Novel System of Simulation Models for Aneurysm Clipping Training: Description of Models and Assessment of Face, Content, and Construct Validity.

BACKGROUND: Aneurysm clipping simulation models are needed to provide tactile feedback of biological vessels in a nonhazardous but surgically relevant environment. OBJECTIVE: To describe a novel system of simulation models for aneurysm clipping training and assess its validity. METHODS: Craniotomy models were fabricated to mimic actual tissues and movement restrictions experienced during actual surgery. Turkey wing vessels were used to create aneurysm models with patient-specific geometry. Three simulation models (middle cerebral artery aneurysm clipping via a pterional approach, anterior cerebral artery aneurysm clipping via an interhemispheric approach, and basilar artery aneurysm clipping via an orbitozygomatic pretemporal approach) were subjected to face, content, and construct validity assessments by experienced neurosurgeons (n = 8) and neurosurgery trainees (n = 8). RESULTS: Most participants scored the model as replicating actual aneurysm clipping well and scored the difficulty of clipping as being comparable to that of real surgery, confirming face validity. Most participants responded that the model could improve clip-applier-handling skills when working with patients, which confirms content validity. Experienced neurosurgeons performed significantly better than trainees on all 3 models based on subjective (P = .003) and objective (P < .01) ratings and on time to complete the task (P = .04), which confirms construct validity. Simulations were used to discuss clip application strategies and compare them to prototype clinical cases. CONCLUSION: This novel aneurysm clipping model can be used safely outside the wet laboratory; it has high face, content, and construct validity; and it can be an effective training tool for microneurosurgery training during aneurysm surgery courses.

Augmented reality for the virtual dissection of white matter pathways.

BACKGROUND: The human white matter pathway network is complex and of critical importance for functionality. Thus, learning and understanding white matter tract anatomy is important for the training of neuroscientists and neurosurgeons. The study aims to test and evaluate a new method for fiber dissection using augmented reality (AR) in a group which is experienced in cadaver white matter dissection courses and in vivo tractography. METHODS: Fifteen neurosurgeons, neurolinguists, and neuroscientists participated in this questionnaire-based study. We presented five cases of patients with left-sided perisylvian gliomas who underwent awake craniotomy. Diffusion tensor imaging fiber tracking (DTI FT) was performed and the language-related networks were visualized separated in different tracts by color. Participants were able to virtually dissect the prepared DTI FTs using a spatial computer and AR goggles. The application was evaluated through a questionnaire with answers from 0 (minimum) to 10 (maximum). RESULTS: Participants rated the overall experience of AR fiber dissection with a median of 8 points (mean ± standard deviation 8.5 ± 1.4). Usefulness for fiber dissection courses and education in general was rated with 8 (8.3 ± 1.4) and 8 (8.1 ± 1.5) points, respectively. Educational value was expected to be high for several target audiences (student: median 9, 8.6 ± 1.4; resident: 9, 8.5 ± 1.8; surgeon: 9, 8.2 ± 2.4; scientist: 8.5, 8.0 ± 2.4). Even clinical application of AR fiber dissection was expected to be of value with a median of 7 points (7.0 ± 2.5). CONCLUSION: The present evaluation of this first application of AR for fiber dissection shows a throughout positive evaluation for educational purposes.

Development and initial evaluation of a novel simulation model for comprehensive brain tumor surgery training.

BACKGROUND: Increasing technico-manual complexity of procedures and time constraints necessitates effective neurosurgical training. For this purpose, both screen- and model-based simulations are under investigation. Approaches including 3D printed brains, gelatin composite models, and virtual environments have already been published. However, quality of brain surgery simulation is limited due to discrepancies in visual and haptic experience. Similarly, virtual training scenarios are still lacking sufficient real-world resemblance. In this study, we introduce a novel simulator for realistic neurosurgical training that combines real brain tissue with 3D printing and augmented reality. METHODS: Based on a human CT scan, a skull base and skullcap were 3D printed and equipped with an artificial dura mater. The cerebral hemispheres of a calf's brain were placed in the convexity of the skullcap and tumor masses composed of aspic, water, and fluorescein were injected in the brain. The skullcap and skull base were placed on each other, glued together, and filled up with an aspic water solution for brain fixation. Then, four surgical scenarios were performed in the operating room as follows: (1) simple tumor resection, (2) complex tumor resection, (3) navigated biopsy via burr hole trepanation, and (4) retrosigmoidal craniotomy. Neuronavigation, augmented reality, fluorescence, and ocular-as well as screen-based (exoscopic)-surgery were available for the simulator training. A total of 29 participants performed at least one training scenario of the simulator and completed a 5-item Likert-like questionnaire as well as qualitative interviews. The questionnaire assessed the realism of the tumor model, skull, and brain tissue as well as the capability for training purposes. RESULTS: Visual and sensory realism of the skull and brain tissue were rated,"very good," while the sensory and visual realism of the tumor model were rated "good." Both overall satisfaction with the model and eligibility of the microscope and neurosurgical instruments for training purposes were rated with "very good." However, small size of the calf's brain, its limited shelf life, and the inability to simulate bleedings due to the lack of perfusion were significant drawbacks. CONCLUSION: The combination of 3D printing and real brain tissue provided surgical scenarios with very good real-life resemblance. This novel neurosurgical model features a versatile setup for surgical skill training and allows for efficient training of technological support like image and fluorescence guidance, exoscopic surgery, and robotic technology.

Training Neurosurgeons in Myanmar and Surrounding Countries: The Resident Perspective.

INTRODUCTION: In recent decades there has been a significant expansion of neurosurgical capabilities in low- and middle-income countries, particularly in Southeast Asia. Despite these developments, little is known about the structure and quality of local neurosurgical training paradigms. METHODS: A 36-question survey was administered to neurosurgical trainees in person at the Southeast Asian Neurosurgical Bootcamp to assess demographics, structure, and exposure of neurosurgical training in Southeast Asia. RESULTS: A total of 45 out of 47 possible respondents participated in the survey; 78% were men, with an age range of 26-40 years. Neurosurgical training most commonly consisted of 3 (n = 22, 49%) or 6 years (n = 14, 31%). The majority of respondents (70.5%) were from Myanmar, with the remainder coming from Indonesia, Cambodia, Thailand, and Nepal. Most residents (n = 38, 84%) used textbooks as their primary study resource. Only 24 (53%) residents indicated that they had free access to online neurosurgical journals via their training institution. The majority (n = 27, 60%) reported that fewer than 750 cases were performed at their institution per year; with a median of 70% (interquartile range: 50%-80%) being emergent. The most commonly reported procedures were trauma craniotomies and ventriculoperitoneal shunting. The least commonly reported procedures were endovascular techniques and spinal instrumentation. CONCLUSIONS: Although the unmet burden of neurosurgical disease remains high, local training programs are devoting significant efforts to provide a sustainable solution to the problem of neurosurgical workforce. High-income country institutions should partner with global colleagues to ensure high-quality neurosurgical care for all people regardless of location and income.

State of the Union in Open Neurovascular Training.

BACKGROUND: The evolution of minimally invasive endovascular approaches and training paradigms has reduced open neurovascular case exposure for neurosurgical residents. There are no published estimates of open neurovascular case volumes during residency or Committee on Advanced Subspecialty Training (CAST) accredited fellowships. METHODS: Case volumes from residency programs submitting data for CAST accredited fellowship applications were collected and analyzed. The study period covered the academic years of 2013-2016. Case index volumes were calculated to provide an estimate of total volume of cases each trainee participated in a given year. The case index volume was defined as the total volume of cases per year divided by the total training complement. RESULTS: Over the study period, institutional data from 46 programs were available. Of those programs, 9 programs had CAST accredited open cerebrovascular fellowships. Across all 46 programs, the median number of vascular cases was 246 (interquartile range [IQR]: 148-340), whereas the median number of open vascular cases was 105 (IQR: 67-152). The median number of open aneurysm cases among programs with CAST cerebrovascular fellowships was 80 (IQR: 54-103) and among programs without CAST cerebrovascular fellowships was 34 (IQR: 24-63). The median open aneurysm case index volume for trainees at programs with and without CAST cerebrovascular fellowships was 23 (IQR: 14-29) and 19 (IQR: 11-24). CONCLUSIONS: Strong neurovascular training can be obtained through dedication and planning. Completion of a CAST accredited cerebrovascular fellowship will often more than double aneurysm case exposure of trainees.

Balancing Operative Efficiency and Surgical Education: A Functional Neurosurgery Model.

BACKGROUND: Attending surgeons have dual obligations to deliver high-quality health care and train residents. In modern healthcare, lean principles are increasingly applied to processes preceding and following surgery. However, surgeons have limited data regarding variability and waste during any given operation. OBJECTIVE: To measure variability and waste during the following key functional neurosurgery procedures: retrosigmoid craniectomy (microvascular decompression [MVD] and internal neurolysis) and deep brain stimulation (DBS). Additionally, we correlate variability with residents' self-reported readiness for the surgical steps. The aim is to guide surgeons as they balance operative safety and efficiency with training obligations. METHODS: For each operation (retrosigmoid craniectomy and DBS), a standard workflow, segmenting the operation into components, was defined. We observed a representative sample of operations, timing the components, with a focus on variability. To assess perceptions of safety and risk among surgeons of various training levels, a survey was administered. Survey results were correlated with operative variability, attempting to identify areas for increasing value without compromising trainee experience. RESULTS: A sampling of each operation (n = 36) was observed during the study period. For MVD, craniectomy had the highest mean duration and standard deviation, whereas the MVD itself had the lowest mean duration and standard deviation. For DBS, the segments with largest standard deviation in duration were registration and electrode placement. For many steps of both procedures, there was a statistically significant relationship between increasing level of training and increasing perception of safety. CONCLUSION: This proof-of-concept study introduces an educational and process-improvement tool that can be used to aid surgeons in increasing the efficiency of patient care.

Preoperative identification of the initial burr hole site in retrosigmoid craniotomies: A teaching and technical note.

BACKGROUND: When fashioning a retrosigmoid craniotomy, precise placement of the initial burr hole is crucial to avoid iatrogenic sinusal injury and to facilitate a corridor that allows for minimal cerebellar retraction. METHODS: 3D CT reconstructions of 16 cadaveric sides were used to identify and measure three discrete anatomical points. These three points and distances between them were plotted onto the surface of the skull using a digital caliper to identify the optimal burr hole location. This technique was subsequently applied in 20 clinical cases. RESULTS: Optimal burr hole placement was achieved in 87.5% of specimens and, with minor refinement, 100% of clinical cases with no significant increase in operative time. Preoperative planning took an average of 10 minutes. CONCLUSION: This technique for localizing the location of the initial retrosigmoid burr hole is a simple, safe, reliable, rapid, and inexpensive solution for surgeons who do not have regular access to neuronavigation.

Trends in Resident Operative Teaching Opportunities for Treatment of Intracranial Aneurysms.

OBJECTIVE: The International Subarachnoid Aneurysm Trial heralded a paradigm shift in the treatment of intracranial aneurysms. During this same time frame, neurosurgical training programs increased in size and scope. The present study examines the impact of trends in surgical clipping and the endovascular treatment of intracranial aneurysms, over one decade, and the neurosurgical resident complement on the resident teaching environment using the Nationwide Inpatient Sample (NIS). METHODS: The NIS was used to estimate the number of aneurysms treated with either surgical clipping and endovascular methods from 2002 through 2011 at teaching institutions. Teaching opportunities per year per resident or chief resident were calculated as the ratio of the number of specified cases to the average number of neurosurgical trainees by year. Annualized trends were assessed. RESULTS: Over the study period, the percent change in odds of occurrence of a clipped ruptured aneurysm was -15.6% per year (P < 0.001) and of ruptured aneurysms undergoing endovascular treatment was 18.7% per year (P < 0.001) within teaching institutions. This corresponded to a decline in teaching opportunities for clipped ruptured aneurysms for both residents and chief residents (P < 0.001). In contrast, teaching opportunities for endovascular treatment of both ruptured and unruptured aneurysms increased dramatically over the study period. CONCLUSIONS: There has been a significant decrease in opportunity for operative exposure to craniotomy for ruptured aneurysm clipping over the past decade, whereas the volume of endovascular procedures for aneurysms has dramatically increased, highlighting the need for a shift in training strategy for those neurosurgeons graduating from residency desiring to subspecialize in neurovascular neurosurgery.

Review of 3-Dimensional Printing on Cranial Neurosurgery Simulation Training.

OBJECTIVE: Shorter working times, reduced operative exposure to complex procedures, and increased subspecialization have resulted in training constraints within most surgical fields. Simulation has been suggested as a possible means of acquiring new surgical skills without exposing patients to the surgeon's operative "learning curve." Here we review the potential impact of 3-dimensional printing on simulation and training within cranial neurosurgery and its implications for the future. METHODS: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a comprehensive search of PubMed, OVID MEDLINE, Embase, and the Cochrane Database of Systematic Reviews was performed. RESULTS: In total, 31 studies relating to the use of 3-dimensional (3D) printing within neurosurgery, of which 16 were specifically related to simulation and training, were identified. The main impact of 3D printing on neurosurgical simulation training was within vascular surgery, where patient-specific replication of vascular anatomy and pathologies can aid surgeons in operative planning and clip placement for reconstruction of vascular anatomy. Models containing replicas of brain tumors have also been reconstructed and used for training purposes, with some providing realistic representations of skin, subcutaneous tissue, bone, dura, normal brain, and tumor tissue. CONCLUSION: 3D printing provides a unique means of directly replicating patient-specific pathologies. It can identify anatomic variation and provide a medium in which training models can be generated rapidly, allowing the trainee and experienced neurosurgeon to practice parts of operations preoperatively. Future studies are required to validate this technology in comparison with current simulators and show improved patient outcomes.

Neurosurgical Skills Assessment: Measuring Technical Proficiency in Neurosurgery Residents Through Intraoperative Video Evaluations.

OBJECTIVES: Although technical skills are fundamental in neurosurgery, there is little agreement on how to describe, measure, or compare skills among surgeons. The primary goal of this study was to develop a quantitative grading scale for technical surgical performance that distinguishes operator skill when graded by domain experts (residents, attendings, and nonsurgeons). Scores provided by raters should be highly reliable with respect to scores from other observers. METHODS: Neurosurgery residents were fitted with a head-mounted video camera while performing craniotomies under attending supervision. Seven videos, 1 from each postgraduate year (PGY) level (1-7), were anonymized and scored by 16 attendings, 8 residents, and 7 nonsurgeons using a grading scale. Seven skills were graded: incision, efficiency of instrument use, cauterization, tissue handling, drilling/craniotomy, confidence, and training level. RESULTS: A strong correlation was found between skills score and PGY year (P < 0.001, analysis of variance). Junior residents (PGY 1-3) had significantly lower scores than did senior residents (PGY 4-7, P < 0.001, t test). Significant variation among junior residents was observed, and senior residents' scores were not significantly different from one another. Interrater reliability, measured against other observers, was high (r = 0.581 ± 0.245, Spearman), as was assessment of resident training level (r = 0.583 ± 0.278, Spearman). Both variables were strongly correlated (r = 0.90, Pearson). Attendings, residents, and nonsurgeons did not score differently (P = 0.46, analysis of variance). CONCLUSIONS: Technical skills of neurosurgery residents recorded during craniotomy can be measured with high interrater reliability. Surgeons and nonsurgeons alike readily distinguish different skill levels. This type of assessment could be used to coach residents, to track performance over time, and potentially to compare skill levels. Developing an objective tool to evaluate surgical performance would be useful in several areas of neurosurgery education.

Training in Brain Retraction Using a Self-Made Three-Dimensional Model.

A hollow brain model was created using soft urethane. A tube passing through the hollow was attached for use as a water inlet and manometer. Water sufficient in quantity to realize the intended initial pressure was infused through the tube. The brain model was retracted with a brain spatula and the surgical corridor was opened. By measuring local force with a sensor set on the brain spatula, the model could be used for training in brain retraction. At the same time, the water column of the manometer was measured and the relationship with the force of the brain spatula was investigated. A positive correlation between the water column and local force was confirmed. This indicated that it was possible to use this model without a force sensor for the same training using water column measurements.

A comparison and cost analysis of cranioplasty techniques: autologous bone versus custom computer-generated implants.

BACKGROUND: Cranioplasty can be performed either with gold-standard, autologous bone grafts and osteotomies or alloplastic materials in skeletally mature patients. Recently, custom computer-generated implants (CCGIs) have gained popularity with surgeons because of potential advantages, which include preoperatively planned contour, obviated donor-site morbidity, and operative time savings. A remaining concern is the cost of CCGI production. The purpose of the present study was to objectively compare the operative time and relative cost of cranioplasties performed with autologous versus CCGI techniques at our center. METHODS: A review of all autologous and CCGI cranioplasties performed at our institution over the last 7 years was performed. The following operative variables and associated costs were tabulated: length of operating room, length of ward/intensive care unit (ICU) stay, hardware/implants utilized, and need for transfusion. RESULTS: Total average cost did not differ statistically between the autologous group (n = 15; $25,797.43) and the CCGI cohort (n = 12; $28,560.58). Operative time (P = 0.004), need for ICU admission (P < 0.001), and number of complications (P = 0.008) were all statistically significantly less in the CCGI group. The length of hospital stay and number of cases needing transfusion were fewer in the CCGI group but did not reach statistical significance. CONCLUSION: The results of the present study demonstrated no significant increase in overall treatment cost associated with the use of the CCGI cranioplasty technique. In addition, the latter was associated with a statistically significant decrease in operative time and need for ICU admission when compared with those patients who underwent autologous bone cranioplasty. LEVEL OF EVIDENCE: IV, therapeutic.

Anatomical pediatric model for craniosynostosis surgical training.

INTRODUCTION: Several surgical training simulators have been created to improve the learning curve of residents in neurosurgery and plastic surgery. Laboratory training is fundamental for acquiring familiarity with the techniques of surgery and the skill in handling instruments. The aim of this study is to present a novel simulator for training in the technique of craniosynostectomy, specifically for the scaphocephaly type. DESCRIPTION OF THE SIMULATOR: This realistic simulator was built with a synthetic thermo-retractile and thermo-sensible rubber which, when combined with different polymers, produces more than 30 different formulas. These formulas present textures, consistencies, and mechanical resistance similar to many human tissues. Fiberglass molds in the shape of the skull constitute the basic structure of the craniosynostectomy training module. It has been possible to perform computerized tomography images due to the radiopacity of this simulator and to compare the pre- and postoperative images. RESULTS: The authors present a training model to practice the biparietal remodeling used in scaphocephaly correction. All aspects of the procedure are simulated: the skin incision, the subcutaneous and subperiosteal dissection, the osteotomies, and finally, the skull remodeling with absorbable microplates. The presence of superior sagittal sinus can simulate emergency situations with bleeding. CONCLUSION: The authors conclude that this training model can represent a fairly useful method to accustom trainees to the required surgical techniques and simulates well the steps of standard surgery for scaphocephaly. This training provides an alternative to the use of human cadavers and animal models. Furthermore, it can represent the anatomical alteration precisely as well as intraoperative emergency situations.

Novel embalming solution for neurosurgical simulation in cadavers.

OBJECT: Surgical simulation using postmortem human heads is one of the most valid strategies for neurosurgical research and training. The authors customized an embalming formula that provides an optimal retraction profile and lifelike physical properties while preventing microorganism growth and brain decay for neurosurgical simulations in cadavers. They studied the properties of the customized formula and compared its use with the standard postmortem processing techniques: cryopreservation and formaldehyde-based embalming. METHODS: Eighteen specimens were prepared for neurosurgical simulation: 6 formaldehyde embalmed, 6 cryopreserved, and 6 custom embalmed. The customized formula is a mixture of ethanol 62.4%, glycerol 17%, phenol 10.2%, formaldehyde 2.3%, and water 8.1%. After a standard pterional craniotomy, retraction profiles and brain stiffness were studied using an intracranial pressure transducer and monitor. Preservation time-that is, time that tissue remained in optimal condition-between specimen groups was also compared through periodical reports during a 48-hour simulation. RESULTS: The mean (± standard deviation) retraction pressures were highest in the formaldehyde group and lowest in the cryopreserved group. The customized formula provided a mean retraction pressure almost 3 times lower than formaldehyde (36 ± 3 vs 103 ± 14 mm Hg, p < 0.01) and very similar to cryopreservation (24 ± 6 mm Hg, p < 0.01). For research purposes, preservation time in the cryopreserved group was limited to 4 hours and was unlimited for the customized and formaldehyde groups for the duration of the experiment. CONCLUSIONS: The customized embalming solution described herein is optimal for allowing retraction and surgical maneuverability while preventing decay. The authors were able to significantly lower the formaldehyde content as compared with that in standard formulas. The custom embalming solution has the benefits from both cryopreservation (for example, biological brain tissue properties) and formaldehyde embalming (for example, preservation time and microorganism growth prevention) and minimizes their drawbacks, that is, rapid decay in the former and stiffness in the latter. The presented embalming formula provides an important advance for neurosurgical simulations in research and teaching.

Smart trepanation system: preclinical analysis of safety, efficiency, and user satisfaction.

BACKGROUND/OBJECTIVE: To reduce the risk of dural tears during craniotomies and the associated complications, we developed the Smart Trepanation System (STS) that provides an image- and sensor-based automatic control of the cutting depth of a manually guided soft tissue preserving saw. This article presents the results of an initial user-centered evaluation. METHODS: Interactive usability tests with six neurosurgeons were conducted. Resection time and accuracy were recorded in a standardized laboratory setting and compared with a standard craniotome. User satisfaction and subjective workload were assessed using the National Aeronautics and Space Administration Task Load Index scale and a questionnaire regarding intuitiveness, fault tolerance, learnability, and user satisfaction. RESULTS: The mean resection time after getting used to the STS was 36.4 ± 9.2 second longer than with the conventional craniotome. All task load indexes except for the temporal demand were rated higher when using the STS, but all were rated smaller than 3 and thus classified as only a small extra task load. The questionnaire showed that the system is not only feasible but also accepted by surgeons and that the user interaction seems to be designed as intuitive, fault tolerant, and easy to learn. CONCLUSION: Although the conventional craniotome seems to perform a trepanation faster and with less workload, the advantage of performing a dura-preserving trepanation with significantly smaller cutting gaps outweighs those disadvantages. For validation of those promising in vitro results, further studies have to be conducted in a fresh human cadaver model or in a clinical setting.

Watertight dural closure in brain surgery: a simple model for training.

BACKGROUND: To avoid cerebrospinal fluid leaks and related possible complications, the dura mater should be meticulously closed after craniotomy procedures. Several techniques for duraplasty and different material for watertight closure have been described. OBJECTIVE: To describe a device to be used for the training of neurosurgical procedures of duraplasty. TECHNICAL REPORT: A plastic dummy with a balloon was developed to test the efficacy of the watertight closure of the dura. The technical notes to reproduce the method have been described. CONCLUSION: The described model represents a new, simple, effective and affordable device to be used for neurosurgical training in the procedures of duraplasty and to test the efficacy of watertight closures.

Model-based simulation for early neurosurgical learners.

BACKGROUND: Restrictions on duty hours and shift length by the Accreditation Council for Graduate Medical Education and public pressure to reduce complications and to improve outcomes in the clinical educational environment have enhanced interest in the use of procedural and surgical simulation to train neurosurgical residents. OBJECTIVE: To introduce simple, available, and, when possible, inexpensive model-based simulation for early learners into the initial stages of neurosurgical residency training. METHODS: Simulation for early-stage trainees in neurological surgery has taken advantage of model-based systems. The Society of Neurological Surgeons postgraduate year 1 courses have served as one paradigm for designing and using model-based simulators for procedural and surgical skill training as part of a purpose-designed overall curriculum. Ongoing surveys of resident and faculty course participants have supported iterative improvements in simulator models and curriculum from year to year. RESULTS: Simulation for basic neurosurgical and intensive care procedures has been undertaken through the use of available materials, surgical technology, and modifications of related existing model simulators. Simulation of common, standard surgical procedures for early learners may be broken into individual surgical skills and maneuvers to prepare trainees for safe practice of these component skills during live procedures under direct supervision appropriate to their training stage. CONCLUSION: Model-based simulation is particularly effective for early surgical learners as part of a coordinated curriculum. Almost 600 residents have used model-based simulation during the first 3 years of the Society of Neurological Surgeons boot camp courses, with ongoing modification and improvement of individual simulation models.

A novel craniotomy simulator provides a validated method to enhance education in the management of traumatic brain injury.

BACKGROUND: In a variety of surgical specialties, simulation-based technologies play an important role in resident training. The Congress of Neurological Surgeons (CNS) established an initiative to enhance neurosurgical training by developing a simulation-based curriculum to complement standard didactic and clinical learning. OBJECTIVE: To enhance resident education in the management of traumatic brain injury by the use of simulation-based training. METHODS: A course-based neurosurgical simulation curriculum was developed and offered at the 2012 CNS annual meeting. Within this curriculum, a trauma module was developed to teach skills necessary in the management of traumatic brain injury, including the performance of craniotomy for trauma. Didactic and simulator-based instruction were incorporated into the course. Written and practical pre- and posttests, as well as questionnaires, were used to assess the improvement in skill level and to validate the simulator as a teaching tool. RESULTS: Fourteen trainees participated in the didactic section of the trauma module. Average performance improved significantly in written scores from pretest (75%) to posttest (87.5%, P < .05). Eight participants completed the trauma craniotomy simulator. Incision planning, burr hole placement (P < .02), and craniotomy size (P < .05) improved significantly. Junior residents (postgraduate years 1-3) demonstrated the most improvement during the course. CONCLUSION: The CNS simulation trauma module provides a complementary method for residents to acquire necessary skills in the management of traumatic brain injury. Preliminary data indicate improvement in didactic and hands-on knowledge after training. Additional data are needed to confirm the validity of the simulator.

Role of cranial and spinal virtual and augmented reality simulation using immersive touch modules in neurosurgical training.

Recent studies have shown that mental script-based rehearsal and simulation-based training improve the transfer of surgical skills in various medical disciplines. Despite significant advances in technology and intraoperative techniques over the last several decades, surgical skills training on neurosurgical operations still carries significant risk of serious morbidity or mortality. Potentially avoidable technical errors are well recognized as contributing to poor surgical outcome. Surgical education is undergoing overwhelming change, as a result of the reduction of work hours and current trends focusing on patient safety and linking reimbursement with clinical outcomes. Thus, there is a need for adjunctive means for neurosurgical training, which is a recent advancement in simulation technology. ImmersiveTouch is an augmented reality system that integrates a haptic device and a high-resolution stereoscopic display. This simulation platform uses multiple sensory modalities, re-creating many of the environmental cues experienced during an actual procedure. Modules available include ventriculostomy, bone drilling, percutaneous trigeminal rhizotomy, and simulated spinal modules such as pedicle screw placement, vertebroplasty, and lumbar puncture. We present our experience with the development of such augmented reality neurosurgical modules and the feedback from neurosurgical residents.