Neurosurgery Oral Board Review PDF
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NEUROSURGERY OR AL BOARD REVIEW Second Edition 978-1-60406-542-8c0fm.indd i 978-1-60406-542-8c0fm.indd i 5/10/11 2:06 PM 5/10/11 2:06 PM 978-1-60406-542-8c0fm.indd ii 978-1-60406-542-8c0fm.indd ii 5/10/11 2:06 PM 5/10/11 2:06 PM NEUROSURGERY OR AL BOARD REVIEW Second Edition Jonathan Stuart Citow, MD Assistant Clinical Professor of Neurosurgery Rosalind Franklin Medical School North Chicago, Illinois Chief of Neurosurgery Condell Medical Center Libertyville, Illinois David Cory Adamson, MD, PhD Associate Professor of Neurosurgery and Neurobiology Duke University Medical Center Chief of Neurosurgery Durham VA Medical Center Durham, North Carolina New York · Stuttgart 978-1-60406-542-8c0fm.indd iii 978-1-60406-542-8c0fm.indd iii 5/10/11 2:06 PM 5/10/11 2:06 PM Thieme Medical Publishers, Inc. 333 Seventh Ave. New York, NY 10001 Executive Editor: Kay Conerly Managing Editor: Lauren Henry Editorial Director, Clinical Reference: Michael Wachinger Production Editor: Barbara A. Chernow International Production Director: Andreas Schabert Vice President, International Marketing and Sales: Cornelia Schulze Chief Financial Offi cer: Sarah Vanderbilt President: Brian D. Scanlan Compositor: Agnew’s, Inc. Printer: Sheridan Press Library of Congress Cataloging-in-Publication Data is available from the publisher. Copyright ©2011 by Thieme Medical Publishers, Inc. This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation without the publisher’s consent is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfi lms, and electronic data processing and storage. Important note: Medical knowledge is ever-changing. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may be required. The authors and editors of the material herein have consulted sources believed to be reliable in their eff orts to provide information that is complete and in accord with the standards accepted at the time of publication. However, in view of the possibility of human error by the authors, editors, or publisher of the work herein or changes in medical knowledge, neither the authors, editors, nor publisher, nor any other party who has been involved in the preparation of this work, warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from use of such information. Readers are encouraged to confi rm the information contained herein with other sources. 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Printed in the United States 5 4 3 2 1 ISBN 978-1-60406-540-4 978-1-60406-542-8c0fm.indd iv 978-1-60406-542-8c0fm.indd iv 5/10/11 2:06 PM 5/10/11 2:06 PM This book is dedicated to my sister Lisa who after 15 years fi nally succumbed to an unrelenting cancer. She was at once a fi erce warrior and yet the kindest, most self- less person I have ever known. She had my back always. This book is also dedicated to her bishert Steve for being such a solid husband, father, brother, and friend. He held it all together so well despite insurmountable resistance. JSC This book is dedicated to my mother, Lucy Ashmore Adamson. As the years pass, I fi nd that I enjoy teaching more and more, largely because it’s how I learn myself, but also because of an obligation to return the favor to the innumerable teachers in my past who have steered my life and often let me stand on their shoulders. My mom didn’t teach me neurosurgery, but I have learned so much more from her that has truly made my life more complete. DCA 978-1-60406-542-8c0fm.indd v 978-1-60406-542-8c0fm.indd v 5/10/11 2:06 PM 5/10/11 2:06 PM 978-1-60406-542-8c0fm.indd vi 978-1-60406-542-8c0fm.indd vi 5/10/11 2:06 PM 5/10/11 2:06 PM PREFACE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi SECTION 1: SPINAL DISORDERS CHAPTER 1: SPINAL ANATOMY AND APPROACHES. . . . . . . . . . . . . . . . . . . 3 CHAPTER 2: SPINE TRAUMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 CHAPTER 3: SPINAL DEGENERATIVE DISEASE. . . . . . . . . . . . . . . . . . . . . . . 42 CHAPTER 4: SPINAL TUMORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 CHAPTER 5: OTHER SPINAL DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 SECTION 2: CRANIAL DISORDERS CHAPTER 6: CRANIAL ANATOMY AND APPROACHES . . . . . . . . . . . . . . . . . 69 CHAPTER 7: HEAD TRAUMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 CHAPTER 8: BRAIN TUMORS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 CHAPTER 9: CEREBROVASCULAR DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . 115 CHAPTER 10: OTHER CRANIAL DISORDERS. . . . . . . . . . . . . . . . . . . . . . . . . . 148 SECTION 3: MISCELLANEOUS TOPICS CHAPTER 11: CONGENITAL AND PEDIATRIC LESIONS. . . . . . . . . . . . . . . . . . 161 CHAPTER 12: FUNCTIONAL AND PAIN NEUROSURGERY. . . . . . . . . . . . . . . . 172 CHAPTER 13: PERIPHERAL NERVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 CHAPTER 14: CRITICAL CARE AND NEUROANESTHESIA. . . . . . . . . . . . . . . . 196 CHAPTER 15: NEUROLOGY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202 C O N T E N T S 978-1-60406-542-8c0fm.indd vii 978-1-60406-542-8c0fm.indd vii 5/10/11 2:06 PM 5/10/11 2:06 PM viii CONTENTS CASE VIGNETTES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226 GLOSSARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247 INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257 978-1-60406-542-8c0fm.indd viii 978-1-60406-542-8c0fm.indd viii 5/10/11 2:06 PM 5/10/11 2:06 PM I wrote this book using the notes that I scribbled down while studying for the neurosurgery oral board examination. This book is not intended to serve as a replacement for classic neurosurgical texts, but as a supplement to the knowledge gained during the long years of residency and in the early stages of practice. I tried to focus on the major aspects of diseases that a neurosurgeon may encounter, both in clinical practice and on the examina- tion. For a more thorough helping of knowledge, consider thumbing through the texts in the reference list. My favorite is Comprehensive Neurosurgical Board Review, but I may be a little biased. That book was geared for the writ- ten boards, but the anatomy, pathology/radiology, neurology, and neuro- surgery sections provide useful information that is not covered in this text. I must admit that I was a tad intimidated by the oral examination before I lived through it. I expected to hear “So, Dr. Citow, can you please show me the incision for the hypoglossal-pundendal nerve anastomsas used for peo- ple who constantly speak out of their asses.” But it really was a fair test and a surprisingly pleasant experience. I truly got the sense that the examiners are out to reinforce their preconceived notion that the examinee (you) is indeed competent —not the other way around—and makes reasonable deci- sions. They are not out to trick you with obscure details. Stay relaxed and suggest exactly what you would do in everyday practice (not in a surreal ivory tower university setting) and all will be fi ne. The only dishearten- ing aspect of the test is that none of the examiners smile (but this may be their baseline state) or acknowledge that you are correct (but neither do your patients in the hospital, unless they have been on the Internet.) Good luck! P R E F A C E 978-1-60406-542-8c0fm.indd ix 978-1-60406-542-8c0fm.indd ix 5/10/11 2:06 PM 5/10/11 2:06 PM 978-1-60406-542-8c0fm.indd x 978-1-60406-542-8c0fm.indd x 5/10/11 2:06 PM 5/10/11 2:06 PM Relax, there is little they will ask you that you have not treated successfully numerous times. Remember, this book is only our view of things. There are many ways to skin a nerve root. As long as the patients are well cared for, all will be fi ne. In this second edition, we have kept true to the major pur- pose of the fi rst successful edition, that is, to serve as a concise and easy-to- read review book that can basically be covered in a few days as a supplement to additional study. We don’t advocate preparing for the boards in one weekend, but the nature of our profession often requires quick reviews. Nevertheless, we have made several changes in this second edition that will greatly enhance your preparation. Sections and chapters are reorganized into topics to better follow the format of the real examination. We have added to the end of each chapter some key helpful hints. In addition, we have added to the end of all chapters very brief classic case vignettes with imaging on which to practice. Because of the nature of the oral board exam, success clearly depends on confi dence, which depends on knowing what to expect. Understanding the conditions will help reduce anxiety and improve success. The American Board of Neurological Surgery (ABNS) states that the purpose is to “deter- mine competency in diagnosis and management;” however, it also explic- itly states that the examinations “focus on problems neurosurgeons can expect.” We would argue that this latter acknowledgment should receive as much if not more attention than the former during your preparation. Yes, you must know the basics in diagnosing and managing diseases of the ner- vous system, but the ABNS wants to make sure you are a safe neurosurgeon and that you avoid and appropriately manage complications. First, do no harm. Most examinees will have recently completed residency and written board exams, so the basics of diagnosis and management are there and sim- ply need review. However, many examinees lack extensive experience deal- ing with complications that come with being in practice for many years. Regardless of your experience with complications, you must demonstrate to the ABNS that you have solid complication avoidance practices. The basic format of the oral examination has not changed for years. It only lasts three hours. One hour is devoted to the spine, one hour is devoted I N T R O D U C T I O N 978-1-60406-542-8c0fm.indd xi 978-1-60406-542-8c0fm.indd xi 5/10/11 2:06 PM 5/10/11 2:06 PM xii INTRODUCTION to intracranial disorders, and the last hour is devoted to everything else— pediatrics, functional, pain, peripheral nerve, critical care, and any concerns the examiners may have encountered looking at your practice data or dur- ing the fi rst two hours. They say that neurology is mixed in all three hours. During each hour, you will meet with two examiners. You may recognize them as they are leaders in neurosurgery, but do not expect them to ask you questions in their fi eld of expertise. Typically, you will be presented a case history with symptoms and physical exam fi ndings via a PowerPoint slide- show, and then asked how you would proceed. You must formulate a dif- ferential diagnosis and then be prepared to discuss how you work up each diagnosis. As you do this, the examiners will give you results that will guide you to the most likely diagnosis, at which time you must be prepared to discuss in detail your medical and surgical treatment options. They will have paper, cranial, and spine models in the room that you can use. Once you demonstrate your knowledge of treatments, the examiners will likely interrupt you to proceed on to something else, for example, postoperative management of a complication. Time is of essence! It is paramount that you practice the real situation to get use to this very short and fast exam. Being comfortable with the rela- tively fast format will greatly help you. The exact scoring system is not discussed in detail in the ABNS literature, so we are unsure of the method- ology. However, members of the ABNS have reviewed it at AANS annual meeting sessions devoted to this topic. Basically, each case is scored 0 to 4 in areas of diagnosis, management, and complications. The “passing” aver- age likely changes each year based on performances that year. Achieving a particular score does not appear to be key; instead, what has been repeat- edly emphasized is that you cover at least 6 cases per hour to accumulate enough points to achieve the passing score. This equates to only 10 min- utes per case. We have found through our own experiences and teaching review courses that most folks are woefully unsatisfi ed with how much they discuss a case in 10 minutes. You will likely not say every important fact that the examiner is looking for about a particular case in 10 minutes, but you can let the examiner know that you know a lot about a particular case’s diagnosis and management. You achieve that by talking. Think quickly, and then say what’s on your mind. You will lose valuable time if you wait for the examiner to ask you a question. Instead, let the examiners interrupt you and redirect the discussion where they want—this is in your best interest. 978-1-60406-542-8c0fm.indd xii 978-1-60406-542-8c0fm.indd xii 5/10/11 2:06 PM 5/10/11 2:06 PM INTRODUCTION xiii People tackle this examination diff erently, but over the years we have accumulated some advice that seems to come up consistently from recent examiners: 1. Apply to ABNS to sit for oral exam as soon as you can after accumulat- ing 1 year of practice data after residency. The day after your residency may be the smartest day of your life, and it will be helpful to do your oral exam as close to this day as possible. Once you apply, it will take many months for them to schedule your exam. 2. Gather review materials months ahead, but give yourself a dedicated 1 to 2 weeks off work before the exam to really focus on it. 3. Practice the exam, especially with senior colleagues or at review courses. This is awkward for some, so you need to get over it, and practice. 4. Spend the night near the testing site, so you can arrive very early, get familiar with the setup, and relax. 5. Very briefl y, review your submitted practice data just in case they ask a question about it. 6. During the exam, you will be provided with paper and pencil, but tak- ing extensive notes may slow you down, so be judicious if you need notes. We recommend not taking notes. 7. If you know the examiner, forget his or her specialty as you will most likely be asked questions from outside that specialty. 8. Don’t guess. If you don’t know, say so, but recommend how you might go about getting an answer. If you don’t do a certain technique, say so, and tell them what you do in the real world (e.g. send patients to your cerebrovascular neurosurgery colleague). BUT, you will still be expected to discuss the basic craniotomy for clipping a particular aneurysm. Con- sults are wise, but typically not available during your exam! The as- sumption is that you should be able to deal with any basic neurosurgery issue if you had to. 9. Be humble. A reasonable assumption is that arrogant and overly self- confi dent neurosurgeons make deadly mistakes. No matter how well you discuss cases, we suspect this type of attitude will be signifi cantly penalized. 10. Lastly, our knowledge of neurosurgery and educational methods are constantly evolving. As you review this book, please email your sug- gestions for improvement to
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