Curriculum for spine fellowship – 2 years
Duration
23 Months
Curriculum overview:
Theoretical knowledge : Syllabus is enclosed below
Skills: Clinical skills and surgical skills (described below)
Research experience: Described below
Attitude: To be shown by candidates throughout the program and assessed by Feedback from mentors. The training involves one to one training.
Theoretical knowledge: Syllabus
Surgical Approaches to Spine
- Cervical
- Thoracic
- Lumbar
Basic osteology of spine
- C1-C2
- Typical subaxial C-spine
- Thoracic spine
- Lumbar
- Sacrum and sacroiliac joint
Basic sciences – Anatomy of spinal column, Neural anatomy, Disc anatomy, biomechanics including spinal stability.
Spinal Instrumentation - Basics (Screw designs, hook designs etc.), Metallurgy basics (properties of SS, Titanium, CC, PEEK) Biomechanics and Applications.
Functional/scoring systems in spine - over view of importance of various scoring systems in different pathologies, validity and reliability, ODI, VAS, SF-36,SRS QUESTTIONAIRE, JOA, MJOA, Nuricks, ASEA grading, tomita, tokuhashi, wang bohlmans, odoms, satisfactions indices.
The Pharmacologic Management of Spine Pain
Therapeutic Exercise for Low Back Pain
Psychosocial Considerations in Spine Disorders
The Interdisciplinary Treatment of Patients With Chronic Pain
Bone Graft Substitutes - Concept of bone healing, pseudoarthrosis, Bone graft substitutes, BMP, Bone matrices, complications, advantages, recent literature
Spinal fusion – PLF, PLIF, TLIF, XLIF , 360 fusion- Indications, techniques, pitfalls and recent literature
Thoracolumbar Trauma - Basic review of classification systems, importance in management, pitfalls, reliability.
Cervical Trauma - Basic review of classification systems, importance in management, pitfalls, reliability.
Lower Lumbar Fractures – Current evidence.
Spondylolisthesis - classification systems, importance in management, pitfalls, overview of low grade versus high grade listhesis management, what’s new in literature.
Scoliosis –Adolescent idiopathicclassification and management
Scoliosis – Congenital / Early onset
Scoliosis - Neuromuscular
Adult deformity – Assessment, Indications and management.
TB spine past present and future. Medical and conservative.
Osteoporotic Fractures overview with indications for cementing
Work life balance
Spinal Dysraphism
CV junction anomalies and AC Malformations
Syringomyelia.
Spinal cord tumours
Overview of literature on various tumours, primary, secondary, management tips from literature, management guidelines on metastasis, GCT SPINE, CHORDOMA SPINE, other primary tumours of spine including recent advances.
Spinal Cord Injury and Rehabilitation strategies/goals
Cervical myelopathy
Options, pros, cons, recent trends
Research methodology.
Ethical issues in spine care.
Clinical competencies: This includes
- Spine degenerative disorders (Clinical competencies)
- Trauma
- Pediatric and adult deformity
- Spinal infections
- Spinal inflammatory disorders
- Spinal fragility fractures
- Spinal tumours
- Congenital disorders of spine
- Afflictions of spinal cord and spinal canal
- Sub-competencies can be developed for each of the above domains and are included in Program outcomes.
Clinical skills:
Clinical competencies: Appropriate clinical competencies under each of these disorders. (for details please refer program outcomes)
Surgical skills:
| Observation | Assist | Perform independently |
|---|---|---|
| Scoliosis correction and instrumentation Thoracoscopic and other anterior assess surgeries | Anterior cervical discectomy and fusion Cervical anterior and posterior instrumentation Long segment cervical, thoracic and lumbar instrumentation Kyphosis correction and stabilization Combined anterior and posterior reconstruction of spinal tumours, spine infections Adult degenerative scoliosis correction and instrumentation Spinal cord tumours Endoscopic discectomy Minimally invasive procedures | Microscopic Discectomy Insertion of thoracic and lumbar pedicle screw insertion and stabilization Decompression Anterior interbody preparation and bone grafting/instrumentation Reduction of thoracolumbar fractures and instrumentation. Vertebroplasty/ percutaneous biopsy |
Research skills:
- At the minimum candidates should submit 2 papers to a pubmed/scopus indexed journal and receive reviews.
- At least two presentation/posters in international/national/state conferences
- To complete two clinical audits (one per year)
Program Outcomes
| No. | Program objective | Program specific Objective. |
|---|---|---|
| Trauma | ||
| PO1 | To make a diagnosis | Examine the patient for a possible spinal cord injury including detailed neurological examination. Maintain spinal immobilization until spinal trauma is excluded Arrange appropriate imaging and identify the radiographic features of instability and cord injury |
| PO2 | To formulate a treatment plan | Classify the spinal injury using standard classification system, and make appropriate treatment plan based on evidence based medicine. Plan a rehabilitation program in patients with neurological deficits using a multidisciplinary approach involving critical care providers (airway management), urologists (for management of bladder problems) Nursing care providers (for bed sores) and physiotherapists. |
| PO3 | To counsel the patient | Describe the risks and benefits of surgical versus conservative management and consider thepatient’s preferences and expectations |
| PO4 | Perform appropriate Procedures | To Perform surgical stabilization of spinal injury patients with or without decompression. |
| PO5 | Manage or prevent Complications | To identify complications at the earliest and initiate appropriate treatment as well as patient counselling. To use appropriate safety checklists for the prevention of complications. |
| Degenerative disc disorders | ||
| PO6 | To make a diagnosis | Elicit detailed history, assessment of disability, and quality of life Examine the patient, including neurological assessment, to exclude myelopathy/radiculopathy Select the appropriate diagnostic tests and interpret imaging results. |
| PO7 | Formulate a treatment plan | Plan a treatment including non-operative and operative treatment using evidence based approach and keeping the patient demands into consideration. Plan appropriate rehabilitation program involving physiotherapists. |
| PO8 | To counsel the patient | Consider the patient’s preferences and expectations Recognize the indications forand limitations ofsurgical intervention. Explain to patient about merits and demerits of both operative and non operative treatment. |
| PO9 | Perform procedures | Reduction/stabilization/decompression/fusion depending upon appropriate indications |
| PO10 | Manage or prevent Complications | Identify complications and manage them. Use of appropriate checklists for the prevention of complications. |
| Adult and pediatricdeformity | ||
| PO11 | To make a diagnosis | Analyze the patient history, comorbidities, disability, and quality of life Examine the patient for spinal imbalance and neurological deficit, other complications including respiratory status. Order appropriate imaging Measure and interpret spinal alignment and spinopelvic parameters Describe the classifications of Scoliosis, Kyphosis, Spondylolisthesis and adult deformities |
| PO12 | Formulate a treatment plan | Form a treatment plan which includes long term goals using evidence based approach. Assess the need for medical optimization of the patient before surgery, including osteoporosis treatment, Plan for augmentation of instrumentation and dealing with the proximal junction. Discriminate between deformity with and without stenosis and the different management required in adult deformities. |
| PO13 | Explain treatment options to patients | Discuss with patients the risks and benefits of surgery compared with conservative treatment Consider the patient’s preferences and expectations Explain to patients about long term outcomes of both non operative and operative treatment. Explain the natural history of progression in pediatric deformities. |
| PO14 | Perform appropriate procedures | Address spinal balance and consider osteotomies, stabilization, augmentation, distal fixation, proximal junction, posterior and/or anterior fusion as a member of team. Perform surgical procedures for deformities like spondylolisthesis, smaller deformities. |
| PO15 | Manage orprevent Complications | Be prepared for the challenges of revision surgery Able to identify the complications and manage them including neurological complications. Use of appropriate checklists. |
| Oncology | ||
| PO16 | To make a diagnosis | Elicit history and examine the patient including neurological assessment and identify the red flag signs. Clinically assess and stage patients with spinal neoplasm using appropriate scoring systems. Classify spinal column neoplasms Describe the pathology of tumors of the spinal column and spinal cord List diagnostic imaging appropriate for tumors of the spine Describe mechanical instability as it relates to spinal column tumors Establish a diagnosis based on histological verification (biopsy) |
| PO17 | Formulate a treatment plan | Plan treatment using evidence based approach including curative and palliative options. Participate in tumour board meetings to discuss options of surgical, chemotherapeutic and radiotherapy treatment. |
| PO18 | Explain treatment options | Discuss with patients and family the surgical and nonsurgical options in view of expected prognosis, risks, outcomes, and quality of life. |
| PO19 | Perform appropriate Procedures | Discuss the surgical principles of resection of primary vertebral tumors Describe the principles of surgical tumor resection for metastatic tumors Perform spine stabilization and decompression in patients with neurological deficits and minimally invasive surgeries like vertebroplasty, |
| PO20 | Manage or prevent complications | Recognize the increased risk of wound problems in patients with debility, prior surgery radiation. Recognise the complications like neurological deterioration and take appropriate measures. To review the prognosis periodically and discuss with the patient. |
| Infection | ||
| PO21 | To make adiagnosis | Describe the clinical features of and differences between pyogenic spondylodiscitis, epiduralabscess, and spinal tuberculosis. Identify the surgical site infections following surgery at the earliest based on clinical features. Order and interpret hematological, microbiological, and imaging tests to confirm spinal infection Isolate and identify the causative organism by aspiration or biopsy, if possible |
| PO22 | Formulate atreatment plan | Identify preoperative risk factors for developing surgical-site infections after spine surgery anddiscuss the preventive strategies to minimize risks. Decide on appropriate antibiotics based on culture and sensitivity and antibiotic policy of hospital and in consultation with microbiologists whenever required. Consider surgical intervention for neurological compression, spinal instability, and debridement |
| PO23 | Explain treatment Options | Discuss with patients the indications for surgical intervention in spinal infection and the potentialrisks and benefits |
| PO24 | Perform appropriate procedures | Perform procedures based on evidence based approach like Debridement, decompression, reconstructionand fusion |
| PO25 | Manage orprevent complications | Manage post-infective complications, including deformity, loss of fixation, pseudarthrosis Emphasize and review patient compliance with frequency and duration of treatment Perform regular clinical and hematological review until resolution of the infection |
| Inflammatory spondyloarthropathy | ||
| PO26 | To make a diagnosis | Assess the patient history, physical findings, disability, and quality of life in patients with suspected inflammatory spondyloarthropathy. Describe the classification of inflammatory spondyloarthropathy List diagnostic tests and imaging modalities Recognize the radiographic features of spinal instability or ankylosis |
| PO27 | Formulate a treatment plan | Describe the principles of medical management of inflammatory arthritis, to initiate appropriate medical management in consultation with rheumatologist using multidisciplinary approach. Describe surgical strategies in ankylosing spondylitis for kyphosis correction, fracture fixation, occipitocervical fusion. |
| PO28 | Explain treatment options to patients | Discuss with patients need for long term treatment, the indications for surgical intervention in spondyloarthropathy and thepotential risks and benefits |
| PO29 | Perform appropriate Procedures | Perform Surgical stabilization of fractures and fusion |
| PO30 | Manage or prevent Complications | Identify Intraoperative and postoperative complications including risk of bleeding, neurological worsening, poor fixation due to associated osteoporosis and take appropriate measures. |
| Osteoporosis and fractures | ||
| PO31 | To make a diagnosis | Recognize that acute vertebral and sacral fragility fractures may be associated with significant morbidity in the elderly List diagnostic tests and imaging modalities for assessing bone density Recognize the radiographic features of spinal fragility fractures Classify osteoporotic fractures of the spine and sacrum |
| PO32 | Formulate a treatment plan | Describe the medical management of osteoporosis Use an evidence based approach for the management of osteoporotic fractures including non operative and operative approaches. |
| PO33 | Explain treatment Options. | Discuss the relative risks and benefits of medical versus surgical treatment of acute vertebralfragility fractures Discuss with patients complications associated with fragility fractures and benefits of the same. |
| PO34 | Perform appropriate Procedures | Perform surgical procedures like instrumentation, vertebroplasty for osteoporotic fractures. |
| PO35 | Manage or prevent Complications | Identify Intraoperative (cement leakage) and postoperative (neuro deficit) complications. Describe strategies for preventing future fractures |
| Research, Ethics and Quality improvement | ||
| PO36 | Research as a lifelong learning tool | Participate in the department research activities as a member of research team. To conduct a research with appropriate research methodology and write a paper and initiate publication. To critically analyse the available literature for a given clinical problem and develop evidence based solutions. |
| PO37 | Participate in quality Improvement | Perform surgical audit on outcomes and complications Enroll patients in a registry/database |
| PO38 | Ethics | Demonstrate ability to recognize and manage ethical and professional conflicts Abide by prescribed ethical and legal codes of conduct and practice |
Teaching Learning Methods:
Mode of teaching-learning methods for knowledge domain:
- Seminars, Power point presentation submission by candidates (should cover entire syllabus).
- Journal clubs (one per month),
- Taking classes for the orthopedic post graduates.
- Self directed learning.
Teaching learning methods for the development of clinical competencies:
Case based discussion
Small group teaching (one to one interaction)
DOAP sessions
Participation as a member of team (Participatory learning).
The fellow will work as a member of team with following responsibilities.
- Work as a member of team involved actively in management of patients including initial assessment, progress recording, participation in team meetings and rounds. Fellow will work directly under supervision of mentors.
- Maintaining documentation for every patient admitted under spine unit.
- Use of skill lab for skill training involving surgical procedures-Use DOAP method.
- Case based discussions as per schedule (2 per week, One to one interaction).
- Maintaining a portfolio of all the activities which includes a reflection on weekly basis summarising the learnings of the week and targets for the subsequent weeks.
- Presentation in conferences.
- Participate in all surgeries as team member.
- Performing the surgical procedures under observation and later independently.
- Case presentation/participation by the fellow in Interdepartmental meetings (pathology and radiology) one for 6 months.
Assessment:
- Assessment
- Evaluation and feedback of Seminar presentation – PPT (2 per month covering the topics mentioned in syllabus)
- Case based discussion- Grade of 8/10 in a minimum of 2 cases per month.
- Internal assessment at 6 months, score of minimum 60%
- Reflections on surgical procedures assisted and identification of goals, evaluated by the mentor.
- Research Project: Two research projects, which should be completed and sent for pubmed/scopus indexed Q1 journals publication and received a review.
- Summative assessment -(Qualifying marks – 50%)
All the academic activities and clinical and surgical work should be documented in the portfolio and must have reflections.
Evaluation of portfolio including reflections with a score of more than 60%
Pattern of examination
- A.Theory examination 200 marks (100 marks short essays, 100 marks problem based)
- B.Clinical examination(mapped for program objectives related to clinical examination, diagnosis and decision making)
Case presentation – two long cases, two short cases (200 marks, so 50 marks each) - C.OSCE- 5 stations 3 on skills, 2 on problem solving or clinical reasoning skills (100Marks) (mapped for program objectives related to examination skills, decision making and counselling)
Books recommended:
- The spine; Rothmon and Simeone
- Spine surgery: techniques, complication avoidance and management – Benzel, Edward.
- Operative techniques – spine surgery – Vaccaro, Alexander
- ASSI textbook on spinal infections and trauma, Dr. S Rajasekaran.
- Operative techniques in spine surgery: Dr. Bhavuk Garg.
Journals:
- Spine
- Global spine journal
- European spine journal
- Indian spine journal.
- Asian spine journal.
