residency review committee for neurological surgery

RESIDENCY REVIEW COMMITTEE FOR NEUROLOGICAL SURGERY515 N State, Ste 2000, Chicago, IL 60610 (312) 755-5027 www.acgme.org

PROGRAM INFORMATION FORM

FOR CONTINUED ACCREDITATION

GENERAL INSTRUCTIONS

REVIEW OF AN ACCREDITED PROGRAM OR RE-ACCREDITATION OF A PROGRAM: If the program information form is being completed for a currently accredited program, use the Continued Accreditation PIF in conjunction with the Web Accreditation Data System (Web ADS). Follow the provided instructions to create the correct PIF Go to the Web Accreditation Data System (Web ADS) found on the ACGME home page (www.acgme.org), using your previously assigned username and password, update your program and resident data, retrieve Part 1 of the PIF under the Site Visit Information section, complete the shaded items (as appropriate), print all sections of Part 1 of the PIF and sign the form. If you find items displayed incorrectly change your data using ADS update sections; in some instances you may need to contact your DIO for the entry of updated information. Next proceed to the section under the RRC for Neurological Surgery to retrieve Part 2 of the PIF for continued accreditation in either Word or WordPerfect. Complete Part 2 of the PIF using your preferred word processor (only after Part 1 has been completed). Combine Part 1 and Part 2, number the pages consecutively on the upper right corner, beginning with Part 1 Section 1 and complete the Table of Contents (found with the Part 2 instructions). Mail one set of the forms to the site visitor at least 10 working days before the site visit. An additional copy should be held to permit corrections that may be required as the site visit proceeds. After the visit, three copies must be mailed to the Executive Director at the above address.

Send 3 complete copies to the Executive Director of the RRC at the address given above. Supply information which will indicate when you expect the program to be activated. The data and description given must be realistic and evidence should be included that your expectations are reasonable.

The Program Director is responsible for the composition and accuracy of the information supplied in this form and must sign it. It must also be signed by the Department Chairman/Chief of Service and the Designated Institutional Official of the sponsoring institution. Incomplete forms will not be accepted for review.

The Institutional Requirements, the Program Requirements and the PIF may be downloaded from the ACGME Website (www.acgme.org).

For questions regarding the site visit, contact the writer of the letter announcing the site visit.

For questions regarding the completion of the form (content), contact the Accreditation Administrator (Phone: 312-755-5028).

For word processing questions/problems, contact the ACGME Help Desk (Phone: 312-755-7464).

For technical questions about Part 1 of the PIF, email [email protected].

For a glossary of terms, use the following link – http://www.acgme.org/acWebsite/GME_info/gme_glossary.asp

SPECIFIC INSTRUCTIONS

Instructions have been provided at the top of each form. Please read them carefully before providing information. Please note that only these forms are to be used for supplying information and surgical statistics and only requested information is to be attached. The information being submitted should be as concise as possible. Do not attach any unnecessary materials such as curriculum vitae, reprints, brochures, annual reports, minutes of meetings, etc. The RRC will not review unsolicited preprinted materials.

This form is designed so that all information regarding intramural or multi-institution programs can be included on one set of forms. A complete set of these forms should be sent to each participating hospital so it can provide its

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http://www.acgme.org/acWebsite/GME_info/gme_glossary.asp

mailto:[email protected]

own statistics. The same reporting period must be used by all participating institutions. Information is to be collected by the Program Director for consolidation and transfer to a single set of forms. The Program Director is responsible for overseeing the accurate compilation of requested data for all participating institutions.

PART 1, SECTION 4: List the key neurological surgery staff under whose supervision the work of the resident staff is performed. Occasional contributors to the program should not be included. List names in alphabetical order with their institution. Programs seeking continued accreditation must use the Accreditation Data System (ADS) to enter these data. The entered information will automatically appear in Part 1, Section 4 of the PIF.

REQUEST FOR PROGRAM CHANGES: If the program is requesting approval to increase or decrease the resident complement, add or change participating institution, indicate this in Part 1 of the PIF and provide the support material. If the program is requesting an increase or decrease in the duration of training, please describe the change including the educational rationale and impact on training in a separate cover letter. Be sure to discuss the requested change fully with the site visitor.

AFFILIATION AGREEMENT(S): If the Program Information Forms comprise an application or reapplication for a new program, copies of current, signed affiliation agreements with each participating institution must accompany these forms. For the resurvey of an existing program, current, signed affiliation agreements must be available for inspection by the site visitor. If the program is seeking approval to include a new participating institution within the program, a current, signed affiliation agreement must accompany these forms. All affiliation agreements must conform to the Institutional Requirements (Attachment 1).

SURGICAL LIST FOR INSTITUTIONS: Statistics are to be provided for the most recent full academic year (July 1st to June 30th) for which this information is available. The same reporting period must be used by all participating institutions. The information is to be provided in separate totals for the Institution's staff and the resident(s) training at the institution. Grand totals are to be provided in the fifth column for all institutions. Forms must be typed. All copies must be legible. NOTE: Computer print-outs or any other method employed in reporting INSTITUTIONAL statistics to the Residency Review Committee will not be accepted. Only the surgical list provided is to be used. Use the "Other" category only for procedures that cannot be classified any other way.

RESIDENT'S SURGICAL LOG: The Resident's Surgical Log is included with these forms. Statistics are to be provided on this form only. Graduating Chief/Senior resident(s) must submit his/her ENTIRE neurological surgery operative experience gained within the approved institutions of the program. Foreign and/or external elective experiences should not be included. Combined surgical statistics from ALL institutions in which the resident served during this time are to be compiled on this one form and not broken down into separate institutions. Please read carefully the instructions provided with the Resident's Surgical Log. Make sure that dates and signatures are provided. Logs will not be accepted without the proper signatures. Forms must be typed.

EXAMPLES: For some sections of the Program Information Forms, an example page has been provided as guidance for completing the form. (The example is not intended to indicate the right way to do any particular program component but merely to provide a sample of a correctly completed form). Do not insert your program information on the example pages and do not include the example pages with your final submitted copies of the Program Information Forms.

SUBMITTING THE FORMS: The forms should be submitted bound by either sturdy rubber bands or binder clips. Do not place the forms in covers such as two or three ring binders, spiral bound notebooks, or any other form of binding. These will be removed and discarded.

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PROGRAM INFORMATION FORM

TABLE OF CONTENTS

When you have the completed forms, number each page sequentially in the upper right hand corner . Start on Part 1, Section 1 of the PIF. Report this pagination in the Table of Contents and submit this cover page with the completed PIF.

Part 1 Section Page(s)General Program Information 1

Accreditation Information 1.AProgram Director Information 1.B

Participating Institutions 2Resident Complement 3

Number of Positions 3.AFaculty / Teaching Staff 4

Faculty Roster 4.AKey Faculty Curriculum Vitae 4.B

Part 2 Section Page(s)Background Information 5

Previous Citations or Concerns (if applicable) 5.AChanges (if applicable) 5.BSponsoring Institution/Single or Limited Residency Institution (if applicable) 5.CGeneral Competencies (if applicable) 5.D

Program Requests 6Change in Residents 6.AAdd/Delete Institution 6.B

Program Organizational Structure 7Statistical Information For Neurological Surgery and Neurology 8Residents Appointment 9Fellows 10Block Rotational Diagram 11Outpatient Department Information, Facilities and Chiefs 12Other Training Programs 13Educational Program Description 14

Narrative Description of the Program 14.ATraining in Neurosciences [PR I.B.4] 14.BExperience in Stereotactic Radiosurgery (Mark one or more as appropriate) 14.CExperience in Endovascular Neurosurgery 14.DConferences [PR V.B] 14.EResident Research 14.FProgram Director's Clinical Responsibility 14.GMoonlighting and Other Extracurricular Activities 14.HSupervision 14.I

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Duty Hours 14.JSupport Services 14.KEvaluation of Residents 14.LEvaluation of Faculty 14.MEvaluation of the Program 14.NFellowships 14.O

Operative Experience 15Residents 15.AFellows 15.BInstitutional 15.C

Attachment 1: Affiliation Agreements for New Participating InstitutionsAttachment 2: Single Site SponsorAttachment 3: Call Schedule

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PROGRAM INFORMATION FORM (Part 2)

FOR CONTINUED ACCREDITATION

SECTION 5. BACKGROUND INFORMATION

A. Previous Citations or Concerns (if applicable)

List the citations from the last RRC accreditation action and discuss how each cited area has been corrected. If documentation is required, provide a specific reference to information provided in the Program Information Forms such as the PSOL, etc., or append additional information supporting the narrative. If no citations were listed, indicate this in your response.

B. Changes (if applicable)

Briefly describe major changes, other than those included in the response to previous citations and/or concerns (above) that have been implemented since the last survey and review. Include changes in sponsoring organization, participating hospitals, required rotations, resident complement, faculty or facilities.

C. Sponsoring Institution/Single or Limited Residency Institution (see ACGME Institutional Requirements)

For those institutions which are either a single-program institution (e.g., neurological surgery only), or an institution with multiple residencies accredited by the same Residency Review Committee, the institutional review will be conducted in conjunction with the review of the program. Only programs in these two categories are to complete the following institutional questions:

1. Provide an institutional statement that commits the necessary financial, educational and human resources to support the GME program(s) and provide documentation that the statement has been approved by the governing body, the administration and the teaching staff (Attachment 2).

2. Describe the formal method by which a periodic evaluation of the program’s educational quality and compliance with the program requirements occurs. Explain how residents and faculty in the program are involved in the evaluation process.

3. Describe how the institution complies with the Institutional Requirements regarding “Resident Eligibility and Selection” and the development of appropriate criteria for the selection, evaluation, promotion and dismissal of residents in accordance with the Program and Institutional Requirements.

4. Summarize how the institution complies with the ACGME Institutional Requirements regarding resident support, benefits and conditions of employment to include the details of the resident contract or agreement as outlined in the ACGME Institutional Requirements. (Do not append the resident contract/agreement to the PIF but state when it is given to the residents and applicants. Have a copy available for verification by the site visitor on the day of the survey with the various items required by the ACGME numbered according to the Institutional Requirements.)

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5. Describe in detail the grievance (due process) procedure(s) that is available to residents, including the composition of the grievance committee, and mechanisms for handling complaints and grievances related to actions which could result in dismissal, non-renewal of a resident’s contract, or other actions that could significantly threaten a resident’s intended career development.

D. General Competencies (not applicable for new applications)

The ACGME is monitoring the implementation of general competencies and assessment by using a common data collection tool. Log onto the Web Accreditation Data System and proceed to the Site Visit Information section and select Update/Verify Competency and Assessment Form to enter your information. Once the information has been entered and saved, select Print ADS Competency and Assessment Form to generate a printed copy of the form and attach it to the end of PIF.

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SECTION 6. PROGRAM REQUESTS (not applicable for new applications)

A. Change in Residents

If any increase in the number of resident positions is being requested in Part 1, Section 3.A, provide the requested details below as to how this change affects the program and how the program complies with PR II.C.3.a-g. Requests for an increase should demonstrate institutional approval and financial support for the additional positions.

B. Add/Delete Institution

If any changes in the program's approved (i.e., institutions previously reviewed by the RRC) participating institutions are being requested in Part 1, Section 2, specify below the name of the institution, the number of months of training to be provided at this institution, and whether the institution is affiliated or integrated.

Institution Name and #

An Institution was:

( ) added/ changed to major site

( ) removed completely

( ) changed from major site to other (minor) site

Type: ( ) Affiliated ( ) Integrated

Number of Months (assigned by year):

Impact on Program (short narrative):

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SECTION 7. PROGRAM ORGANIZATIONAL STRUCTURE

1. Is neurological surgery a separate unit (department/division/section) of surgery? ( ) YES ( ) NO

2. If this is a medical school affiliated program, is neurological surgery a separate division or department within the medical school?

3. How is the Chief of Neurological Surgery and/or Program Director appointed? Provide the information for each institution listed in Part 1, Section 2. Add more lines if needed.

Institution #1:

Chief:Program Director:

Institution #2:


Institution #3:


Institution #4:


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SECTION 8. STATISTICAL INFORMATION FOR NEUROLOGICAL SURGERY AND NEUROLOGY

Provide the information for each institution listed in Part 1, Section 2. Duplicate the tables to add more institutions if needed.

NEUROSURGICAL DATA Institution #1 Institution #2 Institution #3 Institution #4 TotalCurrent Hospital Bed CapacityNumber of Hospital Admissions/YearNeurosurgical Bed CapacityNumber of Neurosurgery Admissions/YearNeurosurgical Discharges/YearAverage Neurosurgery Census/DailyNumber of Neurosurgical Deaths/YearAverage Inpatient Consultations/DayAverage Neurosurgery ED Consultations/Day

NEUROLOGY DATA Institution #1 Institution #2 Institution #3 Institution #4 TotalNumber of Neurology Admissions/YearAverage Neurology Census/Daily

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SECTION 9. APPOINTMENT OF RESIDENTS

1. Does the program routinely participate in the Neurosurgery Match? ( ) YES ( ) NO

2. Date service begins for positions already offered:

3. Date when appointments are made:

4. How many years are appointments made for?

5. Does the program appoint beginning residents at times other than the start of the academic year?( ) YES ( ) NO

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SECTION 10. FELLOWS

List all fellows currently appointed to this program (active clinical residents are listed in 3.B) and provide the information requested. For "Year of NS", give the resident's level of training. For "Description of Training Prior to NS appointment" give the name of the program and type of service. Example: Duke/NS. [PR V.D.6]

Name Service Begin

Service End Year of NS Medical School and Date of Graduation Description of Training Prior to NS

Appointment

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SECTION 11. BLOCK ROTATIONAL DIAGRAM

This block rotational diagram should show the progression of a typical resident (or residents) through his/her educational experience. The PR for Neurological Surgery require that this educational experience be 60 months in length; the diagram should show how the sixty months of required training are spent. Using the six-month blocks, indicate where each resident will be for that period of time. Where rotations are less than six months the table sections may be subdivided with the length of time indicated.

The example provided reflects rotations for two residents, (X and Y) in a five-year program. During the NS1 year, both residents are on clinical rotations at Hospital I. During the NS2 year, Resident X spends his/her first six months in pediatric neurosurgery at the Children's Hospital, followed by three months of Neurology and three months of Neuropathology; the schedule for Resident Y is apparent. During the NS3 year, Resident X spends six months at Hospital II (clinical service) and six months at Hospital I (clinical service); the rotation for Resident Y is apparent. For the NS4 year, Resident X spends six months at Hospital II (clinical service) and six months in the laboratory. This resident subsequently spends twelve months in the laboratory during the NS5 year and a year as Chief Resident during the NS6 year. [Add a "C" on the appropriate blocks to indicate when a resident is chief.]

Block Rotational Diagram Sample

Year July to December January to JunePGY-2(NS1)

X: Hospital IY: Hospital I

Hospital IHospital I

PGY-3(NS2)

X: ELECTIVEY: Neurological/ ELECTIVE

Neurological/ ELECTIVEELECTIVE

PGY-4(NS3)

X: Hospital IIY: Hospital I

Hospital IHospital II

PGY-5(NS4)

X: Lab/ ELECTIVEY: Lab/ ELECTIVE

Lab/ ELECTIVELab/ ELECTIVE

PGY-6(NS5)

X: Hospital I (C)Y: Hospital II (C)

Hospital II (C)Hospital I (C)

PGY-7For 6 year programs Either 6th year of training and/or fellowship

Block Rotational Diagram

Year July to December January to JunePGY-2(NS1)PGY-3(NS2)PGY-4(NS3)PGY-5(NS4)PGY-6(NS5)

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PGY-7For 6 year programs

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SECTION 12. OUTPATIENT DEPARTMENT INFORMATION, FACILITIES AND CHIEFS

Provide the information for each institution listed in Part 1, Section 2. Add another table for more institutions if needed. Provide the information requested for each hospital participating in the program. If position does not exist, enter "None." If position is vacant, enter "vacant."

Institution #1 Institution #2 Institution #3 Institution #4Total Outpatient VisitsPercent Participation by Residents % % % %Emergency DepartmentTotal Number of NS Consultations/YearNeurologyFacilities [PR IV.A]Interventional Neuroradiology ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOStereotactic RadiosurgeryName of Following ChiefsChief of SurgeryChief of NeurologyNeuropathologistNeuroradiologist

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SECTION 13. OTHER TRAINING PROGRAMS

Answer "YES/NO" for the information requested below for each hospital participating in the program. [PR V.D.5]

Other Training Programs In: Institution #1 Institution #2 Institution #3 Institution #4Anesthesiology ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOEndocrinology ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOGeneral Surgery ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOInternal Medicine ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NONeurology ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NONeuroradiology ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOOphthalmology ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOOrthopaedics ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOOtolaryngology ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOPediatrics ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO

Pathology ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO

Psychiatry ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO

Radiology ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO

If residencies do not exist for anesthesiology, endocrinology, ophthalmology, orthopaedics, otolaryngology, pathology, and psychiatry, describe the resources for education of neurological surgery residents below.

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SECTION 14. EDUCATIONAL PROGRAM NARRATIVE DESCRIPTION

Provide a narrative in the following format, addressing each item. Repeat each section heading preceding your narrative for each item. For each item, brevity is appreciated, but explain the program in significant detail. DO NOT append brochures, program descriptions, curricula vitae, or other printed materials.

A. Narrative Description of the Program

1. Describe the training program covering each year specifically. This information must include: a. A chronological rotation of assignments of residents; specify the total number of months of required

clinical Neurological surgery.b. The duties of the residents in each year.c. Scheduled teaching rounds.d. Outpatient and inpatient facilities.e. Research facilities.f. Operating rooms and scheduled surgery days. Indicate whether the residents work simultaneously,

or if not, How many work at one time and at what level in each institution listed.g. If the program trains more than one resident per year, describe how the program ensures that each

resident has a full 12-month chief resident experience.h. Describe how the program provides progressively responsible patient management opportunities at

each level of training. Include a description of the chief resident's clinical and administrative responsibilities.

i. Describe the outpatient experience and responsibilities of the residents, including the role of the resident in preoperative evaluation and management of patients as well as post-discharge follow up.

j. Describe the critical care experiences of the residents. Indicate the specialty and position of the clinical director of the ICU. Describe the position of the individual responsible for the management of critical care neurosurgical patients. Describe the responsibility for management of critical care neurosurgical patients.

k. List by name where each resident in the program took his/her neurology experience and in which years of training.

2. Describe whether the department is used for undergraduate teaching and if yes, by what medical school. Describe the role of the neurosurgery residents in teaching medical students and other residents. Indicate how many medical students are on the same team with the neurosurgery residents.

B. Training in Neurosciences

Describe the amount and type of training the residents receive in the following areas. Include a description of how this training is integrated into the clinical neurological surgery experience.

Neurology

Neuropathology

Neuroanatomy

Neurophysiology

Neuroradiology

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C. Experience in Stereotactic Radiosurgery (Mark one or more as appropriate)

1. What type of Radiosurgery is offered?( ) None ( ) Leksell Gamma Unit ( ) Linear Accelerator ( ) Protein Beam or Particle Beam

2. Do residents have a defined experience in Stereotactic Radiosurgery? ( ) YES - required ( ) YES - elective ( ) NO

D. Experience in Endovascular Neurosurgery

Do residents have a defined experience in Endovascular Neurosurgery? ( ) YES ( ) NO

E. Conferences

Provide a schedule of departmental conferences for the most recent academic year held with resident staff and list other formal teaching exercises including Journal Club. The schedule should include the frequency and year the topic, and the name of the individual responsible for oversight of the conference, and the name of the individual presenting the conference. Below Indicate the "Type" and "Frequency" of conferences and who is required to attend (resident and/or faculty).

Type Frequency Residents Required to Attend Faculty Required to AttendNeurosurgicalNeuropathologyTumor ClinicsM and MNeurologicalNeuroradiologicalOther

F. Resident Research

List the papers published since the last survey of the program in which a resident of the program was author or joint author. Underline the resident participant's name.

G. Program Director's Clinical Responsibility

Describe the program director's major clinical responsibilities at the primary clinical site as well as any responsibilities he/she may have at other participating institutions.

H. Moonlighting and Other Extracurricular Activities

Describe the program's policy on moonlighting.

I. Supervision

Describe how the program ensures direct and appropriate supervision of residents at each level of training.

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J. Duty Hours

Attach the call schedule (Attachment 3).

K. Support Services

Describe the support services the program/institution provides to ensure that residents do not routinely engage in activities that do not require the skills of a physician. Describe the type and availability of sleeping, lounge, and food facilities provided to residents on-call in the hospital.

L. Evaluation of Residents

Describe how the program systematically evaluates each resident, communicates such evaluation to the residents, and documents both the evaluation and the communication.

M. Evaluation of Faculty

Describe how the program evaluates faculty. How is resident evaluation kept confidential?

N. Evaluation of the Program

Describe how the residents and faculty evaluate the conferences and rotations of the residency.

O. Fellowships

Attach a description of any fellowship(s) the program offers, and include an operative log for each most recently graduated fellow. Describe how the Program Director ensures that the fellow does not adversely affect the experience of the residents. Include the number of fellows currently in the programs.

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SECTION 15. OPERATIVE EXPERIENCE

A. Residents

Supply the number of cases for the most recently graduating resident representing his/her entire neurosurgery experience. This information is to be reported separately: by senior clinical year, and by all other clinical years. Combined surgical statistics from ALL institutions in which the resident served are to be included on this one form and not broken down into separate institutions. Count only those cases in which the resident had a significant decision making role (including pre- and post-operative care). "Surgeon" refers to primary responsibility; "Assistant" refers to surgeon acting as an assistant. Patients up to 16 years of age inclusive are considered pediatric cases. Procedures listed as "Other", should be explained in the "Other" section of this log. Attach additional pages as necessary.

Resident's NameLog Covering Period (dates)

Resident Signature

ADULT Senior Clinical Year Other Clinical Years Total Experience All YearsTumor

Glial tumor or metastasis - craniotomyGlial tumor or metastasis - stereotactic biopsyGlial tumor or metastasis - radiosurgeryMeningioma - craniotomyMeningioma - radiosurgeryCP angle tumor - craniotomyCP angle tumor - radiosurgerySellar/Parasellar tumor - craniotomySellar/Parasellar tumor - transsphenoidalSellar/Parasellar tumor - radiotherapyOther (tumor)

Total Tumor

VascularAneurysm - craniotomyAneurysm - endovascularAVM - craniotomyAVM - endovascularAVM - radiosurgery

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ADULT Senior Clinical Year Other Clinical Years Total Experience All YearsOcclusive disease - carotid endarterectomyOcclusive disease - endovascularOcclusive disease - EC/IC bypassNon-traumatic intracerebral hematomaOther (vascular)

Total Vascular

Head TraumaDepressed skull fractureGunshot/penetrating woundEpidural hematomaSubdural hematomaIntracerebral hematomaOther (head trauma)

Total Head Trauma

FunctionalEpilepsy - diagnosticEpilepsy therapeutic - craniotomyEpilepsy therapeutic - vagal nerve stimulationMovement disorder surgery - stereotactic lesion creationMovement disorder surgery - implantation of stimulatorNeuralgia - percutaneous lesion creationNeuralgia - craniectomy for decompressionNeuralgia - stereotactic radiosurgeryOther (functional)

Total Functional

SpineDisc/Spondylosis cervical - discectomy/decompression without instrumentationDisc/Spondylosis cervical - with instrumentationDisc/Spondylosis thoracic - discectomy/decompression without instrumentation

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ADULT Senior Clinical Year Other Clinical Years Total Experience All YearsDisc/Spondylosis thoracic - with instrumentationDisc/Spondylosis lumbar - discectomy/decompression without instrumentationDisc/Spondylosis lumbar - with instrumentationPrimary tumor - resection without instrumentationPrimary tumor - resection with instrumentationMetastatic tumor - resection without instrumentationMetastatic tumor - resection with instrumentationTrauma - operative decompression/reduction without instrumentationTrauma with instrumentationOther (spine)

Total Spine

Peripheral NerveNeuroplasty (entrapment release, neurolysis, transposition)NeurorrhaphyOther (peripheral nerve)

Total Peripheral Nerve

CSF ShuntingInitialRevisionThird ventriculostomy

Total CSF ShuntingMiscellaneous

MiscellaneousTotal ADULT Cases:

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PEDIATRIC Senior Clinical Year Other Clinical Years Total Experience All YearsHead Trauma (pediatric)

Brain Tumor (pediatric)

Cranial Synostosis/Craniofacial Reconstruc (PED)

Functional (pediatric)EpilepsyPump implantationRhizotomyTotal Functional (pediatric)

Spinal Dysraphism (pediatric)

CSF Shunting (pediatric)InitialRevisionThird ventriculostomyTotal CSF Shunting (pediatric)

Other (pediatric)

ADULT & PEDIATRIC Senior Clinical Year Other Clinical Years Total Experience All YearsMinor Procedures (Adult & Pediatric)Muscle/nerve biopsy, ICP monitor, tongs/halo, etc.

Total ADULT & PEDIATRIC Cases:

Diagnostic Procedures -Adult and Pediatric Senior Clinical Year Other Clinical Years Total Experience All Years1. Angiogram2. Myelogram3. Ventriculogram4. Other

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Diagnostic Procedures -Adult and Pediatric Senior Clinical Year Other Clinical Years Total Experience All YearsGrand Total: Diagnostic Procedures

Specify "Other" Procedures: Please check whether the "other" procedure is recorded under MAJOR, MINOR or DIAGNOSTIC (DIAG); ADULT or PEDIATRICS (PEDS). The "CAT" column refers to the number of the category in which the "other" procedure is recorded. For example, if the "other" procedure is recorded under the category, "Craniotomy Other than Trauma," then in the "CAT" column the number one (1) should be listed. Duplicate this page as needed.

Senior Clinical Year Other Clinical YearsMajor Minor Diag. Adult Peds Cat Description Of Procedure Surgeon Assistant Surgeon

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B. Fellows

Supply the number of cases for the most recently graduated fellow representing his/her entire neurosurgery fellowship experience. This information is to be reported separately: by Surgeon, Assistant, and by Teaching Assistant. Combined surgical statistics from ALL institutions in which the fellow served are to be included on this one form and not broken down into separate institutions. Count only those cases in which the fellow had a significant decision making role (including pre- and post-operative care). "Surgeon" refers to primary responsibility; "Assistant" refers to surgeon acting as an assistant;" Teaching Assistant" refers to supervisory responsibility. Patients up to 16 years of age inclusive are considered pediatric cases. Procedures listed as "Other", should be explained in the "Other" section of this log. Attach additional pages as necessary.

Fellow's NameLog Covering Period (dates)

ADULT Senior Clinical Year Other Clinical Years Total Experience All YearsTumor

Glial tumor or metastasis - craniotomyGlial tumor or metastasis - stereotactic biopsyGlial tumor or metastasis - radiosurgeryMeningioma - craniotomyMeningioma - radiosurgeryCP angle tumor - craniotomyCP angle tumor - radiosurgerySellar/Parasellar tumor - craniotomySellar/Parasellar tumor - transsphenoidalSellar/Parasellar tumor - radiotherapyOther (tumor)

Total Tumor

VascularAneurysm - craniotomyAneurysm - endovascularAVM - craniotomyAVM - endovascularAVM - radiosurgeryOcclusive disease - carotid endarterectomyOcclusive disease - endovascularOcclusive disease - EC/IC bypass

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ADULT Senior Clinical Year Other Clinical Years Total Experience All YearsNon-traumatic intracerebral hematomaOther (vascular)

Total Vascular


Total Head Trauma


Total Functional

SpineDisc/Spondylosis cervical - discectomy/decompression without instrumentationDisc/Spondylosis cervical - with instrumentationDisc/Spondylosis thoracic - discectomy/decompression without instrumentationDisc/Spondylosis thoracic - with instrumentationDisc/Spondylosis lumbar - discectomy/decompression without instrumentationDisc/Spondylosis lumbar - with instrumentation

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ADULT Senior Clinical Year Other Clinical Years Total Experience All YearsPrimary tumor - resection without instrumentationPrimary tumor - resection with instrumentationMetastatic tumor - resection without instrumentationMetastatic tumor - resection with instrumentationTrauma - operative decompression/reduction without instrumentationTrauma with instrumentationOther (spine)

Total Spine






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PEDIATRIC Senior Clinical Year Other Clinical Years Total Experience All YearsHead Trauma (pediatric)



Functional (pediatric)EpilepsyPump implantationRhizotomyTotal Functional (pediatric)



Other (pediatric)

ADULT & PEDIATRIC Senior Clinical Year Other Clinical Years Total Experience All YearsMinor Procedures (Adult & Pediatric)Muscle/nerve biopsy, ICP monitor, tongs/halo, etc.


Diagnostic Procedures -Adult and Pediatric Senior Clinical Year Other Clinical Years Total Experience All Years1. Angiogram2. Myelogram3. Ventriculogram4. Other

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Diagnostic Procedures -Adult and Pediatric Senior Clinical Year Other Clinical Years Total Experience All YearsGrand Total: Diagnostic Procedures

Specify "Other" Procedures: Please check whether the "other" procedure is recorded under MAJOR, MINOR or DIAGNOSTIC (DIAG); ADULT or PEDIATRICS (PEDS). The "CAT" column refers to the number of the category in which the "other" procedure is recorded. For example, if the "other" procedure is recorded under the category, "Craniotomy Other than Trauma," then in the "CAT" column the number one (1) should be listed. Duplicate this page as needed.

Senior Clinical Year Other Clinical YearsMajor Minor Diag. Adult Peds Cat Description Of Procedure Surgeon Assistant Surgeon

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C. Institutional Operative Experience

Supply the number of cases for each institution participating in the program. Attach a description of how the data were tabulated and the method used to confirm the accuracy of the information reported. Operative experience for the previous academic year should be reported.

Log Covering Period (dates) July 1, ---- to June 30, ----

Program Director Signature / Date

ADULT Institution 1 Institution 2 Institution 3 Institution 4 Total Experience Tumor

Glial tumor or metastasis – craniotomyGlial tumor or metastasis – stereotactic biopsyGlial tumor or metastasis - radiosurgeryMeningioma – craniotomyMeningioma – radiosurgeryCP angle tumor – craniotomyCP angle tumor – radiosurgerySellar/Parasellar tumor – craniotomySellar/Parasellar tumor - transsphenoidalSellar/Parasellar tumor – radiotherapyOther (tumor)

Total Tumor

VascularAneurysm – craniotomyAneurysm – endovascularAVM – craniotomyAVM – endovascularAVM – radiosurgeryOcclusive disease - carotid endarterectomyOcclusive disease – endovascularOcclusive disease - EC/IC bypassNon-traumatic intracerebral hematomaOther (vascular)

Total Vascular

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ADULT Institution 1 Institution 2 Institution 3 Institution 4 Total Experience


Total Head Trauma


Total Functional

SpineDisc/Spondylosis cervical - discectomy/decompression without instrumentationDisc/Spondylosis cervical - with instrumentationDisc/Spondylosis thoracic - discectomy/decompression without instrumentationDisc/Spondylosis thoracic - with instrumentationDisc/Spondylosis lumbar - discectomy/decompression without instrumentationDisc/Spondylosis lumbar - with instrumentation

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ADULT Institution 1 Institution 2 Institution 3 Institution 4 Total Experience Primary tumor - resection without instrumentationPrimary tumor - resection with instrumentationMetastatic tumor - resection without instrumentationMetastatic tumor - resection with instrumentationTrauma - operative decompression/reduction without instrumentationTrauma with instrumentationOther (spine)

Total Spine






PEDIATRIC Institution 1 Institution 2 Institution 3 Institution 4 Total Experience Head Trauma (pediatric)



Functional (pediatric)

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PEDIATRIC Institution 1 Institution 2 Institution 3 Institution 4 Total Experience EpilepsyPump implantationRhizotomyTotal Functional (pediatric)



Other (pediatric)

ADULT & PEDIATRIC Institution 1 Institution 2 Institution 3 Institution 4 Total Experience Minor Procedures (Adult & Pediatric)Muscle/nerve biopsy, ICP monitor, tongs/halo, etc.


Diagnostic Procedures -Adult and Pediatric Institution 1 Institution 2 Institution 3 Institution 4 Total Experience 1. Angiogram2. Myelogram3. Ventriculogram4. OtherGrand Total: Diagnostic Procedures

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