Neurology

The purpose of the Oral Board Examination is to determine a candidate’s competency in neurosurgical disorders, but also neurological disorders, which may mimic neurosurgical conditions. 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. Some of the common neurological ailments that the Oral Board examinee needs to be well aware of include amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), Guillain-Barré syndrome, and Parsonage=Turner syndrome (brachial plexitis), some of which are covered either in this chapter or in other relevant chapters.

Peripheral Nerve

Peripheral nerve is an important and historical part of neurosurgery. It also has been a major focus of both the written and oral examinations administered by the American Board of Neurological Surgeons (ABNS). The Oral Board candidate must be prepared for potentially one to several questions on some of the common disorders of the peripheral nervous system. In this chapter, a systematic approach to peripheral nerve problems is presented. Common areas that might be examined include tumors, injuries, inflammatory conditions, entrapments, and neuropathic pain. Five cases are illustrated, and “pearls” are provided. At the conclusion of the chapter are nine photographs representing problems the Oral Board candidate should be able to identify and answer.

Pain

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 routinely 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, plexopathy, cordotomy versus morphine pain pump for cancer pain, dorsal root entry zone myelotomy for brachial plexus avulsion, and complex regional pain syndrome.

Endovascular

Endovascular neurosurgery has evolved dramatically since the first description of aneurysm coiling in 1991 and is now employed as a primary treatment strategy for managing a multitude of cerebrovascular pathologies, including aneurysms, arteriovenous malformations (AVMs), and acute ischemic stroke. The endovascular approach offers an attractive, minimally invasive alternative for aneurysm treatment with low procedure-related morbidity and mortality. The durability and long-term efficacy of endovascular interventions is continuously evolving, especially with the introduction of newer coils, stents, and flow-diversion techniques. Endovascular management of AVMs can be used for presurgical embolization, preradiosurgical intervention, or palliative embolization or as a primary treatment for curative embolization, depending on the characteristics of the lesion. Advances in endovascular management of acute stroke have further increased the therapeutic window of recombinant tissue plasminogen activator administration using the intraarterial route and have led to the introduction of new devices for clot removal and vessel recanalization.

Vascular Neurosurgery

Vascular neurosurgery has long been one of the focal points of neurosurgical practice, and the topic is routinely included in the Oral Board Examination process. Each case involves clinical and diagnostic acumen, a solid grasp of the natural history and treatment risks, consideration of operative approaches, alternative treatment options, and the management of potentially catastrophic complications, as a result of what we have done or what we failed to do. Five cases are discussed in this chapter, and for each case the history and physical symptoms, imaging studies, analyses of the cases and treatment plans, and complications are provided. Key points are also presented after each case. The cases discussed include an aneurysmal subarachnoid hemorrhage (aSAH), an unruptured brain arteriovenous malformation (AVM), an intracerebral hemorrhage (ICH), a spinal dural arteriovenous fistula (dAVF), and symptomatic carotid stenosis.

Brain Tumors

Brain tumor cases make up a significant part of the neurosurgery Oral Board Exam. A multitude of brain tumors exist and can be intraaxial or extraaxial. When considering a differential diagnosis for a brain lesion, infection, hematomas, infarctions, thrombosed aneurysms, inflammation, and demyelinating disease must be considered in addition to tumors. Common adult brain tumors consist of gliomas, meningiomas, metastases, and pituitary tumors. Management of brain tumors consists of understanding preoperative care, indications for surgery, surgical approaches, interpretation of preoperative and postoperative imaging, intraoperative and postoperative complications, and the role of adjuvant therapy, including chemotherapy and radiotherapy. Reviewing these essential points for the most common brain tumor cases and mastering the current treatment recommendations for common tumors will also be helpful for the boards.

Epilepsy and Functional 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.

Pediatric Neurosurgery

Common pediatric neurosurgical problems treated by neurosurgeons will be included on the American Board of Neurological Surgeons (ABNS) Oral Board Examination. Therefore, the candidate should be familiar with the neurosurgical management of such problems, which include disorders of cerebrospinal fluid (CSF) dynamics, congenital cranial and spinal malformations, tumors, vascular congenital and acquired disorders, intracranial and spinal infections, and intractable epilepsy. Neurological disorders that mimic pediatric neurosurgical conditions may also be on the examination. In this chapter, clinical vignettes of common pediatric neurosurgical conditions are presented, including hydrocephalus, myelomeningocele, intraventricular hemorrhage (IVH) of prematurity, craniosynostosis, and posterior fossa tumors. The examinee 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.

Spine

Spine cases form a significant component of the neurosurgery Oral Board Examination. 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 armamentariun. 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 examination. The following cases are discussed in this chapter: bilateral cervical facet dislocation with spinal cord injury, central calcified thoracic disk herniation, L5 congenital spondylolysis with spondylolisthesis, metastatic lesion, and intramedullary ependymoma.

The Goodman Oral Board Course

This chapter describes the purpose and format of the Goodman Oral Board certification course. The course is highly interactive and attempts to simulate the examination given by the American Board of Neurological Surgery (ABNS). The course features plenary sessions wherein an examiner interviews a participant in the “hot seat” while the larger group observes. The examiners are experts in their respective fields and try to emulate the examination process and provide feedback to the examinee at the end of each case. Concurrently, 30-minute breakout sessions allow one-on-one interaction between the participant and the examiner. The chapter outlines the learning objectives of the course and discusses how success in the course is measured.