Design of a synthetic simulator for pediatric lumbar spine pathologies

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.

Validation of an endoscopic flavectomy training model

OBJECTIVE

to validate a lumbar spine endoscopic flavectomy simulator using the construct method and to assess the acceptability of the simulator in medical education.

METHODS

thirty medical students and ten video-assisted surgery experienced orthopedists performed an endoscopic flavectomy procedure in the simulator. Time, look-downs, lost instruments, respect for the stipulated edge of the ligamentum flavum, regularity of the incision, GOALS checklist (Global Operative Assessment of Laparoscopic Skills), and responses to the Likert Scale adapted for this study were analyzed.

RESULTS

all variables differed between groups. Procedure time was shorter in the physician group (p < 0.001). Look-downs and instrument losses were seven times greater among students than physicians. Half of the students respected the designated incision limits, compared to 80% of the physicians. In the student group, about 30% of the incisions were regular, compared to 100% in the physician group (p < 0.001). The physicians performed better in all GOALS checklist domains. All the physicians and more than 96% of the students considered the activity enjoyable, and approximately 90% believed that the model was realistic and could contribute to medical education.

CONCLUSIONS

the simulator could differentiate the groups' experience level, indicating construct validity, and both groups reported high acceptability.

Tethered Cord Syndrome After Myelomeningocele Repair: A Literature Update

Tethered cord syndrome (TCS) after myelomeningocele (MMC) repair (or secondary TCS) is a challenging condition characterized by neurological, orthopedic, and urological symptoms, which are combined with a low-lying position of the conus medullaris and damage to the stretched spinal cord owing to metabolic and vascular derangements. It has been reported that this syndrome affects, on average, 30% of children with MMC. In this review, we revisit the historical aspects of secondary TCS and highlight the most important concepts of diagnosis, treatment, and outcomes for secondary TCS as well as the current research regarding the impact of fetal MMC repair in the incidence and management of TCS. In the future, the development of synthetic models of TCS could shorten the learning curve of pediatric neurosurgeons, and research into the cellular proapoptotic features and increased inflammation biomarkers associated with TCS will also improve the treatment of this condition and minimize retethering of the spinal cord.

Advancing spinal fellowship training: an international multi-centre educational perspective

PURPOSE

The purpose of this article is to review the importance of contemporary spine surgery fellowships and educational strategies to assist with fellowship design and delivery.

METHODS

Spine surgery fellowship includes trainees from orthopaedic and neurosurgical backgrounds and is increasingly indicated for individuals wishing to pursue spine surgery as a career, recognizing how spinal surgery evolved significantly in scope and complexity. We combine expert opinion with a review of the literature and international experience to expound spine fellowship training.

RESULTS

Contemporary learning techniques include boot camps at the start of fellowship which may reinforce previous clinical learning and help prepare fellows for their new clinical roles. There is good evidence that surgical specialty training boot camps improve clinical skills, knowledge and trainee confidence prior to embarking upon new clinical roles with increasing levels of responsibility. Furthermore, as simulation techniques and technologies take on an increasing role in medical and surgical training, we found evidence that trainees' operative skills and knowledge can improve with simulated operations, even if just carried out briefly. Finally, we found evidence to suggest a role for establishing competence-based objectives for training in specific operative and technical procedures. Competence-based objectives are helpful for trainees and trainers to highlight gaps in a trainee's skill set that may then be addressed during training.

CONCLUSIONS

Spinal fellowships may benefit from certain contemporary strategies that assist design and delivery of training in a safe environment. Interpersonal factors that promote healthy teamwork may contribute to an environment conducive to learning. These slides can be retrieved under Electronic Supplementary Material.

Developing a 3D composite training model for cranial remodeling

OBJECTIVE

Craniosynostosis correction, including cranial vault remodeling, fronto-orbital advancement (FOA), and endoscopic suturectomy, requires practical experience with complex anatomy and tools. The infrequent exposure to complex neurosurgical procedures such as these during residency limits extraoperative training. Lack of cadaveric teaching tools given the pediatric nature of synostosis compounds this challenge. The authors sought to create lifelike 3D printed models based on actual cases of craniosynostosis in infants and incorporate them into a practical course for endoscopic and open correction. The authors hypothesized that this training tool would increase extraoperative facility and familiarity with cranial vault reconstruction to better prepare surgeons for in vivo procedures.

METHODS

The authors utilized representative craniosynostosis patient scans to create 3D printed models of the calvaria, soft tissues, and cranial contents. Two annual courses implementing these models were held, and surveys were completed by participants (n = 18, 5 attending physicians, 4 fellows, 9 residents) on the day of the course. These participants were surveyed during the course and 1 year later to assess the impact of this training tool. A comparable cohort of trainees who did not participate in the course (n = 11) was also surveyed at the time of the 1-year follow-up to assess their preparation and confidence with performing craniosynostosis surgeries.

RESULTS

An iterative process using multiple materials and the various printing parameters was used to create representative models. Participants performed all major surgical steps, and we quantified the fidelity and utility of the model through surveys. All attendees reported that the model was a valuable training tool for open reconstruction (n = 18/18 [100%]) and endoscopic suturectomy (n = 17/18 [94%]). In the first year, 83% of course participants (n = 14/17) agreed or strongly agreed that the skin and bone materials were realistic and appropriately detailed; the second year, 100% (n = 16/16) agreed or strongly agreed that the skin material was realistic and appropriately detailed, and 88% (n = 14/16) agreed or strongly agreed that the bone material was realistic and appropriately detailed. All participants responded that they would use the models for their own personal training and the training of residents and fellows in their programs.

CONCLUSIONS

The authors have developed realistic 3D printed models of craniosynostosis including soft tissues that allow for surgical practice simulation. The use of these models in surgical simulation provides a level of preparedness that exceeds what currently exists through traditional resident training experience. Employing practical modules using such models as part of a standardized resident curriculum is a logical evolution in neurosurgical education and training.

Simulation-based Education for Endoscopic Third Ventriculostomy: A Comparison Between Virtual and Physical Training Models

BACKGROUND

The relative educational benefits of virtual reality (VR) and physical simulation models for endoscopic third ventriculostomy (ETV) have not been evaluated "head to head."

OBJECTIVE

To compare and identify the relative utility of a physical and VR ETV simulation model for use in neurosurgical training.

METHODS

Twenty-three neurosurgical residents and 3 fellows performed an ETV on both a physical and VR simulation model. Trainees rated the models using 5-point Likert scales evaluating the domains of anatomy, instrument handling, procedural content, and the overall fidelity of the simulation. Paired t tests were performed for each domain's mean overall score and individual items.

RESULTS

The VR model has relative benefits compared with the physical model with respect to realistic representation of intraventricular anatomy at the foramen of Monro (4.5, standard deviation [SD] = 0.7 vs 4.1, SD = 0.6; P = .04) and the third ventricle floor (4.4, SD = 0.6 vs 4.0, SD = 0.9; P = .03), although the overall anatomy score was similar (4.2, SD = 0.6 vs 4.0, SD = 0.6; P = .11). For overall instrument handling and procedural content, the physical simulator outperformed the VR model (3.7, SD = 0.8 vs 4.5; SD = 0.5, P < .001 and 3.9; SD = 0.8 vs 4.2, SD = 0.6; P = .02, respectively). Overall task fidelity across the 2 simulators was not perceived as significantly different.

CONCLUSION

Simulation model selection should be based on educational objectives. Training focused on learning anatomy or decision-making for anatomic cues may be aided with the VR simulation model. A focus on developing manual dexterity and technical skills using endoscopic equipment in the operating room may be better learned on the physical simulation model.

The Barrow Biomimetic Spine: effect of a 3-dimensional-printed spinal osteotomy model on performance of spinal osteotomies by medical students and interns

Background

The Schwab osteotomy grading scale-a unified osteotomy classification system created in 2014 by Schwab et al.-is one of many concepts in spine surgery that require detailed knowledge of 3-dimensional (3D) anatomy. 3D-printed spine models have demonstrated increasing utility in spine surgery as they more quickly communicate information on complex 3D anatomical relationships than planar imaging or 2-dimensional images. The purpose of this study was to evaluate the utility of a custom, 3D-printed spine model to help surgical trainees understand and perform the Schwab osteotomy grading scale.

Methods

Eight participants were randomized into 2 groups: group 1 received written instructional materials about the Schwab osteotomy grading scale, whereas group 2 received both written materials and a 3D-printed model of the spine with osteotomy regions demarcated. All participants were administered written and practical examinations.

Results

The group randomized to receive the 3D-printed model performed significantly better on both the written assessment (mean score, 7.75±0.50 vs. 5.75±0.50, P=0.023) and the practical examination (mean score, 1.75±0.32 vs. 1.08±0.09, P=0.025) than the group that received only written instructions.

Conclusions

Our results support the conclusion that this 3D-printed spine model is an effective adjunct to help early surgical trainees understand the Schwab osteotomy grading scale. Participants who received the model in addition to the source manuscript demonstrated improved theoretical knowledge and better performance on practical tests of complex spinal osteotomies. Similar models are likely to have utility in surgical training programs and as patient education models.

A low cost dural closure simulation model for tomorrow's spinal neurosurgeons

Introduction: We present a low cost model that can be used to improve a trainee's skills in spinal dural closure. Development of microsurgical skills in a simulated environment provides a safe environment in which patients are protected. We argue that this is likely to improve the quality of dural closure, especially for surgeons early in their training and may lead to a commensurate reduction in post-operative CSF leak. Method: In our model, two consultant spine surgeons assessed the ability of participants to close the spinal dura. Participants were scored both quantitatively (time taken to complete the task) and qualitatively under the category of "surgical performance"- assessed by video and inspection of the closed dural substitute. Results: The cohort under assessment included senior and newly appointed consultants, clinical fellows and thirteen specialty trainees. 10 trainees were assessed a second time and a significant majority improved on both domains: 8 (80%) were faster on their second attempt; surgical performance scores also improved in the majority of trainees (90%). Conclusion: Our results, albeit with small numbers, show that a large proportion of trainees improve with practice with a reduction in overall task time and an improvement in surgical performance. Our model is cost-effective and easy to reproduce: simulation need not be an expensive exercise. This study further validates the use of simulation in modern neurosurgical training.

Developing a pediatric neurosurgical training model

OBJECTIVE One of the greatest challenges of pediatric neurosurgery training is balancing the training needs of the trainee against patient safety and parental expectation. The traditional "see one, do one, teach one" approach to training is no longer acceptable in pediatric neurosurgery. The authors have developed the baby Modeled Anatomical Replica for Training Young Neurosurgeons (babyMARTYN). The development of this new training model is described, its feasibility as a training tool is tested, and a new approach of integrating simulation into day-to-day training is suggested. METHODS In part 1 (development), a prototype skull was developed using novel model-making methods. In part 2 (validation), 18 trainee neurosurgeons (at various stages in training) performed the following 4 different procedures: 1) evacuation of a posterior fossa hematoma; 2) pterional craniotomy; 3) tapping of the fontanelle to obtain a CSF specimen; and 4) external ventricular drain insertion. Completion of the procedural stages (scored using a curriculum-based checklist) was used to test the feasibility of babyMARTYN as a training tool. Likert scale-based questionnaires were used to assess the model for face and content validity. Training benefit was assessed using pre- and posttraining ratings on the Physician Performance Diagnostic Inventory Scale (PPDIS). To determine the significance of improvement in median PPDIS score, the Wilcoxon matched-pairs signed-rank test was performed. RESULTS In part 1 (development), the model was successfully developed with good fidelity. In part 2 (validation), the validation data demonstrated feasibility, face, and content validity. The PPDIS score significantly increased for all groups after babyMARTYN training, thereby indicating a potential future role for babyMARTYN in the training of pediatric neurosurgeons. CONCLUSIONS This recent collaborative neurosurgical development by the Royal College of Surgeons of England is designed to supplement current neurosurgical training. High-fidelity, portable, operation-specific models enable preoperative planning and have the potential to be used in an operating room environment prior to novel operations. A "see one, simulate one, do one" approach for pediatric neurosurgical training using babyMARTYN is suggested.

Virtual reality-based simulators for spine surgery: a systematic review

BACKGROUND CONTEXT

Virtual reality (VR)-based simulators offer numerous benefits and are very useful in assessing and training surgical skills. Virtual reality-based simulators are standard in some surgical subspecialties, but their actual use in spinal surgery remains unclear. Currently, only technical reviews of VR-based simulators are available for spinal surgery.

PURPOSE

Thus, we performed a systematic review that examined the existing research on VR-based simulators in spinal procedures. We also assessed the quality of current studies evaluating VR-based training in spinal surgery. Moreover, we wanted to provide a guide for future studies evaluating VR-based simulators in this field.

STUDY DESIGN AND SETTING

This is a systematic review of the current scientific literature regarding VR-based simulation in spinal surgery.

METHODS

Five data sources were systematically searched to identify relevant peer-reviewed articles regarding virtual, mixed, or augmented reality-based simulators in spinal surgery. A qualitative data synthesis was performed with particular attention to evaluation approaches and outcomes. Additionally, all included studies were appraised for their quality using the Medical Education Research Study Quality Instrument (MERSQI) tool.

RESULTS

The initial review identified 476 abstracts and 63 full texts were then assessed by two reviewers. Finally, 19 studies that examined simulators for the following procedures were selected: pedicle screw placement, vertebroplasty, posterior cervical laminectomy and foraminotomy, lumbar puncture, facet joint injection, and spinal needle insertion and placement. These studies had a low-to-medium methodological quality with a MERSQI mean score of 11.47 out of 18 (standard deviation=1.81).

CONCLUSIONS

This review described the current state and applications of VR-based simulator training and assessment approaches in spinal procedures. Limitations, strengths, and future advancements of VR-based simulators for training and assessment in spinal surgery were explored. Higher-quality studies with patient-related outcome measures are needed. To establish further adaptation of VR-based simulators in spinal surgery, future evaluations need to improve the study quality, apply long-term study designs, and examine non-technical skills, as well as multidisciplinary team training.

The role of simulation in neurosurgery

PURPOSE

In an era of residency duty-hour restrictions, there has been a recent effort to implement simulation-based training methods in neurosurgery teaching institutions. Several surgical simulators have been developed, ranging from physical models to sophisticated virtual reality systems. To date, there is a paucity of information describing the clinical benefits of existing simulators and the assessment strategies to help implement them into neurosurgical curricula. Here, we present a systematic review of the current models of simulation and discuss the state-of-the-art and future directions for simulation in neurosurgery.

METHODS

Retrospective literature review.

RESULTS

Multiple simulators have been developed for neurosurgical training, including those for minimally invasive procedures, vascular, skull base, pediatric, tumor resection, functional neurosurgery, and spine surgery. The pros and cons of existing systems are reviewed.

CONCLUSION

Advances in imaging and computer technology have led to the development of different simulation models to complement traditional surgical training. Sophisticated virtual reality (VR) simulators with haptic feedback and impressive imaging technology have provided novel options for training in neurosurgery. Breakthrough training simulation using 3D printing technology holds promise for future simulation practice, proving high-fidelity patient-specific models to complement residency surgical learning.

Development and content validation of performance assessments for endoscopic third ventriculostomy

PURPOSE

This study aims to develop and establish the content validity of multiple expert rating instruments to assess performance in endoscopic third ventriculostomy (ETV), collectively called the Neuro-Endoscopic Ventriculostomy Assessment Tool (NEVAT).

METHODS

The important aspects of ETV were identified through a review of current literature, ETV videos, and discussion with neurosurgeons, fellows, and residents. Three assessment measures were subsequently developed: a procedure-specific checklist (CL), a CL of surgical errors, and a global rating scale (GRS). Neurosurgeons from various countries, all identified as experts in ETV, were then invited to participate in a modified Delphi survey to establish the content validity of these instruments. In each Delphi round, experts rated their agreement including each procedural step, error, and GRS item in the respective instruments on a 5-point Likert scale.

RESULTS

Seventeen experts agreed to participate in the study and completed all Delphi rounds. After item generation, a total of 27 procedural CL items, 26 error CL items, and 9 GRS items were posed to Delphi panelists for rating. An additional 17 procedural CL items, 12 error CL items, and 1 GRS item were added by panelists. After three rounds, strong consensus (>80% agreement) was achieved on 35 procedural CL items, 29 error CL items, and 10 GRS items. Moderate consensus (50-80% agreement) was achieved on an additional 7 procedural CL items and 1 error CL item. The final procedural and error checklist contained 42 and 30 items, respectively (divided into setup, exposure, navigation, ventriculostomy, and closure). The final GRS contained 10 items.

CONCLUSIONS

We have established the content validity of three ETV assessment measures by iterative consensus of an international expert panel. Each measure provides unique assessment information and thus can be used individually or in combination, depending on the characteristics of the learner and the purpose of the assessment. These instruments must now be evaluated in both the simulated and operative settings, to determine their construct validity and reliability. Ultimately, the measures contained in the NEVAT may prove suitable for formative assessment during ETV training and potentially as summative assessment measures during certification.

Simulation and resident education in spinal neurosurgery

BACKGROUND

A host of factors have contributed to the increasing use of simulation in neurosurgical resident education. Although the number of simulation-related publications has increased exponentially over the past two decades, no studies have specifically examined the role of simulation in resident education in spinal neurosurgery.

METHODS

We performed a structured search of several databases to identify articles detailing the use of simulation in spinal neurosurgery education in an attempt to catalogue potential applications for its use.

RESULTS

A brief history of simulation in medicine is given, followed by current trends of spinal simulation utilization in residency programs. General themes from the literature are identified that are integral for implementing simulation into neurosurgical residency curriculum. Finally, various applications are reported.

CONCLUSION

The use of simulation in spinal neurosurgery education is not as ubiquitous in comparison to other neurosurgical subspecialties, but many promising methods of simulation are available for augmenting resident education.