Neurosurgery Resident Rotations

• Peter Rasmussen, MD
• Thomas Masaryk, MD
• Mark Bain, MD
• Erin Dyer, MD

The Section of Cerebrovascular and Endovascular Neurosurgery oversees patient care and postgraduate education in basic and clinical research that pertains to the micro-surgical or endovascular treatment of cerebrovascular disease. The integration of cerebrovascular surgery and endovascular neurosurgery is unique to Cleveland Clinic. It represents a vital component of a multispecialty cerebrovascular center providing a seamless environment for interaction among diagnostic neuroradiology, neuroanesthesia, neurosurgical intensive care, stroke neurology and the basic neuroscience research group. Since its inception, both surgical and endovascular case volumes have increased steadily.

Residents who are assigned to the unified cerebrovascular and endovascular neurosurgery service will find it both busy and challenging. Specialists in the section provide micro-surgical and endovascular treatment for occlusive cerebrovascular disease, cerebral aneurysms, arteriovenous malformation and other extra- and intracranial cerebrovascular diseases. The Cleveland Clinic is a tertiary referral center for complex cerebrovascular surgical problems. However, a large number of patients with less difficult cerebrovascular problems are also treated here, providing a balanced educational opportunity.

Section members view resident training education as an extremely important responsibility. The educational objectives include mastery of key skills in cerebrovascular disease and the management of patient data to provide unified care plans. In addition, emphasis is placed on the development of problem-solving skills in the operating room, angiography suite, intensive care unit, inpatient ward and outpatient clinic. Routine contact with endovascular surgeons gives residents the opportunity to participate in a wide variety of endovascular treatment options for patients with cerebrovascular disease. Neurosurgical residents are exposed to neurovascular surgery while rotating on the cerebrovascular neurosurgery service, as well as during a diagnostic neuroradiology rotation. In addition to cerebrovascular disorders, additional experience is gained in the management of skull base lesions (pre-operative embolization and test balloon occlusions), as well as functional testing [WADA testing]).

The section has active clinical and basic research programs. Residents are strongly encouraged to spend research and elective time in the cerebrovascular research laboratory under the supervision of the appropriate basic scientist or clinical faculty.

Post-graduate fellowships in endovascular and cerebrovascular micro-neurosurgery are offered. Residents desiring additional training may apply for formal training in an ACGME-eligible endovascular neurosurgery fellowship.

• William Bingaman, MD
• Jorge Gonzalez-Martinez, MD

The Section of Epilepsy Surgery collaborates closely with the Department of Neurology's Section of Adult Epilepsy and Sleep Medicine and Pediatric Epilepsy and represents one of the world's largest and most comprehensive clinical epilepsy surgery programs.

More than 250 epilepsy surgeries are performed each year, including implantation of stereotactic depth electrodes; subdural grid electrodes; microsurgical temporal lobectomy; extratemporal resection; hemispherectomy; corpus callosotomy and minimally invasive approaches.

Residents from the departments of Neurological Surgery and Neurology participate in the Epilepsy Surgery clinical and research programs. This involves mastering the skills necessary to perform resective surgeries in pediatric and adult epileptics. Senior residents are expected to master all surgical procedures for intractable epilepsy.

Residents also are encouraged to spend research or elective time on clinical and basic projects within the Section of Epilepsy Surgery, under direct supervision of the section head.

Section members collaborate with Experimental Neurophysiology and Epilepsy Laboratory staff on basic research related to the mechanisms of epileptogenicity. Research includes electrophysiologic and histochemical studies on resected epileptic foci and development of experimental models of focal epilepsy.

The Epilepsy Monitoring Unit staff is researching the fundamental anatomy and mechanisms of epileptogenicity in the human brain, using data from long-term implantation of subdural electrodes in epilepsy patients.

• Andre Machado, MD

The Section for Neurological Restoration and Stereotactic Neurosurgery program has three full time neurosurgeons and a consultant neurosurgeon who perform over 250 functional neurosurgical procedures annually.

The Section for Functional and Stereotactic Neurosurgery program has three full time neurosurgeons and a consultant neurosurgeon who perform over 250 functional neurosurgical procedures annually.

Clinical activities involve surgery for the management of movement disorders, chronic pain, epilepsy and psychiatric disorders. Surgeries performed include deep brain stimulation, motor cortex, spinal cord and peripheral nerve stimulation, intrathecal pumps, and lesioning procedures. A multidisciplinary approach and close collaboration with neurology, neurophysiology, pain management, psychiatry, radiology and biomedical engineering are emphasized.

Neurosurgery residents are exposed to a large volume of procedures encompassing the entire spectrum of functional neurosurgery. Residents assigned to the service will progressively learn and master comprehensive evaluations, patient selection and surgical management of patients with intractable neurological disorders. This includes surgery for Parkinson disease, essential tremor, dystonia, multiple sclerosis, tremor, spasticity, epilepsy, chronic pain, obsessive compulsive disorder and depression.

Research activities encompass intraoperative neurophysiology, functional brain imaging, using functional MRI (fMRI) and magnetoencephalography (MEG). An active research program is also in place studying deep brain stimulation in various laboratory models. Through strong collaboration with biomedical engineering, the next generation of neural pacemakers are being developed. Additionally, molecular biology and targeted gene therapy strategies are being applied to neurorestoration and neuromodulation. A large number of clinical studies are always in progress. Residents are encouraged to participate in any one of these research projects.

• Gene Barnett, MD
• Lilyana Angelov, MD
• Joung Lee, MD
• Michael Vogelbaum, MD
• Robert Weil MD

The neurosurgical oncology program provides unique exposure to state-of-the-art technology and management for residents interested in central nervous system disorders. In this rotation residents participate in the evaluation and management of patients with benign and malignant tumors affecting the brain and its surrounding areas.

Intraoperative MRI, frame and frame less stereotactic brain biopsy, minimal access craniotomy, interstitial irradiation and radiosurgery are well-established procedures at Cleveland Clinic, performed frequently (nearly 450 cases per year) by the Brain Tumor and Neuro-Oncology Center staff. Innovative research in the molecular biology and immunology of brain tumors proceeds in several Cleveland Clinic laboratories. This research is applied to patient management as part of clinical investigations.

An interdisciplinary team of neurosurgeons, neuro-oncologists, radiation therapists, oncologists and neuroradiologists manages tumor patients with the help of physical and occupational therapists and social workers. Residents on this services are expected to participate in weekly tumor board meetings that review patient pathology and devise management strategies. Innovative approaches to the medical management of brain tumor patients include in-house phase I and II clinical trials and participation in national cooperative studies.

This section is active in innovative uses of computers in neuro-oncology and neuroimaging. Advanced radiologic techniques applied to stereotaxy here include interventional neuroradiology, functional MRI (fMRI), intraoperative MRI (iMRI), positron emission tomography (PET), single-photon emission computed tomography (SPECT), magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS).

Residents rotating through this section are expected to master principles of various stereotactic systems and to utilize minimal access, computer-assisted techniques in the removal of brain tumors.

Cleveland Clinic pioneered radiosurgery in the late 1980s. Today, that clinical experience is combined with Ohio's first Gamma Knife Radiosurgery Unit, where approximately 300 procedures are performed each year. Our Center is one of three in the world certified to teach medical professionals new to the technology, and special courses aimed at teaching the principles of radiosurgery are given yearly. Other types of radiosurgery are offered, including the Novalis shaped-beam system.

• Edward C. Benzel, MD
• Iain H. Kalfas, MD
• Ajit Krishnaney, MD
• Tom Mroz, MD
• Richard Schlenk, MD

The Section of Spinal Surgery specializes in the neurosurgical management of patients with spinal disorders. Staff members perform approximately 800 spinal procedures each year.

Cleveland Clinic neurosurgeons manage patients requiring spinal instrumentation and fusion and also perform common spinal procedures. They use diverse instrumentation systems for spinal stabilization, including anterior and posterior cervical spine plate fixation, thoracolumbar rod instrumentation and lumbosacral pedicle fixation.

Members of the spine section collaborate closely with orthopaedic surgeons, neurologists, rheumatologists, anesthesia pain specialists and physical therapists to provide specialized care tailored to the needs of each patient. There are over 15 medical spine specialists at Cleveland Clinic who make up a broad base for surgical referrals.

Neurosurgery residents assigned to the spinal surgery service are exposed to comprehensive evaluation and management of patients with a variety of degenerative, traumatic and neoplastic spinal disorders. An extensive surgical experience allows the resident to rapidly develop technical skills. Junior-level residents gradually learn to perform cervical and lumbar laminectomies, lumbar discectomies and some anterior cervical discectomies. They are also encouraged to participate in all instrumentation and fusion procedures.

The chief resident is further expected to master simple and complex exposures of the spine, and to perform spinal tumor excisions and all instrumentation and fusion procedures.

The section's large patient volume provides multiple opportunities for clinical research. This has been enhanced by the implementation of the Spine Database Management Program. In addition, Cleveland Clinic's Spine Research Laboratory provides a myriad of basic science research opportunities. Residents are encouraged to participate in one or more of these spine-related options, including one- or two-year research fellowships.

• Mark Luciano, MD
• Violette Recinos, MD

Members of the Section of Pediatric Neurosurgery deal with a wide variety of congenital and acquired lesions of the brain, spinal cord and peripheral nerves. Approximately 5,500 children are seen in the pediatric neuroscience outpatient clinic, resulting in over 300 operative cases per year.

Neurosurgical residents usually spend two, three-month rotations as junior residents on the pediatric neurosurgery service. During this time, they are encouraged to undertake a clinical research project for presentation at a national meeting.

Each chief resident spends six months running the pediatric neurosurgery service and performing routine and complex operations. By the end of the year, the chief resident will have managed most pediatric neurosurgical disorders, and is encouraged to participate in the annual meeting of the Pediatric Section of the American Association of Neurological Surgeons.

The following subspecialty programs comprise the Cleveland Clinic's Section of Pediatric Neurosurgery:

Pediatric Brain Tumors

Residents gain extensive intraoperative exposure to microsurgical techniques and computer-assisted stereotactic neurosurgery. Cleveland Clinic neurosurgeons operate on approximately 60 patients with pediatric brain and spinal tumors per year. Cases are discussed at a weekly brain tumor conference.

Birth Defects

Cleveland Clinic Children's birth defect program follows children with a wide range of congenital brain, craniofacial and spinal anomalies, including spina bifida and myelomeningocele, hydrocephalus, tethered cord syndrome and other forms of occult spinal dysraphism.

A multidisciplinary surgical team performs complete craniofacial reconstructions for craniosynostosis and other anomalies.

Cerebral Palsy

In this program, a pediatric neurosurgeon, a pediatric orthopaedic surgeon and physical therapists evaluate children with cerebral palsy to determine their optimal management. Cleveland Clinic neurosurgeons have an active program in selective dorsal rhizotomy, a microsurgical procedure that reduces spasticity in some children. Other children with the disease may benefit from an implanted device for CSF drug delivery.

Epilepsy Surgery

The surgical procedures offered include a variety of electrode placements for monitoring and brain mapping; temporal lobectomy; extra-temporal focal resection; brain tumor resection using functional mapping; corpus callosotomy and hemispherectomy for hemimegalencephaly.

Residents will learn the work-up required to localize epileptic foci, as well as techniques for exposure and removal of epileptic brain tissue.

Hydrocephalus

Advanced treatments in hydrocephalus are being developed and used at Cleveland Clinic. The neuroendoscope is used in placing shunts, locating hydrocephalus and performing ventriculostomies. Computer-assisted neuroendoscopic procedures are being developed here for complex cases.

Basic research in the pathophysiology of hydrocephalus gives the resident a balanced and thorough exposure to hydrocephalus and its treatments. Clinical research programs in hydrocephalus give exposure to treatments in hydrocephalus.

• Joung Lee, MD

The Section of Skull Base Surgery is an integral part of Cleveland Clinic. By combining the highly specialized techniques of interventional neuroradiology, otolaryngology, neurosurgery, ophthalmology and plastic surgery, the principal goal of skull base surgery is to access deep-seated, difficult-to-reach lesions by anatomic displacement or extensive removal of the base of the skull. These techniques reduce or eliminate the need for brain retraction, thereby minimizing injury to the brain, cranial nerves and blood vessels.

Skull base surgery techniques are commonly used to treat various lesions in or around the paranasal sinuses and the floor of the anterior fossa, orbit, infratemporal fossa, sella, clivus, cavernous sinus, temporal bone/petrous apex, posterior fossa and the foramen magnum region.

The Section of Skull Base Surgery annually performs approximately 150 skull base operations. These include acoustic neuroma resections performed in close collaboration with the members of the Section of Neurotology in the Department of Otolaryngology and Communicative Disorders. Other skull base procedures performed treat cavernous sinus tumors, aneurysms, tumors located in the petroclival and the foramen magnum regions, giant pituitary microadenomas and other tumors around the suprasellar/parasellar areas.

During their rotations, residents actively participate in all facets of skull base pathology management, including diagnostic evaluations, surgical planning, postoperative and follow-up care, as well as alternative management plans when surgery is not appropriate. They also learn complex skull base anatomy and various surgical approaches, indications, risks, benefits and outcomes associated with skull base surgery.

Toward the end of their rotation, chief residents are expected to master skull base surgical exposure, tumor resection and closure.

The section holds quarterly surgical anatomy sessions using fixed cadavers. Different surgical techniques including transfacial, transpetrosal, extreme lateral transcondylar, and transoral approaches, as well as cavernous sinus exposure are demonstrated and taught.

This section focuses its research efforts in two areas:

• Functional outcomes following surgical management of skull base surgery.
• Tumorigenesis of benign brain tumors.

• Damir Janigro, PhD

Dedicated to the advancement of neurosurgery through the exploration of clinical questions at the laboratory bench, the department has undertaken a major, long-term commitment to basic research. This effort has been stimulated by success in scientific accomplishments and external funding.

To help fulfill this commitment, the department has a full-time director of neurosurgical research, who is responsible for facilitating all laboratory projects within the department; and several staff neurosurgeons with strong interest and backgrounds in basic research. A dedicated laboratory provides technical support and expertise in molecular biology, morphology, cell culture, animal surgery and imaging.

The expansion of established projects and the initiation of new programs have strengthened the department’s focus on tumor biology, epilepsy, basic biology of cerebral arteries, aneurysm formation and rupture, arteriovenous malformations, hydrocephalus, cerebral protection of hypothermia in ischemia and the potential therapeutic use of neural transplantation. Residents spend two years in one of these laboratories. The expansion of the Department of Neurosciences within Cleveland Clinic Lerner Research Institute lends additional support to basic neurosurgical research.

The Spine Research Laboratory, jointly sponsored by the Departments of Neurosurgery and Orthopaedics, is focused on transferring technological developments to clinical medicine.

Research studies include biomechanics to examine surgical stabilization strategies and degenerative disorders of the spine; neurophysiology research; existing and novel biomaterials and osteobiologics research to enhance the performance of bone, soft tissue, and the surrounding supportive structures; tissue engineering for the development of restorative spinal function; the incorporation of robotic technology for automated surgical applications to the spine; and the use of microsystems technology in the development of microsized devices for in vivo applications to the spine.

A large number of pituitary and parasellar lesions are evaluated through Cleveland Clinic's Neuro-Endocrine Center. Joint evaluation of patients by neurosurgeons, endocrinologists and radiation oncologists enables comprehensive treatment. State-of-the-art technology, including stereotactic navigation, endoscopy and several radiosurgical modalities (Gamma Knife, Peacock, Cyberknife), facilitates treatment of a variety of disorders. Residents at both the junior and senior level participate in patient management and surgical treatment of patients with pituitary lesions.

• J. Javier Provencio, MD
• Gwen Lynch, MD

Cleveland Clinic's Neurological Intensive Care Unit (NICU) is a fully-equipped, state-of-the-art eight-bed unit staffed by a team of neurologists, neurosurgeons, specially trained nurses, respiratory therapists, nutritionists, and pharmacists, all under the direction of neurointensivists. The unit is equipped for intracranial pressure monitoring, continuous EEG/Evoked Potential monitoring, transcranial Doppler ultrasound monitoring, and brain tissue oxygenation and metabolism monitoring. More than

Patients with major, devastating strokes comprise a large portion of the patient population, along with post-surgical patients, and those with encephalitis, Gullain-Barré syndrome and myasthenia gravis. The team also provides comprehensive care for patients in the step-down/Stroke Unit, which is adjacent to the NICU.

Clinical research programs involve several aspects of neurology and neurosurgery. Specific interests include the use of induced hypothermia for neuroprotection in the setting of acute ischemic stroke. Cleveland Clinic leads the nation in this area and the first, randomized, controlled trial for acute stroke (COOL AID) is centered here. A specific interest of program participants is the use and further development of new neuromonitoring techniques such as brain tissue oxygenation and intracerebral microdialysis.

In addition, several studies evaluating surgical techniques for the treatment of raised intracranial pressure and clot evacuation techniques in patients with intracerebral hemorrhages are ongoing.

National activities include several publications annually in peer-reviewed journals, papers and posters presented at national meetings, and a strong annual presence at the American Heart Association Stroke meeting. Cleveland Clinic's Neurological Intensive Care Program hosted an international conference on neuromonitoring and hypothermia (Neurocritical Care 2001: Returning from the Dark Side of the Brain) drawing hundreds of participants from all over the world.