Functional/Stereotactic

The faculty members involved in functional neurosurgery at Yale include Drs. Gerrard, Chiang, King, and Spencer. The Epilepsy Surgery Program is a well-developed, separate clinical program and is described elsewhere. In addition, there is substantial representation in the Gamma-Knife Program, especially in the treatment of trigeminal neuralgia.

The remainder of this program consists of interventions designed to treat several different entities. These include movement disorders, peripheral nerve injury, trigeminal neuralgia, psychiatric disorders, spasticity and pain. Because of the varied nature of these problems, as well as the relative infrequency of any one particular type of patient, these cases are seen in each individual physician’s clinic. The expected goals of educational development for junior, mid-level and senior residents for movement disorders, peripheral nerve surgery and trigeminal neuralgia are outlined below. The educational goals for the potpourri of other disorders follow a similar pattern.

Junior Residents

Movement Disorders – Identify and distinguish the major types of movement disorders, including Parkinson’s disease, essential tremor and dystonia. Develop a working knowledge of the medical management of each of these disorders. Develop an understanding of the differential diagnosis and possible confounding causes of syndromes similar to these. Perform physical examination of a patient with movement disorders. This is accomplished by a combination of clinical neurosurgery and clinical neurology rotations as well as direct didactic discussions.

Trigeminal Neuralgia – Identify the pain syndrome of trigeminal and distinguish it from other causes of facial pain. Develop a working knowledge of the medical management of this disorder. Develop an understanding of the differential diagnosis and possible confounding causes of syndromes similar to these. Perform physical examination of a patient with movement disorders. This is accomplished by a combination of clinical neurosurgery and clinical neurology rotations as well as direct didactic discussions.

Peripheral Nerve Surgery – Identify the major types of peripheral nerve disorders including trauma, entrapment, neoplastic and systemic disorders. Develop a working knowledge of the non-surgical management of these disorders. Perform physical examination of a patient with peripheral nerve disorders. Develop knowledge of the surgical anatomy involved in carpal tunnel surgery, sural nerve biopsy and sural nerve harvest and assist or act as primary surgeon in these cases.  This is accomplished by a combination of clinical neurosurgery rotations as well as direct didactic discussions. This is supplemented by direct operating room supervision of the care of patients with these disorders.

Mid-Level Residents

Movement Disorders – Building upon the foundation established above, further understand the selection of different targets within the extrapyramidal motor system that can be targeted for surgical intervention. Understand the role of ablative surgery with thermal/radiofrequency lesions and stereotactic radiosurgery and distinguish these from deep brain stimulation (DBS). Develop an understanding of the anatomy and surgical techniques utilized for the stereotactic placement of lesions and DBS electrodes.  This is accomplished by a combination of clinical neurosurgery rotations, direct didactic discussions and direct participation in the operative care of patients with movement disorders at an assistive or primary surgeon level.

Trigeminal Neuralgia – Midlevel residents are expected to further their understanding of the selection of different surgical modalities for the treatment of trigeminal neuralgia, including thermorhizolysis, stereotactic radiosurgery and microvascular decompression. Develop a working knowledge of the surgical anatomy and techniques for thermorhizolysis and stereotactic radiosurgery for trigeminal neuralgia.  This is accomplished by a combination of clinical neurosurgery rotations, direct didactic discussions and direct participation in the operative care of patients with trigeminal neuralgia at an assistive or primary surgeon level.

Peripheral Nerve Surgery – Utilizing the concepts established above, further understand the surgical selection and operative management of brachial plexus injury patients, patients with entrapment neuropathies other that carpal tunnel, patients with reflex sympathetic dystrophy and peripheral neuromas.
This is accomplished by a combination of clinical neurosurgery rotations, direct didactic discussions and direct participation in the operative care of patients with peripheral nerve disorders at an assistive or primary surgeon level.

Senior Residents

Movement Disorders – Using the base of knowledge thus far established, further understand the nuances of placement of lesions and electrodes. Develop an understanding of the electrophysiologic placement of subthalamic nucleus electrodes. Understand the steps to identify incorrectly placed electrodes and correct their placement intraoperatively.  This is accomplished by a combination of clinical neurosurgery rotations, direct didactic discussions and direct participation in the operative care of patients with movement disorders at an assistive or primary surgeon level.

Trigeminal Neuralgia –Further understand the options for surgical failures with trigeminal neuralgia. Develop a working knowledge of the surgical anatomy and techniques for microvascular decompression for different cranial neuralgias.
This is accomplished by a combination of clinical neurosurgery rotations, direct didactic discussions and direct participation in the operative care of patients with trigeminal neuralgia at an assistive or primary surgeon level.

Peripheral Nerve Surgery – Further understand the surgical problems, complications and failures of nerve transfer for brachial plexus injury and the indications for other surgical nerve grafting procedures (i.e. hypoglossal to facial transfers).  This is accomplished by a combination of clinical neurosurgery rotations, direct didactic discussions and direct participation in the operative care of patients with peripheral nerve disorders at an assistive or primary surgeon level.