Neurosurgical training is usually based on traditional sources of education, such as papers, books, direct surgical experience, and cadaveric hands-on courses. In low-middle income countries, ...standard education programs are often unavailable, mainly owing to the lack of human and economic resources. Introducing digital platforms in these settings could be an alternative solution for bridging the gap between Western and poor countries in neurosurgical knowledge.
The authors identified from the Internet the main digital platforms that could easily be adopted in low-middle income countries. They selected free/low-cost mobile content with high educational impact.
The platforms that were identified as fulfilling the characteristics described above are WFNS Young Neurosurgeons Forum Stream, Brainbook, NeuroMind, UpSurgeOn, The Neurosurgical Atlas, Touch surgery, The 100 UCLA Subjects in Neurosurgery, Neurosurgery Survival Guide, EANS (European Association of Neurosurgical Societies) Academy, Neurosurgical.TV, 3D Neuroanatomy, The Rhoton Collection, and Hinari. These platforms consist of webinars, 3D interactive neuroanatomy and neurosurgery content, videos, and e-learning programs supported by neurosurgical associations or journals.
Digital education is an emerging tool for contributing to the spread of information in the neurosurgical community. The continuous improvement in the quality of content will rapidly increase the scientific validity of digital programs. In conclusion, the fast and easy access to digital resources could contribute to promote neurosurgical education in countries with limited facilities.
Decompressive craniectomy consists of removal of piece of bone of the skull in order to reduce intracranial pressure. It is an age-old procedure, taking ancient roots from the Egyptians and Romans, ...passing through the experience of Berengario da Carpi, until Theodore Kocher, who was the first to systematically describe this procedure in traumatic brain injury (TBI). In the last century, many neurosurgeons have reported their experience, using different techniques of decompressive craniectomy following head trauma, with conflicting results. It is thanks to the successes and failures reported by these authors that we are now able to better understand the pathophysiology of brain swelling in head trauma and the role of decompressive craniectomy in mitigating intracranial hypertension and its impact on clinical outcome. Following a historical description, we will describe the steps that led to the conception of the recent randomized clinical trials, which have taught us that decompressive craniectomy is still a last-tier measure, and decisions to recommend it should been made not only according to clinical indications but also after consideration of patients' preferences and quality of life expectations.
In the recent years, growing interest in simulation-based surgical education has led to various practical alternatives for medical training. More recently, courses based on virtual reality (VR) and ...three-dimensional (3D)-printed models are available. In this paper, a hybrid (virtual and physical) neurosurgical simulator has been validated, equipped with augmented reality (AR) capabilities that can be used repeatedly to increase familiarity and improve the technical skills in human brain anatomy and neurosurgical approaches.
The neurosurgical simulator used in this study (UpSurgeOn Box, UpSurgeOn Srl, Assago, Milan) combines a virtual component and a physical component with an intermediate step to provide a hybrid solution. A first reported and evaluated practical experience on the anatomical 3D-printed model has been conducted with a total of 30 residents in neurosurgery. The residents had the possibility to choose a specific approach, focus on the correct patient positioning, and go over the chosen approach step-by-step, interacting with the model through AR application. Next, each practical surgical step on the 3D model was timed and qualitatively evaluated by 3 senior neurosurgeons. Quality and usability-grade surveys were filled out by participants.
More than 89% of the residents assessed that the application and the AR simulator were very helpful in improving the orientation skills during neurosurgical approaches. Indeed, 89.3% of participants found brain and skull anatomy highly realistic during their tasks. Moreover, workshop exercises were considered useful in increasing the competency and technical skills required in the operating room by 85.8 and 84.7% of residents, respectively. Data collected confirmed that the anatomical model and its application were intuitive, well-integrated, and easy to use.
The hybrid AR and 3D-printed neurosurgical simulator could be a valid tool for neurosurgical training, capable of enhancing personal technical skills and competence. In addition, it could be easy to imagine how patient safety would increase and healthcare costs would be reduced, even if more studies are needed to investigate these aspects. The integration of simulators for training in neurosurgery as preparatory steps for the operating room should be recommended and further investigated given their huge potential.
Acquisition of neurosurgical anatomy knowledge requires the progressive construction of a 3-dimensional (3D) mental image from the study of 2-dimensional pictures. Tridimensional neuroimaging ...modeling and 3D pictures and videos have facilitated a better understanding of intricate brain anatomy. One of the main limitations of these methods however is that the user is unable to freely change his or her own point of view of the observed structures. The objective of this paper was to develop a 3D reconstruction method to facilitate learning and teaching of neurosurgery.
We developed a 3D reconstruction method by using 3D photogrammetry to convert intraoperative images into a fully explorable 3D textured model. We also developed a mobile application to navigate the virtual scenario by using the gyroscopic technology of mobile devices to simulate the different movements of the surgical microscope. We named this process 3D virtual intraoperative reconstruction (VIR).
We report the detailed methodology for picture acquisition, 3D reconstruction, and visualization with some surgical examples since the first applications in 2015. We also demonstrate how these navigable models can be used to buildup hybrid images derived by the fusion of 3D intraoperative scenarios with neuroimaging-derived 3D models.
3D VIR is a digital reconstruction method developed with the goal of facilitating the teaching and learning of neurosurgical anatomy by allowing the user to directly explore a surgical field and anatomic structures. The result is an interactive navigable 3D textured model for the analysis of the surgical approach and regional anatomy and for reconstruction of hybrid 3D scenarios.
Endoscopic endonasal transsphenoidal surgery is an established technique for the resection of sellar and suprasellar lesions. The approach is technically challenging and has a steep learning curve. ...Simulation is a growing training tool, allowing the acquisition of technical skills pre-clinically and potentially resulting in a shorter clinical learning curve. We sought validation of the UpSurgeOn Transsphenoidal (TNS) Box for the endoscopic endonasal transsphenoidal approach to the pituitary fossa.
Novice, intermediate and expert neurosurgeons were recruited from multiple centres. Participants were asked to perform a sphenoidotomy using the TNS model. Face and content validity were evaluated using a post-task questionnaire. Construct validity was assessed through post-hoc blinded scoring of operative videos using a Modified Objective Structured Assessment of Technical Skills (mOSAT) and a Task-Specific Technical Skill scoring system.
Fifteen participants were recruited of which
= 10 (66.6%) were novices and
= 5 (33.3%) were intermediate and expert neurosurgeons. Three intermediate and experts (60%) agreed that the model was realistic. All intermediate and experts (
= 5) strongly agreed or agreed that the TNS model was useful for teaching the endonasal transsphenoidal approach to the pituitary fossa. The consensus-derived mOSAT score was 16/30 (IQR 14-16.75) for novices and 29/30 (IQR 27-29) for intermediate and experts (
< 0.001, Mann-Whitney
). The median Task-Specific Technical Skill score was 10/20 (IQR 8.25-13) for novices and 18/20 (IQR 17.75-19) for intermediate and experts (
< 0.001, Mann-Whitney U). Interrater reliability was 0.949 (CI 0.983-0.853) for OSATS and 0.945 (CI 0.981-0.842) for Task-Specific Technical Skills. Suggested improvements for the model included the addition of neuro-vascular anatomy and arachnoid mater to simulate bleeding vessels and CSF leak, respectively, as well as improvement in materials to reproduce the consistency closer to that of human tissue and bone.
The TNS Box simulation model has demonstrated face, content, and construct validity as a simulator for the endoscopic endonasal transsphenoidal approach. With the steep learning curve associated with endoscopic approaches, this simulation model has the potential as a valuable training tool in neurosurgery with further improvements including advancing simulation materials, dynamic models (e.g., with blood flow) and synergy with complementary technologies (e.g., artificial intelligence and augmented reality).
Background: Technological advancements have been rapidly integrated within the neurosurgical education track since it is a high-risk specialty with little margin for error. Indeed, simulation and ...virtual reality during training can improve surgical performance and technical skills. Our study aims to investigate the impact of neurosurgical technology-based simulation activities on medical students. Methods and Materials: The “Suturing Mission–The Symposium” was a three-day event held at Humanitas University. Participants had access to live-streamed conferences held by worldwide experts in several fields of neurosurgery and practical simulations of dura mater sutures, microvascular anastomosis, and augmented reality neurosurgical approaches. An anonymous survey was conducted at the beginning and end of the event. Results: 141 medical students with a mean age of 21 participated. After the course, 110 participants (77.5%) showed interest in pursuing a surgical path, with a great prevalence in those who had planned to have a surgical career before the event (88.7% vs. 41.4%, p < 0.001). Participants were also asked about their comfort levels while handling surgical instruments, and a good outcome was reached in 72.7% of participants, with a significant difference between those who had previously attended a suture course (87.8% vs. 66.3%, p = 0.012). Conclusion: Training sessions on surgical simulators were effective in increasing participants’ interest in pursuing a surgical path, improving their understanding of postgraduate orientation, and boosting their confidence with surgical instruments.
Recently, non-technical skills (NTS) and teamwork in particular have been demonstrated to be essential in many jobs, in business as well as in medical specialties, including plastic, orthopedic, and ...general surgery. However, NTS and teamwork in neurosurgery have not yet been fully studied. We reviewed the relevant literature and designed a mock surgery to be used as a team-building activity specifically designed for scrub nurses and neurosurgeons.
We conducted a systematic review by searching PubMed (Medline) and CINAHL, including relevant articles in English published until 15 July 2023. Then, we proposed a pilot study consisting of a single-session, hands-on, and cadaver-free activity, based on role play. Scrub nurses were administered the SPLINTS (Scrub Practitioners' List of Intraoperative Non-Technical Skills) rating form as a self-evaluation at baseline and 20-30 days after the simulation. During the experiment, surgeons and scrub nurses role-played as each other, doing exercises including a simulated glioma resection surgery performed on an advanced model of a cerebral tumor (Tumor Box, UpSurgeOn®) under an exoscope. At the end, every participant completed an evaluation questionnaire.
A limited number of articles are available on the topic. This study reports one of the first neurosurgical team-building activities in the literature. All the participating scrub nurses and neurosurgeons positively evaluated the simulation developed on a roleplay. The use of a physical simulator seems an added value, as the tactile feedback given by the model further helps to understand the actual surgical job, more than only observing and assisting. The SPLINTS showed a statistically significant improvement not only in "Communication and Teamwork" (
= 0.048) but also in "Situation Awareness" (
= 0.031).
Our study suggests that team-building activities may play a role in improving interprofessional teamwork and other NTS in neurosurgery.
To evaluate the viability of exoscopes in the context of neurosurgical education and compare the use of a 4k3D exoscope to a traditional operative microscope in the execution of a task of anatomic ...structure identification on a model of cranial approach.
A cohort of volunteer residents performed a task of anatomical structure identification with both devices three times across an experimental period of 2 months. We timed the residents' performances, and the times achieved were analyzed. The volunteers answered two questionnaires concerning their opinions of the two devices.
Across tries, execution speed improved for the whole cohort. When using the exoscopes, residents were quicker to identify a single anatomical structure starting from outside the surgical field when deep structures were included in the pool. In all other settings, the two devices did not differ in a statistically significant manner. The volunteers described the exoscope as superior to the microscope in all the aspects the questionnaires inquired about, besides the depth of field perception, which was felt to be better with the microscope. Volunteers furthermore showed overwhelming support for training on different devices and with models of surgical approaches.
The exoscope appeared to be non-inferior to the microscope in the execution of a task of timed identification of anatomical structures on a model of cranial approach carried out by our cohort of residents. In the questionnaires, the residents reported the exoscope to be superior to the microscope in eight of nine investigated domains. Further studies are needed to investigate the use of the exoscope in learning of microsurgical skills.
Strengthening health systems requires attention to workforce, training needs, and barriers to service delivery. The World Federation of Neurosurgical Societies Young Neurosurgeons Committee survey ...sought to identify challenges for residents, fellows, and consultants within 10 years of training.
An online survey was distributed to various neurosurgical societies, personal contacts, and social media platforms (April–November 2018). Responses were grouped by World Bank income classification into high-income countries (HICs), upper middle-income countries (UMICs), low-middle-income countries (LMICs), and low-income countries (LICs). Descriptive statistical analysis was performed.
In total, 953 individuals completed the survey. For service delivery, the limited number of trained neurosurgeons was seen as a barrier for 12.5%, 29.8%, 69.2%, and 23.9% of respondents from HICs, UMICs, LMICs, and LICs, respectively (P < 0.0001). The most reported personal challenge was the lack of opportunities for research (HICs, 34.6%; UMICs, 57.5%; LMICs, 61.6%; and LICs, 61.5%; P = 0.03). Other differences by income class included limited access to advice from experienced/senior colleagues (P < 0.001), neurosurgical journals (P < 0.0001), and textbooks (P = 0.02). Assessing how the World Federation of Neurosurgical Societies could best help young neurosurgeons, the most frequent requests (n = 953; 1673 requests) were research (n = 384), education (n = 296), and subspecialty/fellowship training (n = 232). Skills courses and access to cadaver dissection laboratories were also heavily requested.
Young neurosurgeons perceived that additional neurosurgeons are needed globally, especially in LICs and LMICs, and primarily requested additional resources for research and subspecialty training.
Neurosurgical training is changing globally. Reduced working hours and training opportunities, increased patient safety expectations, and the impact of COVID-19 have reduced operative exposure. ...Benchtop simulators enable trainees to develop surgical skills in a controlled environment. We aim to validate a high-fidelity simulator model (RetrosigmoidBox, UpSurgeOn) for the retrosigmoid approach to the cerebellopontine angle (CPA).
Novice and expert Neurosurgeons and Ear, Nose, and Throat surgeons performed a surgical task using the model – identification of the trigeminal nerve. Experts completed a post-task questionnaire examining face and content validity. Construct validity was assessed through scoring of operative videos employing Objective Structured Assessment of Technical Skills (OSATS) and a novel Task-Specific Outcome Measure score.
Fifteen novice and five expert participants were recruited. Forty percent of experts agreed or strongly agreed that the brain tissue looked real. Experts unanimously agreed that the RetrosigmoidBox was appropriate for teaching. Statistically significant differences were noted in task performance between novices and experts, demonstrating construct validity. Median total OSATS score was 14/25 (IQR 10–19) for novices and 22/25 (IQR 20–22) for experts (p < 0.05). Median Task-Specific Outcome Measure score was 10/20 (IQR 7–17) for novices compared to 19/20 (IQR 18.5–19.5) for experts (p < 0.05).
The RetrosigmoidBox benchtop simulator has a high degree of content and construct validity and moderate face validity. The changing landscape of neurosurgical training mean that simulators are likely to become increasingly important in the delivery of high-quality education. We demonstrate the validity of a Task-Specific Outcome Measure score for performance assessment of a simulated approach to the CPA.
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