts of the brain Craniosynostosis Skull masses Cranial spinal fluid leaks Encephaloceles Intractable epilepsy Intracranial dermoids Arachnoid cysts Intracranial epidermoids Malignant meningioma Ependymomas Medulloblastomas DNET Arteriovenous malformations of the brain Arteriovenous malformations of the cerebellum Moya Moya Venous sinous thrombosis Stroke with herniation syndrome Hemorrhagic stroke Intracranial hemorrhages in the cerebrum, basal ganglia, thalamus, brainstem, cerebellum Cerebellar infarct Cistercercosis Brain abcesses Subdural empyema Severe brain injury Malignant brain edema Encephalitis CJ Disease HIV complications of the brain Acute subdural hematomas Chronic Subdural hematomas Epidural hematomas Cerebral Contusions Gunshot wounds to the brain Gunshot wounds to the spine Premie intraventricular hemorrhage

Hydrocephalus Normal pressure hydrocephalus Intracranial hypotension Trigeminal neuralgia Atypical facial pain Hemifacial spasm Glossopharyngeal neuralgia Cervicomedullary tumors Spinal Cord tumors Cauda equina tumors Metastatic lesions to the spine Pathological fractures of the spine Osteomyelitis of the skull and of the spine Fractures of every kind imaginable to the spine Herniated discs of the lumbar, thoracic and cervical spine Degenerative disease of the spine Spondylolisthesis Scoliosis Severe spinal deformity Chronic Spinal pain Chronic Nerve Pain Peripheral nerve tumors Carpal tunnel syndrome Nerve injuries Ulnar neuropathy Osteophyte-related dysphagia Myelopathy Cauda equine syndrome Diastematomyelia Lipomyelomeningocele Failed back syndrome Flat back syndrome Recurrent disc herniation Severe spinal cord injury Central cord syndrome

CURRICULUM

The various rotation tracks make a single unified curriculum impossible to

formulate. In general we subscribe to the Congress of Neurological Surgeons

“Medical Student Curriculum In Neurosurgery” :

(http://w3.cns.org/education/medStudCur/index2.asp) outlined below. The

Curriculum will be modified to the track and the educational needs and desires of

the individual medical student.

. General Skills TopicsK . The Neurological ExaminationK . Evaluate patient’s mental status and speech. . Examine the cranial nerves. . Examine central and peripheral sensory function. . Examine motor function. . Examine cranial and peripheral reflexes. . Examine cerebellar function and gait. . . Fundamentals of Neuro-ImagingK . Recognize spine fractures and dislocations. . Differentiate on computerized images between blood, air, fat,

CSF, and bone. . Recognize specific disease entities listed below such as epidural,

subdural, intracranial hematoma, subarachnoid hemorrhage, brain tumors, and hydrocephalus.

.

. Intracranial hypertensionK

. Understand the pathophysiology of elevated intracranial pressure, cerebral perfusion and the influence of blood pressure, blood gases, and fluid and electrolyte balance.

. Recognize the clinical manifestations of acute brain herniation including the Cushing reflex, midbrain effects and vital signs.

. Understand the impact of focal mass lesions, structural shifts and their consequences.

.

. Intracranial Disease TopicsK

. Diagnosis and Management of Head TraumaK

. Understand and assign the Glasgow Coma Score.

. Recognize the presentation of brain herniation syndromes in the setting of trauma.

. Initiate management of elevated intracranial pressure in head trauma.

. Recognize and initiate management of concussion, brain contusion and diffuse axonal injury.

. Recognize and initiate management of acute subdural and epidural hematoma, including surgical indications.

. Recognize and initiate management of penetrating trauma including gunshot wounds.

. Recognize and understand the principles of management of open, closed and basilar skull fractures, including

cerebrospinal fluid leak, and chronic subdural hematoma (in children and adults).

.

. Diagnosis and Management of Brain Tumor and AbscessK

. Know the relative incidence and location of the major types of primary and secondary brain tumors.

. Understand the general clinical manifestations (focal deficit and irritations, mass effect; supratentorial vs. infratentorial) of brain tumors.

. Recognize specific syndromes: extra-axial (cerebellopontine, pituitary, frontal….) and intra-axial, in brain tumor presentation.

. Review the diagnostic tools that are currently used for evaluation (laboratory tests, radiology, biopsy).

. Understand broad treatment strategies (surgery, radiosurgery, radiation, and chemotherapy) in the treatment of tumors.

. Recognize the clinical manifestations of abscess and focal infections due to local spread, hematogenous disease associated with immune deficiency, and how they differ from the mimic tumors.

. Understand the general principles in the treatment of abscess and focal intracranial infections.

.

. Diagnosis and Management of HeadachesK

. Know the major causes of intracranial hemorrhage: vasculopathy in the aged (hypertension and amyloidosis), aneurysm, vascular malformation, tumor and coagulopathy.

. Recognize the symptoms and signs of subarachnoid, cerebral and cerebellar hemorrhage.

. Apply diagnostic tools in evaluation of acute headache (CT and MRI, role of lumbar puncture).

. Understand the natural history and broad treatment strategies (surgery, radiosurgery, interventional radiology as well as treatment of vasospasm) of intracranial aneurysms and vascular malformations.

. Differentiate the symptomatology of migraine, cluster, and tension headache and sinusitis headache.

.

. Diagnosis and Management of Ischemic Cerebrovascular Disease K

. Recognize the symptoms and signs of anterior and posterior circulation ischemia emphasizing carotid disease and contrasting it with hemorrhagic stroke.

. Differentiate among the types of ischemic stroke: embolic, hemodynamic, lacunar.

. Categorize etiologic factors of brain ischemia including atherosclerosis, cardiac disease, arterial dissection,

fibromuscular dysplasia, vasculitis, venous thrombosis and hematologic disease.

. Understand the treatment options in ischemic disease and their indications, including medical management, risk factor modification and surgical therapy.

. Diagnose and monitor carotid occlusive disease using noninvasive methods and understand indications for angiography and carotid endarterectomy.

.

. Spinal diseaseK

. Diagnosis and Management of Spinal Cord InjuryK

. The emergency room diagnosis and interpretation of radiologic studies in spinal trauma.

. Initiate acute management of spinal cord injury including immobilization, steroids and systemic measures.

. Understand the definition and subsequent management principles of the unstable spine.

. Understand management principles in spinal cord injury including indications for decompressive surgery and treatment of the medical complications associated with cord injury (skin, bladder, bowel movement, respiratory).

.

. Diagnosis and Management of Nontraumatic Neck and Back ProblemsK

. Diagnose and understand the natural history and management principles of whiplash and soft tissue injury.

. Recognize the broad categories of spinal pain and radicolopathy:

. The signs and symptoms (including cauda equina syndrome).

. Their common causes, their diagnosis and their management (cervical and lumbar disc herniation, osteoarthritic disease, spondylolisthesis).

. Their differential diagnosis and management (including metastatic disease and primary spinal tumors).

. Recognize the broad categories of myelopathy:

. The signs and symptoms (including comparison of acute and chronic spinal cord injury).

. The common causes, their diagnosis and their management (cervical and lumbar disc herniation and osteoarthritic disease).

. Differential diagnosis and management (including transverse myelopathy, metastatic disease and primary spinal tumors).

.

. Peripheral nerve diseaseK

. Diagnosis and Management of Peripheral Nerve Injury and EntrapmentK

. Diagnose traumatic nerve injury (laceration, stretch and compression) and understand indications and general

strategies of treatment. . Recognize the signs and symptoms of common nerve

entrapment (carpal tunnel syndrome, ulnar nerve entrapment, thoracic outlet syndrome and meralgia paresthetica), their etiology, conservative management strategies and indications for surgical intervention.

.

. Other common neurosurgical problemsK

. Diagnosis and Management of Hydrocephalus and Spinal DysraphismK

. Recognize the symptoms and signs of hydrocephalus in children.

. Recognize the symptoms and signs of hydrocephalus in adults.

. Understand common etiologies of hydrocephalus in children and adults, and differentiate between communicating and obstructive hydrocephalus.

. Understand treatment strategies for hydrocephalus.

. Recognize common syndromes of spinal dysraphism, their neurologic manifestations and broad principles of management.

.

. Diagnosis and Management of Surgically Treatable Pain Problems, Movement Disorders and EpilepsyK

. Recognize the features of trigeminal and glossopharyngeal neuralgia, causalgia and cancer pain, indications for surgical referral and the spectrum of surgical therapeutic options.

. Recognize movement disorders amenable to surgical intervention, including Parkinson’s disease, dystonia, spasticity, and hemifacial spasm, indications for surgical referral and the spectrum of surgical therapeutic options.

. Understand the general classification of seizure disorders, definition of intractable epilepsy, and the broad categories of surgical intervention for epilepsy including invasive electrodes, resective and disconnective surgery.

.

. Review QuestionsK Review Question Answers