Spine

At the conclusion of the residency rotations on this service, the graduate is expected to be proficient in care of spine problems and their associated rehabilitation as might be encountered in the general practice of orthopaedics. It is important to recognize that competency as a physician extends beyond medical knowledge and direct patient care. Therefore, evaluations for the spine service will include not only those competencies specific for each subspecialty such as medical knowledge, but also demonstration of abilities in practice-based learning, interpersonal communication skills, professionalism, patient care, and systems-based practice.

The overall goal of the Adult Spine Service is to provide the resident with an educational experience that maximizes the opportunity to understand, evaluate, and treat conditions that affect the spine. This is achieved by combining a structured study program that utilizes an extensive recommended reading list with a clinical experience that has an appropriate balance between office and emergency room evaluation and surgical treatment of conditions of the spine. Junior and senior level residents rotate through the Adult Spine Service for two to three month blocks and assume responsibility based upon demonstrated knowledge, previous experience, and clinical skills.

Prior to the beginning of the rotation, each resident must contact Dr. Knaub’s secretary 717-531-2770 to obtain a reading list, and to schedule a beginning, mid-rotation, and end of the rotation final evaluation.

Reading List

The reading List can be found on the Department of Orthopaedics and Rehabilitation Intraweb under the Residency/Curricula section.

The list consists of basic readings from major spine texts and review publications from the AAOS. These readings are intended to serve as a foundation on which the residents build their fund of knowledge. The junior resident on the service should read this material early in their rotation. The senior resident on the service should be familiar with this information from previous experience. The remainder of the reading list is composed of more in-depth reading on specific topics that should be utilized for preparation for surgical cases or for higher-level understanding of conditions that are seen and evaluated in the outpatient setting.

Goals and Objectives

Medical Knowledge and Patient Care:

It is expected that junior level residents on the Adult Spine Service will:

  • Learn/know the appropriate applied anatomy.
  • Become proficient at performing a history and physical exam.
  • Learn/know the indications for obtaining radiographs and other imaging and diagnostic studies and develop interpretive skills.
  • Develop the ability to formulate a basic differential diagnosis.
  • Understand the concepts of nonoperative treatment and indications for surgery.
  • Recognize unstable injuries to the spine and develop the skills to immobilize patients with these injuries.
  • Learn/know the commonly utilized surgical approaches to the spine and become facile with the routine posterior approaches to the cervical and thoracolumbar spine.
  • Become proficient at harvesting autogenous iliac crest bone graft from the anterior and posterior pelvis

It is expected that senior level residents on the Adult Spine Service will:

  • Be knowledgeable of the above expectations of the junior level resident.
  • Have advanced diagnostic skills.
  • Have a clear understanding of surgical indications and conditions amenable to surgery.
  • Have a strong understanding of biomechanical and biological principles guiding surgical techniques and rehabilitation.
  • Recognize traumatic injuries in which closed reduction or halo vest immobilization is needed and develop the ability to implement these treatment methods
  • Become proficient with all surgical approaches to the spine
  • Demonstrate the ability to perform simple spine procedures including lumbar discectomy, lumbar laminectomy, and the placement of lumbar pedicle screw/rod constructs
  • Be familiar with emerging technologies, options, and controversies of surgical management.
  • Demonstrate familiarity with the literature that governs treatment.


Interpersonal and Communication Skills – Goal: Both junior and senior level residents will be expected to be respectful to patients and all members of the health care team at all times. This includes the following objectives:

  • Both junior and senior level residents will demonstrate the ability to discuss difficult matters with patients and families in a compassionate manner. The level of discussion should be commensurate with the medical knowledge and experience of the resident.
  • Both junior and senior level residents will demonstrate the ability to allow patients and families to fully express their concerns and/or symptoms.
  • Both junior and senior level residents will demonstrate the ability to explain operative procedures, risks and post-operative care to the patient/family, commensurate with their medical knowledge and experience.
  • Both junior and senior level residents will demonstrate the ability to develop a professional relationship with the patient/family.
  • Both junior and senior level residents will maintain professional communications and relationships with ancillary staff and medical colleagues.
  • Both junior and senior level residents demonstrates effective communication in the informed consent process.


Professionalism – Goal: Both junior and senior level residents will be expected to act professionally toward patients and all members of the health care team at all times. This includes the following objectives:

  • Both junior and senior level residents will demonstrate sensitivity and responsiveness to differences in culture, gender, age and impairments.
  • Both junior and senior level residents will demonstrate sensitivity to the needs of patients/families.
  • Both junior and senior level residents will respect the need for confidentiality of patient information.
  • Both junior and senior level residents will always demonstrate honesty in written and oral communications.
  • Both junior and senior level residents will demonstrate awareness of limitations and seek advice when appropriate.
  • Both junior and senior level residents will accept advice without personal offense and use it constructively.
  • Both junior and senior level residents will assess their performance with objectivity and accuracy.


Practice Based Learning and Improvement: - Goal: Both junior and senior residents will demonstrate commitment to continuous learning and improvement in their patient care, benefiting from previous experiences and ongoing review of the literature, and contributing to the education of those around them. This includes the following objectives:

  • Both junior and senior level residents will contribute to the education of medical students and other health care professionals. Although senior level residents will provide the leadership in this, the more junior level residents can play a meaningful role as well.
  • Evaluate medical research/scientific evidence and applies findings to patient care. The more junior level residents will frequently utilize textbooks, review articles and “classic” articles. More senior level residents will actively seek out more recent and perhaps “cutting edge” manuscripts that are applicable to patient care.
  • Both junior and senior level residents will monitor their own practice of medicine to identify opportunities for improvement.
  • Both junior and senior level residents participate in the morbidity and mortality process.
  • Both junior and senior level residents will effectively utilize information technology to manage and access medical information.
  • The resident, during their entire residency training, gradually assumes increasing levels of independence with decreasing need for faculty supervision, commensurate with the medical knowledge and patient care competencies outlined previously.


Systems Based Practice – Goal: Residents will recognize their role in a complex and financially challenged health care system, identify resources available to them to contribute to patient care, and demonstrate familiarity with internal and external regulations and policies that impact care delivery. This includes the following objectives:

  • Both junior and senior level residents will complete medical records accurately and in a timely manner.
  • Both junior and senior level residents will effectively utilize health care system resources to provide optimal patient care.
  • Junior level residents should be aware of the need to provide cost efficient patient care, and have a basic understanding of the factors that impact this. Senior level residents should have an advanced understanding of the costs associated with their treatment recommendations, and be able to justify treatment not only on medical decision making but cost considerations as well.
  • Both junior and senior level residents will assist patients in dealing with health care complexities and serve as advocates for patients within the health care system.
  • Both junior and senior level residents are attentive to the manner in which the health care system may impact patient safety and take steps to prevent errors. This includes awareness of National Patient Safety Goals and Federal and hospital quality improvement projects.
  • Both junior and senior level residents are attentive to medication errors, surgical site infection and venous thromboembolic disease.
  • Both junior and senior level residents adhere to the standards of surgical site identification, awareness of wrong site surgery and adherence to surgical time out.