NEUROSURGERY 

GENERAL OBJECTIVES:Neurosurgery as a discipline arose as a result of an increasing need for special expertise in the surgical and non-surgical treatment of various diseases affecting the nervous system and supporting structures. Thus, the discipline involves an ability to diagnose, and the technical expertise for the effective surgical treatment of the neurological diseases of the nervous system which, potentially, can be prevented, alleviated, or cured.

The legacy of the birth of Neurosurgery from General Surgery is reflected in the requirements for neurosurgical resident training. The resident must be well founded in the general principles of both Neurosurgery and General Surgery. Thus, the fully-trained resident must demonstrate proficiency and expertise in the care of neurosurgical emergencies, the principles of pre- and post- operative general surgical care, the treatment of deep vein thrombosis, the management of fluid and electrolyte disturbances, the treatment of sepsis, the use of antibiotic therapy and an understanding of the implications of antibiotic prophylaxis, the understanding of vascular shock and its treatment, an understanding of the diagnostic importance of disordered blood gas analyses and their treatment, and the longitudinal (acute, subacute and chronic) management of parenteral nutritional support.

In addition to satisfactory knowledge, clinical ability, and surgical skill as these apply to surgical diseases of the nervous system, the resident will be expected to have shown familiarity with, and knowledge of, the related disciplines of basic neuroscience, neurology, neuropathology, neuroradiology, and neuropsychology.

Finally, and most important, the resident will be expected to have demonstrated unequivocal high moral and ethical behaviour.

SPECIFIC OBJECTIVES:Upon completion of training, the resident must have demonstrated the following:

  1. Knowledge

1.      A comprehensive general knowledge of the principles of surgery as noted above under General Objectives as well as specific knowledge of the anatomy of those areas outside the nervous system which involves neurosurgical operations, e.g. the abdominal wall and the contents of the peritoneal cavity.

    1. An intimate and precise knowledge of the anatomy of the central and peripheral nervous systems, including the spine and skull, and a working knowledge of the other basic neuroscientific disciplines including physiology, pathology, embryology, endocrinology and neuropsychology.
    2. A thorough understanding of the general field of neurology, with particular emphasis on those neurological entities which have important differential diagnostic considerations with respect to neurosurgical.
    3. Familiarity with and understanding of clinical electrophysiology (EEG, EMG, ECoG, evoked potentials, and neuro-otology), cerebral vascular physiology including cerebral blood flow, and functional cortical localization as derived from neuropsychological principles.
    4. The ability to interpret neuroradiological examinations (plain x-rays, CT, MR, arteriography and ultrasonography) and radioactive nuclide imagining.
    5. An understanding of the physiology and fundamentals of clinical endocrinology, especially neuroendocrinology.
    6. A sufficient awareness of the scientific method, including the principles of epidemiology, in order to provide the basis for critically analyzing the literature for continuing medical education and investigation.
    7. An awareness of gross and microscopic neuropathology such that the recognition of morphological features allows the formulation of a differential (morphological) diagnosis with respect to the common neurological and neurosurgical disorders.
  1. Clinical Skills

1.      The thoroughly practised discipline of obtaining a detailed history and carrying out a detailed neurological examination in order to provide a comprehensive differential diagnosis and localization of diseases affecting the central nervous system.

    1. The demonstration of skills in ordering and interpreting appropriate general diagnostic tests (hematology, x-ray, chemistry, etc.) for the satisfactory management of patients.
    2. The demonstrated ability to order and interpret specific diagnostic tests relating to the management of neurosurgical patients.
    3. The provision of ongoing, high quality, post-operative neurological assessment and care, including neuro-intensive care.
    4. The ability to interpret neuroradiological examinations.
    5. The personal deportment of a professional including the demonstration of a sincere, caring attitude in dealing with patients.
  1. Technical Skills

At the completion of training, the resident must have demonstrated a thorough understanding of the surgical anatomy, and the technical ability to satisfactorily and safely perform in patients of all ages:

1.      Burr holes and the drainage of chronic subdural hematomas, tapping of the ventricles, and the insertion of drainage catheters (for CSF shunts and ICP recording).

    1. Elective and emergent craniotomies (supratentorial and posterior fossa) and the subsequent:
      1. removal of intracranial hematomata
      2. repair of cerebral aneurysms
      3. removal of arteriovenous malformations
      4. surgical treatment of benign and malignant intracranial tumors
    2. Stereotactic biopsy of cerebral tumors
    3. The transsphenoidal removal of pituitary tumors.
    4. The treatment of simple and compound depressed skull fractures.
    5. Neck dissection appropriate to:
      1. exposure of the carotid arteries and endarterectomy
      2. tracheostomy
      3. anterior cervical discectomy and fusion
    6. Lumbar and cervical discectomies, including the relevant anterior and posterior approaches.
    7. The treatment of spinal injuries and other spinal disorders, including internal and external spinal stabilization.
    8. The removal of spinal tumours and arteriovenous malformations.
    9. The following treatments of peripheral nerve:
      1. decompression of the median nerve in the carpal tunnel
      2. transposition of the ulnar nerve
      3. primary suture of lacerated nerve
    10. The ability to treat various pediatric neurosurgical conditions including:
      1. Repair of myelomeningocele and encephalocele
      2. Repair of craniosynostoses
      3. Insertion of various CSF diversionary shunts
      4. Treatment of occult dysraphic conditions including lipomyelomeningocele, tethered cord, and diastematomyelia
  1. Technical Skills in Certain Subspecialized Areas

There are certain subspecialized areas within the specialty which are not necessarily a part of neurosurgical training programs in general. It is recognized that these do not necessarily form part of the "core" of neurosurgical training, but it is just as readily recognized that many of these will gradually, in the future, become part of that core. The minimum expected of the resident in these areas is a complete awareness of the techniques, an understanding of the relevant surgical anatomy and recognition of the principles of management. They are as follows:

    1. Functional neurosurgery pertaining to:
      1. the treatment of pain including dorsal column/deep brain stimulation, epidural infusion of analgesics, etc.
      2. the treatment of spasticity
      3. epilepsy surgery including the use of local anesthesia, functional cortical localization by electrical stimulation and the technique of subpial cortical dissection
      4. stereotaxic surgery including the treatment of basal ganglia disease (movement disorders) and the treatment of various disorders by focused radiosurgery
    2. Complicated peripheral nerve surgery, including brachial plexus lesions.
    3. Special neuro-oncology, e.g. interstitial radiation
    4. Specialized pediatrics procedures:
      1. Craniofacial disorders
      2. Third ventriculostomy
    5. Spinal instability, including the various methods of spinal instrumentation.
  1. Attitude and Deportment

Upon completion of training, the resident will have demonstrated:

    1. An unquestioned sense of honesty and personal integrity and the personal attributes of a professional.
    2. The capacity to relate to, and work effectively with, other medical colleagues and health care professionals.
    3. An exhibition of the ability to develop sincere and effective patient-surgeon relationships, with patients and their relatives.
    4. A sympathetic understanding of human dignity, weaknesses and intolerances as revealed by compassion to patients and their families, particularly in the circumstances of death and dying.
    5. A realization and understanding of the importance of bio-ethical issues in the delivery of health care.
    6. A commitment to continuing medical education and lifelong learning.
    7. A thorough appreciation of the necessity for quality assurance, both objectively and subjectively, in the delivery of health care.

 

CONTENT AND ORGANIZATION OF THE RESIDENCY PROGRAM:

There must be an organized program of rotations and other educational experiences, both mandatory and elective, designed to provide each resident with the opportunity to fulfill the educational requirements and achieve competence in the specialty.

The content and organization of each accredited program in neurosurgery must be consistent with the specialty training requirements.

The resident must be provided with progressively increasing responsibility for the management of neurosurgery patients. Graded surgical responsibility ultimately including the major procedures in the specialty, must be provided under appropriate supervision. Each resident must keep a validated record of all operative procedures in which he or she has participated either as assistant or operating surgeon.

In addition to offering the components noted in the specialty training requirements all accredited programs in neurosurgery should offer community based learning experiences.

RESOURCES:There must be sufficient resources including teaching faculty, the number and variety of patients, physical and technical resources, as well as the supporting facilities and services necessary to provide the opportunity for all residents in the program to achieve the educational objectives and receive full training as defined by the specialty training requirements in neurosurgery.

In those cases where a university has sufficient resources to provide most of the training in neurosurgery but lacks one or more essential elements, the program may still be accredited provided that formal arrangements have been made to send residents to another accredited residency program for periods of appropriate prescribed training.

  1. Teaching Faculty

There must be a sufficient number of qualified teaching staff in the program and at each participating institution, to supervise residents at all levels.

  1. Number and Variety of Patients

The number and variety of patients and of surgical procedures in each category must be satisfactory .

    1. Intracranial Neoplasms, Aneurysms, and Arteriovenous Malformations. There must be an adequate number and variety of patients to ensure experience in a broad spectrum of representative pathology.
    2. Vascular Neurosurgery. This component of the program should include the surgical or medical management of lesions of the intra- and extra-cranial carotid and vertebral arteries and their branches. Facilities and opportunities to learn the principles and techniques of microvascular surgery are highly desirable.
    3. Spinal Surgery. This category must include adequate resources for training in the investigation and management of neoplasms, degenerative disease, and trauma of the spinal cord and nerve roots.
    4. Pediatric Neurosurgery. There must be an organized teaching service for the neurosurgery of infants and children, with all appropriate supporting staff and facilities. There must be a close association with a pediatric service, which should include a pediatric neurologist. There must be an adequate number and variety of patients to ensure experience in the management of neoplastic disease, trauma, congenital disorders, vascular anomalies and hydrocephalus.
    5. Trauma of the Nervous System. There must be adequate numbers of patients within the units of the program to provide each resident with an extensive training in the diagnosis and management of head, spinal and peripheral nerve injuries. Experience in major trauma is essential, including participation in the initial management of multiple injuries as a member of an inter-disciplinary team.
    6. Facilities and opportunities should be available within the program, or by arrangement with other programs or institutions, for experience in the following areas: functional neurosurgery (management of pain, movement disorders, epilepsy); trans-sphenoidal pituitary surgery; and surgery of the peripheral nervous system.
  1. Clinical Services Specific to Neurosurgery
    1. In-Patient

Neurosurgery services participating in the program must be organized into one or more clinical teaching services, each with an adequate number of patients available for teaching and administered by a chief-of-service to whom the senior resident is directly responsible.

The clinical teaching services making up the program must provide full training in diagnosis and management of neurosurgical conditions in each of the areas listed under "Number and Variety of Patients".

Clinical training must be based on adequate resources to ensure full training for each resident in all areas of neurosurgery. The description of the integrated program should specify how the responsibility for each of the components of the clinical program is shared by the participating hospitals.

    1. Ambulatory

In-patient and out-patient clinical teaching services should be integrated as far as possible, in order to provide continuity of observation of patients both in and out of hospital. Organized clinics or other facilities must provide opportunities for pre-admission assessment, investigation and post-discharge follow-up of patients in all categories mentioned above. It is essential that clinics provide a teaching milieu and that schedules of residents be so arranged as to facilitate their attendance.

    1. Consultation

Residents must participate in primary consultations, both elective and emergency to other services such as neurology, psychiatry, internal medicine, and other branches of surgery including trauma on a continuing basis throughout training.

    1. Surgical Services

Hospitals participating in the program must have a designated neurosurgical operating room with sufficient operating time, and facilities for micro-neurosurgery to permit graded responsibility in the performance of operative procedures. Within the residency program, there must be a sufficient number and variety of major neurosurgical cases to represent a well-balanced spectrum of neurosurgery. This must include a good balance of cranial and extra-cranial operative procedures.

    1. Intensive Care Units

The program must provide experience in the broad field of intensive care of critically ill and injured patients. The organization of the intensive care units admitting neurosurgical patients must ensure that residents assume major responsibility under appropriate supervision.

    1. Emergency Facilities

There must be adequate supervision of residents to ensure expertise in the initial management of all types of emergencies related to the specialty, including those presenting in the emergency department. Experience in responding to emergencies and providing a consultative service under such conditions is essential.

    1. Community Learning Experiences

Community experiences should be available to provide a learning environment with appropriate supervision, patient encounters, and opportunities for evaluation based on rotation specific objectives. This assumes administrative support and linkages with the program.

  1. Supporting Services — Clinical, Diagnostic, Technical

There must be appropriate liaison with teaching services in areas relevant to the practice of neurosurgery including all of the following related areas: internal medicine, pediatrics, neurology, anesthesia, anatomical pathology or general pathology or neuropathology, and in diagnostic radiology.

The following facilities and services must be available:

    1. An active teaching neurology service, preferably with an accredited residency program in neurology, with adequate arrangements to ensure an understanding of the methods and concepts of medical neurology.
    2. An active teaching service in neuropathology, or in pathology with provision for the study of neuropathological material under the direction of a neuropathologist, and organized for teaching of neurosurgical residents.
    3. An active teaching service in diagnostic radiology, with facilities for computerized axial tomography, magnetic resonance imaging, myelography, and angiography, under the direction of a neuroradiologist.
    4. Adequate arrangements in neuro-oncology to ensure an understanding of the methods and concepts of neuro-oncology including surgery, radiation therapy, chemotherapy and immuno-therapy.
    5. Other diagnostic services, including specialized staff and facilities, in the following areas: electroencephalography, electromyography and nerve conduction studies; radioisotopic diagnosis of neurological disease, scanning and ultrasonography. Access to neuro-ophthalmology and otology units is desirable.
    6. Other surgical residency programs that provide experience relevant to neurosurgery include general surgery, orthopedic surgery, otolaryngology, plastic and vascular surgery. The Residency Program Committee must ensure that clinical training in surgery other than neurosurgery meets the needs of neurosurgery residents.
    7. Rehabilitation services, staffed by qualified medical personnel and allied non-medical professional staff in physical medicine, psychology, social work, and occupational medicine.

ACADEMIC AND SCHOLARLY ASPECTS OF THE PROGRAM:

The academic and scholarly aspects of the program must be commensurate with the concept of a university postgraduate education. The quality of scholarship in the program will in part, be demonstrated by a spirit of enquiry during clinical discussions, rounds, and conferences. Scholarship implies an in-depth understanding of basic mechanisms of normal and abnormal states and the application of current knowledge to practice.

  1. Organized Scholarly Activities

Organized scholarly activities must be a regular part of the program. The program may include lectures and seminars, teaching rounds, special conferences, interactive sessions, assignments of laboratory work, technical demonstrations, research conferences, and journal clubs which may be interdisciplinary in nature. Attendance at rounds of other services should be arranged if educationally advantageous.

  1. Basic and Clinical Sciences Relevant to Neurosurgery

The academic program must include learning opportunities in the basic and clinical sciences relevant to the specialty, in particular the relevant aspects of anatomy, biochemistry, pharmacology, physiology, psychology and pathology. This teaching must be adequate in the advanced scientific and clinical knowledge essential to an understanding of the practice of neurosurgery in those areas outlined in preceding sections.

 

  1. Biomedical Ethics

The academic program must provide opportunities for residents to gain an understanding of the basic principles of biomedical ethics as it relates to neurosurgery.

  1. Communication Skills

There must be opportunities for residents to learn effective communication skills for interacting with patients and their families, colleagues, allied health professionals and students.

  1. Teaching Skills

Residents must be given opportunities to develop effective teaching skills by teaching junior colleagues and students, as well as through conference presentations, clinical and scientific reports, and patient education.

  1. Quality Assurance/Improvement

The program must provide residents with opportunities to gain an understanding of the principles and practice of quality assurance/improvement and outcome evaluation. Residents must participate actively in such programs in their hospital departments.

  1. Research Opportunities for Residents

The academic program must provide the opportunity for residents to learn biostatistics and the critical appraisal of research methodology and medical literature. Residents should be encouraged to participate in clinical research during the course of the residency program.

There must be adequate facilities for clinical investigation, preferably close to clinical teaching services. The milieu of scholarship should be enhanced by close association between residents and active investigators on the staff.

  1. Faculty Research

A satisfactory level of research and scholarly activity must be maintained among the faculty identified with the program.

  1. Outside Conferences

The program should provide opportunities for residents to attend conferences outside their own university.

SPECIALTY REQUIREMENTS:

Approved training including: 

  1. Core training in surgery.
  2. Approved resident training in neurosurgery.
  3. Training in neurology & neuropathology.

PROGRAMS (WITH TRAINING REQUIREMENTS):

Master of Surgery(M.S):

Thirty six months of approved residency training.

Doctor of Philosophy(Ph.D):

Sixty months(five years)of approved residency training.