Fellowship in Spinal Reconstructive Surgery

Fellowship in Spinal Reconstructive Surgery
(FSRS)
Grande International Hospital, Kathmandu, NEPAL

Course Curriculum

Mentors

Dr. Binod Bijukachhe (Course Director)

Dr. Byapak Paudel

Dr. Ram Krishna Dahal

Dr. Aayush Shrestha

Prof. Chester E Sutterlin III MD (International Course Director)

Log Book maintenance: A fellow is required to keep his / her log book updated and should be reviewed every three months and signed by one of the mentors. The format of the log book is as shown below.

Surgical procedure Log book

SN	Name	Age	Sex	Diagnosis	Procedure	Difficulties observed	Corrective steps	Remarks

Academic Activities Log book

Topic of presentation

Where

When

Remarks

Topic Presentations: A fellow required to present the designated topics along with latest evidences available every week and as per need. You will be asked questions and evaluation will be made based upon your response.

Case Discussions: All pre-operative cases will be discussed and surgical planning done at least a day before. You are expected to ensure all the investigations ready for the discussion. You should be presenting your plan of action. Group discussion will rectify the surgical planning.

All post-operative cases will be discussed with regard to post-operative improvement, challenges during surgery and further follow-up protocols. Patients follow up data should be maintained properly.

Patient evaluations / Documentations: A fellow should be evaluating patients clinically as well as radiologically. All laboratory parameters should be thoroughly evaluated. Clinical examination should be documented properly and standard scoring systems should be utilized to document the clinical findings accurately.

Participation in surgical procedures: A fellow should be participating in surgical activities under supervision of the mentors. He / she should be involved in patient preparation / positioning/ confirming surgical procedures etc.

Research activities: A fellow should be auditing data of the patients admitted in the spine division. He / she should be actively participating in producing papers for presentations in national and international meetings.

Scientific paper writing: A fellow should be publishing at least 2 papers during the course of one year.

Dr. Binod Bijukachhe

Course Director

Director, Division of Spine Surgery

Medical Director

Fellowship in spinal reconstructive surgery
DEPARTMENT OF TRAUMATOLOGY AND ORTHOPEDIC SURGERY
DIVISION OF SPINE SURGERY
GRNDE INTERNATINAL HOSPITAL, Kathmandu, NEPAL

Annually about 150 Spine surgeries are performed at the Grande International Hospital. The types of surgeries include degenerative spine, disc surgeries, spinal infections, spinal tumors, deformities (Scoliosis, Kyphosis) corrections, spinal trauma, injection procedures etc. The rotation is designed to provide training in the evaluation and management of patients with disorders of the spine. It is expected that upon completion of this rotation, fellows will demonstrate an understanding of the anatomy, physiology, pathophysiology, and presentation of disorders of the spine, its connecting ligaments, the spinal cord, the cauda equina, and the spinal roots. Additionally fellows will demonstrate the ability to formulate and implement a diagnostic and treatment plan for diseases of the spine, its connecting ligaments, the spinal cord, the cauda equina, and the spinal roots that are amenable to surgical intervention.

Duration of training program – One year

Observer ship – 4 weeks to 6 months

Criteria for enrollment

Masters or equivalent in orthopedic surgery / Neurosurgery
Must have passed Nepal Medical council licensing examinations

Course Director – Dr. Binod Bijukachhe

Mentors

Dr. Binod Bijukachhe

Dr. Byapak Paudel

Dr. Ram Krishna Dahal

Dr. Aayush Shrestha

Course advisor: Dr. Chester E Sutterlin III

Curriculum

Curriculum is designed under following headings

Surgery

Technical Skills

The fellowship’s primary emphasis is ensuring that the fellow has the highest level of technical expertise possible.

Pathology includes:
- Deformity
  - Scoliosis
    - Congenital
    - Idiopathic
    - Paralytic
    - Thoracic insufficiency syndrome
    - Post traumatic deformity
    - Post infective deformity
    - Kyphosis – Scheuermann
- Degenerative
  - Spinal canal stenosis
  - Cervical myelopathy
  - Spondylolisthesis
  - Adult scoliosis
  - Sagittal balance
    - Principles of management
- Tumor
  - Primary spinal tumours
  - Metastatic spinal tumours
- Infection
  - Tuberculosis of spine
  - Pyogenic spondylitis
  - Parasitic infestation
  - Diagnostic procedures
    - USG guided biopsy
    - CT guided Biopsy
    - Fluoroscopy guided biopsy
  - Decompression techniques
    - Anterior Thoracotomy
    - Thoraco-phreno-lumbotomy
    - Posterior only techniques
    - Anterior column reconstructions
    - Posterior column stabilization
- Trauma
  - Basic principle of management of spinal trauma
  - Cervical spine injury
    - Application of Gardner Well Tong / Crutchfield tong
    - Reduction techniques of facet dislocation
    - Application of Mayfield head rest
    - Anterior and posterior exposure techniques
    - Lateral mass screw fixation techniques
    - Pedicle screws fixation techniques
  - Thoracic and Thoraco-lumbar injury
    - Classification systems
    - Indications for surgery
    - Exposure techniques
    - Short segment / Long segment fixation
    - Pedicle screw insertion techniques
    - Anterior reconstruction techniques and indication
  - Spinal cord injury
    - Complete
    - Incomplete
    - Rehabilitation procedures
Metabolic conditions
- Osteoporosis
  - Vertebroplasty
  - Kyphoplasty
Miscellaneous
- Disc herniation
- Complication of spine surgery
- Management of dural injury

Performance/techniques that will be mastered include:

Posterior Screw Fixation
- Cervical Lateral Mass and Pedicle screw fixation
- Thoracic and Lumbar Pedicles
- C1-C2
- Occipito-Cervical fixation
- Spino -Pelvic Fixation
Anterior Abdominal approach
Anterior Thoracolumbar
Anterior Cervical
Posterior Cervical Foraminotomies
Thoracic costotransvectomy
Vertbrectomies-Cervical, Thoracic, and Lumbar
Minimally Invasive
XLIF
Lumbar
Thoracolumbar
Tube Decompression
Pedicle Screws
Different types of Lumbar Fusions
- Posterior Lumbar Interbody fusion
- Anterior Lumbar Interbody fusion
- Transforaminal Lumbar Interbody Fusion
Spinal Tumours
- Intra and Extra-Dural Spinal Tumors
- Vertebral Body Tumours
- Metastatic tumours
Osteotomies and deformity correction
- Posterior column
- Pedicle substraction
- Vertrbral column resection

Performance skill: The fellowship incorporates an athletic performance coach to implement performance skills in the operating room utilizing the “Awake at the Wound” program.

Clinical Care

Post-Operative Care

Fellows are involved in the post-operative care for both spine and non-spine patients; fellows are also expected to see all of the patients they perform surgery on until discharge.

Post-Op ICU Care
- Spine Patients
- Non-Spine Patients
Post-Op Surgical Patients

Clinic
All spine physicians are in clinic on Monday / Thursday. During this time, fellows are expected to:

Spend equal time in clinic with each physician
Conduct specific literature searches on usual problems
Visit post-ops or interesting cases

General Ortho- Spine Call

Fellows will participate in the general Orthopedics and spine calls.

Didactic

Wednesday Morning Conferences/Case Presentations
These are working conference sessions during which fellows collect questions.

Wednesday Afternoon Conferences

Conference agendas will be altered depending on the fellows’ interests and cases that week.

Discussion of relevant spine topics
Problem Solving (Staff and fellows share feedback.)

Competency Based Curriculum Objectives

Medical Knowledge Fellows must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care.

Review the biomechanics of the craniocervical junction, cervical spine, and thoracolumbar and lumbar spine.
Review the biomechanics of common internal spinal fixation devices.
Review the definition of spinal instability based upon the principles of Punjabi, White and other authors.
Recognize the radiographic signs of degenerative neoplastic, traumatic, and congenital spinal instability.
Review the indications for, uses, and relative effectiveness of common spinal orthoses. Discuss the degree of segmental and regional immobilization these orthoses provide.
Review the indications for, and physiology of, intraoperative spinal cord monitoring. Describe the technical aspects of intraoperative spinal cord monitoring.
Compare and contrast indications for anterior and posterior approaches to the cervical spine for the treatment of herniated cervical discs, spondylosis, and instability.
Discuss the role of corpectomy in the management of cervical disorders.
Compare and contrast the indications for anterior cervical discectomy with and without anterior interbody fusion.
Discuss the indications and techniques for anterior and posterior cervical spinal internal fixators.
Explain the biology of bone healing and options for bone grafting and use of osteobiological agents in spinal surgery.
Review the diagnosis and management of primary spinal tumors, spinal cord tumors, and spinal metastatic disease including indications for dorsal decompression, ventral decompression, and radiotherapy.
Discuss the management principles for gunshot and other penetrating wounds to the spine.
Review the signs, symptoms, and management options in the treatment of the adult tethered cord syndrome and syringomyelia.
Review management principles for spontaneous and postoperative spinal infections.
Review the management principles for intraoperative and postoperative cerebrospinal fluid leaks.
Discuss the surgical management of intradural congenital, neoplastic, and vascular lesions.
Review evaluation and management of arthritic and metabolic disorders of the spine.
Discuss principles of evaluation and management of pediatric and adult spinal deformity
Describe indications for the use of angiography and endovascular procedures in the management of spinal disorders.
Discuss the management of cervical degenerative disease secondary to rheumatoid arthritis. Describe factors that make it different from the management of non-rheumatoid disease.
Compare and contrast the treatment options for cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament, including multilevel anterior cervical corpectomy and fusion, laminectomy, laminectomy and fusion, laminoplasty, and nonoperative therapies.
Discuss the indications for posterior cervical spinal internal fixators.
Compare and contrast the transthoracic, transpedicular, costotransverse, and lateral extracavitary approaches to a herniated thoracic disc, thoracic tumor, or thoracic spinal injury.
Discuss the indications for lumbar fusion for congenital disorders, iatrogenic disease, and degenerative disease, ranking indications from least to most controversial.
Compare and contrast the indications for anterior or posterior lumbar interbody fusion and intertransverse fusion for lumbar disease.
Discuss internal fixation options for posterior lumbar interbody fusion and intertransverse fusion.
Summarize the most common types of spinal tumors in the following categories:
- Intradural/intramedullary
- Intradural/extramedullary
- Extradural/extramedullary.
Discuss nonoperative and operative treatment options for fractures and dislocations affecting the atlas and axis.
Compare and contrast the indications for nonoperative treatment, anterior approaches, and posterior operative approaches for the treatment of fractures and dislocations of the subaxial cervical spine.
Describe the indications for anterior, posterior, and posterolateral procedures in the management of thoracolumbar tumor, trauma, or infection.
Compare and contrast the indications for anterior and posterior spinal fixators in the management of thoracolumbar tumor, trauma, or infection.
Discuss reconstruction options for vertebral body defects after corpectomy for tumor, trauma, or infection.
Discuss reconstruction options for pediatric and adult spinal deformity.
Discuss surgical options for low and high grade spondylolisthesis.

Patient Care

Fellows must be able to provide patient care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health.

Demonstrate the ability to prepare structural bone grafts for use in spinal surgery.
Determine the need for postoperative inpatient or outpatient rehabilitation in patients with spinal disorders.
Demonstrate the ability to perform a ventral exposure of the cervical spine followed by anterior cervical discectomy.
Demonstrate the ability to perform an anterior cervical interbody arthrodesis.
Demonstrate the ability to place anterior cervical instrumentation.
Demonstrate the ability to perform posterior cervical decompressive laminectomy.
Demonstrate the ability to perform posterior cervical foraminotomy with or without discectomy.
Demonstrate the ability to perform medial and lateral approaches to a far lateral lumbar disc herniation.
Demonstrate appropriate surgical technique in the management of recurrent lumbar disc herniations and recurrent lumbar stenosis.
Demonstrate the ability to perform posterior lumbar arthrodesis with or without the use of interbody instrumentation.
Demonstrate exposure of the cervical lateral masses, thoracic and lumbar transverse processes, and the sacral ala.
Demonstrate the ability to perform posterior/intertransverse arthrodesis in the cervical, thoracic and lumbar regions.
Demonstrate the ability to perform a laminectomy with or without transpedicular decompression for tumor, infection, or trauma.
Demonstrate techniques for spinous process arthrodesis of the subaxial cervical spine for fracture or dislocation.
Demonstrate the ability to manage postoperative complications of spinal surgery including:
- Hematoma
- Infection
- Spinal fluid leak
- New neurologic deficit
Demonstrate the ability to perform a tethered cord release.
Demonstrate the ability to function independently in all phases of management of patients with spinal disorders.
Demonstrate the ability to perform occipital-cervical arthrodesis.
Demonstrate the ability to properly place sublaminar wires, lateral mass screws, lower cervical/upper thoracic pedicle screws, C2 pars interarticularis screws, and C1-2 transarticular screws for the management of cervical spine disorders.
Demonstrate the ability to perform, with assistance if necessary, transoral odontoidectomy.
Demonstrate common techniques for performing C1-2 arthrodesis.
Demonstrate the ability to perform anterior cervical corpectomy followed by arthrodesis.
Demonstrate the ability to perform, with assistance if necessary, transthoracic, thoracoabdominal, retroperitoneal, and transabdominal approaches to the thoracic and lumbar spine.
Demonstrate the ability to perform costotransverse and lateral extracavitary approaches to the thoracolumbar spine.
Demonstrate the ability to excise a herniated thoracic disc by use of the above-mentioned approaches.
Demonstrate the ability to perform vertebral corpectomy of the thoracolumbar spine for tumor, infection, or trauma, utilizing the above-mentioned approaches.
Demonstrate the ability to perform anterior arthrodesis of the thoracolumbar spine.
Demonstrate the proper placement of transpedicular screws in the thoracic and lumbar spine.
Demonstrate the proper placement of laminar, transverse process, and pedicle hooks in the thoracic and lumbar spine.
Demonstrate the ability to resect intradural spinal neoplasms.
Demonstrate the ability to perform methylmethacrylate vertebroplasty and Kyphoplasty.
Demonstrate techniques of open reduction of fractures and dislocations of the cervical, thoracic, and lumbar spine.
Demonstrate the ability to surgically manage arachnoid cysts and spinal cord syrinx.
Demonstrate the ability to perform intradural procedures for congenital, neoplastic, and vascular lesions.
Demonstrate the ability to perform spinopelvic fixation techniques.

Professionalism
Fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.

Demonstrate care and compassion for spine patients and their families
Demonstrate respect for patients and colleagues from diverse cultural, ethnic and religious backgrounds
Demonstrate honesty in all professional interactions
Demonstrate punctuality for scheduled conferences and rounds
Provide consultation to the ED and other services in timely fashion and/or arrange for back-up consultation if unavailable
Demonstrate dress, grooming and comportment consistent with institutional guidelines and earning confidence and respect from supervisors, peers and patient families
Comply with all GME and Departmental regulations regarding duty hour restrictions and report personal schedule in timely and accurate fashion
Accurately self-report fatigue in situations that may compromise safety and/or patient care

Interpersonal and Communication Skills Fellows must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families and health professionals.

Demonstrate the ability to communicate complex care plans to families
Demonstrate the ability to provide sensitive, accurate and complete information and consent regarding a surgical procedure or other intervention, particularly in difficult situations:
- Parents consenting on behalf of young minor
- Consent via a translator
- Consent with non-traditional religious or cultural boundaries
Demonstrate the ability to communicate effectively with nurses in NNICU, NIMU and as well as the Neurosurgery Nurses and Nurse Practitioners and peers on other services
Provide complete and effective sign out and sign in with on call neurosurgery residents covering the service
Communicate effectively with other members of the neurosurgery team.

Practice Based Learning and Improvement Fellows must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.

Fellows should be provided with the log books which should be duely filled on regular basis.
Maintain a list of all morbidity and mortality cases. Prepare cases with attending supervision to be discussed at the quarterly Morbidity and Mortality Conference. If appropriate, produce a Quality Improvement project.
Prepare and present cases from the Spine Service at the Interesting Case conference. Describe the outcomes of neurosurgical intervention in infants and children through longitudinal follow-up at subsequent conferences.
Perform at least one literature search from recent articles on an interesting case of your choosing.
Prepare and present a lecture at the Neurosurgery Teaching Conference under the supervision of an attending.
Perform a self-assessment evaluation prior to the end of the rotation. Discuss the results with your attending or program director.

Systems Based Practice Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

Describe the nature of complex interdisciplinary team management in “Disease-focused Care” in a tertiary hospital.
Manage communication with the NICU,HCU,ICU, Joint Surgery , Neurosurgery and Trauma teams regarding co-care patients.
Interact with assigned Nurse , Physical Therapists and Social Workers in planning longitudinal care of pediatric neurosurgery patients.
Demonstrate effective participation in interdisciplinary conferences:
- Neuropathology Conference
- Radio Pathology conferences
- Spine conference
- Neurovascular conference

Rotation Assessment and Evaluation

Morbidity and Mortality Log
Review of presentations at Interesting Case conference and M&M conference.
Review of performance during Mock Oral board examinations.
Conference attendance statistics
Review of Medical Documentation Biopsy (Discharge Summary, Operative Note) by Spine surgery attending
Duty hours tracking data, weekly review by Program Administrator and review as needed
Review of Systems- or Quality Improvement Project (if performed)
Lecture prepared and given under attending supervision.

Non-Spine Exposure

Physical Therapy Fellows are encouraged to spend a minimum of half days of the week throughout the training period to become familiar with the language and techniques utilized by physical therapy.

Pain Specialists Fellows are encouraged to spend a minimum two sessions per week becoming familiar with the pain specialists’ approach and resources.

Spine Injections Fellows are encouraged to spend time whenever cases are posted for Epidural, Root block , Facet blocks and SI joint injections.

Research Activity Individual Projects for fellows Fellows are expected to choose research project, or they will have one assigned to them. The timeline follows: Fellows who are in six months program one article. Those doing one year’s program two papers.

Topic to be decided within 15 day of joining date
Research plan and schedule by end of a month
Outline and abstract draft ready by end of six months
Paper submitted to journal after its ready.