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Silvestre J, Kang JD, Ravinsky RA, Lawrence JP, Reitman CA. Establishing case volume benchmarks for ACGME-accredited orthopedic surgery of the spine fellowship training. Spine J 2024; 24:1495-1501. [PMID: 38554735 DOI: 10.1016/j.spinee.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 03/12/2024] [Accepted: 03/24/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND CONTEXT There has been increasing scrutiny on the standardization of surgical training in the US. PURPOSE This study provides case volume benchmarks for Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopedic spine surgery fellowship training. STUDY DESIGN/SETTING This was a retrospective cross-sectional study of fellows at ACGME-accredited orthopedic spine surgery fellowships (2017-2022). PATIENT SAMPLE N/A. OUTCOME MEASURES Reported case volume during fellowship training. METHODS Case volume percentiles were calculated across ACGME-defined case categories and temporal changes assessed via linear regression. Variability between the highest and lowest deciles by case volume was calculated as fold-differences (90th percentile/10th percentile). Sensitivity analyses were performed to identify potential targets for case minimum requirements. RESULTS A total of 163 spine surgery fellows were included in this study. Total mean reported spine surgery case volume increased from 313.2±122 in 2017 to 382.0±164 in 2022 (p=.19). Most cases were classified as adult (range, 97.2%-98.0%) over pediatric cases (range, 2.0%-2.8%). An average of 322.0 cases were reported and most were classified as laminectomy (32%), posterior arthrodesis (29%), and anterior arthrodesis (20%). Overall variability in total case volume was 2.4 and the greatest variability existed for posterior instrumentation (38.1), application of cage (34.6), anterior instrumentation (20.8), and fractures and dislocations (17.3). If case minimum requirements for total reported cases was assumed at 200 cases, then all spine fellows included in this study would achieve this requirement. However, if case minimum requirements were assumed at 250 total cases, then approximately thirty percent of fellows (n=49) would not achieve this requirement for graduation. CONCLUSIONS Increasingly, national societies and accrediting bodies for surgical education recognize the need for standardized training. This study provides benchmarks to inform potential case minimum requirements and help reduce variability during spine fellowship training. Future studies are needed to establish case minimum requirements for spine surgery fellowship training across comprehensive and granular case categories that cover the full gamut of orthopedic spine surgery.
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Affiliation(s)
- Jason Silvestre
- Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425, USA.
| | - James D Kang
- Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Robert A Ravinsky
- Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425, USA
| | - James P Lawrence
- Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425, USA
| | - Charles A Reitman
- Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425, USA
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Hey HWD, Foong ZNA, Yee YE, Koh TYA, Ong JTY, Goh RSN, Poon MEG, Lim JXY, Tan JHJ, Khoo ET. Virtual reality spine surgical training in Singapore: a preliminary study. Singapore Med J 2024:00077293-990000000-00114. [PMID: 38779923 DOI: 10.4103/singaporemedj.smj-2021-476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 09/27/2022] [Indexed: 05/25/2024]
Affiliation(s)
- Hwee Weng Dennis Hey
- University Orthopaedics, Hand and Reconstructive Microsurgery, National University Health System, Singapore
| | | | - Yang En Yee
- Faculty of Engineering, National University of Singapore, Singapore
| | | | | | | | - Mu En Glenys Poon
- University Orthopaedics, Hand and Reconstructive Microsurgery, National University Health System, Singapore
| | - Joel Xue Yi Lim
- University Orthopaedics, Hand and Reconstructive Microsurgery, National University Health System, Singapore
| | - Jiong Hao Jonathan Tan
- University Orthopaedics, Hand and Reconstructive Microsurgery, National University Health System, Singapore
| | - Eng Tat Khoo
- Engineering Design and Innovation Centre, Faculty of Engineering, National University of Singapore, Singapore
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Sedighim S, Sargent B, Grigorian A, Grabar C, Macherla AR, Oh M, Lee YP, Scolaro J, Chen J, Nahmias J. Neurosurgery compared to orthopedic spine consultation: A single level I trauma center experience. BRAIN & SPINE 2024; 4:102808. [PMID: 38618229 PMCID: PMC11010962 DOI: 10.1016/j.bas.2024.102808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 02/26/2024] [Accepted: 04/04/2024] [Indexed: 04/16/2024]
Abstract
Introduction Both Orthopedic Surgery (OS) and Neurosurgery (NS) perform spine surgery in the setting of trauma. However, it is unknown whether outcomes differ between these specialties. This study compares management and outcomes for vertebral fractures between NS and OS, hypothesizing similar operation rate, length of stay (LOS), and readmission. Research question Do outcomes differ between NS and OS in the management of vertebral fractures following trauma? Methods A retrospective single-center study was conducted on adult patients with cervical, thoracic, lumbar, and sacral fractures treated at a single trauma center, where no standardized pathway exists across NS and OS. Patients were compared for injury profile, diagnostic imaging, and operative techniques as well as LOS, mortality, and complications. Results A total of 630 vertebral fracture patients (OS:350 (55.6%); NS:280 (44.4%)) were included. NS utilized magnetic resonance imaging (MRI) more commonly (36.4% vs. 22.6%, p < 0.001). NS patients more often underwent operation (13.2% vs. 7.4%, p = 0.016) despite similar fracture number and severity (p > 0.05). Post-operative complications, LOS, and readmission rates were similar between cohorts (p > 0.05). Discussion and conclusion Despite similar injury profiles, NS had higher rates of MRI usage and operative interventions in the context of traumatic spine fractures. Despite differences in management, major clinical outcomes were similar between NS and OS. However, we do call for further standardization of evaluation and treatment of patients based on established algorithms from such as the AOSpine Thoracolumbar Spine Injury Classification System (ATLICS).
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Affiliation(s)
- Shaina Sedighim
- Division of Trauma, Burns, And Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Brynn Sargent
- Division of Trauma, Burns, And Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Areg Grigorian
- Division of Trauma, Burns, And Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Christina Grabar
- Division of Trauma, Burns, And Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Anvesh R. Macherla
- Division of Trauma, Burns, And Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Michael Oh
- Department of Neurosurgery, University of California, Irvine, Orange, CA, USA
| | - Yu-Po Lee
- Department of Orthopedic Surgery, University of California, Irvine, Orange, CA, USA
| | - John Scolaro
- Department of Orthopedic Surgery, University of California, Irvine, Orange, CA, USA
| | - Jefferson Chen
- Department of Neurosurgery, University of California, Irvine, Orange, CA, USA
| | - Jeffry Nahmias
- Division of Trauma, Burns, And Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA, USA
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Nawabi NLA, Saway BF, Cunningham C, Rhodes S, Kodali P, Pereira M, Patel SJ, Kalhorn SP. Intraoperative Performance with the Exoscope in Spine Surgery: An Institutional Experience. World Neurosurg 2024; 182:208-213. [PMID: 38061539 DOI: 10.1016/j.wneu.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 11/30/2023] [Accepted: 12/01/2023] [Indexed: 12/31/2023]
Abstract
BACKGROUND Exoscope use in spinal neurosurgery has become a promising surgical option providing enhanced operative field visibility and ergonomics. However, data on its use in spine surgery are underreported in the literature. We aimed to assess the intraoperative outcomes in exoscope-assisted spine surgery compared with similar procedures performed using the operative microscope. METHODS A retrospective review was performed of all spinal surgeries performed using an exoscope and, subsequently, an equal number of operative microscope cases performed by 2 senior surgeons at a single institution from 2016 to 2023. The variables included demographics, clinical presentation, surgical treatment, and operative outcomes. RESULTS A total of 123 exoscope spinal surgeries were performed on 116 unique patients with a mean age of 67 ± 14 years, of whom 60 (52%) were women. The microscope group included 126 surgeries on 120 unique patients with a mean age of 62 ± 14 years, of whom 53 (45%) were women. The mean blood loss (28 mL vs. 132 mL; P = 0.0009), operative time (83 minutes vs. 103 minutes; P = 0.006), and length of stay (1.04 days vs. 1.73 days; P = 0.02) were significantly less for the exoscope group than for the microscope group. CONCLUSIONS The use of the exoscope resulted in a shorter operative time, less blood loss, a shorter length of stay, and favorable clinical outcomes compared with the use of the operative microscope. Neurosurgeons should consider this seemingly efficacious and ergonomically favorable visual technology for spinal surgeries.
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Affiliation(s)
- Noah L A Nawabi
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA.
| | - Brian F Saway
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Conor Cunningham
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sloan Rhodes
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Prudhvi Kodali
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Matheus Pereira
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sunil J Patel
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Stephen P Kalhorn
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Melcher C, Hussain I, Kirnaz S, Goldberg JL, Sommer F, Navarro-Ramirez R, Medary B, Härtl R. Use of a High-Fidelity Training Simulator for Minimally Invasive Lumbar Decompression Increases Working Knowledge and Technical Skills Among Orthopedic and Neurosurgical Trainees. Global Spine J 2023; 13:2182-2192. [PMID: 35225716 PMCID: PMC10538343 DOI: 10.1177/21925682221076044] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Prospective comparative study. OBJECTIVE To quantify the educational benefit to surgical trainees of using a high-fidelity simulator to perform minimally invasive (MIS) unilateral laminotomy for bilateral decompression (ULBD) for lumbar stenosis. METHODS Twelve orthopedic and neurologic surgery residents performed three MIS ULBD procedures over 2 weeks on a simulator guided by established AO Spine metrics. Video recording of each surgery was rated by three blinded, independent experts using a global rating scale. The learning curve was evaluated with attention to technical skills, skipped steps, occurrence of errors, and timing. A knowledge gap analysis evaluating participants' current vs desired ability was performed after each trial. RESULTS From trial 1 to 3, there was a decrease in average procedural time by 31.7 minutes. The cumulative number of skipped steps and surgical errors decreased from 25 to 6 and 24 to 6, respectively. Overall surgical proficiency improved as indicated by video rating of efficiency and smoothness of surgical maneuvers, most notably with knowledge and handling of instruments. The greatest changes were noted in junior rather than senior residents. Average knowledge gap analysis significantly decreased by 30% from the first to last trial (P = .001), signifying trainees performed closer to their desired technical goal. CONCLUSION Procedural metrics for minimally invasive ULBD in combination with a realistic surgical simulator can be used to improve the skills and confidence of trainees. Surgical simulation may offer an important educational complement to traditional methods of skill acquisition and should be explored further with other MIS techniques.
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Affiliation(s)
- Carolin Melcher
- Department of Orthopedic Surgery, Physical Medicine and Rehabilitation, University Hospital Munich, Munich, Germany
| | - Ibrahim Hussain
- Department of Neurological Surgery Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Sertac Kirnaz
- Department of Neurological Surgery Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Jacob L. Goldberg
- Department of Neurological Surgery Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Fabian Sommer
- Department of Neurological Surgery Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Rodrigo Navarro-Ramirez
- Department of Neurological Surgery Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Branden Medary
- Department of Neurological Surgery Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Roger Härtl
- Department of Neurological Surgery Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
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Kuruba V, Cherukuri AMK, Arul S, Alzarooni A, Biju S, Hassan T, Gupta R, Alasaadi S, Sikto JT, Muppuri AC, Siddiqui HF. Specialty Impact on Patient Outcomes: Paving a Way for an Integrated Approach to Spinal Disorders. Cureus 2023; 15:e45962. [PMID: 37900519 PMCID: PMC10600402 DOI: 10.7759/cureus.45962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/25/2023] [Indexed: 10/31/2023] Open
Abstract
Spinal surgical procedures are steadily increasing globally due to broad indications of certain techniques encompassing a wide spectrum of conditions, including degenerative spine disorders, congenital anomalies, spinal metastases, and traumatic spinal fractures. The two specialties, neurosurgery (NS) and orthopedic surgery (OS), both possess the clinical adeptness to perform these procedures. With the advancing focus on comparative effectiveness research, it is vital to compare patient outcomes in spine surgeries performed by orthopedic surgeons and neurosurgeons, given their distinct approaches and training backgrounds to guide hospital programs and physicians to consider surgeon specialty when making informed decisions. Our review of the available literature revealed no significant difference in postoperative outcomes in terms of blood loss, neurological deficit, dural injury, intraoperative complications, and postoperative wound dehiscence in procedures performed by neurosurgeons and orthopedic surgeons. An increase in blood transfusion rates among patients operated by orthopedic surgeons and a longer operative time of procedures performed by neurosurgeons was a consistent finding among several studies. Other findings include a prolonged hospital stay, higher hospital readmission rates, and lower cost of procedures in patients operated on by orthopedic surgeons. A few studies revealed lower sepsis rates unplanned intubation rates and higher incidence of urinary tract infections (UTIs) and pneumonia postoperatively among patient cohorts operated by neurosurgeons. Certain limitations were identified in the studies including the use of large databases with incomplete information related to patient and surgeon demographics. Hence, it is imperative to account for these confounding variables in future studies to alleviate any biases. Nevertheless, it is essential to embrace a multidisciplinary approach integrating the surgical expertise of the two specialties and develop standardized management guidelines and techniques for spinal disorders to mitigate complications and enhance patient outcomes.
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Affiliation(s)
- Venkataramana Kuruba
- Department of Orthopedic Surgery, All India Institute of Medical Sciences, Vijayawada, IND
| | | | - Subiksha Arul
- Department of Medicine, JONELTA Foundation School of Medicine, University of Perpetual Help System DALTA, Manila, PHL
| | | | - Sheryl Biju
- Department of Medicine, Christian Medical College, Vellore, IND
| | - Taimur Hassan
- Department of Medicine, Texas A&M College of Medicine, College Station, USA
| | - Riya Gupta
- Department of Medicine, Shri Atal Bihari Vajpayee Medical College and Research Institute, Bangalore, IND
| | - Saya Alasaadi
- Department of Medicine, University College of Dublin, Dublin, IRL
| | - Jarin Tasnim Sikto
- Department of Medicine, Jahurul Islam Medical College and Hospital, Bhagalpur, BGD
| | - Arnav C Muppuri
- Department of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Humza F Siddiqui
- Department of Internal Medicine, Jinnah Postgraduate Medical Center, Karachi, PAK
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Silvestre J, Qureshi SA, Fossett D, Kang JD. Impact of Specialty on Cases Performed During Spine Surgery Training in the United States. World Neurosurg 2023; 175:e1005-e1010. [PMID: 37087030 DOI: 10.1016/j.wneu.2023.04.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 04/14/2023] [Indexed: 04/24/2023]
Abstract
OBJECTIVE Two general pathways exist for spine surgery training in the United States: orthopedic surgery and neurological surgery. Previous studies have not quantified the impact of fellowship training when comparing case volumes between these 2 training pathways. This study compares reported spine surgery case volume upon graduation from orthopedic surgery and neurological surgery training. METHODS This was a retrospective cohort study of recent graduates from orthopedic surgery and neurological Surgery training programs in the United States (2018-2021). The Accreditation Council for Graduate Medical Education provided case logs for residents in neurological surgery and orthopedic surgery as well as fellows in orthopedic spine surgery. Case volumes were compared for adult and pediatric spine surgery cases using parametric tests. RESULTS Case logs from 3146 orthopedic surgery residents, 107 orthopedic spine surgery fellows, and 766 neurological surgery residents were included in this study. Across each cohort, neurological surgery trainees reported more total adult spine surgery cases than orthopedic surgery trainees (514 ± 206 vs. 383 ± 171, P < 0.001). Orthopedic surgery trainees reported more total pediatric spine surgery cases (21 ± 14 vs. 17 ± 12, P = 0.006). CONCLUSIONS Neurological surgery training affords a greater volume of adult spine surgery cases, but orthopedic surgery affords more pediatric spine surgery cases. Identification of relative strengths and weaknesses can help facilitate multidisciplinary training experiences in spine surgery.
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Affiliation(s)
- Jason Silvestre
- Department of Orthopaedic Surgery, Howard University College of Medicine, Washington, District of Columbia, USA
| | - Sheeraz A Qureshi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Damirez Fossett
- Department of Orthopaedic Surgery, Howard University College of Medicine, Washington, District of Columbia, USA
| | - James D Kang
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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Silvestre J, Wu HH, Thompson TL, Kang JD. Utility of Spine Surgery Fellowship Training for Orthopaedic Surgeons in the United States. J Am Acad Orthop Surg 2023; 31:335-340. [PMID: 36729747 DOI: 10.5435/jaaos-d-22-00788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 10/21/2022] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Orthopaedic spine surgeons gain surgical experience through cases conducted during residency and fellowship training. This study elucidates the incremental benefit in spine surgery volume from orthopaedic spine surgery fellowship training. METHODS This was a retrospective national cohort study of orthopaedic surgery residents and orthopaedic spine surgery fellows graduating from US Accreditation Council for Graduate Medical Education-accredited training programs during the 2017 to 2020 academic years. Comparisons in spine surgery case volume were made with parametric tests. RESULTS One hundred fourteen spine surgery fellows and 3,000 orthopaedic surgery residents were included. There was a 3.5-fold increase in total spine surgery cases conducted during fellowship versus residency (314 ± 129 vs. 89 ± 61, P < 0.001). Spine surgery fellows one standard deviation more than the mean reported 443 total spine cases. The largest differences between fellows and residents were Decompression (104 ± 48 vs. 28 ± 23, P < 0.001), Posterior Arthrodesis (94 ± 46 vs. 21 ± 18, P < 0.001), Anterior Arthrodesis (64 ± 31 vs. 13 ± 13, P < 0.001), and Instrumentation (43 ± 25 vs. 22 ± 12, P < 0.001). DISCUSSION Spine surgery fellowship training affords orthopaedic surgeons the opportunity to increase spine surgery case volume by over threefold. The greatest increases in case volume were reported for Decompression, Posterior Arthrodesis, Anterior Arthrodesis, and Instrumentation.
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Affiliation(s)
- Jason Silvestre
- From Howard University College of Medicine, Washington, DC (Silvestre and Thompson), University of California San Francisco School of Medicine, San Francisco, CA (Wu), and Brigham and Women's Hospital, Boston, MA (Kang)
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Reich A, Mirchi N, Yilmaz R, Ledwos N, Bissonnette V, Tran DH, Winkler-Schwartz A, Karlik B, Del Maestro RF. Artificial Neural Network Approach to Competency-Based Training Using a Virtual Reality Neurosurgical Simulation. Oper Neurosurg (Hagerstown) 2022; 23:31-39. [PMID: 35726927 DOI: 10.1227/ons.0000000000000173] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 11/08/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The methodology of assessment and training of surgical skills is evolving to deal with the emergence of competency-based training. Artificial neural networks (ANNs), a branch of artificial intelligence, can use newly generated metrics not only for assessment performance but also to quantitate individual metric importance and provide new insights into surgical expertise. OBJECTIVE To outline the educational utility of using an ANN in the assessment and quantitation of surgical expertise. A virtual reality vertebral osteophyte removal during a simulated surgical spine procedure is used as a model to outline this methodology. METHODS Twenty-one participants performed a simulated anterior cervical diskectomy and fusion on the Sim-Ortho virtual reality simulator. Participants were divided into 3 groups, including 9 postresidents, 5 senior residents, and 7 junior residents. Data were retrieved from the osteophyte removal component of the scenario, which involved using a simulated burr. The data were manipulated to initially generate 83 performance metrics spanning 3 categories (safety, efficiency, and motion) of which only the most relevant metrics were used to train and test the ANN. RESULTS The ANN model was trained on 6 safety metrics to a testing accuracy of 83.3%. The contributions of these performance metrics to expertise were revealed through connection weight products and outlined 2 identifiable learning patterns of technical skills. CONCLUSION This study outlines the potential utility of ANNs which allows a deeper understanding of the composites of surgical expertise and may contribute to the paradigm shift toward competency-based surgical training.
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Affiliation(s)
- Aiden Reich
- Neurosurgical Simulation and Artificial Intelligence Learning Centre, Department of Neurology & Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
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Hart RA, Daniels AH, Shah K, Amendola AA, Harner CD, Marsh LL, Kenter K, Hu S. Is It Time to Create Training Pathways Allowing Earlier Subspecialization within the "House of Orthopaedics"?: AOA Critical Issues. J Bone Joint Surg Am 2022; 104:e52. [PMID: 35133994 DOI: 10.2106/jbjs.20.02166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The ability to train an orthopaedic resident in all aspects of orthopaedics in 5 years has become increasingly difficult due to the growth in knowledge and techniques, work-hour restrictions, and reduced resident autonomy. It has become nearly universal for our residents to complete at least 1 subspecialty fellowship prior to entering practice. In some subspecialties, the skills necessary to practice competently have become difficult to master. Simply adding to the current length of training may not address these issues effectively and would add to the economic cost of residency training. Novel training pathways that allow residents to focus earlier and in greater depth on their intended subspecialty while maintaining general orthopaedic competencies can be created without lengthening training. It is time to initiate discussions about these possibilities.
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Affiliation(s)
| | - Alan H Daniels
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | | | | | | | - Keith Kenter
- Western Michigan University, Kalamazoo, Michigan
| | - Serena Hu
- Stanford University, Palo Alto, California
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11
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Simulation Training in Spine Surgery. J Am Acad Orthop Surg 2022; 30:400-408. [PMID: 35446299 DOI: 10.5435/jaaos-d-21-00756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 01/19/2022] [Indexed: 02/01/2023] Open
Abstract
Simulated surgery is part of a growing paradigm shift in surgical education as a whole. Various modalities from cadaver models to virtual reality have been developed and studied within the context of surgical education. Simulation training in spine surgery has an immense potential to improve education and ultimately improve patient safety. This is due to the inherent risk of operating the spine and the technical difficulty of modern techniques. Common procedures in the modern orthopaedic armamentarium, such as pedicle screw placement, can be simulated, and proficiency is rapidly achieved before application in patients. Furthermore, complications such as dural tears can be simulated and effectively managed in a safe environment with simulation. New techniques with steeper learning curves, such as minimally invasive techniques, can now be safely simulated. Hence, augmenting surgical education through simulation has great potential to benefit trainees and practicing orthopaedic surgeons in modern spine surgery techniques. Additional work will aim to improve access to such technologies and integrate them into the current orthopaedic training curriculum.
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Alomari S, Porras JL, Lo SFL, Theodore N, Sciubba DM, Witham T, Bydon A. Does the Specialty of the Surgeon Performing Elective Anterior/Lateral Lumbar Interbody Fusion for Degenerative Spine Disease Correlate with Early Perioperative Outcomes? World Neurosurg 2021; 155:e111-e118. [PMID: 34390873 DOI: 10.1016/j.wneu.2021.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Comparative effectiveness research has a vital role in health reform and policies. Specialty training is one of these provider-side variables, and surgeons performing the same procedure who were trained in different specialties may have different outcomes. The objective of this study was to investigate the impact of spine surgeon specialty (neurosurgery vs. orthopedic surgery) on early perioperative outcome measures of elective anterior/lateral lumbar interbody fusion (ALIF/LLIF) for degenerative disc diseases. METHODS In a retrospective, 1:1 propensity score-matched cohort study, 9070 patients were reviewed from the American College of Surgeons National Surgical Quality Improvement Program database. Propensity score matching and subgroup analysis were used. RESULTS In both groups (single-level and multilevel ALIF/LLIF), patients operated on by neurosurgeons had longer operative time (188 minutes vs. 172 minutes/239 minutes vs. 221 minutes); shorter total hospital stay (71 hours vs. 90 hours/89 hours vs. 96 hours); and lower rates of return to the operating room (2.1% vs. 4.1%/2.4% vs. 4.2%), nonhome discharge (8.7% vs. 11.1%/10.1% vs. 14.9%), discharge after postoperative day 3 (22.0% vs. 30.0%/38.0% vs. 43.9%), and perioperative blood transfusion (2.1% vs. 5.1%/5.0% vs. 9.9%) (P < 0.05). In multilevel ALIF/LLIF, patients operated on by neurosurgeons had lower readmission rates (3.9% vs. 6.9%) (P < 0.05). Other outcome measures and mortality rates were similar between the single-level and multilevel ALIF/LLIF cohorts regardless of surgeon specialty. CONCLUSIONS Our analysis found significant differences in early perioperative outcomes of patients undergoing ALIF/LLIF by neurosurgeons and orthopedic surgeons. These differences have significant clinical and cost implications for patients, physicians, program directors, payers, and health systems.
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Affiliation(s)
- Safwan Alomari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jose L Porras
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sheng-Fu L Lo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Timothy Witham
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ali Bydon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Lad M, Gupta R, Para A, Gupta A, White MD, Agarwal N, Moore JM, Heary RF. An ACGME-based comparison of neurosurgical and orthopedic resident training in adult spine surgery via a case volume and hours-based analysis. J Neurosurg Spine 2021; 35:553-563. [PMID: 34359032 DOI: 10.3171/2020.10.spine201066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 10/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In a 2014 analysis of orthopedic and neurological surgical case logs published by the Accreditation Council for Graduate Medical Education (ACGME), it was reported that graduating neurosurgery residents performed more than twice the number of spinal procedures in their training compared with graduating orthopedic residents. There has, however, been no follow-up assessment of this trend. Moreover, whether this gap in case volume equates to a similar gap in procedural hours has remained unstudied. Given the association between surgical volume and outcomes, evaluating the status of this disparity has value. Here, the authors assess trends in case volume and procedural hours in adult spine surgery for graduating orthopedic and neurological surgery residents from 2014 to 2019. METHODS A retrospective analysis of ACGME case logs from 2014 to 2019 for graduating orthopedic and neurological surgery residents was conducted for adult spine surgeries. Case volume was converted to operative hours by using periprocedural times from the 2019 Medicare/Medicaid Physician Fee Schedule. Graduating residents' spinal cases and hours, averaged over the study period, were compared between the two specialties by using 2-tailed Welch's unequal variances t-tests (α = 0.05). Longitudinal trends in each metric were assessed by linear regression followed by cross-specialty comparisons via tests for equality of slopes. RESULTS From 2014 to 2019, graduating neurosurgical residents logged 6.8 times as many spinal cases as their orthopedic counterparts, accruing 431.6 (95% CI 406.49-456.61) and 63.8 (95% CI 57.08-70.56) cases (p < 0.001), respectively. Accordingly, graduating neurosurgical residents logged 6.1 times as many spinal procedural hours as orthopedic surgery residents, accruing 1020.7 (95% CI 964.70-1076.64) and 166.6 (95% CI 147.76-185.35) hours (p < 0.001), respectively. Over these 5 years, both fields saw a linear increase in graduating residents' adult spinal case volumes and procedural hours, and these growth rates were higher for neurosurgery (+16.2 cases/year vs +4.4 cases/year, p < 0.001; +36.4 hours/year vs +12.4 hours/year, p < 0.001). CONCLUSIONS Graduating neurosurgical residents accumulated substantially greater adult spinal case volumes and procedural hours than their orthopedic counterparts from 2014 to 2019. This disparity has been widened by a higher rate of growth in adult spinal cases among neurosurgery residents. Accordingly, targeted efforts to increase spinal exposure for orthopedic surgery residents-such as using cross-specialty collaboration-should be explored.
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Affiliation(s)
- Meeki Lad
- 1Department of Neurosurgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Raghav Gupta
- 1Department of Neurosurgery, Rutgers-New Jersey Medical School, Newark, New Jersey
- 2Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ashok Para
- 1Department of Neurosurgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Arjun Gupta
- 1Department of Neurosurgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Michael D White
- 3Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Nitin Agarwal
- 3Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Justin M Moore
- 4Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Robert F Heary
- 5Department of Neurosurgery, Hackensack Meridian School of Medicine, Nutley, New Jersey
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Malik AT, Kim J, Ahmed U, Yu E, Khan SN. Understanding the Trends and Variability in Procedures Performed During Orthopedic Spine Surgery Fellowship Training: An Analysis of ACGME Case Log Data. JOURNAL OF SURGICAL EDUCATION 2021; 78:686-693. [PMID: 32919922 DOI: 10.1016/j.jsurg.2020.08.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/10/2020] [Accepted: 08/16/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To understand trends and variability of procedures performed by orthopedic spine surgery fellows during training. DESIGN Cross-sectional survey. SETTING Accreditation Council on Graduate Medical Education (ACGME) case logs. PARTICIPANTS Fellows enrolled in ACGME-accredited "Orthopaedic Surgery of the Spine" fellowships from 2010 to 2015. RESULTS The 2010 to 2015 ACGME fellowship case logs for "Orthopaedic Surgery of the Spine" were retrieved. Spine cases in case logs are grouped into the following categories: (1) Excision, (2) Osteotomy, (3) Fracture and/or Dislocation, (4) Decompression, (5) Anterior fusion/arthrodesis, (6) Posterior fusion, (7) Deformity surgery, (8) Exploration, (9) Instrumentation, and (10) other/uncategorized. The total number of spine cases logged by each fellow increased from 821 in 2010 to 1134 in 2015 (38.2% increase). The greatest increases were noted from fracture/dislocation cases (77.9%), followed by posterior fusions (62.2%), anterior fusions (43.6%), decompressions (36.3%), and instrumentation (29.5%). The average number of deformity cases decreased from 23 in 2010 to 19 in 2016 (18.6% decrease). The average number of adult-only cases increased from 770 in 2010 to 1100 in 2015 (42.8% increase), whereas the average number of pediatric-only cases declined from 51 in 2010 to 35 in 2015 (32.1% decrease). Based on case logs from 2015, the greatest variation in case volume between the 10th centile and 90th centile of fellows was noted for deformity cases, followed by decompressions and posterior fusions. CONCLUSIONS Even though there has been a 38% increase in the overall number of spine cases performed by fellows during training, a large amount of variation in type of case exposure exists between fellowships. The findings of our study call for the establishment of minimal case volumes and/or uniformity of training spectrums across the nation to ensure appropriate surgical care is made accessible to all patients.
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Affiliation(s)
- Azeem Tariq Malik
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jeffery Kim
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Uzair Ahmed
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Elizabeth Yu
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Safdar N Khan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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Rabski JE, Saha A, Cusimano MD. Setting standards of performance expected in neurosurgery residency: A study on entrustable professional activities in competency-based medical education. Am J Surg 2020; 221:388-393. [PMID: 33341234 DOI: 10.1016/j.amjsurg.2020.12.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 12/06/2020] [Accepted: 12/06/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Competency-based medical education requires evaluations of residents' performances of tasks of the discipline (ie. entrustable professional activities (EPAs)). Using neurosurgical Faculty perspectives, this study investigated whether a sample of neurosurgical EPAs accurately reflected the expectations of general neurosurgical practice. METHOD A questionnaire was sent to all Canadian neurosurgery Faculty using a SurveyMonkey® platform. RESULTS The proportion of respondents who believed the EPAs were representative of general neurosurgery competences varied significantly across all EPAs [47%-100%] (p < 0.0001). For 9/15 proposed EPAs, ≥75% agreed they were appropriate for general neurosurgery training and expected residents to attain the highest standard of performance. However, a range of 27-53% of the respondents felt the other six EPAs would be more appropriate for fellowship training and thus, require a lower standard of performance from graduating residents. CONCLUSION The shift towards subspecialization in neurosurgery has implications for curriculum design, delivery and certification of graduating residents.
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Affiliation(s)
- Jessica E Rabski
- Injury Prevention Research Office, St. Michael's Hospital, Toronto, Ontario, Canada; Division of Neurosurgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada.
| | - Ashirbani Saha
- Injury Prevention Research Office, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Michael D Cusimano
- Injury Prevention Research Office, St. Michael's Hospital, Toronto, Ontario, Canada; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
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Correlates of Google Search Rankings for Spine Surgeons: An Analysis of Academic Pedigree, Social Media Presence, and Patient Ratings. Spine (Phila Pa 1976) 2020; 45:1376-1381. [PMID: 32453226 DOI: 10.1097/brs.0000000000003567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective observational study. OBJECTIVE The objective of this study is to identify correlates of search ranking among academic pedigree, online ratings, and social media following. SUMMARY OF BACKGROUND DATA Patients increasingly rely on online search in selecting healthcare providers. When choosing a spine surgeon, patients typically value surgical skill and experience as well as demeanor/bedside manner. It is unclear whether current search engine ranking algorithms reflect these preferences. METHODS A Google.com search for the top 25 spine surgeon websites by search ranking was conducted for each of the largest 25 American cities. Resulting websites were then perused for academic pedigree, experience, and practice characteristics. Surgeons' research output and impact were then quantified via number of publications and H-index. Online ratings and followers in various social media outlets were also noted. These variables were assessed as possible correlates of search ranking via linear regression and multivariate analyses of variance. RESULTS A total of 625 surgeons were included. Three categorical variables were identified as significant correlates of higher mean Google search ranking-orthopedics (vs. neurosurgery) as a surgical specialty (P = 0.023), board certification (P = 0.024), and graduation from a top 40 residency program (P = 0.046). Although the majority of the identified surgeons received an allopathic medical education, there was no significant difference in the mean rank of surgeons who had an MD versus DO medical degree (P = 0.530). Additionally, none of the continuous variables collected, including years in practice (P = 0.947), publications (P = 0.527), H-index (P = 0.278), social media following such as on Facebook (P = 0.105), or online ratings such as on Healthgrades (P = 0.080), were significant correlates of Google search ranking. CONCLUSIONS Google search rankings do not always align with patient preferences, currently promoting orthopedic over neurosurgical specialists, graduation from top residency programs, and board certification, while largely ignoring academic pedigree, research, social media presence, and online ratings. LEVEL OF EVIDENCE 3.
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Lubbe RJ, Miller J, Roehr CA, Allenback G, Nelson KE, Bear J, Kubiak EN. Effect of Statewide Social Distancing and Stay-At-Home Directives on Orthopaedic Trauma at a Southwestern Level 1 Trauma Center During the COVID-19 Pandemic. J Orthop Trauma 2020; 34:e343-e348. [PMID: 32815849 PMCID: PMC7446999 DOI: 10.1097/bot.0000000000001890] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare orthopaedic trauma volume and mechanism of injury before and during statewide social distancing and stay-at-home directives. DESIGN Retrospective. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS One thousand one hundred thirteen patients sustaining orthopaedic trauma injuries between March 17 and April 30 of years 2018, 2019, and 2020. INTERVENTION Statewide social distancing and stay-at-home directives. MAIN OUTCOME MEASUREMENTS Number of consults, mechanism of injury frequency, and type of injury frequency. RESULTS During the COVID-19 pandemic, orthopaedic trauma consult number decreased. Injuries due to gunshot wounds increased and those due to automobile versus pedestrian accidents decreased. Time-to-presentation increased and length of stay decreased. Operative consults remained unchanged. CONCLUSIONS Orthopaedic trauma injuries continued to occur during the COVID-19 pandemic at an overall decreased rate, however, with a different distribution in mechanism and type of injury. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ryan J. Lubbe
- Department of Orthopaedic Surgery, University of Nevada Las Vegas School of Medicine, Las Vegas, NV; and
| | - Jordan Miller
- Department of Orthopaedic Surgery, University of Nevada Las Vegas School of Medicine, Las Vegas, NV; and
| | - Casey A. Roehr
- Department of Orthopaedic Surgery, University of Nevada Las Vegas School of Medicine, Las Vegas, NV; and
| | - Gayle Allenback
- Department of Orthopaedic Surgery, University of Nevada Las Vegas School of Medicine, Las Vegas, NV; and
- OptumCare Orthopaedics and Spine, OptumCare, Las Vegas, NV
| | - Karen E. Nelson
- Department of Orthopaedic Surgery, University of Nevada Las Vegas School of Medicine, Las Vegas, NV; and
- OptumCare Orthopaedics and Spine, OptumCare, Las Vegas, NV
| | - Jessica Bear
- Department of Orthopaedic Surgery, University of Nevada Las Vegas School of Medicine, Las Vegas, NV; and
- OptumCare Orthopaedics and Spine, OptumCare, Las Vegas, NV
| | - Erik N. Kubiak
- Department of Orthopaedic Surgery, University of Nevada Las Vegas School of Medicine, Las Vegas, NV; and
- OptumCare Orthopaedics and Spine, OptumCare, Las Vegas, NV
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18
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Myers M, Hall S, Sadek AR, Dare C, Griffith C, Shenouda E, Nader-Sepahi A. Differences in management of isolated spinal fractures between neurosurgery and orthopaedics: a 6-year retrospective study. Br J Neurosurg 2020; 35:68-72. [PMID: 32441143 DOI: 10.1080/02688697.2020.1763256] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The acute management of spinal fractures is traditionally split between neurosurgeons and orthopaedic surgeons and the specialities have varying approaches to management. This study investigates differences between neurosurgeons and spinal orthopaedic surgeons in the management of spinal fractures at a single trauma centre in the United Kingdom. METHODS A retrospective study at a single trauma centre of patients identified using the Trauma Audit and Research Network (TARN). Case notes and radiological investigations were reviewed for demographics, fracture classification, clinical management and outcomes. Polytrauma cases and patients managed by non-neurosurgical/orthopaedic specialties were excluded. RESULTS A total of 465 patients were included in this study (neurosurgery n = 266, orthopaedics n = 199). There were no significant differences between groups for age, gender, Charlson co-morbidity score or distribution of fractures using the AO spine classification. Patients admitted and managed under the orthopaedic surgeons were more likely to undergo a surgical procedure when compared to those admitted under the neurosurgeons (n = 71; 35.7% vs n = 71; 26.8%, p = 0.042, OR 1.56 95%CI 1.056 to 2.31). The median overall length of stay was 8 days and there was no significant difference between teams; however, the neurosurgical cohort were more likely to be admitted to an intensive care unit (24.3% vs 16.2%, p = 0.04). CONCLUSION This study is the first in the United Kingdom to compare neurosurgical and orthopaedic teams in their management of spinal fractures. It demonstrates that differences may exist both in operating rates and outcomes.
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Affiliation(s)
- Matthew Myers
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain and Northern Ireland.,Division of Clinical Neurosciences, School of Medicine, University of Southampton, Southampton, United Kingdom of Great Britain and Northern Ireland
| | - Samuel Hall
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain and Northern Ireland.,Division of Clinical Neurosciences, School of Medicine, University of Southampton, Southampton, United Kingdom of Great Britain and Northern Ireland
| | - Ahmed-Ramadan Sadek
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain and Northern Ireland.,Division of Clinical Neurosciences, School of Medicine, University of Southampton, Southampton, United Kingdom of Great Britain and Northern Ireland
| | - Christopher Dare
- Department of Trauma and Orthopaediacs, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain and Northern Ireland
| | - Colin Griffith
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain and Northern Ireland.,Division of Clinical Neurosciences, School of Medicine, University of Southampton, Southampton, United Kingdom of Great Britain and Northern Ireland
| | - Emad Shenouda
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain and Northern Ireland.,Division of Clinical Neurosciences, School of Medicine, University of Southampton, Southampton, United Kingdom of Great Britain and Northern Ireland
| | - Ali Nader-Sepahi
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain and Northern Ireland.,Division of Clinical Neurosciences, School of Medicine, University of Southampton, Southampton, United Kingdom of Great Britain and Northern Ireland
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Orthopaedics and neurosurgery: Is there a difference in surgical outcomes following anterior cervical spinal fusion? J Orthop 2020; 21:278-282. [PMID: 32508432 DOI: 10.1016/j.jor.2020.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 04/24/2020] [Accepted: 05/15/2020] [Indexed: 11/21/2022] Open
Abstract
Objective The superiority of neurosurgical over orthopaedic spinal procedures is a point of contention. While there is the perception that neurosurgeons are more specifically trained to deal with spinal pathology, no study has directly compared outcomes of spinal surgeries performed by both groups. Methods We sought to evaluate the differences in length of surgery, hospital stay, complications, mortality, and readmission for anterior cervical decompression and fusion (ACDF) performed by neurosurgeons versus orthopaedic surgeons. Results 17,967 ACDF procedures were analyzed. Neurosurgeons performed 74.3% of the fusions with a trend towards longer operative times and significantly more patients that were discharged to extended care facilities. There was no significant difference in the length of stay, overall complications, mortality, readmission, or reoperation when comparing the two specialties. Conclusion Despite a significantly higher volume of ACDF performed by neurosurgeons, outcomes are comparable following orthopaedic and neurosurgical procedures.
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20
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Malige A, Yuh R, Yellapu V, Lands V, Woods B, Sokunbi G. Review of Physician Referrals to Orthopedic Spine versus Neurosurgery. Clin Orthop Surg 2020; 12:55-59. [PMID: 32117539 PMCID: PMC7031437 DOI: 10.4055/cios.2020.12.1.55] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 08/20/2019] [Indexed: 11/06/2022] Open
Abstract
Background Previous studies have reported what patients value while choosing their surgeon, but there are no studies exploring the patterns of referral to spine surgeons among primary care physicians (PCPs). This study aims to identify any trends in PCPs' referral to orthopedic surgery versus neurosurgery for spinal pathology. Methods In total, 450 internal medicine, family medicine, emergency medicine, neurology, and pain management physicians who practice at one of three locations (suburban community hospital, urban academic university hospital, and urban private practice) were asked to participate in the study. Consenting physicians completed our 24-question survey addressing their beliefs according to pathologies, locations of pathologies, and surgical interventions. Results Overall, 108 physicians (24%) completed our survey. Fifty-seven physicians (52.8%) felt that neurosurgeons would provide better long-term comprehensive spinal care. Overall, 66.7% of physicians would refer to neurosurgery for cervical spine radiculopathy; 52.8%, to neurosurgery for thoracic spine radiculopathy; and 56.5%, to orthopedics for lumbar spine radiculopathy. Most physicians would refer all spine fractures to orthopedics for treatment except cervical spine fractures (56.5% to neurosurgeons). Most physicians would refer to neurosurgery for extradural tumors (91.7%) and intradural tumors (96.3%). Most would refer to orthopedic surgeons for chronic pain. Finally, physicians would refer to orthopedics for spine fusion (61.1%) and discectomy (58.3%) and to neurosurgery for minimally invasive surgery (59.3%). Conclusions Even though both orthopedic surgeons and neurosurgeons are intensively trained to treat a similar breath of spinal pathology, physicians vary in their referring patterns according to spinal pathology, location of pathology, and intended surgery. Education on the role of spine surgeons among PCPs is essential in ensuring unbiased referral patterns.
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Affiliation(s)
- Ajith Malige
- Department of Orthopedic Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Roger Yuh
- Department of Orthopedic Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Vikas Yellapu
- Department of Orthopedic Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Vince Lands
- Department of Orthopedic Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | | | - Gbolabo Sokunbi
- Department of Orthopedic Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
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The perceived efficacy and utility of spine bioskills curricula for resident and fellow education. J Orthop 2020; 20:87-91. [PMID: 32042235 DOI: 10.1016/j.jor.2020.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 01/06/2020] [Indexed: 11/24/2022] Open
Abstract
The purpose of this study is to assess the role of bioskills in orthopaedic and neurosurgical resident education. A survey of the utilization and perceived efficacy of bioskills was submitted to Lumbar Spine Research Society (LSRS) members. 36/104 surgeons responded, including 25 orthopaedic, 7 neurosurgical, and 4 integrated respondents. 63% of orthopaedic and 83% of neurosurgery faculty, reported using bioskills. When asked if completion of bioskills modules would encourage advancing trainees' participation (1-10 scale, 10 greatly increase), neurosurgical faculty reported 4.00 versus orthopaedics 6.43. Although orthopaedic faculty perceive greater efficacy of bioskills, the clinical impact of this difference remains uncertain.
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22
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Pham MH, Jakoi AM, Wali AR, Lenke LG. Trends in Spine Surgery Training During Neurological and Orthopaedic Surgery Residency: A 10-Year Analysis of ACGME Case Log Data. J Bone Joint Surg Am 2019; 101:e122. [PMID: 31764374 DOI: 10.2106/jbjs.19.00466] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Spine surgery training in the United States currently involves residency training in neurological or orthopaedic surgery. Because of different core residency surgical requirements, the volume of spine surgery procedures may vary between the 2 residencies. METHODS We reviewed the Accreditation Council for Graduate Medical Education resident case logs for both orthopaedic surgery and neurological surgery for exposure to spine surgery procedures for the graduating years of 2009 to 2018. RESULTS The average number of spine surgery procedures performed during that 10-year period was 433.8 for neurosurgery residents and 119.5 for orthopaedic surgery residents (p < 0.01). From 2009 to 2018, neurosurgery residents saw an increase of 26.5% in spine surgery procedures (from 389.6 to 492.9 procedures), whereas orthopaedic surgery residents saw a decrease of 41.3% (from 141.1 to 82.8 procedures). The 10-year average percentage of total spine procedures among all total surgical cases was 33.5% for neurosurgery residents compared with 6.2% for orthopaedic surgery residents (p < 0.01). This percentage decreased for both neurosurgery residents (35.8% in 2009 to 31.3% in 2018) and orthopaedic surgery residents (7.2% in 2009 to 4.9% in 2018). Neurosurgical residents performed 3.6 times more total spine procedures than orthopaedic surgery residents on average, a number that increased from 2.8-fold in 2009 to 6.0-fold in 2018. CONCLUSIONS The case volume of spine surgery procedures varies greatly, with higher rates for neurological surgery and lower rates for orthopaedic surgery residencies, with an increasing discrepancy over time. Although case volume alone cannot solely determine quality of training, it is one measure to assess opportunities to develop optimal spine education around a certain accepted volume of surgical patient care. Not accounted for here are additional postgraduate spine cases performed by orthopaedic surgery residents who pursue spine fellowship training (an additional 300 to 500 cases). The results described herein may help to explore the various needs of and differences between residents seeking to pursue careers in spine as well as the role of spine surgery fellowships currently and in the future.
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Affiliation(s)
- Martin H Pham
- Department of Neurosurgery, University of California San Diego School of Medicine, San Diego, California
| | - Andre M Jakoi
- Orthopedic Health of Kansas City, North Kansas City, Missouri
| | - Arvin R Wali
- Department of Neurosurgery, University of California San Diego School of Medicine, San Diego, California
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, The Daniel and Jane Och Spine Hospital at New York-Presbyterian, Columbia University College of Physicians and Surgeons, New York, NY
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Kumaria A, Bateman AH, Eames N, Fehlings MG, Goldstein C, Meyer B, Paquette SJ, Yee AJM. Advancing spinal fellowship training: an international multi-centre educational perspective. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:2437-2443. [PMID: 31407164 DOI: 10.1007/s00586-019-06098-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 03/19/2019] [Accepted: 08/05/2019] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Ashwin Kumaria
- Royal Derby Spinal Centre, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Antony H Bateman
- Royal Derby Spinal Centre, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK.
| | - Niall Eames
- Belfast Health and Social Care Trust, Royal Victoria Hospital, 274 Grosvenor Road, Belfast, BT12 6BA, Northern Ireland, UK
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, University of Toronto, Toronto, ON, Canada
| | - Christina Goldstein
- Missouri Orthopaedic Institute, University of Missouri, 1100 Virginia Ave, Columbia, MO, 65212, USA
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | | | - Albert J M Yee
- Department of Surgery, University of Toronto, Toronto, Canada
- University of Toronto Spine Program, Toronto, Canada
- Marvin Tile Chair, Division Head of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Rm MG 371-B, Toronto, ON, M4N 3M5, Canada
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Baek J, Malik AT, Khan I, Yu E, Kim J, Khan SN. Orthopedic versus Neurosurgery-Understanding 90-Day Complications and Costs in Patients Undergoing Elective 1-Level to 2-Level Posterior Lumbar Fusions by Different Specialties. World Neurosurg 2019; 131:e447-e453. [PMID: 31415887 DOI: 10.1016/j.wneu.2019.07.194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 07/25/2019] [Accepted: 07/26/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Lumbar fusions are routinely performed by either orthopedic or neurologic spine surgeons. Controversy still exists as to whether a provider's specialty (orthopedic vs. neurosurgery) influences outcomes. METHODS The 2007-2015Q2 Humana Commercial Database was queried using Current Procedural Terminology codes (22612, 22614, 22630, 22632, 22633 and 22634) to identify patients undergoing elective 1-to-2 level posterior lumbar fusions (PLFs) with active enrollment up to 90 days after procedure. Ninety-day complication rates were calculated for the 2 specialties. The surgical and 90-day resource utilization costs for the 2 groups were compared, by studying average reimbursements for acute-care and post-acute-care categories. Ninety-day complications and costs were compared using multivariable logistic and linear regression analyses. RESULTS A total of 10,509 patients (5523 orthopedic and 4986 neurosurgery) underwent an elective 1-to-2 level PLF during the period. With the exception of a significantly lower odds of wound complications (odds ratio, 0.81) and a higher odds of dural tears (odds ratio, 1.29) in elective PLFs performed by orthopedic surgeons, no statistically strong differences were seen in 90-day complication rates between the 2 groups. Total 90-day costs were also similar between orthopedic surgeons and neurosurgeons, with the only exception being that surgeon reimbursement was lower for orthopedic surgery versus neurosurgery ($1202 vs. $1372; P < 0.001). CONCLUSIONS It seems that a provider's specialty does not largely influence 90-day surgical outcomes and costs after elective PLFs. The results of the study promote the formation and acceptance of dual training pathways for entry into spine surgery.
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Affiliation(s)
- Jae Baek
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Azeem Tariq Malik
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Inamullah Khan
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Elizabeth Yu
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jeffery Kim
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Safdar N Khan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
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Post AF, Dai JB, Li AY, Maniya AY, Haider S, Sobotka S, Germano IM, Choudhri TF. Workforce Analysis of Spine Surgeons Involved with Neurological and Orthopedic Surgery Residency Training. World Neurosurg 2019; 122:e147-e155. [DOI: 10.1016/j.wneu.2018.09.152] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 09/18/2018] [Accepted: 09/19/2018] [Indexed: 10/28/2022]
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Bateman AH, Larouche J, Goldstein CL, Sciubba DM, Choma TJ, Lawrence B, Cheng J, Fehlings MG, Paquette SJ, Yee AJM. The Importance of Determining Trainee Perspectives on Procedural Competencies During Spine Surgery Clinical Fellowship. Global Spine J 2019; 9:18-24. [PMID: 30775204 PMCID: PMC6362552 DOI: 10.1177/2192568217747574] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Longitudinal survey. OBJECTIVE It remains important to align competence-based objectives for training as deemed important by clinical fellows to those of their fellowship supervisors and program educators. The primary aim of this study was to determine trainee views on the relative importance of specific procedural training competencies. Secondarily, we aimed to evaluate self-perceived confidence in procedural performance at the commencement and completion of fellowship. METHODS Questionnaires were administered to 68 clinical fellows enrolled in the AOSNA fellowship program during the 2015-2016 academic year. A Likert-type scale was used to quantify trainee perspectives on the relative importance of specific procedural competencies to their training base on an established curriculum including 53 general and 22 focused/advanced procedural competencies. We measured trainee self-perceived confidence in performing procedures at the commencement and completion of their program. Statistical analysis was performed on fellow demographic data and procedural responses. RESULTS Our initial survey response rate was 82% (56/68) and 69% (47/68) for the follow-up survey. Although most procedural competencies were regarded of high importance, we did identify several procedures of high importance yet low confidence among fellows (ie, upper cervical, thoracic discectomy surgery), which highlights an educational opportunity. Overall procedural confidence increased from an average Likert score of 4.2 (SD = 1.3) on the initial survey to 5.4 (SD = 0.8) by follow-up survey (P < .0001). CONCLUSIONS Understanding trainee goals for clinical fellowship remains important. Identification of areas of low procedural confidence and high importance to training experience will better guide fellowship programs and supervisors in the strategic delivery of the educational experience.
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Affiliation(s)
- Antony H. Bateman
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada,Royal Derby Hospital, Derby, UK
| | | | | | | | | | | | | | | | - Scott J. Paquette
- The University of British Columbia, Vancouver, British Columbia,
Canada
| | - Albert J. M. Yee
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada,Albert J. M. Yee, Sunnybrook Health Sciences
Centre, 2075 Bayview Avenue, MG-371B, Toronto, Ontario, Canada M4N 3M5.
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Bronheim RS, Cheung ZB, Phan K, White SJW, Kim JS, Cho SK. Anterior Lumbar Fusion: Differences in Patient Selection and Surgical Outcomes Between Neurosurgeons and Orthopaedic Surgeons. World Neurosurg 2018; 120:e221-e226. [PMID: 30121412 DOI: 10.1016/j.wneu.2018.08.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 08/04/2018] [Accepted: 08/06/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Anterior lumbar fusion (ALF) is performed by both neurosurgeons and orthopaedic surgeons. The aim of this study was to determine differences between the 2 surgical subspecialties in terms of patient selection and postoperative outcomes after ALF. METHODS A retrospective cohort study of adult patients undergoing ALF in the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2014 was performed. Univariate analyses were performed to identify differences in baseline patient demographics, comorbidities, operative characteristics, and 30-day postoperative outcomes between neurosurgery and orthopaedic surgery patients. Multivariate logistic regression analysis was used to determine whether surgical subspecialty was an independent risk factor for postoperative complications. RESULTS The study included 3182 patients, with 1629 (51.2%) neurosurgery patients and 1553 (48.8%) orthopaedic surgery patients. A greater proportion of neurosurgery patients were >65 years old, were being treated with preoperative steroids, had cardiac or pulmonary comorbidities, and had an American Society of Anesthesiologists classification III or higher. ALF procedures performed by neurosurgeons more frequently involved use of intervertebral devices and bone graft. On multivariate logistic regression analysis, ALF procedures performed by neurosurgeons were independently associated with a higher risk of reoperation (odds ratio = 1.61; 95% confidence interval, 1.02-2.56; P = 0.042) and urinary tract infection (odds ratio = 1.94; 95% confidence interval, 1.02-3.68; P = 0.043). CONCLUSIONS In addition to differences in baseline patient demographics and comorbidities and operative characteristics, ALF performed by neurosurgeons had a higher risk of 30-day reoperation and urinary tract infection compared with ALF performed by orthopaedic surgeons.
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Affiliation(s)
- Rachel S Bronheim
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zoe B Cheung
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kevin Phan
- NeuroSpine Surgery Research Group, Prince of Wales Private Hospital, Sydney, Australia; Department of Neurosurgery, Prince of Wales Hospital, Randwick, Sydney, Australia
| | - Samuel J W White
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jun S Kim
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samuel K Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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Development of a Competence-Based Spine Surgery Fellowship Curriculum Set of Learning Objectives in Canada. Spine (Phila Pa 1976) 2016; 41:530-7. [PMID: 26966976 DOI: 10.1097/brs.0000000000001251] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Modified-Delphi expert consensus method. OBJECTIVE The aim of this study was to develop competence-based spine fellowship curricula as a set of learning goals through expert consensus methodology in order to provide an educational tool for surgical educators and trainees. Secondarily, we aimed to determine potential differences among specialties in their rating of learning objectives to defined curriculum documents. SUMMARY OF BACKGROUND DATA There has been recent interest in competence-based education in the training of future surgeons. Current spine fellowships often work on a preceptor-based model, and recent studies have demonstrated that graduating spine fellows may not necessarily be exposed to key cognitive and procedural competencies throughout their training that are expected of a practicing spine surgeon. METHODS A consensus group of 32 spine surgeons from across Canada was assembled. A modified-Delphi approach refined an initial fellowship-level curriculum set of learning objectives (108 cognitive and 84 procedural competencies obtained from open sources). A consensus threshold of 70% was chosen with up to 5 rounds of blinded voting performed. Members were asked to ratify objectives into either a general comprehensive or focused/advanced curriculum. RESULTS Twenty-eight of 32 consultants (88%) responded and participated in voting rounds. Seventy-eight (72%) cognitive and 63 (75%) procedural competency objectives reached 70% consensus in the first round. This increased to 82 cognitive and 73 procedural objectives by round 4. The final curriculum document evolved to include a general comprehensive curriculum (91 cognitive and 53 procedural objectives), a focused/advanced curriculum (22 procedural objectives), and a pediatrics curriculum (22 cognitive and 9 procedural objectives). CONCLUSION Through a consensus-building approach, the study authors have developed a competence-based curriculum set of learning objectives anticipated to be of educational value to spine surgery fellowship educators and trainees. To our knowledge, this is one of the first nationally based efforts of its kind that is also anticipated to be of interest by international colleagues.
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Abstract
STUDY DESIGN Cross-sectional analysis of the American College of Surgeons' National Surgical Quality Improvement Program database between 2005 and 2011. OBJECTIVE To determine whether differences exist in 30-day rate of return to the operating room, mortality, and other perioperative outcomes for spinal fusion by specialty. SUMMARY OF BACKGROUND DATA Although both neurosurgeons and orthopedic surgeons perform spinal fusions, it is unclear whether surgeon specialty impacts perioperative outcomes. METHODS Unadjusted bivariate analysis was performed to determine whether outcomes differed by surgeon specialty. A Bonferroni correction was applied to account for multiple comparisons. For outcomes with a statistically significant association, further multivariate analysis was performed. RESULTS A total of 9719 patients receiving a spinal fusion were identified. Of them, 54.0% had their operation completed by a neurosurgeon. Orthopedic surgeons had practices with a greater percentage of lumbar spine cases (76.0% vs. 65.0%, P < 0.001). There was not a statistically significant difference in the number of levels fused or operative technique used between specialties. There was no difference in the majority of perioperative outcomes between orthopedic surgeons and neurosurgeons including death, rate of return to the operating room, and other complications associated with significant morbidity. On unadjusted analysis, it was found that neurosurgeons were associated with a decreased incidence of operations requiring blood transfusion relative to orthopedic surgeons (8.3% vs. 14.6%, P < 0.001). This trend persisted on multivariate analysis controlling for preoperative hematocrit, history of bleeding disorder, anatomical location of the operation, number of levels fused, operative technique, demographics, and comorbidities (odds ratio, 0.49; 95% confidence interval, 0.43-0.57). CONCLUSION Spine surgeons, regardless of specialty, seem to achieve equivalent outcomes on measured metrics of mortality, 30-day readmission, and surgical site infection. Observed differences in blood transfusion rates by specialty were noted, but the cause of this difference is unclear and warrants further investigation to assess the impact of this difference, if any, on patient outcomes and cost. LEVEL OF EVIDENCE 3.
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Daniels AH, Ames CP, Garfin SR, Shaffrey CI, Riew KD, Smith JS, Anderson PA, Hart RA. Spine surgery training: is it time to consider categorical spine surgery residency? Spine J 2015; 15:1513-8. [PMID: 25442094 DOI: 10.1016/j.spinee.2014.08.452] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 08/17/2014] [Indexed: 02/03/2023]
Affiliation(s)
- Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, 2 Dudley Street. Providence, RI 02905, USA.
| | - Christopher P Ames
- Department of Neurological Surgery, University of California San Francisco, 505 Parnassus Ave., Rm. M779, San Francisco, CA 94143, USA
| | - Steven R Garfin
- Department of Orthopaedic Surgery, University of California San Diego, Perlman Ambulatory Care Center, 9350 Campus Point Drive, La Jolla, CA 92037, USA
| | - Christopher I Shaffrey
- Department of Neurological Surgery, University of Virginia, P.O. Box 800386, Charlottesville, VA, 22908, USA
| | - K Daniel Riew
- Department of Orthopaedic Surgery, Washington University, Cervical Spine Institute. 4921 Parkview Place, A12, St. Louis, MO 63110, USA
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia, P.O. Box 800386, Charlottesville, VA, 22908, USA
| | - Paul A Anderson
- Department of Orthopaedic Surgery, University of Wisconsin, 1685 Highland Ave., UWMFCB - 6215, Madison, WI 53705, USA
| | - Robert A Hart
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA
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Gottschalk MB, Yoon ST, Park DK, Rhee JM, Mitchell PM. Surgical training using three-dimensional simulation in placement of cervical lateral mass screws: a blinded randomized control trial. Spine J 2015; 15:168-75. [PMID: 25194517 DOI: 10.1016/j.spinee.2014.08.444] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 07/28/2014] [Accepted: 08/24/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The skills and knowledge that residents have to master has increased, yet the amount of hours that the residents are allowed to work has been reduced. There is a strong need to improve training techniques to compensate for these changes. One approach is to use simulation-training methods to shorten the learning curve for surgeons in training. PURPOSE To analyze the effect of surgical training using three-dimensional (3D) simulation on the placement of lateral mass screws in the cervical spine on either cadavers or sawbones. STUDY DESIGN A blinded randomized control study. METHODS Fifteen orthopedic residents, postgraduate year (PGY) 1 to 6, were asked to simulate Magerl lateral mass screw trajectories from C3-C7 on cadavers using a navigated drill guide, but with no feedback as to the actual trajectory within the bone (Baseline 1). This was repeated to determine baseline accuracy (Baseline 2). They were then randomized into three groups: Group 1, control, did not receive any training, whereas Groups 2 and 3 received 3D navigational feedback as to the intended drill trajectory on sawbones and cadavers, respectively. All three groups then performed final simulated drilling (final test). All 3D images were deidentified and reviewed by a blinded single fellowship-trained orthopedic spine surgeon. Each image/screw was measured for the starting site, caudad/cephalad angle, and medial/lateral angle to determine trajectory accuracy. RESULTS The aggregate mean difference from a perfect screw was compiled for each session for each group. A negative difference shows improvement, whereas a positive difference shows regression. The difference between final test and Baseline 1 in the control group was 2.4°, suggesting regression. In contrast, the differences for groups sawbone and cadaver were -8.2° and -7.2°, respectively, suggesting improvement. When comparing the difference in aggregate sum angle for the sawbones and cadaver groups with the control group, the difference was statistically significant (p<.0001). CONCLUSIONS Training with 3D navigation significantly improved the ability of orthopedic residents to properly drill simulated lateral mass screws. As such, training with 3D navigation may be a useful adjunct in resident surgical education.
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Affiliation(s)
- Michael B Gottschalk
- Emory Orthopaedic Department, Emory University, 59 Executive Park Drive South, Atlanta, GA 30323, USA
| | - S Tim Yoon
- Emory Orthopaedic Department, Emory University, 59 Executive Park Drive South, Atlanta, GA 30323, USA.
| | - Daniel K Park
- William Beaumont Hospital, William Beaumont-Oakland University, 26205 Lahser Rd Southfield, MI 48301, USA
| | - John M Rhee
- Emory Orthopaedic Department, Emory University, 59 Executive Park Drive South, Atlanta, GA 30323, USA
| | - Phillip M Mitchell
- Vanderbilt Orthopaedic Department, 1215 21st Ave S, Suite 4200 Nashville, TN 37232, USA
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Daniels AH, Ames CP, Smith JS, Hart RA. Variability in spine surgery procedures performed during orthopaedic and neurological surgery residency training: an analysis of ACGME case log data. J Bone Joint Surg Am 2014; 96:e196. [PMID: 25471922 DOI: 10.2106/jbjs.m.01562] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Current spine surgeon training in the United States consists of either an orthopaedic or neurological surgery residency, followed by an optional spine surgery fellowship. Resident spine surgery procedure volume may vary between and within specialties. METHODS The Accreditation Council for Graduate Medical Education surgical case logs for graduating orthopaedic surgery and neurosurgery residents from 2009 to 2012 were examined and were compared for spine surgery resident experience. RESULTS The average number of reported spine surgery procedures performed during residency was 160.2 spine surgery procedures performed by orthopaedic surgery residents and 375.0 procedures performed by neurosurgery residents; the mean difference of 214.8 procedures (95% confidence interval, 196.3 to 231.7 procedures) was significant (p = 0.002). From 2009 to 2012, the average total spinal surgery procedures logged by orthopaedic surgery residents increased 24.3% from 141.1 to 175.4 procedures, and those logged by neurosurgery residents increased 6.5% from 367.9 to 391.8 procedures. There was a significant difference (p < 0.002) in the average number of spinal deformity procedures between graduating orthopaedic surgery residents (9.5 procedures) and graduating neurosurgery residents (2.0 procedures). There was substantial variability in spine surgery exposure within both specialties; when comparing the top 10% and bottom 10% of 2012 graduates for spinal instrumentation or arthrodesis procedures, there was a 13.1-fold difference for orthopaedic surgery residents and an 8.3-fold difference for neurosurgery residents. CONCLUSIONS Spine surgery procedure volumes in orthopaedic and neurosurgery residency training programs vary greatly both within and between specialties. Although orthopaedic surgery residents had an increase in the number of spine procedures that they performed from 2009 to 2012, they averaged less than half of the number of spine procedures performed by neurological surgery residents. However, orthopaedic surgery residents appear to have greater exposure to spinal deformity than neurosurgery residents. Furthermore, orthopaedic spine fellowship training provides additional spine surgery case exposure of approximately 300 to 500 procedures; thus, before entering independent practice, when compared with neurosurgery residents, most orthopaedic spine surgeons complete as many spinal procedures or more. Although case volume is not the sole determinant of surgical skills or clinical decision making, variability in spine surgery procedure volume does exist among residency programs in the United States.
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Affiliation(s)
- Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, 593 Eddy Street, Providence, RI 02903. E-mail address for A.H. Daniels:
| | - Christopher P Ames
- Department of Neurological Surgery, University of California San Francisco, 505 Parnassus Avenue, Room M779, Box 0112, San Francisco, CA 94143
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia, P.O Box 800212, Charlottesville, VA 22908
| | - Robert A Hart
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Suite OP31, Portland, OR 97239
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Daniels AH, DiGiovanni CW. Is subspecialty fellowship training emerging as a necessary component of contemporary orthopaedic surgery education? J Grad Med Educ 2014; 6:218-21. [PMID: 24949124 PMCID: PMC4054719 DOI: 10.4300/jgme-d-14-00120.1] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Daniels AH, DePasse JM, Magill ST, Fischer SA, Palumbo MA, Ames CP, Hart RA. The Current State of United States Spine Surgery Training: A Survey of Residency and Spine Fellowship Program Directors. Spine Deform 2014; 2:176-185. [PMID: 27927415 DOI: 10.1016/j.jspd.2014.02.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 02/16/2014] [Accepted: 02/18/2014] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Program director survey. OBJECTIVES To collect data on spine surgical experience during orthopedic and neurological surgery residency and assess the opinions of program directors (PDs) from orthopedic and neurological surgery residencies and spine surgery fellowships regarding current spine surgical training in the United States. SUMMARY OF BACKGROUND DATA Current training for spine surgeons in the United States consists of a residency in either orthopedic or neurological surgery followed by an optional spine surgery fellowship. Program director survey data may assist in efforts to improve contemporary spine training. METHODS An anonymous questionnaire was distributed to all PDs of orthopedic and neurological surgery residencies and spine fellowships in the United States (N = 382). A 5-point Likert scale was used to assess attitudinal questions. A 2-tailed independent-samples t test was used to compare responses to each question independently. RESULTS A total of 147 PDs completed the survey. Orthopedic PDs most commonly indicated that their residents participate in 76 to 150 spine cases during residency, whereas neurological surgery PDs most often reported more than 450 spine cases during residency (p < .0001). Over 88% of orthopedic surgery program directors and 0% of neurological surgery PDs recommended that their trainees complete a fellowship if they wish to perform community spine surgery (p < .001). In contrast, 98.1% of orthopedic PDs and 86.4% of neurological surgery PDs recommended that their trainees complete a fellowship if they wish to perform spinal deformity surgery (p = .038). Most PDs agreed that surgical simulation and competency-based training could improve spine surgery training (76% and 72%, respectively). CONCLUSIONS This study examined the opinions of orthopedic and neurological surgery residency and spine fellowship PDs regarding current spine surgery training in the United States. A large majority of PDs thought that both orthopedic and neurological surgical trainees should complete a fellowship if they plan to perform spinal deformity surgery. These results provide a background for further efforts to optimize contemporary spine surgical training.
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Affiliation(s)
- Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University and Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA.
| | - J Mason DePasse
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University and Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA
| | - Stephen T Magill
- Department of Neurological Surgery, University of California at San Francisco, 505 Parnassus Ave, RM M779, Box 0112, San Francisco CA 94143, USA
| | - Staci A Fischer
- Office of Graduate Medical Education, Rhode Island Hospital, 593 Eddy Street, Aldrich 120, Providence RI 02903, USA
| | - Mark A Palumbo
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University and Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California at San Francisco, 505 Parnassus Ave, RM M779, Box 0112, San Francisco CA 94143, USA
| | - Robert A Hart
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, OP31, Portland OR 97239, USA
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Konczalik W, Elsayed S, Boszczyk B. Experience of a fellowship in spinal surgery: a quantitative analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23 Suppl 1:S40-54. [PMID: 24549385 DOI: 10.1007/s00586-014-3209-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 01/19/2014] [Accepted: 01/19/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The objective of our paper was to ascertain the self-reported competency level of surgeons who had completed a 1-year spine fellowship versus those who had not. Our secondary objective was to determine whether there was any difference between orthopaedic and neurosurgeons. METHODS A 60 question online questionnaire was provided to AOSpine Europe members for completion online. RESULTS 289 members provided a response, of which 64% were orthopaedic surgeons and 31% neurosurgeons (5% did not specify). Eighty (28%) had completed a 1-year fellowship. Theoretical and practical knowledge of the management of spinal deformity was the greatest difference seen upon completing a fellowship. Multiple elective and emergent conditions were demonstrated to have a significant difference upon completion of a fellowship. There was no difference between orthopaedic surgeons and neurosurgeons. CONCLUSIONS In order to provide an efficient and safe service covering the broad spectrum of spinal pathology, a formal spine fellowship, ideally with a formal curriculum, should be considered.
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Haji FA, Dubrowski A, Drake J, de Ribaupierre S. Needs assessment for simulation training in neuroendoscopy: a Canadian national survey. J Neurosurg 2013; 118:250-7. [DOI: 10.3171/2012.10.jns12767] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Object
In recent years, dramatic changes in surgical education have increased interest in simulation-based training for complex surgical skills. This is particularly true for endoscopic third ventriculostomy (ETV), given the potential for serious intraoperative errors arising from surgical inexperience. However, prior to simulator development, a thorough assessment of training needs is essential to ensure development of educationally relevant platforms. The purpose of this study was to conduct a national needs assessment addressing specific goals of instruction, to guide development of simulation platforms, training curricula, and assessment metrics for ETV.
Methods
Canadian neurosurgeons performing ETV were invited to participate in a structured online questionnaire regarding the procedural steps for ETV, the frequency and significance of intraoperative errors committed while learning the technique, and simulation training modules of greatest potential educational benefit. Descriptive data analysis was completed for both quantitative and qualitative responses.
Results
Thirty-two (55.2%) of 58 surgeons completed the survey. All believed that virtual reality simulation training for ETV would be a valuable addition to clinical training. Selection of ventriculostomy site, navigation within the ventricles, and performance of the ventriculostomy ranked as the most important steps to simulate. Technically inadequate ventriculostomy and inappropriate fenestration site selection were ranked as the most frequent/significant errors. A standard ETV module was thought to be most beneficial for resident training.
Conclusions
To inform the development of a simulation-based training program for ETV, the authors have conducted a national needs assessment. The results provide valuable insight to inform key design elements necessary to construct an educationally relevant device and educational program.
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Affiliation(s)
- Faizal A. Haji
- 1Schulich School of Medicine and Dentistry, University of Western Ontario, London
- 2Clinical Neurological Sciences, London Health Sciences Centre, London
- 3The Wilson Centre, Faculty of Medicine, University of Toronto
- 4SickKids Learning Institute, and
| | - Adam Dubrowski
- 3The Wilson Centre, Faculty of Medicine, University of Toronto
- 4SickKids Learning Institute, and
| | - James Drake
- 5Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sandrine de Ribaupierre
- 1Schulich School of Medicine and Dentistry, University of Western Ontario, London
- 2Clinical Neurological Sciences, London Health Sciences Centre, London
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Spinal surgery fellowship education in Canada: evaluation of trainee and supervisor perspectives on cognitive and procedural competencies. Spine (Phila Pa 1976) 2013; 38:83-91. [PMID: 22718224 DOI: 10.1097/brs.0b013e3182640f69] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A cross-sectional survey of spine surgery fellowship educators and trainees. OBJECTIVE To determine educator and trainee perspectives on the relative importance of core cognitive and procedural competencies in fellowship training. To determine perceptions of confidence in competencies by trainees near the end of their fellowship. Finally, to determine potential differences comparing surgeons by background specialty training (neurosurgical or orthopedic) of their views on competencies. SUMMARY OF BACKGROUND DATA Spine surgery is a growing subspecialty with increasing collaboration among specialists of varied specialty backgrounds involved in education. With the recent implementation of competency-based curricula during specialty training, opportunities may exist in enhancing fellowship education. METHODS A questionnaire on cognitive and procedural competencies was administered (online and paper) to fellowship educators and trainees across Canada. A follow-up questionnaire was administered to nonresponders 3 months later. Survey results were summarized using qualitative and descriptive statistics with comparative analyses performed. RESULTS Of the identified respondents, the response rate was 91%, (15/17 fellow trainees; 47/51 educators). Twelve of the 13 core cognitive skill categories were rated as being important to acquire by the end of fellowship. Trainees were not comfortable performing, and requested additional training in 8 of the 29 less common and technically demanding procedural skills. There were different perceptions on the relative importance of competencies comparing trainees by specialty background as well as different perceptions on the types of competencies where additional training was desired to achieve competency (P < 0.05). Fellowship educators and trainees possessed similar perceptions on the relative importance of core cognitive and procedural competencies required for successful training. CONCLUSION Background specialty influenced the perceptions of both fellowship educators and trainees. This study identified potential gaps or perceived deficiencies in the competency of current fellows. Improvements in spine fellowship education should target these areas through developing evidence-based curriculum changes.
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Variations in Practice Patterns among Neurosurgeons and Orthopaedic Surgeons in the Management of Spinal Disorders. Asian Spine J 2011; 5:208-12. [PMID: 22164314 PMCID: PMC3230647 DOI: 10.4184/asj.2011.5.4.208] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Revised: 04/09/2011] [Accepted: 04/25/2011] [Indexed: 12/05/2022] Open
Abstract
Study Design This is a case series. Purpose We wanted to identify variations in the practice patterns among neurosurgeons and orthopedic surgeons for the management of spinal disorders. Overview of Literature Spinal disorders are common in the clinical practice of both neurosurgeons and orthopedic surgeons. It has been observed that despite the availability of various guidelines, there is lack of consensus among surgeons about the management of various disorders. Methods A questionnaire was distributed, either directly or via e-mail, to the both the neurosurgeons and orthopedic surgeons who worked at 5 tertiary care centers within a single region of Korea. The surgeons were working either in private practice or in academic institutions. The details of the questionnaire included demographic details and the specialty (orthopedic/neurosurgeon). The surgeons were classified according to the level of experience as up to 5 years, 6-10 years and > 10 years. Questions were asked about the approach to lumbar discectomy (fragmentectomy or aggressive disc removal), using steroids for treating discitis, the fusion preference for spondylolisthesis, the role of an orthosis after fusion, the preferred surgical approach for spinal stenosis, the operative approach for spinal trauma (early within 72 hours or late > 72 hours) and the role of surgery in complete spinal cord injury. The data was analyzed using SPSS ver 16. p-values < 0.05 were considered to be significant. Results Of the 30 surgeons who completed the questionnaire, 20 were neurosurgeons and 10 were orthopedic surgeons. Statistically significant differences were observed for the management of spinal stenosis, spondylolisthesis, using an orthosis after fusion, the type of lumbar discectomy and the value of surgical intervention after complete spinal cord injury. Conclusions Our results suggest that there continues to exist a statistically significant lack of consensus among neurosurgeons and orthopedic spine surgeons when considering using an orthosis after fusion, the type of discectomy and the value of intervention after complete spinal injury.
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Wadey VMR, Halpern J, Bouchard J, Dev P, Olshen RA, Walker D. Orthopaedic surgery core curriculum: the spine. Postgrad Med J 2007; 83:268-72. [PMID: 17403955 PMCID: PMC2600031 DOI: 10.1136/pgmj.2006.053900] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To develop a core curriculum for orthopaedic surgery and to conduct a national survey to assess the importance of 281 items in the curriculum. Attention was focused specifically on 24 items pertaining to the curriculum that are pertinent to the spine. STUDY DESIGN A cross-sectional survey of a random sample of orthopaedic surgeons whose primary affiliation was non-academic, representing the provinces and territories of Canada METHODS A questionnaire containing 281 items was developed. A random group of 131 (out of 156) orthopaedic surgeons whose primary affiliation is non-academic completed the questionnaire. The data were analysed quantitatively using average mean scores, histograms, the modified Hotelling's T2 test and the Benjimini-Hochberg procedure. RESULTS 131 of 156 (84%) orthopaedic surgeons participated, in this study. 14 of 24 items were ranked at no less than 3 out of 4 thus suggesting that 58% of the items are important or probably important to know by the end of residency (SD< or =0.07). Residents need to learn the diagnosis and principles of managing patients with common conditions of the spine. CONCLUSIONS The study shows, with reliable statistical evidence, that orthopaedic residents are no longer expected to be able to perform spinal fusions with proficiency on completion of residency. Is the exposure to surgical spine problems and the ability to be comfortable with operating expectations specific to the fellowship level? If so, the focus during residency or increasing accredited spine fellowships needs to be addressed to ensure that enough spine surgeons are educated to meet the future healthcare demands projected for Canada.
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