Grand Rounds-The Oral Boards Part II: Pearls for Success and Review of Cases

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- Hello, ladies and gentlemen, thank you for joining us for another session of the AANS operative grand rounds. This morning we're very privileged to have with us Dr. Dan Barrow and Dr. Nelson Oyesiku from Emory University. They'll be talking to us about the important processes of oral boards and maintenance of certification. Gentlemen, thank you for joining us and please go ahead.

- Good morning, Aaron, thank you very much. Nelson, I wanna take the opportunity today to discuss some of the issues regarding the American Board of Neurological Surgery, a little bit about its history and about the processes of certification and maintenance of that certification. The American Board of Neurological Surgery is one of 24 boards that make up the American Board of Medical Specialties, which is the authoritative resource and voice for issuing physician certification. There are other boards, so-called rump boards that exist that carry on certain of these activities, but ABMS and it's member boards are really, the authoritative resource for this. The ABMS Member Boards give certificates, both general certificates, and many of the boards get subspecialty certificates as well. Neurosurgery is one of the specialties that does not provide subspecialty certifications the present time. The ABNS has had a long history, it's now in it's 71st year of existence, you can see from this slide that it was the 16th board that was incorporated, so the early boards on this slide, ophthalmology being first and others before the ABNS. Max Peet was the neurosurgeon who really drove the organization of the ABNS back in 1939. And he and some of his esteemed colleagues had an organizational meeting back in may of 1939 and you see the names on the slide or some of the giants of neurosurgery at the time who thought that it was important to have a board certification process. Aims of the board worked to improve the study, improve the practice, elevate the standards and advanced the science of our specialty. And the first meeting of the board was held in Chicago and again, you can see the names of the individuals that were there, all very esteemed neurosurgeons who were representing both the society of neurological surgeons and the Harvey Cushing society, which were the two preeminent neurosurgical organizations at that time. The vice chair of ABNS was Dr. Nafzigger and the first secretary treasurer, Dr. Spurling. The ABNS has learned a lot of lessons from its history. First of all, it was founded by the very best leaders in the specialty whose primary goal was to elevate the specialty and make sure the board certified neurosurgeons met certain criteria that would give the public a comfort that they were well-trained and knew what they were doing. Since that time, I think the directors selected have been leaders in neurosurgical education and importantly, they're all very active neurosurgeons, they're all practicing neurosurgeons that have a practical understanding of what it involves the practice of our specialty. I think the other great strength throughout the history of our organization is that our executive director and the entire staff have represented our board so very well. There are a lot of traditions with the board, it's a rigorous process, but I think it's very, very fair, I think it always has been, I think it's very efficiently administered given the fact that the work is done really purely on a volunteer basis. The oral exam is a rite of passage, it's something that inspires residents and candidates. I think it's remembered with pride by almost every diplomat. I think all of us can remember the individual examiners that examined us on different subjects. We can remember most of the cases that were presented and hopefully most of us remember that with pride and with good feelings. It's an interesting piece from the archives of the ABNS, it's actually a letter written by A. Earl Walker about his board examination that he took in 1969 and I'll just give the audience a moment to read it because it actually is very compelling and even somebody of the stature of Dr. Walker went through his career remembering the details of his oral board examination and the physicians that actually examined him. And you can see as you read this, that some of the questions probably were a little different back in 1969 than they are today. But the goal was to explore candidates knowledge and make sure they were safe and to make sure that they were practicing within what would be a recognized standards. Although I think there's a extremely proud history of the board, obviously things change and our complex relationship with outside entities has made it necessary to change on a continuous basis, but those changes that have occurred have been carried out after thoughtful deliberation among the directors of the board and oftentimes change is made only after we pilot those changes, specifically some of the changes in the oral exam, which we'll talk about a little bit later. But as we change, we need to maintain our traditions and ensure that the board continues to be respected and to be credible and I think that's been accomplished. The American board has very close relationship with the residency review committee and we interact on a regular basis. The ABNS is responsible for certification and maintenance of that certification whereas the RRC is responsible for accrediting the training programs that individuals have to complete in order to be a board certified. And together, those two organizations create residents and fully trained neurosurgeons that maintain their reputation throughout their careers. The board and the residency review committee have their membership nominated by some of our societies, the senior society, Congress and neurological surgeons, the American Association of Neurological surgeons. In turn, we have liaison relationships with those organizations to communicate our activities back and forth. So, there's an enormous amount of interplay among the various organizations. The ABNS, as I mentioned, is one of 24 member boards of the ABMS and the residency review committee is part of the ACGME. Back in the beginning of the board, the ABMS and the ACG GME were relatively small organizations and the ABNS and RRC really have most of the interaction. But today, the ABMS is a much, much bigger organization and you'll hear when we talk about members of organizations, some of the activities that the ABMS has encouraged and in some cases dictated and then rewards follow. Likewise, the ACGME is a much, much bigger organization and now the relationships among these organizations by pointing out that our executive director, Mary Luiz Sanderson has been with the board for decades, she has been absolutely incredible and anyone who has gone through the certification process is interactive with Mary Louise and understands how important she has been to the board. One of the changes that's occurring actually over the next year is the central office for the ABNS will be moving from Houston, Texas to New Haven, Connecticut, because of Mary Louise's move to New Haven and in this electronic age where the office is, it makes really little difference, that is a move that we're making. Mary Louise has announced that she will likely retire over the next few years and so we're gonna use this period of time as a transition to identify a new executive director, it's gonna be a very hard act to follow because she has been absolutely magnificent, I personally can't imagine the board without her, but we're going to, again, have to deal with change. What we'd like to go on to next is to talk about the oral examination. One of the most important aspects of board certification and one of the events that all candidates look forward to is the oral examination, which is kind of the culmination of the process of becoming certified. In order to sit for the oral board, the candidate must be credentialed. They must complete a neurosurgical residency program that's approved by the ACGME, and they must have passed the written examination for credit, which currently it has to be done before completion of a residency. The applicant then has five years from the time they complete their residency to complete the oral examination process. During that time, the candidate submits 150 consecutive cases of operative data that is reviewed by the credentials committee of the board made up of some of the directors. And the purpose of that is just to simply get patterns, to be sure there aren't a series of cases or complications that would indicate that the candidate is in some way unsafe. And then there are letters of recommendation, there has to be documentation of licensure and current hospital appointments. And then the candidate is scheduled for the exam. The exam was made up of three sessions with three pairs of examiners and each of the exams are one hour in duration. The two individuals that examine the candidate are either a director or a former director and a guest examiner that is chosen typically from the neurosurgical community because of their interest in education and these two examiners give alternating vignettes. It is important to understand that the oral exam, that was all topics that are included in definition of neurosurgery. Neurosurgery does not certify neurosurgeons in spinal neurosurgery or cerebrovascular neurosurgery or the neuro-oncology, you're certified in field of neurosurgery, and so the exam, like a certification, is comprehensive. The behavior of the examiners is something that we view with them, particularly the guest examiners, we pretty much try to avoid humorous or aggressive comments, unlike your grand rounds where people give you immediate feedback, there is no attempt during the exam to correct or to try to teach a candidate, there's no verbal cue or feedback. It's also important that the examiner not dwell on weaknesses or strengths. If it's obvious with a candidate is lost on a particular vignette, a particular case, examiners are encouraged just to move on to another case, certainly there are no questions and we don't ask for didactic material. The examination is made up of clinical encounters that a typical neurosurgeon would likely encounter in their office, in the emergency room, it might be like a colleague walking down the hallway and stopping you and asking you for a consult. What would you do under these circumstances? Candidates are asked to actively participate in the process of describing what they would do for that particular case and provide a rationale for the insurgence. The format for the typical exam is that there is a prior presentation of the history, the examination, the test results and images are typically shown, there are appropriate images. What the candidate needs to do is develop a differential diagnosis, it needs to be rational, we don't need to hear every possible explanation for the patient's symptoms, but the ones that would be reasonable. And just basically how would the candidate manage it? what would the initial management be if there's a surgical option, how would the candidate go about preparing and executing the operation and typically managing interoperative and or postoperative complications and understanding the natural history of the conditions that they are being tested to them? I think some of the key issues about the oral exam is that we try to get through a minimum of six questions per session. So, if you do the math, you understand that you gotta kind of move along. Therefore, it's important for the candidate not to dwell on issues that are not pertinent to demand from the case. What the examiners wanna know is do you understand what this problem is the patient's presenting with? Do you understand the differential diagnosis and how to manage it and not to dwell on things that are not important so we can move on and try to get a minimum of six cases. It is not centered on interpreting images, but remember that part of neurosurgical board certification is interpreting images. And so, we would expect that that candidate to be able to interpret key neurosurgical, neuroradiological images, but it's certainly appropriate for the candidate and say, let me see what our radiologists would would think. Again, I repeat that it's important, the exam's comprehensive and regardless of what the individual's sub-specialty might be, the exam will cover all aspects of neurosurgery, including spinal neurosurgery, peripheral node, intracranial neurosurgery, functional neurosurgery, pediatrics, endovascular therapy, and so on. Grading is done for each of the three vignettes for three separate tasks. The grade on how well the candidate came to a diagnosis by evaluating the exam, the history and pertinent diagnostic tests, grading on the management of the patient, the grading on the complications. If the case were a non-surgical case, let's say multiple sclerosis and the candidate made the correct diagnosis, obviously there are no complications of surgery unless the candidate inappropriately operated on a patient with MS. But the complication portion will be graded on the candidates knowledge of the management and the actual history and assessment of prognosis of that condition. You can see that the grading scale on the slide is a fairly intuitive one, it's five points that correlate pretty much with the A, B, C, D, and F that most of us have as we went through our educational process and each session is then graded by the two examiners for those three tasks that I outlined. The composite grade is not necessarily an average, but it's an overall assessment, so a candidate can do extremely poorly on one particular case and still come out of the exam with a very good passing score, it's really an assessment of how that candidate did over the entire session. And that's part of the importance of trying to get through several cases. The grading is dependent on a number of things. Is the management plan likely to work? Is the diagnosis, the treatment consistent with expectations for what a junior faculty member would do in a sound neurosurgical practice? And very importantly, asking the question, is this a safe neurosurgeon? Grades are then expected after the exam on the following subject areas, on spine, on cranial neurosurgery, and then comprehensive other. There's subspecialty areas of functional pediatrics, critical care, peripheral node, and it is very important that one of the relatively new changes in the exam is that it's required that the candidate pass each of those three subject areas. In other words, somebody who does exclusively through neurosurgery in their practice can't come to the oral exam with the expectation that they're going to do extremely well on the spinal portion of the exam and fail miserably the intracranial portion and expect a board certified neurosurgeon. Again, neurosurgery does not currently provide sub-specialty certification. And so, the expectation is that normal examination will be passed in a comprehensive manner. After the exams, there is a discussion period of marginal candidates and the purpose for this is to be absolutely sure we've been fair with each and every candidate. The directors and the guests examiners will point out obviously unfair questions, it's not uncommon or somebody who may be marginal be discussed and for one of the directors, former directors, guests examiners to listen to the vignette that the candidate was given and say, you know, that option for management really is not unreasonable and grades can be changed during that period. I would say that much more often, the grade is elevated rather than lowered during that period of time. The presentation of all the questions and answers for each of the marginal candidates is performed to understand why the candidate did poorly and what the responses of concern were and why the grades were given, so we give everybody a completely fair chance to demonstrate their abilities. Very, very importantly, when the directors leave the oral examination process, which is virtually a week long, we oftentimes don't really know who was passed and failed. The grades are actually evaluated by a psychometrician, and there is a computer analysis that determines the past sales standard and that computer analysis actually takes into consideration the severity of the examiners. For example, if a particular candidate happened to be graded by examiners that tended to grade more harshly than others, that is actually taken into consideration so that somebody who is disadvantaged because during the short straw and Dr. Oyesiku for example, who might be a much more difficult and a harsh examiner than somebody nice like myself.

- Gentlemen, I wanna thank you again for your time. I thought at the request of some of our viewers who would be reasonable to just have a very brief discussion for some of the common questions that we get asked about, and as well as review some general cases, just to get comments regarding how to answer the questions. I think Nelson covered the issue of the MOC very well and I think we can skip that topic. What issue that I personally have found out in terms of talking to other folks is although every aspect of the oral board is important, some of the most important steps where people stop and have a problem and may fail is the initial management. In other words, if your initial management is wrong, then you really gonna go down the slippery slope, and also postoperative complications, you've gotta be able to manage your complications well. We all agree that anybody can do well in a practice if the cases always go well, but it's those who can rise and there is a complication and take care of the patient and make sure the patient arrives to a safe place. So, and then Nelson, if I may ask you, you guys have extensive experience, obviously Dan is the chairman of the board and Nelson, you have been involved for a very long time. What are the steps that you would say most people fail when they're answering the question? Go ahead, Dan, please.

- Well, I think in my experience, I think the most common reason for failure is for a candidate to fail to study parts of the field of neurosurgery they don't practice them as much, that's probably the most common issue. A neurosurgeon, for example, whose practice is exclusively spinal neurosurgery that has failed to study peripheral nerve, pediatric neurosurgery, intracranial neurosurgery. As I said earlier, the ABNS does not certify spinal neurosurgeons, does not certify oncology neurosurgeons. We certify neurosurgeons and if one reads the definition of neurosurgery, it is a very comprehensive one, it includes critical care, it includes spine, it includes radiosurgery, functional neurosurgery, neuro endovascular. And so that's probably the most common reason. A second issue is that oftentimes, a candidate will be very, very nervous and I can tell you that almost all of the directors and former directors and even guest examiners recognize that they'll go out of their way to make sure that they put the candidate at ease. We don't want anybody to stay over the exam, we certainly don't want anybody to fail the exam simply because they are nervous. Beyond that, I think the common mistakes I make are seen made by candidates are dwelling too much on minutiae, spending a lot of time talking about things and asking questions that really aren't important. I encourage all of the candidates when I speak with them before the exam, to just deal with the oral exam as though you're talking to a colleague, you wouldn't ask the colleague for a lot of completely unnecessary information, you focus on what would you do? What exactly would you do? You don't wanna, well, you could do this, you could do that, you could do the other, what would you do? Just tell us what you would do in managing this patient. And if the examinee does that, they tend to move through the examination very smoothly, get to a lot of cases so they can really demonstrate that they are safe, effective neurosurgeons that have good practices.

- Now, so would you please comment what are your pearls, or what are the pitfalls you have seen during exams that causes the candidate to fail?

- Yes, so in addition to the ones that Dan mentioned, which I would totally endorse, I would also add that in the examination, clearly directors and examiners are counseled to recognize the fact that different approaches and different options, same results are perfectly legitimate. And just because a candidate prefers an option that may not be your first choice, as long as it's safe and effective, that should be okay. What is not okay is when options are offered that are clearly unsafe or would not result in the optimal outcomes and effective treatment of the conditions at hand. And I think that usually results in a red flag if case after case, scratch on this margin of safety issue, I think is something that candidates should be very cautious of in picking their options.

- Okay, thank you, I think to summarize is that candidates come to the exam, the become so nervous they don't act like themselves in practice, they feel like the examiner is trying to play trick with them, which I personally don't feel anyone is out there to do that. I mean, my experience was extremely positive and the friends that I have talked to. And so, when they feel like the examiner is trying to trick them, they end up answering, they go on a fishing expedition, they just throw out all they know and they hope that something they said would be the right answer so they get credit. And the moment you do that, you're gonna start taking a lot of time, fall behind, don't answer even four questions and end up failing the exam, go ahead, please.

- Yes, I was gonna add to this issue about the feeling of the candidate that something is being withheld, or perhaps they're being led on the garden path. No examiner that I know of behaves that way, the examination is over and over. The examiners are being counseled to be fair and not withhold information and when an examiner tells a candidate that this is all the imaging that's available, or there is nothing else available, I think that's a prompt for the candidate to recognize that they can move on and make a decision and answer the question as opposed, or if it's a material on the history of the physical findings and you've been told everything that's in town, don't keep persisting when the examiner is holding something and risk your time and doesn't get on with answering the question. So, I would endorse that issue about this trick concern that people have that examiners may be trying to pull a fast one over them.

- Thank you, so very briefly, how many times can you take the test, I believe now you can take that three times before you have to take your written exam, that is correct Dan?

- Yes, that's correct, that's a recent change. It used to be two times and for a variety of reasons, the board changed that during the past year. And if one fails the test on three occasions, unfortunately they have to start the entire process over again, taking a written examination, turning in there 150 cases to the credentials committee and then resitting the oral exam. That decision was based upon looking very carefully historically at how many individuals fail the exam twice and then went on to pass it again. And we think that now that's a very fair mechanism for people to become board certified.

- Thank you and I think we have had another session with build Caldwell, and I'll try to skip some of the questions that he has very rightly and appropriately answered. If I may ask you what are the pearls for success as you guys who have been examiners for many years? Obviously we can ask for a radiologist's help, endocrinologist help. I assume not everyone encourages that, but if one asks for it, they can have it. So, what are the perils for success? That Nelson, go ahead, or Dan please go ahead.

- I think that there are several, I've touched on some of those is prepare for the exam. I find that an occasional candidate comes in with a somewhat arrogant attitude that I know everything about small part of neurosurgery that I do, and I'm going to Excel on that part of the exam. I don't really care how I do on the other parts and I've said it already a few times, but this is a comprehensive exam because the certification is in a field that is comprehensive. A second core, I think for success is to be piffy, don't feel like you have to tell the examiner everything you know about that particular case, that particular vignette or that particular diagnosis. Don't ask for information that really isn't predominant because you're using up precious time that could be used for other cases where you can demonstrate to the examiners your level of knowledge. Another coral, I suppose, is to remind the candidate that we understand that not every candidate does everything that's done in neurosurgery, but what we don't want is for the candidate to say, well, I don't do that, I would refer that to one of my partners. Well, I don't do this, I would refer that to a neurosurgeon somewhere else. We understand that and that's okay. And so, what the candidates should do, let's say for example, that we present an aneurysmal subarachnoid hemorrhage and the candidate determines that the best course of therapy is endovascular therapy. We recognize they may not be trained in endovascular therapy. So, we are not going to ask the candidate what French catheter they're going to put into the internal carotid artery and what type of coil. What we explore with a candidates is to be sure they understand the principles, understand the benefits of endovascular therapy, the risks, why it would be appropriate or inappropriate for this particular patient and not move down the road of asking for the details that a group practitioner in a faculty level position would be able to provide, certainly asking for help is okay but as we mentioned earlier, we would expect a good candidate to be able to interpret most imaging studies that will be shown during these vignettes. Perfectly reasonable to say this is what I think, I would certainly review this with my neuroradiologist and the exam and say they agree me or they agree with you and also noted the following. So as Nelson said, there are no tricks, we're not trying to trick somebody or throw her balls.

- Thank you, Nelson, do you have any pros on your side, please?

- Yeah, I would make a couple of comments about the issue of radiology or imaging studies and test results. As Dan said, there is an element of neurosurgery that is concerned with interpretation of imaging, that's part of neurosurgery training and that's probably the code we carry on our certification. What we're looking for in the examination is not subtle issues about what a magnetic scan on the T1 is and how that would differ with fat and protein. What we're concerned with is recognizing what the imaging study tell in terms of diagnosis. What does this look like based on what you see on the imaging, and more importantly, how does the application of that imaging apply to guide your treatment of this patient. And how does that alter your surgical plan or make you decide about this approach as opposed to that approach? A good example would be if you look at an imaging study and it's obviously an extradural tumor, we want you to recognize that this is an extradural tumor and therefore the approach you will choose will be tailored towards the extradural tumor and you may then offer options as what type of extradural tumor it might be but we're not really concerned about the issue of the imaging in that regard. Same thing for test results, when the test results are shown is how does that test result interpretation guide the diagnosis that you're gonna make or the treatment of it, subtle issues about what are the test results you might want to get? But I think the other thing I would say in the steps in describing the operation, what the examiners are looking for is the method of the candidate in going through the steps of the operation, everything from choice of positions to placement of incisions or both lab, and then, and then, and then, and then all the way through so that the candidates are, what you're really looking for is a clear statement as to what the steps of the operation should be and then the best candidates will interject those steps of the operations with what they think the pitfalls of the operation could been avoid such and such in trying to mitigate complications and this is another way by which we assess complications in addition to actually asking about complications. So, good candidates will integrate that kind of discussion with their management as they go along. Aaron, I would just add one other thing, looking at your list here on pitfalls. One of the very common pitfalls that we see in this era is the inability of some candidates to localize lesions and plan a flap in the absence of frameless stereotactic guidance. It is not uncommon in this era for a candidate to be shown a cerebellar punting angle mask and say, well, I would bring in my stealth station and blah, blah, blah, and the examiner may say, well, your stealth station is broken and you don't have one. And an occasional candidate in this era will absolutely be panic stricken and penalized in decision-making because they don't have a stealth system. And it is not common, but it's also not aware to see a candidate today put flaps in the most unorthodox positions, because there is a lack of understanding of localization and so that is something that I think candidates that maybe don't do a lot of intracranial neurosurgery should focus on for the exam is learning, relearning and studying localization and the appropriate craniotomy flaps for standard approaches, aneurysms, brain tumors, things of that nature in the event that they can't rely on their frameless stereotactic guidance system.

- Thank you, those are really very valuable points. So, I think Dan already described the details regarding the subspecialty focus. You need to know, essentially in all the subspecialties, because this is a certification in a field, but not a sub-specialty. And may I ask then, do these examinees who only do cranial, who only do spine, do they get treated in any way a little bit differently just taking into account the fact that their practice is very super specialized?

- No. I would say no to that because the examination kind of be tailored to the candidate, the examination must really be tailored to the specialty. Having said that, we do have access to the reports by the reviewing director of the candidates practice data so that clearly, the practice data will inform us of candidates who are in exceptionally narrowed fields. Obviously, we wanna make sure that in those cases, we do make certain that we've provided a comprehensive examination and examine areas perhaps that are not well subscribed already. And even those that are well subscribed already, we wanna make sure that even those areas are being taken care of, so I think the devil's in the details, I think most examiners would want to examine comprehensively, no matter the candidate, but withholding in the back of the mind does not hurt, especially when you're tried to make certain that every part has been covered adequately in the context of the candidate's practice. I would agree with that, I don't think that people are treated differently because of that. As Nelson said, we do have access to their practice data, so we know when we're examining somebody, what they're doing and the example I used earlier, if somebody is a pediatric neurosurgeon and I asked them a question about endovascular management of aneurysm, I'm not going to expect that candidate to know the type of catheter that they might use to navigate the anterior cerebral artery, we just wanna make sure they understand the principles. The other side of that, that Nelson did touch on a bit is that the practice data does allow us to focus the exam when there is a concern. Let's say that a candidate turns in 150 cases and every one of them is a one bar operation with fusion and instrumentation. It may raise a question that maybe that individual's indications for spinal fusion may be appropriate, they may not. So, we may focus for example, on giving a case where the examiners feel there's no indication for spinal fusion to let the candidate demonstrate that indeed in their practice, they were using good judgment. We have no way, obviously of knowing those hundred empty cases they turn in the details of them although we do look over the material very, very carefully. So, those are the ways in which the practice data help us, it's to explore and make sure that the neurosurgeon that we're examining to the best of our ability is determined to be safe.

- Thank you, I think those are important and I really like one statement that Nelson made is when you, as an examinee, answering questions, think about pitfalls of the case. I mean, don't obviously dragging on too much to include too much detail about pitfalls. Let's say, well, now I'm trying to explore the fisher and I'm gonna lift up the frontal lobe, but because this is a peak calm aneurism, I'm not gonna retract the temporal lobe because I worry about premature rupture. These details of the surgeon knowing how to be safe, which is the critical part of the exam, I believe it's what's mostly the examiners are looking for. So, the three most important things in my mind is be safe and be humble most importantly I think, and be confident. Obviously, you don't want to have a person who is so humble that they sort of give the impression that they're not confident in what they do. So, letting the examiner know the confidence level is very important. So, I thought we can briefly review a few cases, I really do appreciate you guys' time. 32 year old female with a two history of neck pain, several months history of numbness in the neck and arms and trunk, and a sense of band around the chest at the nipple level and the neck pain was specially worse with neck flexion. Patient had a normal strength, normal reflexes, some decreased sensation in the neck and arms and the legs, but the legs were spared and they gait was normal. And the neck had a normal range of motion. Obviously at this juncture, you would like to ask for certain studies and one of them well sure has to be to the MRI specially because of the sensory level. You may want a differential diagnosis, we're not gonna dwell on those at this time very much, but obviously a compressive lesion should be in the differential diagnosis. The imaging was performed and revealed an enhancing mass, which you would expect the examinee recognize and as a extradural homogeneously mass with a dural tail consistent with a meningioma. May I ask either of you, if a person says it's a meningioma and don't give any more differential, because we really know this is a meningioma and it's really a very small chance it's anything else, I mean, rarely, maybe a metastasis. Would you expect them to give you a larger differential diagnosis only in this particular case? Dan, go ahead, please.

- No, that's perfectly reasonable and I think that points out one of the pitfalls we talked about earlier, I think that after the history of the physical examination, it maybe that an examiner may say, what are you thinking about as myelopathy of two months duration? And at that point, it's perfectly appropriate for the candidate to give a differential diagnosis that may include demyelinating disease, it may include inflammatory infection. Once you get to the image for somebody to go through a huge differential diagnosis, this image is just really wasting time and not focusing on the issue. Perfectly fine to mention that there could be durable metastases that can mimic this, but you don't need to go into the zebrans, so I would agree this is pretty obvious what this is, and this is a time to move on the management.

- Thank you, go ahead, Nelson, did you wanna say something?

- Sure, I think when you first put the first two slides that basically describe the clinical symptoms, history and physical findings, one of the things you want, there's a score given to the diagnosis. So typically at that point, there's a little break point where the examiner asks the candidate what do you think. And it's at this point that the candidates should plainly elucidate that what they think about the type of disease that's going on, is it an acute process or chronic process? where in the cranial primal axis do they think that the findings and the symptoms and the history may localize? These kinds of comments from the candidate at that point are what one's looking for and then perhaps, maybe as Dan said, at that point is where they all have a top three of potential diagnosis that would fit with the chronicity or the acuteness of disease with the physical findings and the symptoms and with the level in the nervous system where the lesion might be. And then once the imaging is shown to the candidate, then those one, two, three diagnosis become one with a relative degree of certainty, if it is backed with something . And then here's the point where I was making where we imaging should then trigger the minus surgical management, obviously, as you mentioned, this is something that is ventral and is largely coming from-

- So, here is actual images, obviously you would like to make sure examinee appreciates, this is very ventral to the canal. A CT scan, you may record from them, you see what other imaging studies you would like to be done, maybe a CT scan to evaluate the level of calcification as you can see, this tumor slightly calcified. And I assume at this juncture, you would ask them what are the treatment options? And if the patient is symptomatic with spinal cord compression surgery is reasonable. And as an examiner, if I were the examiner, I would like to make sure they're not approaching this through Laminectomy, because that's one of the pitfalls of resecting the mass, which is very ventral to the spinal cord. So, I assume every case in the boards has a point where you would like to see if the examinee is gonna go the wrong way. And here is the approach where if the tel her, well, I'm gonna do a laminectomy and try to gently retract the spinal cord, well that aint gonna work. The patient is gonna wake up quadriplegic. So, at this juncture, I assume you want the examinee to tell you what are the options? Well, posterior is gonna be a very high risk procedure, posterolateral maybe with a partial facetectomy can be an option versus an anterior approach. And you really want them to sort of go through that thought process that they examinee realizes that what are the risks anteriorly, antrolaterally, facet removal, what it means in terms of requiring stabilization with fusion and what are the tricks in order to mobilize a spinal cord very gently, if you have to transect the adente. And then eventually, this is a case just for our information with one of my colleagues, Dr. Potts actually did anteriorly and delivered the tumor, and here's the post-operative scan and MRI. What else, Dan, would you expect the examiner to provide for you besides what I mentioned?

- Well, a few things I would mention, just to go back to the very beginning. The two scenarios in which the candidate would fail, in my opinion, would be number one, if they did a pure laminectomy and try to manage this, this would indicate that for that case, that surgeon was unsafe. I don't think there's really any debate about that. At the other extreme, the candidate who says, well, I don't do this kind of surgery and therefore I would just not treat the problem. That also is an unacceptable solution. The candidate can certainly say, I don't do this kind of surgery, but these are the principles that I would utilize in doing it. The candidate really needs to discuss how they would manage it if they needed to. The other issue that I would mention, in this particular case, because of the calcification and the fact that is almost dead ventral, certainly I think the answer to your approach is the most appropriate. But let's just say that this lesion, we're a little bit eccentric on one side, very much neutral and not calcified. And the examiner felt that that anterior approach was the only option, but the candidate described a far lateral facetectomy, cutting the depth pain ligaments. Many of us would feel that was a perfectly appropriate choice. And just because we wouldn't do it the way that candidate discussed it doesn't mean that they would have a failing grade. And those are the kinds of issues that come out during the discussion session. Some candidates that had mentioned that an examiner felt that it was an inappropriate approach. So, as Nelson had said earlier, there's more than one way to skin a cat and we don't necessarily have to have a candidate say they would manage the case exactly the way that we would.

- Nelson, do you have any thoughts? Go ahead.

- I can just, one other thing, another thing what happened with that case, because as you remember, there was a third part of the grading system, and that would be managing complications and for a case like this, if I were giving this case, probably the complication would be the patient came back to the hospital a few weeks later with a massive swelling in their neck and then the candidate has to manage the issue of whether this is an infection, whether this is a cerebral spinal fluid leak. The challenge in this case is closing the dural from a ventral approach and likely the postoperative complications would be a CSF leak and how the candidate would manage that. Manage with a long hard drain that may or may not work, we may force the candidate to go back and actually re-explore the wound to redo the neuro repair. That would be a very logical complication to manage.

- Okay, thank you, Dan. You have any thoughts, Nelson?

- I think those are well said thoughts and the other things that kind of made me want to mention in a case like this in terms of going through the steps of the operation would be making certain that he told the examiner how he would be certain that he was at the right level and localization was done correctly. And those kinds of issues doing the steps of the surgery or how you deal with the two may turn out to be much firmer or more difficult to extricate than he anticipated. These kinds of things during the step of the operation would be so in there to convince us that he was well prepared for any eventualities of the case.

- Well, gentlemen, I wanna thank you so much. First of all, for great pearls. I think all of us need to learn some of the details, not only about MOC, but about the oral boards. Thank you for all you guys do for neurosurgery and I look forward to having you guys with us for one of our upcoming sessions as well.

- Thanks, Aaron.

- Thanks you, Aaron, pleasure being with you.

- Thank you.

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