Neurosurgery Self Assessment Questions and Answers

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NEUROSURGERY
SELF-ASSESSMENT
Questions and Answers

Rahul S. Shah, BSc(Hons), MBChB(Hons), MRCS(Eng)

Specialty Registrar in Neurosurgery and
Wellcome Trust Clinical Research Fellow
University of Oxford
Oxford, UK

Thomas A.D. Cadoux-Hudson, DPhil, FRCS, MB BS

Honorary Consultant Neurosurgeon
Department of Neurosurgery
Oxford University Hospitals NHS Trust
Oxford, UK

Jamie J. Van Gompel, MD

Associate Professor of Neurosurgery and Otolaryngology
Mayo Clinic College of Medicine
Rochester, MN, USA

Erlick A.C. Pereira, MA, BM BCh, DM, FRCS(Neuro.Surg),

SFHEA
Senior Lecturer in Neurosurgery and Consultant Neurosurgeon
Atkinson Morley Neurosciences Centre, St George’s Hospital
St George’s, University of London
London, UK

Foreword by

Edward C. Benzel, MD
Chairman, Department of Neurosurgery
Center for Spine Health, Cleveland Clinic
Cleveland, OH, USA

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Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2017
© 2017, Elsevier Inc. All rights reserved.

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 CONTENTS

FOREWORD, VII 16 NEUROPSYCHOLOGY AND NEUROLOGICAL

REHABILITATION, 236
PREFACE, IX
17 STATISTICS, 241
HOW TO PASS NEUROSURGICAL
EXAMINATIONS, XI 18 PROFESSIONALISM AND MEDICAL
ETHICS, 242

19 SURGICAL TECHNOLOGY AND

PART I PRACTICE, 256

BASIC SCIENCE
1 NEUROANATOMY, 1 PART III
2 EMBRYOLOGY, 22 CRANIAL NEUROSURGERY
3 NEUROPHYSIOLOGY, 34 20 GENERAL NEUROSURGERY AND CSF
DISORDERS, 257
4 NEUROPATHOLOGY I: BASICS, 55
21 CRANIAL TRAUMA, 268
5 NEUROPATHOLOGY II: GROSS
PATHOLOGY, 66 22A CRANIAL VASCULAR NEUROSURGERY I:
ANEURYSMS AND AVMS, 290
6 NEUROPATHOLOGY III: HISTOLOGY, 86
22B CRANIAL VASCULAR NEUROSURGERY II:
7 PHARMACOLOGY, 121 CEREBRAL REVASCULARIZATION
AND STROKE, 306

23 CRANIAL ONCOLOGY, 322

PART II
24 SKULL BASE AND PITUITARY
CARE OF THE SURGERY, 340
NEUROSURGICAL PATIENT 25 CRANIAL INFECTION, 354

8 NEUROLOGY AND STROKE, 127

9 NEURO-OPHTHALMOLOGY, 161 PART IV

10 NEURO-OTOLOGY, 176 SPINAL NEUROSURGERY
11 NEUROINTENSIVE AND PERIOPERATIVE
CARE, 185 26 SPINE: GENERAL PRINCIPLES, 364

12 INFECTION, 201 27 SCOLIOSIS AND SPINAL

DEFORMITY, 377
13 SEIZURES, 203
28 SPINAL TRAUMA AND ACUTE
14 NEURORADIOLOGY, 216 PATHOLOGY, 386

15 RADIOTHERAPY AND STEREOTACTIC 29 DEGENERATIVE SPINE, 403

RADIOSURGERY, 226
v
vi CONTENTS

30 SPINAL INFECTION, 418 PART VII

31 SPINAL ONCOLOGY, 424 PEDIATRIC
32 SPINAL VASCULAR NEUROSURGERY, 440
NEUROSURGERY
38 PEDIATRIC NEUROSURGERY: GENERAL
PRINCIPLES AND NORMAL
PART V DEVELOPMENT, 513
FUNCTIONAL 39 CRANIOSYNOSTOSIS, 521
NEUROSURGERY
40 CONGENITAL CRANIAL AND SPINAL
33 PAIN SURGERY, 448 DISORDERS, 527

34 ADULT AND PEDIATRIC EPILEPSY 41 PEDIATRIC NEUROSURGERY: GENERAL AND

SURGERY, 459 HYDROCEPHALUS, 546

35 ADULT MOVEMENT DISORDERS, 471 42 PEDIATRIC NEURO-ONCOLOGY, 557

36 SURGERY FOR PSYCHIATRIC 43 PEDIATRIC HEAD AND SPINAL TRAUMA, 569

DISORDERS, 485 44 PEDIATRIC VASCULAR NEUROSURGERY, 584
45 PEDIATRIC MOVEMENT DISORDERS AND

PART VI SPASTICITY, 589

PERIPHERAL NERVE 46 NEUROSURGERY AND PREGNANCY, 593

SURGERY
INDEX, 600
37 PERIPHERAL NERVE, 489
 FOREWORD

Neurosurgery Self-Assessment: Questions and the multiple choice question strategy employed
Answers by Shah, Cadoux-Hudson, Van Gompel by the authors particularly relevant to modern
and Pereira is a true masterpiece. All neurosur- day foundational neurosurgery information
geons need ‘refreshers’; some for certification, acquisition and retention.
some for maintenance of certification, and others I commend the authors for their tried and true,
for the mere need to ‘keep up’. With over 1000 but uncommonly used, approach to education. It
questions and 700 images available both in print takes the agony out of reading a chapter. It min-
and interactively online, this volume provides imizes the laborious efforts required to gather
an extensive coverage of neurosurgery from top information via searches and other strategies. It
to bottom, and all points in between. Multiple brings the art and craft of neurosurgery to life
choice questions are used to test foundation of in an enjoyable and relatively painless format.
knowledge and, most importantly, educate. Finally, it provides a near complete coverage of
As adults, we learn most efficiently and effec- the field – at least as complete as is humanly pos-
tively when our minds are exercised and stressed. sible in the space afforded.
When multiple modalities are employed (such as So, whether you have an impending examina-
questions, answers and explanations), learning tion, or you simply desire to ‘spiff up’ on your
becomes more efficient, with a greater long term neurosurgical foundations, this book is for you.
retention of the newly acquired information. Use it as one might use a bedside novel. Use it
This becomes particularly relevant to those who to prepare. Use it to simply stay at the top of
are to soon be ‘tested’ in the form of certification your field. This book can truly fulfill all of these
or maintenance of certification examinations. needs – and much, much more.
Reading, thinking, answering, and then the con-
templation of answers and their rationales makes Ed Benzel

vii
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 PREFACE

Neurosurgical training is delivered worldwide those about sit their examinations who require a
with the goal of producing a surgeon who is safe mix of questions (in terms of both topic and diffi-
for independent practice. Today, neurosurgical culty), this is provided by the interactive question
residents and their trainers are trying to achieve bank accessed via the online Inkling platform and
this goal in the face of reduced working hours, smartphone app. This book consists of single best
increasing demand on services, individual sur- answer (SBA) and extended matching item (EMI)
geon outcome publication, and increasing litiga- questions constructed according to the guidelines
tion, to name but a few challenges. In this from the US National Medicine Licensing Board
environment, the value of targeted learning mate- and the UK Joint Committee on Intercollegiate
rials and advanced surgical simulation is clear. Examinations, to enable the user to become
The content of this question book aims to reflect familiar with the respective formats before the
the evolving expectations placed on residents in exam. While SBA- and EMI-style questions are
an age of evidence-based practice, subspecializa- not yet universal in postgraduate neurosurgical
tion, and multidisciplinary teams: one must also examinations across the world, we hope all trainees
be familiar with allied specialties advancing just find them valuable and cost-effective for self-
as fast as our own. study.
As a counterpoint to currently available self- Finally, I would like to thank Elsevier—their
assessment books, we have organized questions support has ensured that this book could also
by the highly specific topic areas outlined in most serve as a comprehensive and representative cat-
modern neurosurgical textbooks and training cur- alogue of commonly examined clinical images
ricula. Furthermore, most questions are accompa- and investigation results in a single resource for
nied by in-depth answers and, where appropriate, neurosurgical residents. I hope you enjoy using it!
suggestions for further reading. We hope this will
enable junior trainees to use it as a learning aid and Rahul S. Shah
for focused revision prior to rotating onto partic- Oxford
ular neurosurgical firms. For senior trainees or July 2016

ix
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 HOW TO PASS NEUROSURGICAL
EXAMINATIONS
LEARNING BY MULTIPLE For the vast majority of multiple choice ques-
tions (MCQs) in this book, we provide a detailed
CHOICE QUESTIONS explanation of the correct answer with references
to current evidence-based data where appropri-
The World Federation of Neurosurgical Societies
ate. Like the real examinations, questions test
estimates that there are 30,000 neurosurgeons
the reader's knowledge of basic and clinical neu-
worldwide. In the United States, there are approx-
rosciences and neurosurgery, and are arranged by
imately 3500 board certified neurosurgeons and
topic to be useful to doctors in neurology, neuro-
800 neurosurgical residents. In the United radiology, and neuropathology, and medical stu-
Kingdom, there are close to 300 consultants and
dents. Illustrations include anatomical pictures,
200 trainees, with a total of approximately 8000
graphs, tables, radiology images, and histology
qualified neurosurgeons and trainees in Europe.
slides in questions and answers where required.
Due to international collaboration through
We suggest the following approach to using
research and education, neurosurgical training
this book and learning by MCQs:
curricula have become increasingly standardized
• Firstly, start early! Learning throughout
across most countries. Both UK and US-style
one's training will lead to reinforcement
examinations are well established in other coun-
and consolidation of deep knowledge not
tries (e.g. India and Brazil, respectively), and
easily forgotten. Use books like this at the
recently developed training programs in Africa beginning, middle, and end of training,
have based their examinations on the UK format.
and relate them to your clinical practice.
Additionally, the need for already qualified neuro-
• Secondly, let this book be a guide to con-
surgeons to demonstrate continuing professional solidate the information learnt. Annotate
development for revalidation purposes has also
material from other resources like compre-
increased the demand for courses and objective
hensive textbooks. Use the “red,” “amber,”
self-assessment tools in neurosurgery.
and “green” gradings to distinguish bet-
Although the duration of postgraduate neuro-
ween lower-yield and more difficult ques-
surgical training varies by country, completion
tions and high-yield easy questions. Make
of training usually requires the candidate to pass
connections between different subspe-
both written and oral examinations set by the
cialties and general principles, and focus
relevant national training board or committee.
on material most likely to be tested.
For the written examinations, questions are gener-
Remember that this is neither a compre-
ally multiple choice and cover the basic and clinical hensive review book nor a panacea for inad-
sciences; short answer and essay questions are used
equate preparation in the last few months
in some regions. Topics include neuroanatomy,
before the exam.
neurophysiology, neuropharmacology, critical
• Thirdly, prime your memory by returning
care, fundamental clinical skills, neuroradiology,
to challenging and annotated questions in
neuropathology, neurology, neurosurgery, and
the final days before the exam. This book
other disciplines deemed suitable and important
can serve as a useful way of retaining key
(e.g. statistics, medical law, medical ethics). Ques-
associations and refreshing important facts
tions relating to clinical neurosurgery also cover
fresh in your memory for the exam. Finally,
the main subspecialties, including trauma,
contribute to the book to enable active
neuro-oncology, skull base and pituitary surgery,
learning. Email us if you find errors or see
vascular neurosurgery, spinal surgery, pediatric
ways in which the book can be updated.
neurosurgery, peripheral nerve surgery, and
functional/epilepsy/pain surgery.

xi
xii HOW TO PASS NEUROSURGICAL EXAMINATIONS

HOW TO TACKLE SINGLE BEST in most cities in front of desktop computers with
headphones, pencil, and paper available, and the
ANSWER (SBA) AND EXTENDED software is controlled by a mouse. Residents
MATCHING ITEM (EMI) QUESTIONS taking the US examination use certified laptops
provided by the residency program. Both have
Test performance is influenced not just by your high-quality, distinct images, and sometimes
knowledge but also by your test-taking skills. include audio and video material.
You can improve your performance by honing Given the artificial environment of computer-
your test-taking skills and strategies well in based testing, it is important to become familiar
advance of the exam so that you can concentrate with it before the actual exam. Most examination
on the information and your knowledge during boards offer a downloadable or interactive mock
the test itself. The following strategies may be examination with a few sample questions to famil-
useful. iarize yourself with the environment. Skipping
Try to deal with each question in turn, identi- the tutorial on the exam day sometimes adds extra
fying it as easy, workable or impossible from your time to answer the actual questions in the test
own perspective; our green, amber, and red clas- itself. Learn how to mark questions, go back to
sification provides an approximate examiner's them and if there are any rules preventing going
guide to difficulty for someone having completed back to previous blocks. Become familiar with
their neurosurgical training. Aim to answer all the how to view images and spot the icons for playing
easy questions, resolve the workable ones in rea- audio and video clips. Be vigilant that some multi-
sonable time, and make quick educated guesses at part questions prevent changing the answer to the
any apparently impossible ones. There are differ- first part of the question once the second part has
ent techniques for question reading that include been revealed.
reading the stem, thinking of the answer, and
turning to the choices or skimming the answer
choices and the last part of the question before US, UK, AND EUROPEAN
returning to the stem. Try different techniques
to see what work best for you and yields the high- NEUROSURGICAL EXAMINATION
est marks. Our online testing area should help STRUCTURE
with that.
Set a good pace for answering the questions. MCQ tests generally form the first part of most
Divide the total time for the exam by the number neurosurgical examinations, with the subsequent
of questions and be strict with yourself. If you are parts being a combination of oral and clinical
taking too long then mark the question, pick your examinations. The 2015 ABNS Primary Exami-
best answer, and come back to it later if you have nation consisted of 350 questions (in 6 h 45 min),
time at the end. Avoid burnout by practicing while the UK FRCS Written Examination is in
timed tests to develop endurance. Use extra time two parts, the first consisting of 135 SBA questions
to check marked questions. Never give up—take a (in 2 h) and the second part of 110 EMI questions
short one-minute break and come back to the test (in 2.5 h). The European Association of Neuro-
if too disheartened. surgical Societies Part 1 examination consists of
Answer all test questions—even if it means approximately 200 MCQs to be answered in 3 h.
guessing! Whereas in the past many neurosurgi- Questions in all three examinations cover neuro-
cal examinations were negatively marked, that anatomy, neurobiology, neuropathology, neuro-
process has largely been superseded by only pos- logy, neuroradiology, clinical neurosurgery
itively marked exams, so there is no harm in an (including subspecialties), fundamental clinical
educated or instinctive guess, or even just a blind skills, and other disciplines deemed suitable and
punt. If you have to guess, go on a hunch and pick important.
an answer you are vaguely familiar with rather The marking of such MCQ examinations is
than something you have never heard of. now quite standardized and relies upon principles
of statistics and psychology. Many examination
boards use the modified Angoff method, whereby
COMPUTER-BASED TESTING experts are briefed then allowed to take part or all
of the test with the performance levels in mind.
The UK FRCS (Neurological Surgery) examina- They are then asked to provide estimates for each
tion has been using computer-based testing for question of the proportion of minimally accept-
several years, the American Board of Neurologi- able candidates that they would expect to get
cal Surgery moved to a web-based format for the the question correct. The final determination of
Primary Examination in 2015, and the EANS the cut score is then made by averaging the esti-
Part 1 remains a pencil-and-paper test. The UK mates. Controversial questions—those that
exam takes place in dedicated test centers found polarized the candidates' answers between two
 HOW TO PASS NEUROSURGICAL EXAMINATIONS xiii

answers or those that candidates scoring highly ability to satisfy patients and colleagues that those
overall got wrong whereas those scoring poorly passing have attained a minimum standard
overall got right—are scrutinized and potentially of basic and applied science knowledge and clin-
removed from the overall scoring at examiners' ical decision-making to practice independently.
standard setting meetings. It is good practice Oral examinations are crucial in this process as
for a trainee representative who has sat the exam- they assess communication skills, clinical skills,
ination to participate in the whole process. and decision-making and professionalism in a
Whereas the written examination explores an high-pressure environment. In contrast, MCQs
applicant's knowledge in various relevant disci- focus on assessing knowledge and analytical and
plines, the oral examination explores knowledge decision-making skills. More clinically integra-
and judgment in clinical neurosurgical practice tive questions test higher orders of Bloom's tax-
after an applicant has been an independent prac- onomy and are more effective than simple
titioner. The oral examination is accomplished factual questions in assessing and developing
in a series of face-to-face examinations. The the clinical problem-solving skills of trainee
applicant is presented with a series of clinical surgeons.
vignettes using real patients, clinical descriptions, Patients fundamentally wish for their treating
radiographs, computerized images, anatomical surgeon to be as independent as possible in order
models, and/or diagrams. The examiners grade to maximize their chances for an excellent
the applicant on specific tasks including diagnos- outcome. Therefore, when setting minimum
tic skills, surgical decision-making, and manage- standards for independent practice, an expert
ment of complications. peer group of examiners is accountable to
patients, other neurosurgeons and healthcare
professionals, and the general public. Postgrad-
STANDARDS FOR INDEPENDENT uate medical examinations have therefore gen-
NEUROSURGICAL PRACTICE erally evolved to become as standardized and
fair as possible, while maintaining rigor, expand-
The credibility of professional examinations ing, and adapting as trends change in clinical
taken at the end of surgical training rests on their practice.
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