MEDICAL STUDENTS
To perform a general spine and orthopedic screening exam.
To be able to perform a directed history and physical examination of each of the body areas pertinent to spine surgery with particular attention to the range of motion of the spine, gait, standard reflex, abnormal reflexes, muscle strength and sensory exam.
To demonstrate general understanding of various diagnostic modalities of the spine including xrays, MRI, CT scans.
To present a differential diagnosis of a patient with axial spine pain and/or radiculopathy. To devise a general treatment plan starting with non surgical management to type of surgical management appropriate for a specific spine condition.
To be able to assess a patient with cauda equina syndrome and to understand spinal emergencies.
R-2 RESIDENTS
Medical Knowledge
To be able to differentiate the common spine conditions from each other, e.g. degenerative disc disease, facet arthropathy, neurogenic claudication, spondylolisthesis, and scoliosis.
To describe the various traumatic conditions of the spine. To differentiate the stable and unstable traumatic conditions of the spine.
To be able to devise general treatment modalities for various spinal disorders.
Patient Care and Operative Procedures
To be able to interpret and expand on the radiographic characteristics of the following conditions on plain films:
To examine a spine patient:
Typical Exam Questions as an example outlined below:
Inspection
Disrobe patient, ROM spine, skin for: lipomata, café au lait, birth marks, Faun's Beard, pedunculated tumors, port wine marks. Pathology: spina bifida, neurofibromatosis, diastematomyelia. Posture: scoliosis, Gibbus deformity, excessive lumbar lordosis.
Bony Palpation
Posterior:Seated with patient standing, L4-L5 interspace, S2 spinous process, PSIS line), Coccydinia (Rectal exam), Iliac crests, ASIS, Greater trochanters, ischial tuberosities.
Anterior: Supine with knees flexed, L3-L4 (umbilicus and aortic division), Sacral promontory (most prominent),
Soft Tissue Palpation
Supraspinous ligaments (interspinous non-palpable)
Paraspinal muscles: extend back to relax fascia
Iliac Crest region: Gluteal muscles, cluneal nerves, fatty nodule under crest rim
Post superior iliac spine region: sacral triangle, sacrotuberous, sacrospinous
Sciatic area: midway between ischial tuberosity and greater trochanter
Anterior abdominal area and inguinal area
Range of Motion
Flexion: fingers to floor distance with knees straight
Extension: estimate extension; increased pain with spondylolisthesis
Lateral bending: coupled with rotation, note discrepancy between L and R
Rotation: stabilize pelvis with one hand and rotate patient with other hand
Neurologic Exam
Sensory, Motor and Reflex exam of the cervical and lumbar nerve roots.
As it relates to surgical procedures:
To be able to explain surgical indications based on history and exam findings. To be able to first assist in the surgical exposure of the cervical, thoracic and lumbar spine, understand bony and anatomic landmarks used in these exposures. To be able to obtain various types of autogenous bone graft from the iliac crest and to fashion various allograft bone samples for implantation, while minimizing operative time and blood loss. To be able to apply cervical spine stabilization (halo vest) with the supervision of the senior resident or the spine fellow.
R-4 RESIDENTS
Medical Knowledge
To construct a differential diagnosis of a spine patient and to order the tests appropriate to refine the diagnoses
Practice-Based Learning and Improvement
To articulate specific treatment approaches and their alternatives based on the strength of the literature evidence and applicability to a specific patient.
To elucidate current treatment concepts for the spine patients based on the diagnosis.
Systems-based Practice
To organize and manage the clinic environment
Develop an operative schedule in consultation with the Attending Surgeon and Fellows
Assess patient load and complexity
Evaluate the specific abilities of clinic staff and junior residents
Delegate responsibilities to junior team members based on their specific abilities.
Monitor and adjust work flow
Supervise patient care including chart reviews
Organize weekly academic conference
Practice-based Learning and Improvement
To participate in advanced diagnostic work ups
Perform and interpret xrays of the spine
Interpret complex MRI and CT studies
Discuss cases in relation to recent literature on the subject.
Interpersonal and Communication Skills
To be able to interact skillfully with the staff and community
Assess special equipment needs
Conduct equipment safety checks.
Patient Care and Operative Procedures
To be able to transcend what is published and create a surgical solution as required by specific circumstances.
To be able to first assist in complex procedures utilizing and directing assistants, while minimizing operative time and blood loss. Typical procedures would include:
