FRCS (SN)

This section provides information about applying for and passing the FRCS (Surgical Neurology) exam. The tips are mostly written by Kat Whitehouse, Michael Canty, and Patrick Grover.
For more information or if you have questions about the content of this section,  you can contact the BNTA Examinations Representative, Arnab Gosh.

Applying for the Exam

The exams occur twice per year. Section 1 is in January or July, and Section 2 is March or October. 

For NTNs, you cannot apply before you have had a successful outcome at ARCP at ST6. Therefore, if you applied for the exam straight after a successful ST6 ARCP, you could do the exam in ST7 Jan/March (apply by October); ST7 July/Oct (apply by April); or ST8 Jan/March (apply by October).

You have a maximum of 7 years to complete the examination process. Section 1 has to be completed within 2 years of the first attempt, with a maximum of 4 attempts. Section 2 again has a maximum of 4 attempts.

To apply, you need:

  • 3 references that have gone through your operative logbook. They fill in a structured form, so make sure you get them to do that well before the application date.

  • CV

  • Logbook

  • Section 1 costs £536 and Section 2 £1313. You have to pay the whole £1849 at the start. If you fail, you pay again to take the section you’ve failed. This is a standard amount for all the FRCS exams.

  • For full details of applications, including rules, regulations, and current fees, see: www.jcie.org.uk.


Format of the Exam

By Kat Whitehouse, Michael Canty and Patrick Grover

Section 1

Taken in a Pearson VUE Test Centre wherever you choose. It is done on the same day as some other surgical specialties. Note that there will be people in there doing their driving tests etc. 

Paper 1 is Single Best Answer and takes 2 hours. Paper 2 is Extended Matching Items and takes 2 hours 30 minutes. They are both taken on the same day. You go to the test centre, they check you don’t have any notes etc on you, you put your belongings in a locker and then do the exam. In between the two there is a break where you can go and get some food. Note that you can’t revise or read through textbooks in the examination centre.

They tell you that it takes 2 weeks for results to come out, but, possibly because we are a relatively small specialty, it took under a week for my cohort.

Within the exam, there are some questions that will be removed at the standard-setting. All questions are analysed and anything unexpected is discussed, and if incorrect or irrelevant, questions may be removed. Therefore, when you sit the exam, if there is a question that you find difficult, or don’t understand – answer it to the best of your ability, and move on to the next one. I certainly came out of the exam thinking I had failed, but hadn’t, so don’t be disheartened straightaway.

Section 2

This is held over 2 days, somewhere within the UK. This is the clinical exam. In my case, the clinical examinations were the first day, and oral examinations on the second day. What time you have your exam is alphabetical by surname.

The marking scale is 4-8, with a 6 being a “pass”, over 84 marking events. Each section is double-marked. If you do badly in one section, you can make up the marks in the next section (there is no requirement for an aggregate pass).


The long case

This is 30 minutes long. It is somewhat like what you would expect from seeing a patient in clinic with no notes. You take a history, examine the patient, and summarise your findings. You then discuss differential diagnoses, what investigations you would request, and interpret whatever scans etc they give you (in our case, eg laminated A4 sheets with one axial cut CT). Then you discuss management options and perhaps how you would do any appropriate operation. Of course, there are marks for communication and professionalism.


The short cases

This section is 30 minutes to see 4 patients (therefore, allowing 1 minute to move from room to room, approx. 6 mins each case). These are really quick-fire, and are intended to make you target your thinking. You do not get the chance to do proper introductions etc, and the examiner will say something like “This patient has difficulty with speech, please examine this function” – you have to be fast, smooth and specific. They’ll ask for the likely diagnosis (maybe say one or two, don’t go on and on) and then ask you some pretty quick questions to test your higher thinking. The short cases are so quick-fire you come out feeling dizzy from all the spinning around between different rooms.


Day 2

There are 3 stations:

  • Operative/surgical anatomy

  • Investigation of neurosurgical patient including neuroradiology

  • Non-operative practice/applied basic sciences

So, on this second day you go to a hotel and the examiners are sat, two-to-a-table, and you circulate between them, so that you go to three of the “stations” and have 30 mins on each of the above areas. Each station has, I think 6 different topics/cases to be discussed.


Other general things

For the second exam, again, results are said to take about 2 weeks, but ours were back quicker.

The Norman Dott medal is an annual award to the most outstanding candidate at the first sitting of section 2.

For those who are unsuccessful in the exam, they receive a final performance report, so they can see where their weaknesses lie.

There is an appeal process that applies to the conduct of the examination. The appeal fee is £1250.

Full examination information with rules, regulations, and example questions is available at: www.jcie.org.uk

Recommended Reading

By Kat Whitehouse, Mike Canty and Paddy Grover

Below are the main books we bought and read in anticipation for the exams, or had recommended to us, along with the prices on Amazon (secondhand/RRP on Amazon 09/09/17).

For Paper 1

  • Neurosurgery self-assessment – Shah, Cadoux Hudson etc etc £45.99/£57.99

  • Neurosurgery practice questions and answers – Shaya, Nader, Nanda £16.00/£33.98

  • Neurosurgery board review – Alleyne, Woodall, Citow £55.98/£71.00

  • Psarros “Intensive Neurosurgery Board Review: Neurological Surgery Q and A £82.36

  • Landmark Papers in Neurosurgery – Johnson and Green £64.10 /£69

  • Anatomic basis of neurologic diagnosis – Albertstone, Benzel etc £59.02/£98.00

  • Basic Clinical neuroscience – Young, Young and Tolbert £30.89/£53.10

  • Manter and Gatz’s Essentials of clinical neuroanatomy and neurophysiology (£6.71/£29.95)

  • Of course – Greenberg’s “Handbook of Neurosurgery” (£67.91/£93); or Samandouras’s “The neurosurgeon’s handbook”(£45/£67.50) – which is a bit more readable.

For Paper 2

  • Neurosurgery – Elwell, Kirollos etc £23.83/£56.04

  • Neurosurgery oral board review – Citow and Adamson £24.90/£46.50

  • Rhoton

  • Atlas of Neurosurgical Techniques – Sekhar and Fessler (£277.69/£356.50 for all you rich people out there, although this book is definitely not necessary to pass!)

  • Core techniques in operative neurosurgery – Jandial, McCormick etc £98/166.56

  • FRCS Neurosurgery viva case book – Ian Anderson and Paul Marks £42 used

  • Neurosurgery case review – Nader £65/£112


Exam Tips

By Kat Whitehouse, Mike Canty and Paddy Grover

Section 1

There are a few areas that you might not usually consider needing to revise, such as:

  • Medications, side effects and indications

  • Neurological conditions and differential diagnoses

  • Landmark neurosurgery papers, especially high-impact recent ones

  • Guidelines: WHO Tumour Classification, RCP Stroke guidelines, Society for Endocrinology Pituitary Apoplexy Guidelines

  • DVLA guidelines

  • Ethical issues, especially including recent issues and SBNS position statements, for example on the transfer of emergency patients; Duty of Candour; Montgomery v Lanarkshire ruling

  • Medical school physiology – eg coagulation cascade and drugs, ABG interpretation

Section 2

There are 8 weeks-ish between the first exam results and second exam. The Aberdeen FRCS course was one month before the exam, and we highly recommend it, as it directs your learning well. It teaches you how to concentrate your examinations and speed up in the short cases. There is a London course too.

You should attend clinics and discuss cases/topics with allied consultants – ophthalmology, electrophysiology, ENT, neurology, paeds, parkinson’s, neuroradiologists. Go to epilepsy-, neurovascular-, neuro-oncology-, spinal-, and skull base-MDTs; and any others that may be appropriate. Practise examinations properly on patients – ask for good patient examples from the neurology team and your neurosurgical colleagues. Talk through how you do operations – simple stuff like ACDFs, lumbar microdiscectomies, craniotomy, FMDs etc. A lot of people recommend doing this out loud in front of a mirror – that’s good to get you used to saying things out loud and seeing what your body language is like.

There are a lot of things you won’t find in textbooks, because they are out of date, such as guidelines and new reviews.

Things you may need to know but might not have considered (definitely not exhaustive!)

  • Pituitary apoplexy guidelines

  • Stroke guidelines (more recently the RCP including decompressive craniectomy)

  • Massive transfusion protocols

  • ATLS

  • DVLA guidelines

  • NICE Head injury guidelines including paediatric

  • Ways to measure cerebral perfusion including transcranial doppler

  • Different methods of measuring ICP including PRx

  • ICP waveforms

  • Autoregulation

  • SIADH vs cerebral salt wasting

  • Complex regional pain syndrome guidelines from RCP

  • Parkinson’s guidelines for diagnosis and treatment (inc mechanisms of medications)

  • CJD/TSE guidelines

  • How shunt valves work

  • Epilepsy surgery work up

  • C-spine imaging guidelines (Canadian and NEXUS) and spine clearance

  • Seizure classification system

  • Spinal conditions – eg rheumatoid, ank spond, achondroplasia, Klippel-Feil

  • TLICS/SCLICS – although in the clinical they generally just need to know if you are able to accurately classify a fracture as stable or not, so the AO system should be ok.

  • Spinal trauma eg dislocated spine

  • Draw a sarcomere

  • Draw and interpret the reflex arc

  • Draw and interpret an action potential

  • Draw and interpret a synapse

  • Brainstem testing guidelines (try to talk to your friendly local ITU docs)

  • How does the body sense and modulate pain?

  • How does MRI work?

  • Paeds emergency guidelines including fluid management

  • Management of the sick child

  • Developmental milestones

  • Non-accidental injury

  • Doses of drugs including lignocaine, bupivacaine, mannitol and how they work with side effects

  • Mechanism of action of the anaesthetic drugs

  • Outcome scores – MRS/GOS/eGOS

  • Tumours – awake craniotomy/gliadel/gliolan/PFS and life expectancy after surgery +/- RTx +/- chemo

  • Coagulation cascade and how warfarin, heparin, rivaroxaban, dagibatran, aspirin, DIC, clopidogrel affect it

  • You’ll need to interpret ABGs, visual field tests (Humphrey and Goldman), BAEPs, PTA (pure tone audiometry), as well as the standard radiology scans