Educating residents in spine surgery: A study of Entrustable professional activities in neurosurgery and orthopedic surgery.

BACKGROUND: Surgery for spinal disorders represents some of the commonest surgical procedures performed in many countries worldwide, carried out by neurosurgeons and orthopedic surgeons. Residency training is shifting to competency-based medical education, which requires setting standards for graduating residents and their assessments. However, gaps exist in the literature regarding the parameters used for assessment and the mastery levels expected of graduating residents in the performance of common spinal procedures as defined in Entrustable Professional Activities (EPAs). The objectives of the study were to describe the assessment parameters used for residents, identify the standard of performance expected of graduating residents of EPAs of spinal procedures, and identify factors predicting the expected standard of competent performance of graduating residents. METHODS: The survey was sent to neurosurgery and orthopedic surgery Faculty requesting their recommendations on parameters of assessment and the expected standard competence performance for EPAs related to spinal procedures using our entrustment scale (A-E). RESULTS: Based on total responses, the recommended number of assessments and assessors for each EPA was 5 and 2, respectively. Regarding each specialty, there was no significant difference in the recommended number of assessments for each EPA. However, neurosurgery Faculty recommended higher number of assessors(n = 3) than orthopedic surgery Faculty(n = 2) for both posterior spinal decompression EPA(PSD) (p = 0.01) and spinal instrumentation EPA(SI) (p = 0.04). Based on total responses, 83% felt PSD was appropriate to the general practice, 86.8% considered it not too broad, and 62.3% expected entrustment level E as a graduation target. The proportions of these ratings were slightly lower for SI at 58.5%, 71.7% and 56.6%, respectively. Both specialties indicated that the EPAs were not too broad. In contrast, neurosurgery Faculty were more likely to consider these EPAs appropriate for general practice than orthopedic surgery Faculty for both PSD (94.7% vs 53.3%, p = 0.0003) and SI (68.4% vs 33.3%, p = 0.02). Moreover, neurosurgery Faculty had a higher expected standard of performance as a graduation target for both PSD (Level E 76.3% vs 26.7%, p = 0.001) and SI (Level E 65.8% vs 33.3%, p = 0.03) than orthopedic surgery Faculty. Expectations of entrustment level E for PSD was associated with the belief that the current EPA was appropriate for the general practice of their specialty with an odds ratio of 8.35 (p = 0.01, 95%CI 1.53-45.67). CONCLUSIONS: A difference exists in parameters of assessment and expected standard competence performance of spine procedures among spinal surgery specialties. In our opinion, there should be efforts to develop consensus between specialties for the sake of uniform delivery of high-quality care for patients regardless of the specialty of their surgeon. Our results will be particularly valuable to certification bodies in the assessment of spinal milestones. This study has important implications for the design of residency and fellowship education in spinal surgery internationally.

Comment on - "Simulation training approaches in intracranial aneurysm surgery-a systematic review".

With the increasing complexity of intracranial aneurysm surgery and the reduced opportunities for hands-on training, there is a need for effective simulation-based training methods. This systematic review examines 26 studies on various simulation training approaches for intracranial aneurysm clipping, including ex vivo methods, virtual reality platforms, and 3D-printed models. The review evaluates these methods based on their effectiveness, realism, usability, and validation, highlighting that current simulation models are heterogeneous and lack standardization. Most existing simulations fail to replicate the complete microsurgical workflow, and their validation methods vary widely, limiting generalizability. The review recommends developing a standardized, comprehensive, and cost-effective simulation model that incorporates advanced haptic feedback and detailed anatomical features. Future research should focus on creating a universal validation framework to reliably assess simulation efficacy and ensure that neurosurgical trainees receive consistent, high-quality training experiences.

Comment on - "The impact of the COVID-19 pandemic on global neurosurgical education: a systematic review".

This systematic review examines the impact of the COVID-19 pandemic on global neurosurgical education, with a focus on the disparities between low- and middle-income countries (LMICs) and high-income countries (HICs). The study analyzes 26 articles, highlighting significant disruptions in neurosurgical training, including reduced surgical exposure and a transition to online learning. LMICs faced greater challenges, including limited access to virtual education and increased financial insecurities for trainees. Despite these setbacks, advancements in virtual technology provided new educational opportunities. The review underscores the need for continued innovation, particularly in cost-effective, immersive technologies, to bridge the gap in surgical training and enhance resilience for future crises.

Gender Differences in Operative Autonomy Using the Surgical Autonomy Program: A Multicenter Study.

Background The proportion of women surgeons is increasing, but studies show that women in surgical residency are granted less autonomy than men. Objective We utilized the Surgical Autonomy Program (SAP), an educational framework, to evaluate gender differences in self-reported autonomy, attending-reported autonomy, and operative feedback among US neurosurgical residents. Methods The SAP tracks resident progression and guides teaching in neurosurgery. Surgeries are divided into zones of proximal development (opening, exposure, critical portion, and closure). Postoperatively, resident autonomy is rated on a 4-point scale by the resident and the attending for each part of the case, or zone. We utilized data from July 2017 to February 2024 from 8 institutions. Ordinal regression was used to evaluate the odds of self- and attending-evaluated autonomy, accounting for gender, training year, case difficulty, and institution. Differences between attending assessment and self-assessment were calculated across time. Chi-square analyses were used to measure any differences in feedback given to men and women. Results From 128 residents (32 women, 25%), 11894 cases were included. Women were granted less autonomy (OR 0.81; 95% CI 0.74-0.89; P<.001) and self-evaluated as having less autonomy (OR 0.73; 95% CI 0.67-0.80; P<.001). The odds of women operating at higher autonomy were similar to the odds of operating on a hard case compared to average difficulty (OR 0.77; 95% CI 0.71-0.84; P<.001). Men's and women's self-assessment became closer to attending assessment over time, with women improving more quickly for the critical portions of surgeries. Women residents received meaningful postoperative feedback on fewer cases (women: 74.2%, men: 80.5%; X2=31.929; P<.001). Conclusions Women operated with lower autonomy by both attending and self-assessment, but the assessment gap between genders decreased over time. Women also received less feedback from their attendings.

Developing a non-cadaveric brain tumour surgery lab in resource-constrained settings.

OBJECTIVE: To develop the country's first brain tumour surgery lab in resource-constrained settings, for training young neurosurgeons and residents. METHODS: A workshop was developed using mixed-fidelity models for assessing and training a participant's psychomotor skills, hand-eye coordination, and teaching the principles of brain tumour surgery. Affordable noncadaveric models were used to compare and contrast the benefit of each teaching model. Within the existing space for wet labs at our institution, 8 different dissection stations were set up with adequate space for 2 people to work at a time. Each station was equipped with an operating room-Caliber microscope, a lighting system and a camera linked to a screen and high-powered electric drills and basic surgical equipment. RESULTS: Our team was able to develop and use 3D-printed skull models and animal brain models for training in complex approaches and craniotomy. CONCLUSIONS: Surgical simulation training, in a cost-effective manner, provides the benefit of training residents and students in neurosurgical techniques in a safe, controlled environment leading to improvement in skills and technique.

Education and Training in Global Neurosurgery: Current State and Path Toward a Uniform Curriculum.

Education is a sustainable long-term measure to address the global burden of neurosurgical disease. Neurosurgery residencies in high-income countries are accredited by a regional governing body and incorporate various educational activities. Few opportunities for training may be present in low-income and middle-income countries due to a lack of neurosurgery residency programs, tuition, and health care workforce reductions. Core components of a neurosurgical training curriculum include operative room experience, clinical rounds, managing inpatients, and educational conferences. A gold standard for neurosurgical education is essential for creating comprehensive training experience, though training must be contextually appropriate.

Establishing Microsurgery Skills Laboratories in Low- and Middle-income Countries with Integrated Remote Teaching: A Novel Approach.

Microneurosurgical techniques remain crucial for managing neurosurgical diseases, especially in low- and middle-income countries (LMICs) where other advanced treatment modalities are not available. The global distribution of these techniques is uneven due to disparities in infrastructure, equipment, and training. Medical professionals from LMICs face barriers in reaching training centers in high-income countries, as well as in accessing microsurgical techniques. To address these disparities in microsurgery training, we offer free and accessible microsurgery training model by combining the donations of microsurgery kits with a comprehensive support system that includes live-streamed, offline, and in-person assistance within LMICs.

Continuing Education for Global Neurosurgery Graduates: Visiting Surgeons, Skills Teaching, Bootcamps, and Twinning Programs.

Neurosurgeons require post-graduate training to deliver safe, effective, and evidence-based care; to continually improve and adapt their methods through assessing the effect of their care and patient outcomes; and to train the future neurosurgeons of tomorrow to surpass current standards of care. We describe methods used by global collaborations to address these training needs on a worldwide scale, their risks, and their perceived benefits.

Nongovernmental Organizations in Global Neurosurgery: Foundation for International Education in Neurological Surgery and Solidarity Bridge.

Health care disparities between high-income countries (HICs) and low- and middle-income countries (LMICs) are well established. The focus of the surgical aspect of health was identified in the early twenty-first century, and efforts to provide safe surgical intervention require the shift of resources from HICs to LMICs with specialized surgeons, anesthesiologists, and equipment. This intervention may make a difference on the short run; however, to achieve a long-term self-sustaining surgical service in the region of need, education and training of local physicians is key.

Intraoperative ultrasound and magnetic resonance comparative analysis in brain tumor surgery: a valuable tool to flatten ultrasound's learning curve.

BACKGROUND: Intraoperative ultrasound (IOUS) is a profitable tool for neurosurgical procedures' assistance, especially in neuro-oncology. It is a rapid, ergonomic and reproducible technique. However, its known handicap is a steep learning curve for neurosurgeons. Here, we describe an interesting postoperative analysis that provides extra feedback after surgery, accelerating the learning process. METHOD: We conducted a descriptive retrospective unicenter study including patients operated from intra-axial brain tumors using neuronavigation (Curve, Brainlab) and IOUS (BK-5000, BK medical) guidance. All patients had preoperative Magnetic Resonance Imaging (MRI) prior to tumor resection. During surgery, 3D neuronavigated IOUS studies (n3DUS) were obtained through craniotomy N13C5 transducer's integration to the neuronavigation system. At least two n3DUS studies were obtained: prior to tumor resection and at the resection conclusion. A postoperative MRI was performed within 48 h. MRI and n3DUS studies were posteriorly fused and analyzed with Elements (Brainlab) planning software, permitting two comparative analyses: preoperative MRI compared to pre-resection n3DUS and postoperative MRI to post-resection n3DUS. Cases with incomplete MRI or n3DUS studies were withdrawn from the study. RESULTS: From April 2022 to March 2024, 73 patients were operated assisted by IOUS. From them, 39 were included in the study. Analyses comparing preoperative MRI and pre-resection n3DUS showed great concordance of tumor volume (p < 0,001) between both modalities. Analysis comparing postoperative MRI and post-resection n3DUS also showed good concordance in residual tumor volume (RTV) in cases where gross total resection (GTR) was not achieved (p < 0,001). In two cases, RTV detected on MRI that was not detected intra-operatively with IOUS could be reviewed in detail to recheck its appearance. CONCLUSIONS: Post-operative comparative analyses between IOUS and MRI is a valuable tool for novel ultrasound users, as it enhances the amount of feedback provided by cases and could accelerate the learning process, flattening this technique's learning curve.

Advancing Neurosurgical Skills: A Comparative Study of Training Models for Intra-Extracranial Cerebral Bypass.

BACKGROUND: Training in anastomosis is fundamental in neurosurgery due to the precision and dexterity required. Biological models, although realistic, present limitations such as availability, ethical concerns, and the risk of biological contamination. Synthetic models, on the other hand, offer durability and standardized conditions, although they sometimes lack anatomical realism. This study aims to evaluate and compare the efficiency of anastomosis training models in the intra-extracranial cerebral bypass procedure, identifying those characteristics that enhance optimal microsurgical skill development and participant experience. METHODS: A neurosurgery workshop was held from March 2024 to June 2024 with 5 vascular techniques and the participation of 22 surgeons. The models tested were the human placenta, the Wistar rat, the chicken wing artery, the nasogastric feeding tube, and the UpSurgeOn Mycro simulator. The scales used to measure these models were the Main Characteristics Score and the Evaluation Score. These scores allowed us to measure, qualitatively and quantitatively, durability, anatomical similarity, variety of simulation scenarios, risk of biological contamination, ethical considerations and disadvantages with specific infrastructure. RESULTS: The human placenta model, Wistar rat model, and UpSurgeOn model were identified as the most effective for training. The human placenta and Wistar rat models were highly regarded for anatomical realism, while the UpSurgeOn model excelled in durability and advanced simulation scenarios. Ethical and cost implications were also considered. CONCLUSIONS: The study identifies the human placenta and UpSurgeOn models as optimal for training in intra-extracranial bypass procedures, emphasizing the need for diverse and effective training models in neurosurgery.

International Hackathon as a Tool to Augment Education, Collaboration, and Innovation in Global Neurosurgery.

BACKGROUND AND OBJECTIVES: Health care providers' exposure to global surgical disparities is limited in current nursing and/or medical school curricula. For instance, global health is often associated with infectious diseases or maternal health without acknowledging the growing need for surgical care in low- and middle-income countries (LMICs). We propose an international virtual hackathon based on neurosurgical patient cases in under-resourced settings as an educational tool to bring awareness to global surgical disparities and develop relationships among trainees in different countries. METHODS: Participants were recruited through email listservs, a social media campaign, and prize offerings. A 3-day virtual hackathon event was administered, which included workshops, mentorship, keynote panels, and pitch presentations to judges. Participants were presented with real patient cases and directed to solve a barrier to their care. Surveys assessed participants' backgrounds and event experience. The hackathon was executed through Zoom at Harvard Innovation Lab in Boston, MA, on March 25 to 27, 2022. Participants included medical students, with additional participants from business, engineering, or current health care workers. RESULTS: Three hundred seven applications were submitted for 100 spots. Participants included medical students, physicians, nurses, engineers, entrepreneurs, and undergraduates representing 25 countries and 82 cities. Fifty-one participants previously met a neurosurgeon, while 39 previously met a global health expert, with no difference between LMIC and high-income countries' respondents. Teams spent an average of 2.75 hours working with mentors, and 88% of postevent respondents said the event was "very" or "extremely conducive" to networking. Projects fell into 4 categories: access, language barriers, education and training, and resources. The winning team, which was interdisciplinary and international, developed an application that analyzes patient anatomy while performing physical therapy to facilitate remote care and clinical decision-making. CONCLUSION: An international virtual hackathon can be an educational tool to increase innovative ideas to address surgical disparities in LMICs and establish early collaborative relationships with medical trainees from different countries.