Children's Rotation

The primary objective of the rotation blocks on the pediatric service is an education that integrates exposure to a variety of operative experiences, structured didactic sessions, and mentoring by accomplished faculty in an extraordinary environment. The division of pediatric neurosurgery at UTSW is comprised of 6 fellowship trained pediatric neurosurgeons. They maintain one of the highest volume practices in North America. This care is primarily delivered at the Children’s Health flagship hospital. Children’s Medical Center Dallas is the seventh-largest pediatrics hospital in the nation. It is a multispecialty inpatient and outpatient facility that is equipped with state-of-the-art resources. It is equipped to provide comprehensive and high-level care. It serves as a Level 1 Trauma Center, has a Level IV NICU, and is the endpoint tertiary referral center for North Texas.

Residents learn to evaluate and manage children of all age ranges that require all types of procedures in pediatric neurosurgery. They are exposed to the full spectrum of neurosurgical conditions that affect children. The depth of this clinical exposure is distinctive. It includes the surgical management of intracranial congenital disorders, hydrocephalus, brain and spinal cord tumors, epilepsy, craniosynostosis and complex craniofacial conditions, spinal dysraphism, vascular disorders (both endo- and open), cranio-cervical and traumatic spinal deformities, spasticity and movement disorders, and trauma. Trainees develop operative skills in microsurgery, endoscopy, radiosurgery, and endovascular therapies during their time on the pediatric service. Junior and mid-level residents work directly with the pediatric neurosurgery faculty and fellows without intermediary senior or chief residents. They gain more opportunities for increased responsibility. Our residents have described this rotation as a time when both their clinical decision-making, operative skills, and critical thinking have matured. Residents operate almost daily, and have frequent opportunities to work on their microsurgical skills.

The pediatric service also educates residents in the value of teamwork, cooperation, and compassionate care through its partnerships in several multidisciplinary programs. Residents actively participate in conferences and clinics. We are part of comprehensive programs in spina bifida, neuro-oncology, craniofacial disorders, surgical epilepsy, spasticity, cerebrovascular disorders of childhood, trauma, fetal care, and neonatal injury.

We offer a robust didactic curriculum to support the educational experience. Knowledge in the evaluation and operative management of patients is supplemented through a daily afternoon conference to review elective cases for the upcoming day. A weekly educational conference is conducted each Thursday at noon. The schedule has been developed to enhance the understanding of basic pediatric neurosurgical principles and conditions. It includes a quality improvement (morbidity and mortality) conference, faculty lecture conference, journal club, and house officer presentation conference each month. In addition, faculty offer and provide exposure to a myriad of clinical research opportunities to those who seek such.

Time spent on the pediatric service provides our residents further development of their operative skills, surgical judgement, decision-making, and leadership with a well-rounded clinical exposure to the nuances of pediatric neurosurgery.

ICU Rotation

UT Southwestern Medical Center has three Neurocritical Care Units: a 24-bed unit at the Clements University Hospital, a 12-bed unit at Parkland Hospital and a 12-bed unit at Texas Health Presbyterian Hospital. Neurosurgery residents usually spend two 3-month blocks at the Clements University Hospital Neurocritical Care Unit. Residents are exposed to a variety of neurological and neurosurgical conditions including hemorrhagic and large ischemic strokes, status epilepticus, traumatic brain injury, etc. This rotation gives them the opportunity to learn and implement the principles of cerebrovascular pathophysiology and autoregulation, management of raised intracranial pressure, treatment of cerebral vasospasm, determination of brain death and management of intractable seizures. In addition, the residents also learn the principles of general critical care including mechanical ventilation, hemodynamic management and management of infections. Procedural skills such as placement of arterial and central venous catheters and point-of-care ultrasound are taught. Bedside teaching is supplemented with didactic lectures, journal clubs, debates, quizzes and sessions in our simulation center.

Parkland Rotation

The residents on the neurosurgery service at Parkland play a very large role in managing and running the service. A PGY-7 and PGY-6 resident serve as chief residents and work together. Four days each week are spent in the operating room and one day in clinic. The chiefs supervise selection of cases from clinic as well as from patients admitted through the emergency department. They develop plans for surgical approach and technique. Although all these decisions are discussed with the appropriate attending, the chiefs enjoy a large amount of autonomy in the operating room. All the UTSW neurosurgical faculty are available to cover cases in their areas of subspecialty expertise, with a designated faculty member serving as chief of the service to provide continuity. Types of cases include neuro-oncology, cerebrovascular, spine, and trauma, among others. The operating room has dedicated neurosurgery personnel and state-of-the-art equipment.

The chiefs are responsible for selecting cases for conference and supervising and teaching the younger residents on the service. Major emphasis is placed on getting younger residents to the operating room early and often and helping them develop basic surgical skills, with progressively greater roles as they gain experience. These residents also have primary responsibility for seeing ICU and floor patients, which gives them a solid foundation in neurocritical care.

Tumor Rotation

The tumor service is based at Clements University hospital and provides comprehensive training in the management of primary brain tumors, metastatic tumors to the brain and skull base disorders. On this busy clinical service, residents are taught advanced techniques including awake craniotomy, motor mapping, procedures utilizing intraoperative MRI and brachytherapy. Residents also gain experience in classic skull base exposures and expanded endonasal approaches (EEA). In addition, residents have the opportunity to learn radiosurgery techniques and participate in the Gamma Knife Training Program prior to graduation for official certification. The supervising faculty members of this service are all fellowship trained in either Neuro-Oncology and Skull Base Neurosurgery. A weekly Neuro-Oncology conference and a monthly Skull Base conference provide opportunities for multi-disciplinary management and discussion regarding complex cases.

Vascular and Functional Rotation

The vascular neurosurgery and functional neurosurgery combine to form one rotation. This clustering provides opportunities for residents at all levels of training to have varied operative experiences, depending on level of training and skill. Didactic and hands on training is an integral. A chief resident and a junior resident rotate each block. The vascular and soon to be functional fellow augment the experience, although resident operative experience always takes precedence.

The residents are exposed to a wide range of simple and complex cerebrovascular pathology. The chief resident also has an administrative role in running the service, planning the urgent and emergency operative schedule and serves as the administrative resident in charge of the residency program. Complex cases are divided between the Chief resident and vascular fellow. The junior resident also has near daily operative responsibilities and opportunities. This unique, high-volume exposure to both open and endovascular cases gives an opportunity for exposure to vascular pathology for all trainees and early subspecialty training for those with special interest. The vascular chief is responsible for vascular conference, including the weekly lecture schedule and preparing the junior resident for case presentations. The vascular junior resident manages the daily service with the help of the inpatients NPs, the ICU team and the Chief resident. They also present the cases at the weekly, multidisciplinary working vascular conference with the goal of creating a treatment plan for the following weeks’ cases.

The functional component of the rotation includes the planning and implementing of functional cases. Residents work closely with the chairman and the other functional faculty to gain an understanding of the field as well as the technical nuances. Operative cases include deep brain stimulation implantation surgeries for a variety of indications including movement disorders, epilepsy, psychiatric indications, and pain, epilepsy surgeries including invasive monitoring and microsurgical resection of epileptic foci, stereotactic laser ablation, amongst other stereotactic and functional procedures.

An area of overlap between the vascular and functional neurosurgery services is the treatment of facial pain, including microvascular decompression and percutaneous procedures for trigeminal neuralgia. Other procedures for less common facial pain diagnoses include peripheral nerve stimulation, nerve blocks and ablations, nerve decompressions, motor cortex stimulation, and deep brain stimulation.

Outpatient clinic experiences include participation in cerebrovascular and deep brain stimulation clinics when the inpatient schedule allows.

Veteran Affairs

The Veterans Affairs Neurosurgery rotation provides a chance for residents to progress toward independence. One senior-level resident at a time is responsible for a general neurosurgical service including cranial and spine clinics and surgeries. There is ample support from mid-level providers (NPs, PAs, admin assistants) to ensure that the resident can focus on his or her neurosurgical training. Emergencies at the VA are infrequent, and most operative cases mimic a typical general neurosurgical practice – basic cranial tumors, chronic subdural hematomas, and various forms of spinal pathologies requiring either decompression alone or with stabilization. Thus, residents have tremendous potential on this rotation to hone essential neurosurgical skills – evaluate patients with common pathology and identify surgical candidates, plan for operative cases, practice and perform the cases largely independently building confidence, improving technique, and managing patients post-operatively.