Surgical experience of neurosurgical residents in Europe: an alarming trend

Microneurosurgical training in the anatomical specimen: A structured plan for endoscopic and microsurgical skull base training during the residency

BACKGROUND AND OBJECTIVE

The development of a high level of competence and technical proficiency is one of the main objectives of any neurosurgical training program. Due to many factors, this progressive skill development can be complex during the residency. Despite its high cost and infrastructure requirements, there is renewed interest regarding the role of anatomy labs. The study and dissection of the human cadaver has been the environment where many surgeons have developed the necessary skills for microneurosurgery. We propose a structured endoscopic and microsurgical training dissection program to enable residents to maximize the benefits of their training in the lab.

MATERIAL AND METHODS

During the months of September, October and November 2021, a stay was done at the Microneurosurgery and Skull Base Laboratory of the Miguel Hernández University of Alicante. A total of 2 specimens were used. The first specimen underwent a first endoscopic endonasal dissection phase. After completing the endonasal part, a set of incisions were made to perform the transcranial part. In the second specimen, the transcranial part was performed first, leaving the endonasal endoscopic work for the last phase.

RESULTS

The results of the dissection program are presented. During the endonasal endoscopic phase, the transsphenoidal approach to the sella was simulated while focusing on the extended approaches in the sagittal plane. During the transcranial phase, right and left anterolateral approaches, a left anterior transcallosal interhemispheric approach, a left transcondylar posterolateral approach and a combined right lateral approach were performed.

CONCLUSIONS

The structured dissection of the specimen allowed both endonasal endoscopic and transcranial microsurgical training in the same specimen. This design facilitated the realization of the core skull base approaches in the same specimen. According to our initial experience, we believe that developing common dissection programs is a powerful tool to maximize the results of our residents' laboratory training.

Neurosurgical training and education - General European certification is supported: Results of an EANS survey

Introduction

Delivering high-quality Neurosurgical care is dependent on excellence in neurosurgical training. Across Europe requirements of these programs vary from state to state. This study aims to determine satisfaction with these programs and views towards a unified certifications process for Neurosurgical training.

Methods

An electronic survey was disseminated to European trainees, Fellows and Consultants from 11/21 to 02/22. For descriptive purposes, categorical variables, i.e. Age, Gender, year of training, country and outcomes were analyzed.

Results

A total of 339 responses were submitted, representing all EANS member states except for Cyprus and Macedonia. Seventy-five were <30 years, 82.3% were male, ∼60% were Specialists, and twenty-four per cent held a fellowship with the European Board of Neurosurgery. 80.2% believed that a joint standardized Neurosurgical certificate in Europe is necessary, with 31.6% believing residency had not prepared them fully as a neurosurgeon.

Conclusion

This survey shows that views towards general European-wide certification is positive and that there is ongoing consensus that there is concern with some aspects of training and high variability in its delivery across Europe.

International Learner Perceptions, Educational Value, and Cost Associated With the Use of Start-to-Finish Surgical Simulation Compared With Cadaveric Models

BACKGROUND

Graduate surgical education is highly variable across regions and institutions regarding case volume and degree of trainee participation in each case. Dedicated educational curriculum using cadaveric tissue has been shown to enhance graduate surgical training, however with associated financial and utility burden to the institution.

OBJECTIVE

To investigate the utility of educational and cost applications of a novel method of combining mixed organic hydrogel polymers and 3-dimensional printed anatomic structures to create a complete "start-to-finish" simulation for resident education in spinal anatomy, instrumentation, and surgical techniques.

METHODS

This qualitative pilot study investigated 14 international participants on achievement of objective and personal learning goals in a standardized curriculum using biomimetic simulation compared with cadaveric tissue. A questionnaire was developed to examine trainee evaluation of individual anatomic components of the biomimetic simulators compared with previous experience with cadaveric tissue.

RESULTS

A total of 210 responses were acquired from 14 participants. Six participants originated from US residency education programs and 8 from transcontinental residency programs. Survey results for the simulation session revealed high user satisfaction. Score averages for each portion of the simulation session indicated learner validation of anatomic features for the simulation compared with previous cadaveric experience. Cost analysis resulted in an estimated savings of $10 833.00 for this single simulation session compared with previous cadaveric tissue sessions.

CONCLUSION

The results of this study indicate a strong potential of establishing biomimetic simulation as a cost-effective and high-quality alternative to cadaveric tissue for the instruction of fundamental spine surgical techniques.

Motivators of becoming and staying a neurosurgeon in the Netherlands: a survey and focus group

OBJECTIVE

The aim of this study was to gain insight in motivators and demotivators of the Dutch neurosurgical residents and neurosurgeons.

METHODS

A mixed method study was conducted. A survey was sent by the Dutch Neurosurgical Society to all Dutch neurosurgeons and residents in the framework of the yearly national quality conference. The focus groups were held during the Dutch national training days for neurosurgical residents. Baseline statistics were made of all survey data. Focus group recordings were transcribed verbatim and open coded in a constant comparative manner.

RESULTS

The survey yielded a response rate of 47.3% of neurosurgeons and 72.5% of residents. 42.5% of residents participated in the focus groups. Overall, motivators according to residents and neurosurgeons were divided between autonomous and controlled motivation. For residents, the motivators to become a neurosurgeon were mostly patient-centered. Neurosurgeons had the same general motivators as residents. Around one-third of neurosurgeons considered ending their career as a neurosurgeon. Among residents, 9.5% considered quitting residency. Neurosurgeons and residents indicated that no time for their family life, increased administrative burden and non-patient-related tasks were reasons to consider leaving the profession. Also, less perceived respect from patients and society was a reason to consider ending their career as a neurosurgeon.

CONCLUSION

Neurosurgeons and residents in neurosurgery are mostly motivated by intrinsic motivators. Factors such as administrative burden, less perceived respect from patients and society, and increase in non-patient-related tasks are large demotivators for both neurosurgeons and residents.

Microsurgical training: vascular control and intraoperative vessel rupture in the human placenta infusion model

BACKGROUND

Microsurgery is a challenging discipline. Regular lab training under the operating microscope has been the environment where most surgeons have mastered the skills and techniques inherent to most microneurosurgical procedures. However, some critical scenarios remain difficult to master or simulate. We describe a step-by-step method for how to build a low-cost, feasible, and widely available model that allows residents to familiarize themselves with demanding critical situations such as intraoperative rupture of major vessels.

METHODS

After delivery, nine fresh human placentas were transferred to the lab. The umbilical vein was cannulated for normal saline infusion. Several hands-on procedures were performed under direct microscope vision. Operating microscope setup, allantoic membrane splitting, vascular dissection and vessel injury, and repair exercises were simulated and video recorded. Indocyanine green was administered to simulate intraoperative angiography.

RESULTS

The model can be setup in less than 15 min, with minimal cost and infrastructure requirements. All the exercises described above can be conducted with a single placenta. Umbilical vein cannulation adds realism and allows quantification of the volume of saline required to complete the exercise. The final check with indocyanine green simulates intraoperative angiography and allows the assessment of distal vessel patency.

CONCLUSIONS

Minimal infrastructure requirements, simplicity, and easy setup models provide a suitable environment for regular training. The human placenta is inexpensive and widely available, making it a feasible model for residents training. Neurosurgery residents may benefit from this model to familiarize with microsurgery and critical scenarios in a risk-free environment without time or resource constraints.

Paving the Path to Wellness: A Systematic Review of Wellness Programs for Neurosurgery Trainees

BACKGROUND

Neurosurgical trainees have a heavy workload and poor quality of life, resulting in high rates of burnout and attrition. Consequently, wellness programs have been used by various training institutions to combat this situation.

OBJECTIVE

We aimed to identify and describe wellness programs available for neurosurgical trainees in their training institutions, the outcome measures used to assess them, and their efficacy.

METHODS

A systematic review of the literature was made following PRISMA guidelines.

RESULTS

Six studies were included in the review, describing wellness programs from 9 institutions. All programs except 1 used exercise as the core component. The other components included physical and mental well-being lectures, team-building activities, and cultural excursions. Most institutions used piloted satisfaction and perception questionnaires to assess efficacy. Trainee perceptions of wellness programs were generally positive, but the responses on validated questionnaires and surveys were mixed. Barriers to the program included lack of institutional support, time constraints, fatigue, and feelings of guilt in prioritizing wellness over patient care.

CONCLUSIONS

There is a paucity of literature regarding trainee wellness in neurosurgery. A few training programs have instituted wellness initiatives for trainees, and the feedback was generally positive. However, objective measures of efficacy such as validated questionnaires and scales yielded mixed results.

Does work time limit for resident physician affect short-term treatment outcome and hospital length of stay in patients with spontaneous intracerebral hemorrhage?: a two-year experience at a single training hospital in South Korea

Objective

To compare short-term treatment outcomes at hospital discharge and hospital length of stay (LOS) in patients with spontaneous intracerebral hemorrhage (sICH) before and after introduction of resident physician work time limit (WTL).

Methods

We retrospectively reviewed consecutive patients treated for sICH at our institution between 2016 and 2019. Then we dichotomized these patients into two groups, pre-WTL and post-WTL. We analyzed demographic elements and clinical features, and hospital length of stay (LOS). We evaluated short-term outcome using modified Rankin scale score at hospital discharge and then divided it into “good” and “poor” outcome groups. We subsequently, compared short-term treatment outcome and hospital LOS between the pre-WTL and post-WTL groups.

Results

Out of 779 patients, 420 patients (53.9%) were included in the pre-WTL group, and 359 (46.1%) in post-WTL. The mortality rate in sICH patients was higher in the post-WTL group (pre-WTL; 13.6% vs. post-WTL; 17.3%), but there was no statistically significant difference in short-term outcome including mortality (p=0.332) between the groups. The LOS also, was not significantly different between the two groups (pre-WTL; 19.0 days vs. post-WTL; 20.2 days) (p=0.341). The initial Glasgow Coma Scale score, personal stroke history, and mean age were the only independent outcome predicting factors for patients with sICH.

Conclusions

Some neurosurgeons may expect poorer outcome for sICH after implementation of the WTL of the K-MHW for resident physician however, enforcement of the WTL did not significantly influence the short-term outcome and hospital LOS for sICH in our hospital. Further well-designed multi-institutional prospective studies on the effects of WTL in sICH patient outcome, are anticipated.

Procedures performed during neurosurgery residency in Europe

Background

In a previous article (10.1007/s00701-019-03888-3), preliminary results of a survey, aiming to shed light on the number of surgical procedures performed and assisted during neurosurgery residency in Europe were reported. We here present the final results and extend the analyses.

Methods

Board-certified neurosurgeons of European Association of Neurosurgical Societies (EANS) member countries were asked to review their residency case logs and participate in a 31-question electronic survey (SurveyMonkey Inc., San Mateo, CA). The responses received between April 25, 2018, and April 25, 2020, were considered. We excluded responses that were incomplete, from non-EANS member countries, or from respondents that have not yet completed their residency.

Results

Of 430 responses, 168 were considered for analysis after checking in- and exclusion criteria. Survey responders had a mean age of 42.7 ± 8.8 years, and 88.8% were male. Responses mainly came from surgeons employed at university/teaching hospitals (85.1%) in Germany (22.0%), France (12.5%), the United Kingdom (UK; 8.3%), Switzerland (7.7%), and Greece (7.1%). Most responders graduated in the years between 2011 and 2019 (57.7%). Thirty-eight responders (22.6%) graduated before and 130 responders (77.4%) after the European WTD 2003/88/EC came into effect. The mean number of surgical procedures performed independently, supervised or assisted throughout residency was 540 (95% CI 424–657), 482 (95% CI 398–568), and 579 (95% CI 441–717), respectively. Detailed numbers for cranial, spinal, adult, and pediatric subgroups are presented in the article. There was an annual decrease of about 33 cases in total caseload between 1976 and 2019 (coeff. − 33, 95% CI − 62 to − 4, p = 0.025). Variables associated with lesser total caseload during residency were training abroad (1210 vs. 1747, p = 0.083) and female sex by trend (947 vs. 1671, p = 0.111), whereas case numbers were comparable across the EANS countries (p = 0.443).

Conclusion

The final results of this survey largely confirm the previously reported numbers. They provide an opportunity for current trainees to compare their own case logs with. Again, we confirm a significant decline in surgical exposure during training between 1976 and 2019. In addition, the current analysis reveals that female sex and training abroad may be variables associated with lesser case numbers during residency.

Electronic supplementary material

The online version of this article (10.1007/s00701-020-04513-4) contains supplementary material, which is available to authorized users.

Investigation of the "Superior Facet Rule" Using 3D-Printed Thoracic Vertebrae With Simulated Corticocancellous Interface

BACKGROUND

Pedicle screw placement is the most common method of fixation in the thoracic spine. Use of the "superior facet rule" allows the operator to locate the borders of the pedicle reliably using posterior landmarks alone. This study investigated the ability of 3-dimensionally (3D)-printed thoracic vertebrae, made from combined thermoplastic polymers, to demonstrate pedicle screw cannulation accurately using the superior facet as a reliable landmark.

METHODS

An anonymized computed tomography scan of the thoracic spine was obtained. The T1-T12 thoracic vertebrae were anatomically segmented and 3D-printed. The pedicle diameters and distance from the midpoint of the superior facet to the ventral lamina were recorded. A total of 120 thoracic pedicles in 60 thoracic vertebral models were instrumented using a freehand technique based only on posterior landmarks. The vertebral models were then coronally cut and examined for medial or lateral violations of the pedicle after screw placement.

RESULTS

A total of 120 pedicle screws were placed successfully within the 3D-printed thoracic vertebral models. Average measurements fell within 1 standard deviation of previous population studies. There were no pedicle wall violations using standard posterior element landmarks for instrumentation. There were 3 lateral violations of the vertebral body wall during screw placement, all attributable to the insertion technique.

CONCLUSIONS

3D-printed thoracic vertebral models using combined thermoplastic polymers can accurately demonstrate the anatomical ultrastructure and posterior element relationships of the superior facet rule for safe thoracic pedicle screw placement. This method of vertebral model prototyping could prove useful for surgical education and demonstrating spinal anatomy.