Establishment of Next-Generation Neurosurgery Research and Training Laboratory with Integrated Human Performance Monitoring

The Weill Cornell Skull Base and Microneurosurgery Skills-Based Neurosurgery Fellowship: A 20-Year, 200-Fellow Retrospective

BACKGROUND

Since 2004, the Weill Cornell Fellowship in Skull Base and Microneurosurgery has provided surgeons from around the world with structured, proficiency-driven instruction in complex skull base anatomy, approaches, and techniques in a lab-based setting. We report on the design of this program, review the factors that have contributed to its success, and evaluate its impact on 200 neurosurgeon-alumni over the past 20 years.

METHODS

The 6-12-month fellowship program is tuition-free and open to surgeons worldwide, from senior residents to midcareer surgeons. The program consists of an initial 3 months of training in skull base surgical anatomy, followed by 3-9 months of training in skull base surgical approaches and techniques. All training is closely supervised and follows a standardized sequential dissection curriculum covering the entirety of the skull base. In order to assess the effectiveness and impact of the fellowship program, all alumni were asked to complete a detailed anonymous survey reflecting on their experience and its influence on their surgical abilities and careers.

RESULTS

As of January 2025, 200 neurosurgeons from 57 countries have completed the fellowship program, of which 170 were reachable and 133 (78.2%) completed the survey. Respondents indicated a substantial 58.8% increase in their overall neurosurgical skills, abilities, and armamentarium following the fellowship. A significant increase in specific surgical skills was similarly found postfellowship, with the greatest improvements in navigating the skull base (80.4%), skull base techniques (74.7%), and complications management (70.4%). Overall confidence in performing skull base approaches increased by 50.8%, with the greatest improvements seen in lateral (76.6%) and posterolateral approaches (78.8%). Overall confidence as a neurosurgeon increased by a notable 50.8%, and there was strong agreement that the fellowship was fundamental to their neurosurgery training and made them better neurosurgeons. A total of 98.5% would recommend the program to other neurosurgeons.

CONCLUSIONS

The Weill Cornell Fellowship in Skull Base and Microneurosurgery has become one of the most sought-after neurosurgery training programs in the world and has had a profound and positive impact on its alumni, significantly enhancing their surgical skills and careers. The substantial degree of increases in skills and abilities gained following the fellowship are especially notable given the fellowship's limited duration and are evidence that this model of focused, supervised training can serve as a global benchmark for skills-based neurosurgical training.

Neuroendoscopy Training

Neuroendoscopy can be learnt by assisting or doing live human surgery, cadaver dissection with or without augmented pulsatile vessel and cerebrospinal fluid (CSF) perfusion, and practicing on live animal, dead animal model, synthetic models, three-dimensional printing model with or without augmentation with animal, cadaver tissue, pulsatile vessel and reconstructed CSF model, virtual reality (VR) simulator, and hybrid simulators (combined physical model and VR model). Neurosurgery skill laboratory with basic and advanced learning should be there in all teaching hospitals. Skills can be transferred from simulation model or VR to cadaver to live surgery. Staged learning (first with simple model to learn basic endoscopic technique, then animal model, and then augmented cadavers) is the preferred method of learning. Although most surveys favor live surgery and practice on animal models and cadavers as the most preferred training model now, in future VR may also become a favored method of learning. This article is based on our experience in over 10,000 neuroendoscopic surgeries, and feedback from over 950 neuroendoscopic fellows or consultants who attended workshops conducted every 6 monthly since 2010. A literature search was done on PubMed and Google Scholar using (neuroendoscopy) AND (learning), and (neuroendoscopy) AND (training), which resulted in 121 and 213 results, respectively. Out of them, 77 articles were finally selected for this article. Most of the training programs typically focus on microneurosurgical training. There is lack of learning facilities for neuroendoscopy in most centers. Learning of neuroendoscopy differs greatly from microneurosurgery; switching from microneurosurgery to neuroendoscopy can be challenging. Postgraduate training centers should have well-equipped neuroendoscopy skill laboratory and the surgical educational curriculum should include neuroendoscopy training. Learning endoscopy is about taking advantages of the technique and overcoming the limitations of endoscopy by continuous training.

Development and Evaluation of a Mixed Reality Model for Training the Retrosigmoid Approach

BACKGROUND

The use of simulation has the potential to accelerate the learning curves and increase the efficiency of surgeons. However, there is currently a scarcity in models dedicated to skull base surgical approaches. Thus, the objective of this study was to develop a cost-effective mixed reality system consisting of an ultrarealistic physical model and augmented reality and evaluate its use in training surgeons on the retrosigmoid approach.

METHODS

The virtual models were developed from images of patients with vestibular schwannoma. The tumor was mirrored to allow bilateral approaches and the model has drawers for repositioning structures, allowing reuse of the material and cost reduction. Pre and posttest assessments were applied to 10 residents and young neurosurgeons, divided into control and test groups. Only the control group was exposed to the model. The difference in scores obtained by participants before and after exposure to the models was considered for analysis and participants in the control group answered self-satisfaction questionnaires.

RESULTS

The mean differences were 4.80 in the control group (95% credibility intervals=1.08-9.79) and 5.43 in the test group (95% credibility intervals=1.67-8.20). The average score of the self-satisfaction questionnaires was 24.0 (23-25).

CONCLUSIONS

The ultrarealistic model efficiently allowed retromastoid access to the cerebellopontine angle. A tendency toward greater gains in performance in the group exposed to the model was verified. Scores from the self-satisfaction questionnaires demonstrated that participants considered the model relevant for neurosurgical training and increased confidence among surgeons.

The Sellar Region as Seen from Transcranial and Endonasal Perspectives: Exploring Bony Landmarks Through New Surface Photorealistic Three-Dimensional Model Reconstruction for Neurosurgical Anatomy Training

BACKGROUND

Virtual reality-based learning of neuroanatomy is a new feasible method to explore, visualize, and dissect interactively complex anatomic regions. We provide a new interactive photorealistic three-dimensional (3D) model of sellar region microsurgical anatomy that allows side-by-side views of exocranial and endocranial surfaces to be explored, with the aim of assisting young neurosurgery residents in learning microsurgical anatomy of this complex region.

METHODS

Four head specimens underwent an endoscopic endonasal approach extended to the anterior and posterior skull base to expose the main bony anatomic landmarks of the sellar region. The same bony structures were exposed from a transcranial perspective. By using a photogrammetry method, multiple photographs from both endocranial and exocranial perspectives, different for angulations and depth, were captured, fused, and processed through dedicated software.

RESULTS

All relevant bony structures were clearly distinguishable in the 3D model reconstruction, which provides several benefits in neuroanatomy learning: first, it replicates bony structures with high degrees of realism, accuracy, and fidelity; in addition, it provides realistic spatial perception of the depth of the visualized structures and their anatomic relationships; again, the 3D model is interactive and allows a 360° self-guided tour of the reconstructed object, so that the learner can read the bones and their anatomic relationship from all desired points of view.

CONCLUSIONS

Detailed knowledge of key surgical landmarks representing keyholes and/or anatomic structures to not violate is mandatory for safer surgery, especially for a complex region such as the skull base. Highly accurate virtual and functional neurosurgical models, such as photogrammetry, can generate a realistic appearance to further improve surgical simulators and learn neuroanatomy.

The Vertebrobasilar Trunk and Its Anatomical Variants: A Microsurgical Anatomical Study

BACKGROUND

The trunk of the basilar artery has not been included in microanatomy studies. Anatomical variants of the perforant branches of the vertebrobasilar trunk and their relationship with neural structures are very important in surgical approaches. Surgical dissection for the treatment of vascular lesions requires a perfect knowledge of the microsurgical anatomy.

METHODS

We conducted a descriptive analysis of 50 brains, which were fixed with formalin at 10% for 2 weeks, and the arterial system was injected with colored latex. After microsurgical dissection, it was divided into three segments: the lower portion went from the anterior spinal artery to the anteroinferior cerebellar artery, the middle segment was raised from the upper limit of the lower portion to the origin of the superior cerebellar artery, and the upper segment ranged from the previous portion until the origin of the posterior cerebral artery.

RESULTS

The basilar artery had an average length of 30 mm. The average diameter at its junction with the vertebral arteries was 4.05 mm. The average middle segment was 3.4 mm in diameter and 15.2 mm in length. The diameter of the upper segment was 4.2 mm, and its average length was 3.6 mm. The average number of bulbar arteries was three, and their average diameter was 0. 66 mm. The number of caudal perforator arteries were five on average, with a diameter of 0.32 mm. We found three rare cases of anatomical variants in the vertebra-basilar junction.

CONCLUSIONS

The basilar artery emits penetrating branches in its lower, middle, and upper portions. The origin of penetrating branches was single or divided after forming a trunk. However, we observed long branches from perforant arteries.

Latex vascular injection as method for enhanced neurosurgical training and skills

Background

Tridimensional medical knowledge of human anatomy is a key step in the undergraduate and postgraduate medical education, especially in surgical fields. Training simulation before real surgical procedures is necessary to develop clinical competences and to minimize surgical complications.

Methods

Latex injection of vascular system in brain and in head-neck segment is made after washing out of the vascular system and fixation of the specimen before and after latex injection.

Results

Using this latex injection technique, the vascular system of 90% of brains and 80% of head-neck segments are well-perfused. Latex-injected vessels maintain real appearance compared to silicone, and more flexible vessels compared to resins. Besides, latex makes possible a better perfusion of small vessels.

Conclusions

Latex vascular injection technique of the brain and head-neck segment is a simulation model for neurosurgical training based on real experiencing to improve surgical skills and surgical results.

Virtual simulations for neonatal education

Virtual simulation (VS) education involves the use of virtual reality, augmented reality, mixed reality and screen-based platforms, collectively referred to as extended reality, to provide education and assessment. This novel simulation modality supports experiential learning and increases access to practice opportunities, supplementing manikin-based simulation. VS has been used successfully for neonatal resuscitation training in high and low resource settings. Virtual simulators can be used to objectively assess learner performance in neonatal resuscitation knowledge and skills. When implementing VS for neonatal resuscitation training, key considerations include matching learning objectives with suitable technology, pre-session preparation, supporting learners, and debriefing. Additional research is needed to evaluate the impact of VS applications on clinical practice and patient outcomes.

Key role of microsurgical dissections on cadaveric specimens in neurosurgical training: Setting up a new research anatomical laboratory and defining neuroanatomical milestones

Introduction

Neurosurgery is one of the most complex surgical disciplines where psychomotor skills and deep anatomical and neurological knowledge find their maximum expression. A long period of preparation is necessary to acquire a solid theoretical background and technical skills, improve manual dexterity and visuospatial ability, and try and refine surgical techniques. Moreover, both studying and surgical practice are necessary to deeply understand neuroanatomy, the relationships between structures, and the three-dimensional (3D) orientation that is the core of neurosurgeons' preparation. For all these reasons, a microsurgical neuroanatomy laboratory with human cadaveric specimens results in a unique and irreplaceable training tool that allows the reproduction of patients' positions, 3D anatomy, tissues' consistencies, and step-by-step surgical procedures almost identical to the real ones.

Methods

We describe our experience in setting up a new microsurgical neuroanatomy lab (IRCCS Neuromed, Pozzilli, Italy), focusing on the development of training activity programs and microsurgical milestones useful to train the next generation of surgeons. All the required materials and instruments were listed.

Results

Six competency levels were designed according to the year of residency, with training exercises and procedures defined for each competency level: (1) soft tissue dissections, bone drilling, and microsurgical suturing; (2) basic craniotomies and neurovascular anatomy; (3) white matter dissection; (4) skull base transcranial approaches; (5) endoscopic approaches; and (6) microanastomosis. A checklist with the milestones was provided.

Discussion

Microsurgical dissection of human cadaveric specimens is the optimal way to learn and train on neuroanatomy and neurosurgical procedures before performing them safely in the operating room. We provided a “neurosurgery booklet” with progressive milestones for neurosurgical residents. This step-by-step program may improve the quality of training and guarantee equal skill acquisition across countries. We believe that more efforts should be made to create new microsurgical laboratories, popularize the importance of body donation, and establish a network between universities and laboratories to introduce a compulsory operative training program.

Tailored Surgical Access to the Cavernous Sinus and Parasellar Region: Assessment of Cavernous Sinus Entry Corridors and the Periclinoid and Pericavernous Surgical Maneuvers

BACKGROUND

Lesions involving the cavernous sinus (CS) represent some of the most challenging pathologies of the skull base owing to the dense traversing and surrounding neurovasculature. Extradural exposure and preparation of this region, whether as initial preparation for a combined intra-extradural approach or as the main avenue of surgical exposure, can enlarge surgical corridors and minimize the need for brain retraction in this very confined space. We provide a detailed assessment of the entry corridors to the CS that are available within each approach, the surgical exposure and freedom provided by each of these corridors, and demonstrate how extradural and intradural preparation of these corridors can be used to widen the available working space and facilitate surgery.

METHODS

Pterional, frontotemporal-orbital, frontotemporal-orbitozygomatic, frontotemporal-zygomatic, perilabyrinthine transtentorial, and endoscopic transnasal transsphenoidal approaches were performed on cadaveric heads to access the perisellar and CS regions. Periclinoid maneuvers (extradural cutting of the meningo-orbital band, anterior clinoidectomy, unroofing of the optic canal, opening of the superior orbital fissure, displacement of the extra-annular structures, opening of the annulus of Zinn, and interdural dissection), pericavernous maneuvers (intradural cutting of the distal dural ring, mobilization of the supraclinoid internal carotid artery, opening of the oculomotor porus, and mobilization of cranial nerve (CN) III), peritrigeminal extensions (extradural mobilization of CN V2 [maxillary] and/or V3 [mandibular]), and other surgical maneuvers were performed and evaluated. The CS was divided into 8 anatomical compartments and 9 entry corridors were described, and exposure and freedom were assessed accordingly.

RESULTS

Intradurally, the standard unextended pterional, frontotemporal-orbital, and frontotemporal orbitozygomatic transsylvian approaches provided access solely to the parasellar entry corridor into the superior wall of the CS. Expanding these approaches with extradural periclinoid maneuvers allowed for subsequent application of the intradural pericavernous maneuvers and enlargement of the parasellar corridor and exposure of the carotid cave. Extradurally, the frontotemporal-orbital approach could be expanded via application of periclinoid maneuvers, which provided access to the anterior portions of the main lateral wall entry corridors. The frontotemporal-orbitozygomatic approach could also be expanded with periclinoid maneuvers to provide extradural access to all 6 lateral wall entry corridors. The extradural frontotemporal-zygomatic approach only provided exposure following interdural dissection, which allowed for access to the inferolateral entry corridors into the lateral wall. Extradural peritrigeminal extension in the frontotemporal-orbitozygomatic and frontotemporal-zygomatic approaches allows for enlargement of the supramaxillary and pre- and postmandibular corridors. The perilabyrinthine approach to the posterior wall was enlarged with opening of Dorello's canal and the endoscopic transnasal transsphenoidal approach was enlarged with opening of the optic canal.

CONCLUSIONS

Targeted extradural preparation optimizes exposure and significantly improves access to deep-seated targets by enhancing surgical maneuverability through the unlocking of neurovascular structures and widening of surgical corridors without the need for additional brain retraction.

A novel 3D surgical neuroanatomy course for medical students: Outcomes from a pilot 6-week elective

BACKGROUND

Developing and maintaining a three-dimensional working knowledge of neuroanatomy is an essential skill in neurosurgery. However, conventional 2D head, neck, and neuroanatomy education is typically characterized by the separate rote learning of constituent tissues and often fails to provide learners with a contextual understanding of the relationships between these highly complex and interconnected structures. This can pose a significant challenge to medical students entering neurosurgery who lack a topographic understanding of intracranial anatomy.

METHODS

We report on the design and efficacy of a novel 6-part 3D surgical neuroanatomy pilot elective for medical students that utilized a navigation-based pedagogical technique with the goal of providing students with a framework for developing a 3D mental map of the skull base, neurovasculature, ventricular system, and associated brain regions. Students took on the perspective of physically traveling along the paths of key structures with a 360-degree view of surrounding anatomy such that they could appreciate the integration and relative spatial relationships of the varying tissues within the cranium. Mental navigation exercises and pre- and post-course surveys were used to assess students' baseline and learned familiarity with the different anatomical regions covered.

RESULTS

At the conclusion of the course, all students were able to successfully complete all of the multifaceted mental navigation exercises. Post-course survey data indicated that respondents perceived significant increases in their knowledge of cranial nerves; anterior, middle, and posterior skull base anatomy; anterior and posterior cranial circulation; and the ventricular system.

CONCLUSION

3D navigation-based fly-through instruction is a novel and effective technique for teaching complex anatomy and can provide learners with the foundational skills for developing and maintaining a 3D mental map of intracranial anatomy.

Evolution and Revolution of Imaging Technologies in Neurosurgery

We understand only a small fraction of the events happening in our brains; therefore, despite all the progress made thus far, a whole array of questions remains. Nonetheless, neurosurgeons invented new tools to circumvent the challenges that had plagued their predecessors. With the manufacturing boom of the 20th century, technological innovations blossomed enabling the neuroscientific community to study and operate upon the living brain in finer detail and with greater precision while avoiding harm to the nervous system. The purpose of this chronological review is to 1) raise awareness among future neurosurgeons about the latest advances in the field, 2) become familiar with innovations such as augmented reality (AR) that should be included in education given their ready applicability in surgical training, and 3) be comfortable with customizing these technologies to real-life cases like in the case of mixed reality.

Establishing the First Neurosurgical Skill Laboratory in West Africa: An Initiative for an Affordable Regional Education Center

Background

The benefits of a neurosurgical skill laboratory (NSL) are unquestionable. Despite the increasing number of sub-Saharan African neurosurgeons, few cadaveric laboratories are available for neurosurgical education. The first of its kind in West Africa, a NSL opened in 2019 in Abidjan, Cote d’Ivoire to promote neurosurgeons' education and technical skills. We have described our experience in creating and running this facility.

Methods

NSL is a private academic center in Abidjan, Cote d’Ivoire. It includes 2 rooms dedicated to cadaveric hands-on training and microscopic neurosurgery and multipurpose rooms, which contain 7 table-mounted microscopes and 3 endoscopes. The designed layout replicates an operating room. The curriculum was designed to meet the needs for training for complex brain and spine surgeries.

Results

The training covers skull base (conventional and extended) approaches, microsuturing, and anterolateral and posterior approaches for spine surgeries. The training was open to residents and consultants. The faculty members included anatomists, neurosurgeons, otolaryngologists, and orthopedists. Additionally, the NSL welcomes fellows from foreign countries. Fellows from 4 countries have been trained, and 14 educational activities have been organized.

Conclusions

In the present report, we have provided insight into a sub-Saharan African neurosurgical laboratory striving toward an affordable and self-sustainable center. The short-term goal of the NSL is to be a center for developing technical skills for African neurosurgeons for better patient outcomes.

Simulation for skills training in neurosurgery: a systematic review, meta-analysis, and analysis of progressive scholarly acceptance

At a time of significant global unrest and uncertainty surrounding how the delivery of clinical training will unfold over the coming years, we offer a systematic review, meta-analysis, and bibliometric analysis of global studies showing the crucial role simulation will play in training. Our aim was to determine the types of simulators in use, their effectiveness in improving clinical skills, and whether we have reached a point of global acceptance. A PRISMA-guided global systematic review of the neurosurgical simulators available, a meta-analysis of their effectiveness, and an extended analysis of their progressive scholarly acceptance on studies meeting our inclusion criteria of simulation in neurosurgical education were performed. Improvement in procedural knowledge and technical skills was evaluated. Of the identified 7405 studies, 56 studies met the inclusion criteria, collectively reporting 50 simulator types ranging from cadaveric, low-fidelity, and part-task to virtual reality (VR) simulators. In all, 32 studies were included in the meta-analysis, including 7 randomised controlled trials. A random effects, ratio of means effects measure quantified statistically significant improvement in procedural knowledge by 50.2% (ES 0.502; CI 0.355; 0.649, p < 0.001), technical skill including accuracy by 32.5% (ES 0.325; CI - 0.482; - 0.167, p < 0.001), and speed by 25% (ES - 0.25, CI - 0.399; - 0.107, p < 0.001). The initial number of VR studies (n = 91) was approximately double the number of refining studies (n = 45) indicating it is yet to reach progressive scholarly acceptance. There is strong evidence for a beneficial impact of adopting simulation in the improvement of procedural knowledge and technical skill. We show a growing trend towards the adoption of neurosurgical simulators, although we have not fully gained progressive scholarly acceptance for VR-based simulation technologies in neurosurgical education.

NIH funding trends for neurosurgeon-scientists from 1993-2017: Biomedical workforce implications for neurooncology

INTRODUCTION

Neurosurgeons represent 0.5% of all physicians and currently face a high burden of disease. Physician-scientists are essential to advance the mission of National Academies of Science (NAS) and National Institutes of Health (NIH) through discovery and bench to bedside translation. We investigated trends in NIH neurosurgeon-scientist funding over time as an indicator of physician-scientist workforce training.

METHODS

We used NIH Research Portfolio Online Reporting Tools (RePORTER) to extract grants to neurosurgery departments and neurosurgeons from 1993 to 2017. Manual extraction of each individual grant awardee was conducted.

RESULTS

After adjusting for U.S. inflation (base year: 1993), NIH funding to neurosurgery departments increased yearly (P < 0.00001). However, neurosurgeon-scientists received significantly less NIH funding compared to scientists (including basic scientists and research only neurosurgeons) (P = 0.09). The ratio of neurosurgeon-scientists to scientists receiving grants was significantly reduced (P = 0.002). Interestingly, the percentage of oncology-related neurosurgery grants significantly increased throughout the study period (P = 0.002). The average number of grants per neurosurgeon-scientists showed an upward trend (P < 0.001); however, the average number of grants for early-career neurosurgeon-scientists, showed a significant downward trend (P = 0.05).

CONCLUSION

Over the past 23 years, despite the overall increasing trends in the number of NIH grants awarded to neurosurgery departments overall, the proportion of neurosurgeon-scientists that were awarded NIH grants compared to scientists demonstrates a declining trend. This observed shift is disproportionate in the number of NIH grants awarded to senior level compared to early-career neurosurgeon-scientists, with more funding allocated towards neurosurgical-oncology-related grants.

Microscopic and Endoscopic Skull Base Approaches Hands-On Cadaver Course at 30: Historical Vignette

Laboratory-based cadaveric training is essential for the development and refinement of neurosurgical technical skills in the operating room and has become an integral training component around the world. Postresidency fellowship-the first pillar of skull base surgery training-includes both hands-on clinical care and surgery supervised by an experienced skull base surgeon. Time is spent in a skull base laboratory practicing approaches and developing anatomic mastery. The second pillar includes formal skull-base courses-institutional dissection laboratories provide continuous anatomic and surgical education while complementary annual or semiannual cadaver courses gather recognized experts to share their knowledge and experience in an essential 2- to 3-day setting. In this paper, we present the history of the longest running annual skull-base cadaver microsurgical course, which was started by Dr. Ossama Al-Mefty: Annual Surgical Approaches to the Skull Base Course. At the Microscopic and Endoscopic Hands-on Cadaver Workshop, held in St. Louis, Missouri, we celebrated its 30th anniversary in April 2019. We also present the impact this course has had on neurosurgery and skull base surgery and on the professional and scientific developments of its participants in particular.

Spatial abilities training in the field of technical skills in health care: A systematic review

OBJECTIVE

To conduct a systematic review of the effect of interventions on spatial abilities in the field of technical skills in health care.

METHODS

A literature search was conducted up to November 14, 2017 in Scopus and in several databases on EBSCOhost platform. Citations were obtained, articles related to retained citations were reviewed and a final list of included studies was identified. Methods in the field of technical skills relating an intervention to spatial abilities test scores between intervention groups or obtained before and after the intervention were identified as eligible. The quality of included studies was assessed and data were extracted in a systematic way.

RESULTS

A series of 5513 citations was obtained. Ninety-nine articles were retained and fully reviewed, yielding four included studies. No difference in the Hidden Figure Test score after one year was observed after residency training in General Surgery of at least nine months. A first-year dental curriculum was not found to elevate the Novel Object Cross-Sections Test score (P = 0.07). A two-semester learning period of abdominal sonography was found to increase the Revised Minnesota Paper Form Board Test score (P < 0.05). A hands-on radiology course using interactive three-dimensional image post-processing software consisting of seven two-hour long seminars on a weekly basis was found to amplify the Cube Perspective Test score (P < 0.001).

CONCLUSION

Spatial abilities tests scores were enhanced by courses in abdominal sonography and hands-on radiology, but were not improved by residency training in General Surgery and first-year dental curriculum.