Spine

Spine cases form a significant component of the neurosurgery Oral Board Examinations. A familiarity with the common cases is essential in preparing for the boards. Spine includes cases that span from the skull base to the sacrum. Another component of spine includes an understanding of spine stability as well as the use of spinal instrumentation such as cervical plating and pedicle screws. These techniques are now a standard part of the neurosurgical armamentarium. Current new technologies or approaches to the spine whether minimally invasive techniques or surgery for deformity are actively used and will continue to form a larger part of the oral exam. The following cases are discussed in this chapter: bilateral cervical facet dislocation with spinal cord injury, central calcified thoracic disc herniation, L5 congenital spondylolysis with spondylolisthesis, metastatic lesion, and a thoracolumbar spine deformity.

Cranial Trauma and ICU Management

Head trauma is a commonly encountered diagnostic problem in neurosurgery and is thought by some to be relatively limited in its technical challenges, and, as such, it gives the examinee an opportunity to excel in this area. Six cases are presented and include the history and physical symptoms, imaging studies, analyses, and plan of each case. Cases include closed head injury with raised intracranial pressure, a gunshot wound to the head, an epidural hematoma, trauma with intracerebral hemorrhage, and a depressed skull fracture. Sample questions and reasonable answers are also provided. For those choosing Trauma/Critical Care for the focused component of their exam, there are more in-depth questions oriented particularly to critical care. These are marked with asterisks.

Brain Tumors

Having a general understanding of brain tumors is integral to mastering the oral board examination. For the general session, examinees should be able to identify both intra-axial and extra-axial tumors and provide a comprehensive understanding of the differential diagnosis and plan regarding treatment, while also verbalizing concepts behind the treatment modalities and articulating to a patient and family the alternative approaches as well as the complications related to management. Pathologies to familiarize oneself with include gliomas, meningiomas, metastatic lesions, and pituitary lesions. For subspecialty examinees, complex cases such as endonasal, endoscopic, keyhole, and skull base approaches should be mastered. For each case, a broad differential diagnosis should include infection, hematoma, infarction, thrombosed aneurysm, inflammation, and/or demyelinating disease. Discuss the preoperative workup the indications for surgery and surgical approach. Interpret the preoperative and postoperative imaging critically. Be prepared for potential intraoperative complications and discussion of postoperative management including adjuvant radiation and chemotherapy and long-term care.

The ABNS Oral Board Examination

This chapter describes the American Board of Neurological Surgery (ABNS) Oral Board Examination as well as the requirements necessary to be able to sit the examination. Additionally, the organization of the examination, including how examiners score each individual and the process are also described. There is a particular emphasis on how the format of the examination has changed in recent years. The rational for the new examination changes are discussed as well as the importance of how to upload your own case data to POST and tips for preparing to defend your cases at the time of the exam.

Endovascular Neurosurgery

This chapter is designed in a case base fashion covering common vascular problems treated by endovascular techniques such as aneurysms, arteriovenous malformations, and strokes. The neurointerventionalist armamentarium is becoming rich with alternatives enabling management of broad range of pathologies in a less invasive way. The most recent innovation was the endosaccular flow diversion device indicated for wide-neck bifurcating aneurysms. Preliminary reports have shown it’s efficacy in treating both ruptured and unruptured aneurysms. Similarly, stents for aneurysm and stroke treatment, and microcatheters for embolization procedures are in continuous refinements for improved safety, deliverability, and outcomes. Six clinical cases are presented in this chapter with an analysis of the cases, a clinical management, and a focused review on the topic relevant to each scenario.

Neurology

The purpose of the Oral Board Examination is to determine a candidate’s competency in neurosurgical disorders, as well as in neurological disorders which may mimic neurosurgical conditions. Clearly, this goal of the examination process must be kept in the back of an examinee’s mind during questioning. It is not uncommon for a candidate to be presented imaging studies that clearly appear surgical; however, after carefully listening to the history and relevant neurological findings, it will become apparent that the imaging does not explain the patient’s symptoms. When this occurs, start by trying to localize the lesion within the neuraxis—brain, brainstem, spinal cord, peripheral nerve, neuromuscular junction, or the muscle itself. Clues such as hyporeflexia or hyperreflexia and distribution or absence of sensory symptoms are key. Then develop a differential diagnosis of neurological conditions that may present in these areas—vascular, demyelinating, inflammatory, axonal loss, and neuromuscular blockade. Some of the common neurological ailments that the oral board examinee needs to be well aware of include amyotrophic lateral sclerosis, multiple sclerosis, Guillain-Barré syndrome, and Parsonage-Turner syndrome (brachial plexitis), some of which are covered either in this chapter or in other relevant chapters.

Pediatric Neurosurgery

The ABNS Oral Examination evaluates an applicant’s knowledge and judgment in clinical neurosurgical practice after an applicant has been an independent practitioner. With the new format, the oral exam is divided into 3 sessions, each consisting of 5 questions. Questions in the first session deal with general neurosurgery, questions in the second session focus on the preidentified area of practice chosen by the applicant (e.g., pediatric neurosurgery), and questions in the third session are based on cases submitted by the applicant. Common pediatric neurosurgical problems treated by neurosurgeons may be included on the American Board of Neurological Surgery Oral Examination in the general neurosurgery session. Therefore, one should be familiar with the neurosurgical management of pediatric cases, including disorders of cerebrospinal fluid dynamics, congenital cranial and spinal malformations, tumors, vascular congenital and acquired disorders, intracranial and spinal infections, and intractable epilepsy. In this chapter, clinical vignettes of common pediatric neurosurgical conditions will be presented including (a) myelomeningocele, (b) craniosynostosis, (c) hydrocephalus, (d) posterior fossa tumors, and (e) moyamoya disease, with the cases subdivided into those that may be seen in the general session (1 to 3) and those more likely to be seen in the subspecialty specific session (4 and 5). The applicant will be given the history, physical examination, pertinent imaging studies, and test results and will then be expected to provide a rational differential diagnosis and plan of management, outline the risks of surgery, and describe the operation, if proposed, and handle intraoperative and postoperative complications that occur.

Vascular Neurosurgery

This chapter reviews a variety of neurovascular conditions including aneurysmal subarachnoid hemorrhage, arteriovenous malformation of the brain, intracerebral hemorrhage, spinal dural arteriovenous fistula, carotid stenosis, and decompressive craniectomy for malignant middle cerebral artery infarction. Emphasis is placed on the considerations for surgical management. Decisions on treatment need to be based on an understanding of the natural history of the disease process, possible alternative treatment options, and the potential risks and benefits of a chosen procedure. The general management aspects concerning these conditions are also discussed. These six case studies review the important features of the medical history, imaging, medications, surgical, and endovascular treatments associated with the specific condition. Findings from key neurovascular studies are incorporated into the discussion of each case.

Complications

Complications form a very significant element of the Oral Board Examination. The scoring system gives a grade for the handling of complications relevant to the treatment. The good news is that there are a limited number of complications in neurosurgery. Again, complications are expected on the Oral Board Examination. The most common complications are: postoperative neuropathic pain, postoperative wound infection, cerebrospinal fluid leak, C5 nerve palsy, postoperative cranial or spinal hematoma, hyponatremia, vasospasm, intraoperative aneurysm rupture (open or endovascular), major arterial injuries with cranial and spinal surgery, uncontrolled intracranial pressure, brain swelling during operative exposure, and esophageal injury. These are discussed in this chapter.

Epilepsy, Functional, and Pain Neurosurgery

This chapter covers several aspects of the management of seizures and epilepsy relevant to a general neurosurgical practice. First, all candidates should know how to manage a patient presenting with a new-onset seizure or in status epilepticus with a brain lesion or after a craniotomy. Second, they are expected to be able to explain how to perform fundamental epilepsy procedures such as a temporal lobectomy for hippocampal sclerosis or resection of an epileptogenic lesion. Third, it is useful to have a clear process in place for mapping language and motor function for the resection of tumors located in the eloquent cortex. Lastly, the thought process behind developing an appropriate plan for the surgical management of movement disorders and the technical nuances of managing such cases are discussed. Historically, surgery for pain has been a large part of general neurosurgical practice. A variety of destructive and decompressive interventions have been developed over the years, and a number of comprehensive textbooks have summarized neurosurgical involvement with management of all kinds of medically refractory pain syndromes. It is included in the core neurosurgical education curriculum and is an integral part of neurosurgical knowledge that is tested during the oral board examination. Not surprisingly, cases involving complex pain conditions that require neurosurgical interventions may show up during examinations, and it is expected that examinees are comfortable performing these interventions and able to discuss indications, surgical details, outcomes and complications. Cases include trigeminal neuralgia, cordotomy versus morphine pain pump for cancer pain and a spinal cord stimulator.