Spine surgery is performed at the Swedish Health Services. 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.
The fellowship’s primary emphasis is ensuring that the fellow has the highest level of technical expertise possible.
- Pathology includes:
- Performance/techniques that will be mastered include:
- Posterior Screw Fixation
- Cervical Lateral Mass
- Thoracic and Lumbar Pedicles
- Pelvic Fixation
- Anterior Abdominal
- Anterior Thoracolumbar
- Anterior Cervical
- Posterior Cervical Foraminotomies
- Thoracic OstotranVersectomies
- Vertbrectomies-Cervical, Thoracic, and Lumbar
- Minimally Invasive
- Tube Decompression
- Pedicle Screws
- Wiltse Muscle-Splitting Lumbar Fusions
- Intra-Dural Spinal Tumors
- Three Column
- Multiple Chevron
- Posterior Screw Fixation
The fellowship incorporates an athletic performance coach to implement performance skills in the operating room utilizing the “Awake at the Wound” program.
Awake at the Wound Model
Skill = Performance – Interference
- Awake at the Wound
- Introductory Seminar
- Ongoing Intra-Operative Coaching
- Individual Coaching
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
Comprehensive Non-Operative Care (DOCC Project)
The DOCC (Defined, Organized, Comprehensive Care) project is an operative structured framework of spine care conceived by the fellowship’s co- director, David Hanscom, M.D.
- Fellows will read the book “Back In Control”
- Key book topics will be adderssed in collaborative discussions
All spine physicians are in clinic on 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
- Participate in non Swedish Neuroscience Specialists (SNS) activities
General Neurosurgical Call
Fellows will participate in the general neurosurgical call organized by SNI Chief of Neuroscience, David Newell, M.D.
Wednesday Morning Conferences/Case Presentations
These are working conference sessions during which fellows collect questions. Click here to learn more.
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.)
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:
- 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.
- Demonstrate the ability to prepare structural allografts 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:
- 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.
- 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.
- 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 NNICU, NIMU, Orthopedic Surgery and Trauma teams regarding co-care patients
- Interact with Neurosurgical Nurse Practitioners, Physical Therapists and Social Workers in planning longitudinal care of pediatric neurosurgery patients.
- Demonstrate effective participation in interdisciplinary conferences:
- Neuropathology Conference
- Saturday Pediatric Neuroradiology Conference
- Spine conference
- Neurovascular conference
- If possible, prepare a systems-improvement project (such as dedicated order set, documented policy improvement, etc.)
- Written faculty evaluation of all 6 competencies (Neurosurgery Resident evaluation)
- Completion of study questions and assignments from Medical Knowledge and Patient Care Competency Curriculum.
- 360 degree evaluation by Fellow, NNICU Unit Manager, Neurosurgery Nurse Practitioner, and Transcription specialist
- Goals met for surgical case experience.
- On the fly Surgery 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 Neurosurgery 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.
Fellows are encouraged to spend a minimum of four half days throughout the year becoming familiar with the language and techniques utilized by physical therapy.
Fellows are encouraged to spend a minimum of four half days throughout the year becoming familiar with the pain specialists’ approach and resources.
Fellows are encouraged to spend a minimum of four half days throughout the year exposing themselves to the actual performance of this type of procedure.
Back On Track
Swedish Pain and Headache Center has a back school run by the physical therapy program that is two two-hour sessions in a group setting of 8-12 patients; fellows sit in both sessions to:
- Understand how the session is set up
- Get feedback from patients
- Understand how their future practice can develop this resource
Fellows are expected to choose a research project, or they will have one assigned to them. The timeline follows:
- Topic to be decided by end of August
- Research plan and schedule by end of September
- Outline and abstract draft ready by end of December
- Paper submitted to journal in mid-June
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Birch R, Bonney G, Wynne P. Surgical Disorders of Peripheral Nerves. Churchill-Livingstone, London, 1998.
Gelberman R (Ed). Operative Nerve Repair and Reconstruction. I. P. Lippincott Co.,Philadelphia, 1991.
Kline D, Hudson A. Nerve Injuries: Operative Results for Major Nerve Injuries, Entrapments and Tumors. W. B. Saunders Co., Philadelphia, 1995.
Lunborg G. Nerve Injury and Repair. Churchill-Livingstone, New York, 1998.
MacKinnon S, Dellon A. Surgery of Peripheral Nerves. Thieme, New York, 1988.
Ormer G, Spinner M, Van Beeb A. Management of Peripheral Nerve Problems. Second Edition,W. B. Saunders Co., Philadelphia, 1998.
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Sunderland S. Nerve Injuries and Repair: A Critical Appraisal. Churchill-Livingstone, Edinburgh, 1991.
Sunderland S. Nerve and Nerve Injuries. First and Second Editions, E & S Livingston Stone, London, 1968 and 1978.
Terzis J (Ed). Microreconstruction of Nerve Injuries. W. B. Saunders, Philadelphia, 1987.
Kline D, Hudson A, Kim D. Atlas of Peripheral Nerve Surgery. W. B. Saunders Co., Philadelphia, 2001.
Birch R, Bonney G, Winn-Parry c: Surgical Disorders of the Peripheral Nerve Churchill-Livingston, London 1998.
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Gelberman, R: (Ed) Operative Nerve Repair and Reconstruction, JB Lippincott, Philadelphia 1991.
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Kempe L: Operative Neurosurgery Vol. 2, Springer, NY, 1970.
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Leffert R: Brachial Plexus Injuries, Churchill Livingstone, Edinburgh 1988.
MacKinnon S, Dellon A: Surgery of the Peripheral Nerve, Thieme, New York, 1988.
Medical Research Council Nerve Injuries MRC was Memorandum No. 7 London, His Majesty’s Stationary Office, Balliere Tindall, London 1943.
Midroni G, Bilbao J, Cohen S: Biopsy Diagnosis of Peripheral Neuropathy Butterworth-Heinemann, Toronto 1995.
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Seddon H: Surgical Disorders of Peripheral Nerves, E&S Livingston, Edinburgh and London, 1972.
Seddon H: Peripheral Nerve Injuries, MRC Report 282. Her Majesty’s Stationary Office, London, 1954.
Spinner M.: Injuries to the Major Branches of Peripheral Nerves of the Forearm. 2nd Ed., W.B. Saunders, Phila. 1978.
Sunderland S., Nerve and Nerve Injuries, Williams and Wilkins Baltimore, 1968.
Sunderland S., IBID 1978.
Sunderland S., Nerve Injuries and Their Repair: A Critical Appraisal, Churchill Livingston, Edinburgh, 1991.
Woodhall B, Beebe G: Peripheral Nerve Regeneration V.A. Monograph, U.S. Gov’t. Printing Office, Washington, DC, 1957.
Rothman-Simeone. The Spine. 1999.
Clark CR. The Cervical Spine. CSRS.
Menezes A. Benzel E. Spine Surgery: Techniques, Complication Avoidance, and Management.
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Aebi M. Principles in Spine Surgery. AO/ASIF.
Aids to the examination of the peripheral nervous system, 4th edition. W. B. Saunders, Philadelphia, 2000.
Grant GA, Goodkin R, Kliot M. Evaluation and surgical management of peripheral nerve problems. Neurosurgery 44:825-40, 1999.
Birch R, Bonney G, Wynn Parry CB. Surgical Disorders of the Peripheral Nerves. Churchill Livingstone, Edinburgh, 1998.
Mackinnon SE, Dellon AL. Surgery of the peripheral nerve. Thieme, New York, 1988.
Gelverman RH. Operative Nerve Repair and Reconstruction. J B. Lippincott Co. Philadelphia, 1991.
Kline DG, Hudson AR. Nerve Injuries. W. B. Saunders, Philadelphia, 1995.
Omer GE, Spinner M, Van Beek AE. Management of Peripheral Nerve Problems, 2nd ed. W. B. Saunders,
Sunderland S. Nerves and Nerve Injuries, 2nd ed. Churchill Livingstone, Edinburgh, 1978.
Turnbull IM. Microvasculature of the human spinal cord. J Neurosurg 35:141-147, 1971.
Lu K, Liang CL, Lee TC, Chen HJ, Su TM, Liliang PC. Changes of bilateral palmar skin temperature in transthoracic endoscopic T-2 sympathectomy. J Neurosurg (Spine 1 Suppl) 92:44-49, 2000.
Milhorat TH, Kotzen RM, Anzil AP. Stenosis of central canal of spinal cord in man: incidence and pathological findings in 232 autopsy cases. J Neurosurg 80:716-722, 1994.
Menezes, AH, Sonntag VKH, Principles of Spinal surgery. McGraw Hill, NewYork, 1995
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