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In Loving Memory

Mrs Carole D. Elwell

Dr Wadie Kirollos and Mrs Dalal Mikhael

Mr Syed Mohamed Abdullah Al-Haddad

Mr Alwyn Bodkin

This new edition of Neurosurgery: The Essential Guide to the Oral and Clinical Neurosurgical Exam provides a concise and practical guidebook of the core knowl- edge and principles for the International and Intercollegiate FRCS Specialty Examination in Neurosurgery. It is a vital resource for the American Board of Neurological Surgery (ABNS) and other neurosurgical examinations around the world.

Written by neurosurgeons at the top of their field and based on new guidelines, this book takes students through how to succeed in the FRCS neurosurgery exams and provides an overview of crucial short and intermediate cases designed to mirror the exam’s testing of a candidate’s clinical knowledge, diagnostic acumen, investigation and interpretation, treatment options and taking consent.

Including 72 vital online revision flash cards, covering critical and diverse examina- tion cases from trauma to paediatric spine exams, this edition also contains crucial guidance to Vivas on the following:

• Operative surgery and surgical anatomy
• Investigation of the neurosurgical patient
• The non-operative clinical practice of neurosurgery

This book is a must-read for candidates preparing for the final Intercollegiate Specialty Examination in Neurosurgery (UK), International FRCS Specialty Examination in Neurosurgery as well as the American, Canadian, European and Australasian exams. In addition to helping candidates pass their final exams, this book provides wonderful insight into Neurosurgery for Medical Students, Surgical Residents and Neurosurgical Consultants.

NEUROSURGERY

Second edition published 2023 by CRC Press 6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487- and by CRC Press 4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN CRC Press is an imprint of Taylor & Francis Group, LLC © 2023 Taylor & Francis Group, LLC This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal to them and do not necessarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended for use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the relevant national drug formulary and the drug companies’ and device or material manufacturers’ printed instructions, and their websites, before administering or utilizing any of the drugs, devices or materials mentioned in this book. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, access www.copyright.com or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-

8400. For works that are not available on CCC please contact mpkbookspermissions@tandf.co.uk Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used only for identification and explanation without intent to infringe. ISBN: 978-1-032-18405-0 (hbk) ISBN: 978-1-032-13874-9 (pbk) ISBN: 978-1-003-25437-9 (ebk) DOI: 10.1201/ Typeset in Utopia by KnowledgeWorks Global Ltd. Online Support Materials (Craven Flashcards) available at: https://resourcecentre.routledge.com/books/

Dedication

This book is dedicated to all healthcare staff for their

responses to the COVID pandemic.

A certain excessiveness seems a necessary element in all

greatness.

Harvey Cushing (1869–1939)

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Contents

Foreword by Alistair Jenkins.... .xi Foreword by John Pickard...... xiii Preface to the Second Edition... xv Acknowledgements.......... xvi Authors................. xvii Contributors............... xix Examination Cases: Craven Flash Cards................ xxi Introduction: Getting Familiar with Exam Format.......... .xxv

1 How to Succeed.............. 1

2 Clinical Intermediate and Short Cases............ 11

3 The Viva: Operative Surgery and Surgical Anatomy........ 57

4 The Viva: Investigation of the Neurosurgical Patient... 105

5 The Viva: The Non-operative Clinical Practice of Neurosurgery............. 145

6 Key Illustrative Cases........ 183

7 Landmark Publications....... 197

8 Key Terms................ 227

Index..................... 237

xii Foreword by Alistair Jenkins

Would I pass the Neurosurgery exit exam if I sit it tomorrow? Not a chance. But a few weeks with this book and I’d be well on my way – if I remembered not to pretend I had done operations I hadn’t …

Mr. Alistair Jenkins, Consultant Neurosurgeon Newcastle Hospitals NHS Foundation Trust, UK Immediate Past President of Society of British Neurological Surgeons (SBNS) 2022–

xiii

Foreword by John Pickard

When I took the final FRCS in 1974, I had been working a 1:2 rota as a young registrar in general surgery, commuting from Glasgow to Falkirk. I had completed 18 months as SHO and Research Assistant in Neurosurgery with a first author paper in Nature New Biology. In London, the examiner asked me what specialty I wished to follow. On hearing that I was a fledgling neurosurgeon, he asked me to tell him what I knew about haemorrhoids.

‘Plus ça change, plus c’est la même chose’.

Two weeks later, I had better luck in Edinburgh. Shortly thereafter, I was on the plane to Philadelphia for my research fellowship. Stress, what stress.

Examinations are a necessary evil. Necessary because they provide an independent assurance to patients, families, the general public, employers, defence organiza- tions, GMC, future colleagues, and all grades of staff that a successful candidate has acquired a basic core of knowledge and has displayed the ability to use it, albeit in the artificial environment of the examination hall. It is one important hurdle in the completion of training that indicates that the candidate is probably safe and has the flexibility of mind to cope with the ever-changing understanding of and technology within their specialty. ‘Evil’ because too many examinations and assessments can stultify, regiment thought and delay the development of lateral thinking and initiative.

However, like life, examinations can sometimes be unfair. As George Cruikshank’s cartoon from 1811 illustrates, there was a time when examiners could be capricious in their judgement. There are now many checks and balances to reduce the risk of such errant behaviour. It is only right that examinations should be professionally organized and transparent in what is expected. Examinees in school and university

xv

Neurosurgery: The Essential Guide to the Oral and Clinical Neurosurgical Examination (Second Edition) provides a concise, logical and practical guidebook of the core knowledge and principles for the neurosurgical clinical exit examination.

You have demonstrated that you have the required knowledge by passing the written component of this examination. Your written knowledge must now be translated into an oral format in a safe, organized and confident manner. The main purpose of this ‘exit’ examination is to ensure that you are a safe and competent neurosurgeon.

Since the publication of the first edition of Neurosurgery: The Essential Guide to the Oral and Clinical Neurosurgical Examination, there have been major changes in many aspects of neurosurgical exam content, format and style. This reflects advances in current clinical practice as well as shifts in educational principles. The impact of COVID-19 has also had its effects on many aspects of life not least the delivery of neu- rosurgical exams. Some of these changes may be temporary but the ingenuity that had to be employed to maintain social distancing rules has been an opportunity to make the most of modern technology. It may well be that some of the lessons learnt will be continued in future exams.

Regarding advances in clinical practice, we have been particularly mindful of import- ant subjects (e.g. increasing prominence of instrumentation in routine spinal work, changes in WHO grading of tumours, endoscopic techniques replacing the micro- scope in the anterior skull base, new scoring systems).

Although primarily designed to cover the UK exam, we recognize the increasingly global readership. We have now included many international exam formats as possi- ble without diluting the intention of the original publication.

We continue to learn from teaching trainees at both the Aberdeen FRCS course and more recently at international courses for the International FRCS. Our interaction with trainees provides repeated opportunities to develop our understanding of how to get a trainee to maximize their potential in the exam. We provide ideas of the types of questions that may be asked and remain current on any changes in format. We cannot cover every aspect of exam preparation and there will always be an element of good or bad fortune on the day, but it is true that ‘luck favours the prepared’. We hope this book helps and guides you with your preparation and the luck which comes along in equal measure!

Vivian A. Elwell Ramez Kirollos Syed Abdullah Al-Haddad Peter Alwyn Bodkin

Preface to the Second Edition

xvi

We would like to thank our colleagues, family and friends. This book would not have been possible without the ongoing support and encouragement of the follow- ing people: Miss Elwell The late Carole D. Elwell, Dr Nigel D. Mendoza, Miss Charlotte A. Mendoza Mr and Mrs John A. Cervieri Jr., The late Carole D. Elwell, Dr Nigel D. Mendoza, Miss Charlotte A. Mendoza, Mr and Mrs John A. Cervieri Jr., Mr and Mrs Lawrence Flick, Mr and Mrs Stephen Cervieri, The van Trotensburg Family, The Carey- Carpenter Family, The Archer Family, Dr Sandra J Ginsberg, Dr Richard Katz and the late Mr Khai Lam. Dr Kirollos The inspiration of my late parents Dr Wadie Kirollos and Mrs Dalal Mikhael, the support of my wife Nivine and sons Karim and Sherif Dr Al-Haddad The late Mr Syed Mohamed Al-Haddad, Mrs Rabiah bt Othman, Munirah Aljoofre, Khadijah, Alwi, Zainab and Mohamed, Osman, Ading, Aman, Intan and Hussein Al-Haddad Dr Bodkin The encouragement (and cajoling) of my parents Alwyn and Norah Bodkin, the constant support of my wife Leeanne and our two children Jessica and Lewis

Acknowledgements

xviii Authors

Syed Abdullah Al-Haddad MB BCh BAO (NUI), MSc (Trauma), MRCS, FRCS (Neuro. Surg) Dr Al-Haddad is originally from Malaysia, where he studied and won the Most Outstanding Student Award from the Royal Military College. Subsequently, he was awarded a full schol- arship to study medicine in the UK. During his undergradu- ate years, he excelled in both academic and extracurricular activities. He represented his college at the intervarsity level in rugby, hockey and volleyball. He was nominated as the sportsman of the year and won the Barker Anatomy Prize. He graduated from the Royal College of Surgeons in Ireland in 1996. In 2000, he went on to complete a mas- ter’s degree at the University of Birmingham in the study of surgical outcome of depressed skull fractures. He commenced his neurosurgical training at the Walton Centre in Liverpool, where he developed his interest in neuro-oncology research. He undertook further training in neurosurgery in Manchester, Leeds, Aberdeen and Edinburgh before being appointed as a Consultant Neurosurgeon in Aberdeen, Scotland. Throughout, he has been actively involved in teaching both undergraduate and postgraduate students. He is a faculty member for Leeds and Edinburgh operative neuroanatomy courses. He has published numerous articles in peer-reviewed journals and also contributed a section to the online neuroscience module (www.ebrainjnc.com). Dr Al-Haddad is the Founder and Director of the highly successful Aberdeen FRCS (SN) Viva course. The course has run twice a year since 2010, with the emphasis on giving practical advice to produce outstanding neurosurgeons who are well prepared for the challenge of the neurosurgical exam. Peter Alwyn Bodkin BSc Hons (Anatomical Sci), MBChB, FRCS (Neuro. Surg) Dr Bodkin grew up in Belfast and moved to Manchester for his medical degree. Whilst there, he took the opportunity of doing an Intercalated BSc in Anatomical Sciences. He reconstructed the facial features of ancient Egyptian mum- mies for his BSc project and has remained keenly interested in anatomy ever since. After graduating from Manchester, he went on to work in a number of neurosurgical units including Cambridge and Edinburgh. He was a lecturer and spine fellow at the Royal College of Surgeons in Ireland before embark- ing on his consultant post in Aberdeen. He maintains a wide breadth of surgical interests particularly in complex spine and facial pain. He was instru- mental in setting up the Scottish National Teaching programme for Neurosurgery; he is the Chairman of the Scottish Neurosurgical Training Committee, a question writer for Section One FRCS (NS) exam, a member of the Surgical Specialty Board in Neurosurgery at RCSEd and Clinical Lead for Neurosurgery in Aberdeen. He teaches widely including the Surgical Approaches to the Spine Course in Edinburgh as well as his own course, the Aberdeen White Matter Tract Dissection Course. In addition, Dr Bodkin is responsible for the running of the Aberdeen FRCS (Neuro. Surg) Viva Preparation course.

xix

Contributors

Professor Nabeel S Alshafai Consultant Neurosurgeon Nabeel S. Alshafai Neurospine Centre Bahrain Introduction

Mr Nicholas DP Hall Consultant Neurosurgeon Epworth Neurosciences Clinical Institute Melbourne Introduction

Mr Sohail Majeed Neurosurgical Registrar Aberdeen Royal Infirmary Introduction International FRCS

Mr Bedansh Roy Chaudhary Consultant Spinal Consultant Oxford University Hospitals NHS Foundation Trust Chapter 1: How to Succeed

Mr Ioannis Tsonis Neurosurgical Registrar Aberdeen Royal Infirmary Chapter 2: Clinical Intermediate and Short Cases—Paediatric Examination

Mr Phil Copley Neurosurgical Registrar Aberdeen Royal Infirmary Chapter 4: The Viva: Investigation of the Neurosurgical Patient—Paediatric Short Case Dr Charles Fry Registrar in Neurophysiology The Newcastle Upon Tyne Hospitals NHS Foundation Trust Chapter 4: The Viva: Investigation of the Neurosurgical Patient Mr Ravi Vashu Consultant Neurosurgeon Ampang, Malaysia Chapter 4: The Viva: Investigation of the Neurosurgical Patient Mr Khandkar Ali Kawsar Consultant Neurosurgeon The Royal Infirmatory of Edinburgh Chapter 7: Landmark Publications Miss Claudia L. Craven Paediatric Spinal Fellow Great Ormond Street Hospital Foundation Trust London Craven Flashcards