Core Objectives
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Learn the Neurological Exam.
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Evaluate outpatients with a wide range of neurosurgical problems.
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Assist in the operating room with neurosurgical procedures.
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Demonstrate improved knowledge of patient care, neuroanatomy, and surgical pathologies of the nervous system.
Desired Objectives
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List the early symptoms and signs of increased intracranial pressure.
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Discuss the diagnosis, motoring and treatment of hydrocephalus.
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Discuss the initial evaluation and management of traumatic brain injury- from mild to severe (from concussion).
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Describe the clinical manifestations, diagnostic workup, conservative management and surgical indications for patients with spine disease or spinal cord injury.
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Discuss the diagnosis and management of intracranial hemorrhage.
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List the most common brain tumors that afflict adults and children, the prognosis of each and the symptoms that herald brain tumor.
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Identify the most common neuro-infections, and describe the diagnosis and treatment.
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Discuss casus and standards of care for stroke and movement disorders.
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Categorize headache presentations and offer relevant differential diagnosis.
Grade Policy
The final grade (100 points total) will be composed from:
6o points total: Summative evaluation (including clinical evaluation, assignment grades, and mid-rotation evaluation)
40 points total: Final examination
The clinical grade will be calculated based upon adding each of the 1-5 point ratings on the 12 items on the evaluation form used for the clerkship. This evaluation is a consensus grade from the faculty and residents, if applicable, and incorporates the work done on the History and Physical write-ups, the Case Presentation with Literature Review, and Patient Log.
The examination is a multiple-choice examination, wherein the percentage correct is equal to the number of questions answered correctly. That number will be multiplied by a factor of 0.4 to generate a possible total of 40 points. The final grade will be assigned according to the following point cut-offs:
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Honors = 88 or above
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High pass = 83-87
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Pass = 66-82
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Fail = 65 or below
Topic List / Required Case Types for Patient Log
-Examination of Neurosurgical patients
-Neurological Exam
-Exam of lumbar and cervical spine patients
-Exam of comatose patients
-Spinal Disease
-Disc disease
-Degenerative (Spondylotic) disease
-Tumors
-Cerebrovascular Disease
-Ischemic
-Hemorrhagic
-Brain Tumors
-Adult: Malignant, Benign, Pituitary
-Pediatric
-Trauma
-Cranial
-Spinal
-Congenital Malformations and Hydrocephalus
-Epilepsy
-Pain
Procedures to Observe
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Lumbar Puncture
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Placement of EVD (External Ventricular Drain)
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Placement of ICP (Intracranial Pressure) monitor
Advanced Objectives
**For students interested in Neurological Surgery, these Advanced Objectives offer a comprehensive list of expectations.**
MEDICAL KNOWLEDGE
Fundamentals of Neuro-imaging
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Recognize common spine fractures and dislocations
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Differentiate on computerized images between blood, air, fat, CSF, and bone
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Distinguish the typical imaging characteristics of epidural hematoma, acute subdural hematoma, chronic subdural hematoma, intracerebral hemorrhage, and subarachnoid hemorrhage
Diagnosis and Management of Head Trauma
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Learn the Glasgow Coma Score and its significance
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Initiate management of elevated intracranial pressure in head trauma
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Define sports concussion, brain contusion, and diffuse axonal injury, and initiate management of each
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Distinguish anatomically and radiographically acute subdural and epidural hematoma, and describe the surgical indications for each
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Describe the initial management of penetrating high and low velocity head trauma
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Describe the management of chronic subdural hematoma
Intracranial Hypertension
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Define cerebral perfusion pressure, and explain how it is used in the management of patients with elevated intracranial pressure
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Describe how blood gases, fluids, and electrolyte balance influence intracranial pressure
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Describe the clinical manifestations of acute brain herniation, including transtentorial, uncal, and subfalcine herniation syndromes
Diagnosis and Management of Ischemic Cerebrovascular Disease
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Distinguish the symptoms and signs of anterior and posterior circulation ischemia
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Differentiate the radiographic presentations of the different types of ischemic stroke: embolic, hemodynamic, and lacunar
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Describe the roles and indications of the following treatment options in ischemic disease: medical management, risk factor modification, and surgical therapy
Diagnosis and Management of Nontraumatic Neck and Back Problems
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Define radiculopathy, myelopathy, and cauda equina syndrome
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Describe the general management of cervical disc herniation, lumbar disc herniation, lumbar instability, and low back pain
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List the most common examples of extradural, intradural-extramedullary, and intramedullary spine tumors
Diagnosis and Management of Peripheral Nerve Injury and Entrapment
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Describe the differences in thee management of sharp lacerating injuries, blunt lacerating injuries, gunshot wounds, stretch injuries, compression injuries, and avulsion injuries to peripheral nerves
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Describe the signs and symptoms of carpal tunnel syndrome and ulnar neuropathy, and outline the surgical indications
Diagnosis and Management of Hydrocephalus and Spinal Dysraphism
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List common symptoms and signs of acute hydrocephalus in children
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List most common congenital problems in children: hydrocephalus, spina bifida, craniosynostosis, tumors and developmental anomalies.
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List common symptoms and signs of normal pressure hydrocephalus in adults
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Define communicating and noncommunicating hydrocephalus and describe the differences in their treatments
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List two examples each of open and closed spinal dysraphism
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Describe the principles of management of myelomeningocele
Diagnosis and Management of Surgically Treatable Pain Problems, Movement Disorders, and Epilepsy
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Describe the classic presentations of trigeminal neuralgia, failed back surgery syndrome, complex regional pain syndrome-1, and complex regional pain syndrome-
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Describe the differences in indications for spinal cord stimulation versus spinal infusion pump
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List at least one different surgical treatment each for Parkinson’s disease, dystonia, spasticity, and hemifacial spasm
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Define the different types of seizures (simple, partial, etc)
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Describe the differences between temporal lobectomy, lesionectomy, and disconnective surgery for seizure disorders
PATIENT CARE
The Neurological Examination
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Evaluate patient’s mental status and speech
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Examine the cranial nerves
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Examine central and peripheral sensory function
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Examine motor function
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Examine cranial and peripheral reflexes
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Examine cerebellar function and gait
Diagnosis and Management of Brain Tumor and Abscess
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Know the relative incidence and location of the major types of primary and secondary brain tumors
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Describe the general clinical presentations of brain tumors in the following locations: cerebral hemisphere, cerebellum, brainstem, pituitary, and cerebellopontine angle
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List the advantages and limitations of the following diagnostic tools used in the evaluation of brain tumors: CT, MRI, MR spectroscopy, and angiography
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Describe the surgical indications for the most common benign and malignant tumors in the locations listed in #2
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Describe the indications for and the differences between radiotherapy and radiosurgery in the treatment of malignant brain tumors
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List the major differences between the diagnosis and management of brain tumor and abscess
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List the most common etiologies of cerebral abscess
Diagnosis and Management of Headache
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Distinguish the radiographic presentation of the major causes of intracranial hemorrhage: hypertensive intracerebral hemorrhage, amyloid intracerebral hemorrhage subarachnoid hemorrhage, arteriovenous malformation hemorrhage, tumor hemorrhage, and coagulopathy hemorrhage
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Apply the following diagnostic tools in evaluation of acute headache (CT, MRI, angiogram, and lumbar puncture)
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Describe the broad treatment strategies (surgery, radiosurgery, interventional radiology as well as treatment of vasospasm) of intracranial aneurysms and vascular malformations
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Differentiate the symptomatology of migraine, cluster, tension, and sinusitis headache
Spinal Trauma
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Describe the rapid assessment of the patient with spinal trauma
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Recognize the common spine fractures on X-ray
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Initiate acute management of spinal cord injury including immobilization, steroids, and systemic measures
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Define the unstable spine
INTERPERSONAL AND COMMUNICATION SKILLS
Case Presentations
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Present a case to your preceptor, include relevant history, neurological examination, imaging findings, and treatment plan each week
Participation on the Neuro-ICU and Acute Care Areas of the Hospital
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Ask neurosurgical staff (residents, attendings, etc) questions as appropriate to enhance learning opportunities both in and out of the OR
PROFESSIONALISM
Operating Room
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Demonstrate professionalism in the operating room; feel free to participate as medical students, including asking questions, reviewing images, pathology, intraoperative findings, etc.
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Demonstrate level of interest by scrubbing in on cases at the discretion of the resident and attending