The Evolving Role of Postgraduate Year 7 in Neurological Surgery Residency

BACKGROUND AND OBJECTIVES

In 2013, all neurosurgery programs were mandated to adopt a 7-year structure. We sought to characterize how programs use the seventh year of training (postgraduate year 7 [PGY7]).

METHODS

We surveyed all accredited neurosurgery programs in the United States regarding the PGY7 residents' primary role and the availability of enfolded fellowships. We compiled responses from different individuals in each program: chair, program director, program coordinator, and current chiefs.

RESULTS

Of 120 accredited neurological surgery residency programs within the United States, 91 (76%) submitted responses. At these programs, the primary roles of the PGY7 were chief of service (COS, 71%), enfolded fellowships (EFF, 18%), transition to practice (10%), and elective time (1%). Most residencies have been 7-year programs for >10 years (52, 57%). Sixty-seven programs stated that they offer some form of EFF (73.6%). The most common EFFs were endovascular (57, 62.6%), spine (49, 53.9%), critical care (41, 45.1%), and functional (37, 40.7%). These were also the most common specialties listed as Committee on Advanced Subspecialty Training accredited by survey respondents. Spine and endovascular EFFs were most likely to be restricted to PGY7 (24.2% and 23.1%, respectively), followed by neuro-oncology (12, 13.2%). The most common EFFs reported as Committee on Advanced Subspecialty Training accredited but not restricted to PGY7 were endovascular (24, 26.4%) and critical care (23, 25.3%).

CONCLUSION

Most accredited neurological surgery training programs use the COS as the primary PGY7 role. Programs younger in their PGY7 structure seem to maintain the traditional COS role. Those more established seem to be experimenting with various roles the PGY7 year can fill, including enfolded fellowships and transition-to-practice years, predominantly. Most programs offer some form of enfolded fellowship. This serves as a basis for characterization of how neurological surgery training may develop in years to come.

Terson syndrome secondary to aneurysmal subarachnoid hemorrhage in a child: illustrative case

BACKGROUND

Terson syndrome is the phenomenon of intraocular hemorrhage in the setting of subarachnoid hemorrhage (SAH). Vision loss can lead to morbidity for the affected individual. Aneurysmal SAH related to intracranial aneurysms is rare in children. Studies have shown the incidence of Terson syndrome in adults with aneurysmal SAH to be over 40%; however, few cases of Terson syndrome in pediatric aneurysmal SAH have been reported.

OBSERVATIONS

A 9-year-old male presented with altered mental status and seizures. Computed tomographic angiography showed aneurysmal SAH from a ruptured, left-sided posterior inferior cerebellar artery aneurysm. The patient underwent endovascular treatment with coiling and external ventricular drainage for SAH. Ophthalmological consultation for blurry vision revealed the diagnosis of Terson syndrome with decreased vision in the left eye, which was managed conservatively.

LESSONS

Terson syndrome after SAH can occur in children. Prompt ophthalmological evaluation in pediatric patients with aneurysmal SAH is vital for recognition and management to decrease overall morbidity.

A Three-dimensional Printed Low-cost Anterior Shoulder Dislocation Model for Ultrasound-guided Injection Training

Anterior shoulder dislocations are the most common, large joint dislocations that present to the emergency department (ED). Numerous studies support the use of intraarticular local anesthetic injections for the safe, effective, and time-saving reduction of these dislocations. Simulation training is an alternative and effective method for training compared to bedside learning. There are no commercially available ultrasound-compatible shoulder dislocation models. We utilized a three-dimensional (3D) printer to print a model that allows the visualization of the ultrasound anatomy (sonoanatomy) of an anterior shoulder dislocation. We utilized an open-source file of a shoulder, available from embodi3D® (Bellevue, WA, US). After approximating the relative orientation of the humerus to the glenoid fossa in an anterior dislocation, the humerus and scapula model was printed with an Ultimaker-2 Extended+ 3D® (Ultimaker, Cambridge, MA, US) printer using polylactic acid filaments. A 3D model of the external shoulder anatomy of a live human model was then created using Structure Sensor®(Occipital, San Francisco, CA, US), a 3D scanner. We aligned the printed dislocation model of the humerus and scapula within the resultant external shoulder mold. A pourable ballistics gel solution was used to create the final shoulder phantom. The use of simulation in medicine is widespread and growing, given the restrictions on work hours and a renewed focus on patient safety. The adage of "see one, do one, teach one" is being replaced by deliberate practice. Simulation allows such training to occur in a safe teaching environment. The ballistic gel and polylactic acid structure effectively reproduced the sonoanatomy of an anterior shoulder dislocation. The 3D printed model was effective for practicing an in-plane ultrasound-guided intraarticular joint injection. 3D printing is effective in producing a low-cost, ultrasound-capable model simulating an anterior shoulder dislocation. Future research will determine whether provider confidence and the use of intraarticular anesthesia for the management of shoulder dislocations will improve after utilizing this model.