Design-Based Comparison of Spine Surgery Simulators: Optimizing Educational Features of Surgical Simulators

doi:10.1016/j.wneu.2017.07.021

World Neurosurgery

Volume 106, October 2017, Pages 870-877.e1

https://doi.org/10.1016/j.wneu.2017.07.021 Get rights and content

Background

Simulation-based education has made its entry into surgical residency training, particularly as an adjunct to hands-on clinical experience. However, one of the ongoing challenges to wide adoption is the capacity of simulators to incorporate educational features required for effective learning. The aim of this study was to identify strengths and limitations of spine simulators to characterize design elements that are essential in enhancing resident education.

Methods

We performed a mixed qualitative and quantitative cohort study with a focused survey and interviews of stakeholders in spine surgery pertaining to their experiences on 3 spine simulators. Ten participants were recruited spanning all levels of training and expertise until qualitative analysis reached saturation of themes. Participants were asked to perform lumbar pedicle screw insertion on 3 simulators. Afterward, a 10-item survey was administrated and a focused interview was conducted to explore topics pertaining to the design features of the simulators.

Results

Overall impressions of the simulators were positive with regards to their educational benefit, but our qualitative analysis revealed differing strengths and limitations. Main design strengths of the computer-based simulators were incorporation of procedural guidance and provision of performance feedback. The synthetic model excelled in achieving more realistic haptic feedback and incorporating use of actual surgical tools.

Discussion

Stakeholders from trainees to experts acknowledge the growing role of simulation-based education in spine surgery. However, different simulation modalities have varying design elements that augment learning in distinct ways. Characterization of these design characteristics will allow for standardization of simulation curricula in spinal surgery, optimizing educational benefit.

Introduction

Simulation-based education has entered the surgical resident education paradigm, particularly as an adjunct to hands-on clinical experience.1, 2 This stems from both a heightened focus on patient safety by the hospitals, licensing bodies, and accreditation committees and a growing concern over declining clinical exposure during residency training potentially associated with a detrimental effect on patient outcome.3, 4, 5, 6, 7 Historically, supplementary educational modalities in surgery have involved cadaveric or animal models, but increasing cost and declining availability have led to the increasing utilization of alternative simulation platforms.8, 9 These include synthetic bench-top models and computer-based simulations. While the educational benefits of these educational tools have been recognized, one of the barriers to wide adoption is ensuring ongoing utility of simulators for higher-level competencies beyond basic technical skills.1, 10, 11 In order to achieve this goal, new simulators must incorporate global and specialty-specific educational features into their design from inception rather than as an afterthought.²

The process of developing and enhancing surgical simulation systems may benefit from employing theories from other academic fields such as education. For example, design-based research is a type of research methodology that allows iterative assessment of new educational interventions in a real-life setting focusing on examining how, when, and why certain innovations may lead to enhanced learning experience.¹² In the context of surgical education, it allows characterization of the algorithm required to bridge innovations in simulation technology and their implementation as training tools for residents.¹³ With the growing number of spine surgery simulators being developed, critical review and analysis of these simulation systems can serve as an important starting point of design-based research. This analysis may subsequently provide novel insights that can guide future efforts of building effective surgical simulators for resident education. The aim of this study was to investigate the strengths and limitations of current spine simulators to characterize design elements that may enhance future supplemental educational models.

Section snippets

Methods

We performed a mixed qualitative and quantitative cohort study through focused interview of stakeholders in spine surgery pertaining to their experiences on 3 spinal surgery simulators. This study was approved by the University of Calgary Research Ethics board.

Results

Overall impressions of the spine simulators were positive in regards to their educational benefit with 90% of responders reporting the computer simulators provided acquisition of useful surgical skills and 70% of responders reporting the synthetic simulator provided same benefits (Figure 2A). Furthermore, 80% of the participants agreed that all 3 simulators provided effective means of repetitive practice with only 1 responder noting that the synthetic model is limited in the supporting user's

Promote Formation of Explicit and Implicit Memory

The participants noted that spine simulators could provide an opportunity where trainees can gain beneficial clinical experiences even in an artificial environment. Actively participating in simulation-based education can instill a sense of familiarity more effectively than didactic teaching or textbooks. These experiences, in turn, lead to building of explicit and implicit memories depending on the specific design of the simulators. Synthetic models, with the use of real surgical tools,

Discussion

In this exercise, the pervasive impression of the stakeholders (residents, fellows, and surgeons) toward the simulators was both positive and enthusiastic. This parallels findings by other investigators.1, 15 Our results highlight that different spine simulators employ different design elements, which augment learning in distinct ways. Specifically, while synthetic spine models better support development of psychomotor skills through use of real surgical tools, computer-based spine simulators

Conclusion

Stakeholders, from trainees to expert surgeons, acknowledge the growing role of simulation-based education. However, different simulation modalities (computer-based simulators vs. synthetic models) have unique design elements that augment effective learning in distinct ways. Characterization and appropriate weighting of these design characteristics will allow for standardization of simulation curricula in spinal surgery, optimizing educational benefit.

Acknowledgments

We thank all the volunteers and reviewers who provided valuable feedback on this document. We also thank the LINDSAY Virtual Human researchers for providing the 3-dimensional models of the spine for the NeuroSimVR system.

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Cited by (13)

Resident Training in Spine Surgery: A Systematic Review of Simulation-Based Educational Models
2023, World Neurosurgery
With the increasing prevalence of spine surgery, ensuring effective resident training is becoming of increasing importance. Training safe, competent surgeons relies heavily on effective teaching of surgical indications and adequate practice to achieve a minimum level of technical proficiency before independent practice. American Council of Graduate Medical Education work-hour restrictions have complicated the latter, forcing programs to identify novel methods of surgical resident training. Simulation-based training is one such method that can be used to complement traditional training. The present review aims to evaluate the educational success of simulation-based models in the spine surgical training of residents.
Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the PubMed, Web of Science, and Google Scholar databases were systematically screened for English full-text studies examining simulation-based spine training curricula. Studies were categorized based on simulation model class, including animal-cadaveric, human-cadaveric, physical/3-dimensional, and computer-based/virtual reality. Outcomes studied included participant feedback regarding the simulator and competency metrics used to evaluate participant performance.
Seventy-two studies were identified. Simulators displayed high face validity and were useful for spine surgery training. Objective measures used to evaluate procedural performance included implant placement evaluation, procedural time, and technical skill assessment, with numerous simulators demonstrating a learning effect.
While simulation-based educational models are one potential means of training residents to perform spine surgery, traditional in-person operating room training remains pivotal. To establish the efficacy of simulators, future research should focus on improving study quality by leveraging longitudinal study designs and correlating simulation-based training with clinical outcome measures.
Development of a Pedicle Screw Fixation Simulation Model for Surgical Training Using a 3-Dimensional Printer
2023, World Neurosurgery
Training surgeons in pedicle screw fixation (PSF) techniques during actual surgery is limited because of patient safety, complications, and surgical efficiency issues. Recent technical developments are leading the world to an era of personalized three-dimensional (3D) printing. This study aimed to evaluate the educational effect of using a 3D-printed spine model to train beginners in PSF techniques to improve screw accuracy and procedure time.
Computed tomography (CT) scan data were used in a 3D printer to produce a life-size lumbar spine replica of L1–3 vertebrae. Four residents performed PSF thrice. Each resident performed 18 screw fixations on both sides (6 screws per trial). The time to complete the procedure and pedicle violation was recorded.
The average time for the 3 procedures was 42.1±2.9 minutes, 38.8±3.3 minutes, and 32.1±2.5 minutes, respectively. Furthermore, the average pedicle screw score for the 3 procedures was 13.0±0.8, 14.5±0.6, and 16.0±0.8, respectively. As the trial was repeated, the procedure time decreased and the accuracy of screw fixation tended to be more accurate.
It was possible to decrease the procedure time and increase accuracy through repeated training using the 3D-printed spine model. By implementing a 3Dprinted spine model based on the patient's actual CT data, surgeons can perform simulation surgery before the actual surgery. Therefore, this technology can be useful in educating residents to improve their surgical skills.
Simulation on synthetic bone: A tool for teaching thoracolumbar pedicle screw placement
2021, Revue de Chirurgie Orthopedique et Traumatologique
La simulation dans la formation des internes prend une place croissante en chirurgie. Le gold standard de l’enseignement théorique de la visée pédiculaire reste la pratique sur sujets anatomiques. La disponibilité des corps représente une limite de cet enseignement. L’objectif principal de cette étude était de vérifier si un enseignement sur modèle en os synthétique premier permettait d’améliorer l’apprentissage du positionnement de vis pédiculaires. L’objectif secondaire était de vérifier l’influence de l’expérience préalable de l’interne en chirurgie du rachis.
L’hypothèse principale était qu’un enseignement théorique couplé à une mise en pratique sur os synthétique était supérieur à un enseignement théorique seul.
Vingt-trois internes en orthopédie ont bénéficié d’une formation théorique sur la méthode de vissage pédiculaire à main levée. Six internes avaient une expérience préalable du vissage pédiculaire. Après tirage au sort, 11 internes ont bénéficié d’un enseignement premier sur os synthétique (groupe 1) et 12 internes n’ont eu qu’un enseignement théorique (groupe 2). Chaque étudiant a ensuite positionné 2 vis thoraciques (T7–T11) et 2 vis lombaires (L1–L5) sur cadavre. Les visées pédiculaires étaient analysées par tomodensitométrie selon la classification de Gertzbein (grades 0 et 1 = bon positionnement ; grades 2 et 3 = effraction > 2 mm).
Les taux de bons positionnements sur cadavre étaient de 64,0 % et de 62,5 % en thoracique, de 72,7 % et de 66,6 % en lombaire pour les groupes 1 et 2 respectivement. En comparant les internes des groupes 1 et 2, il n’y avait pas de différence significative du taux d’effractions sur cadavre (p = 0,1809). Un interne ayant bénéficié d’un entraînement en simulation avait une chance de diminuer le score de Gertzbein avec un odds-ratio de 1,7714 [0,7710–4,1515]. L’odds-ratio était de 4,5188 [0,0456–0,8451] lorsqu’on comparaît les internes avec une expérience préalable du vissage pédiculaire aux internes novices.
L’enseignement théorique associé à un modèle de simulation est intéressant pour enseigner la technique chirurgicale. Un atelier de simulation ponctuel sur os synthétique semble insuffisant pour aboutir à une meilleure précision du vissage pédiculaire par rapport à un simple enseignement théorique de la visée pédiculaire. L’expérience progressive et la répétition de gestes techniques au cours du compagnonnage en chirurgie du rachis avaient une influence sur la précision du vissage pédiculaire.
II.
Simulation on synthetic bone: A tool for teaching thoracolumbar pedicle screw placement
2021, Orthopaedics and Traumatology: Surgery and Research
Citation Excerpt :
In another study, Hou et al. [9,19] showed that use of a Virtual Surgical Training System helps to significantly improve the competencies of a novice surgeon during pedicle screw placement. We now have a large number of tools that can be used for training of surgery residents, although hands-on supervised training in the OR remains the gold standard [20]. Lee et al. [15] analyzed 306 pedicle screw insertions done by young spine surgeons who have trained under the supervision of an experienced surgeon.
Simulation workshops for surgical training of residents are becoming popular. The gold standard for teaching thoracolumbar pedicle screw placement are cadaver labs; however, the availability of human bodies is limited. The primary objective of this study was to determine if training on a synthetic bone model improves the apprenticeship of accurate pedicle screw placement. The secondary objective was to check the influence of residents’ previous experience in spine surgery.
The main hypothesis was that theoretical learning with practical application on synthetic bone was superior to theoretical learning alone.
Twenty-three orthopedic residents were taught about free-hand pedicle screw placement using a theoretical presentation. Six residents had previous experience with screwing techniques. After randomization in two groups, 11 residents (group 1) participated in a workshop on synthetic bone, whereas 12 residents received only theoretical instruction (group 2). Each resident was asked to place two thoracic screws (T7-T11) and two lumbar screws (L1-L5) on a cadaver. Screw placement accuracy was analyzed using the Gertzbein classification on computed tomography (grades 0 and 1 = accurate positioning; grades 2 and 3 = malposition > 2 mm).
Rates of accurate screw positioning were 64.0% and 62.5% for thoracic levels, and 72.7% and 66.6% for lumbar levels in group 1 and 2, respectively. There was no significant difference in malposition rates on cadavers between the groups (p = 0.1809). A resident who was first trained by simulation had a chance of decreasing the Gertzbein score with an odds-ratio of 1.7714 [0.7710–4.1515]. The odds ratio was 4.5188 [0.0456–0.8451] when comparing residents with previous experience in spinal surgery to novice residents.
Theoretical teaching associated with a simulation model is relevant for learning a surgical technique. A single simulation workshop on synthetic bone seems insufficient to improve pedicle screw placement accuracy compared to theoretical teaching alone. Progressive experience and the repetition of technical gestures during hands-on supervised learning in spine surgery with a senior surgeon had an influence on the accuracy of pedicle screw placement.
II.
Establishing validity of the fundamentals of spinal surgery (FOSS) simulator as a teaching tool for orthopedic and neurosurgical trainees
2020, Spine Journal
Citation Excerpt :
Studies looking at these virtual reality simulators have reported promising results even in nonexpert participants [18,19]. However, while there are increased efforts toward development and technological advancements of these high-cost virtual reality simulators for spine surgery, virtual reality simulators are still inferior to physical models in achieving more realistic haptic feedback and incorporating use of actual surgical tools for proprioceptive feedback [17,20]. To our knowledge, a hands-on, low-cost model for pedicle screw placement does not currently exist [18,21,22].
Pedicle screw placement is a demanding surgical skill as a spine surgeon can face challenges including variations in pedicle morphology and spinal deformities. Available CT simulators for spine pedicle placement can be very costly and hands-on cadaver courses are limited by specimen availability and are not readily accessible.
To conduct validation of a simulated training device for essential spine surgery skills.
Cross-sectional, empirical study of physician performance on a surgical simulator model.
Spine attending physicians and residents from four different academic institutions across the United States.
Performance metrics on two surgical simulator tasks.
After IRB approval, an inexpensive ($30) simulator was developed to test two main psychomotor tasks (1) creation of the pedicle screw path with a standard gearshift probe without cortical breaks and (2) the ability to palpate for the presence or absence of cortical breaches as well as determine the location of wall defects. Orthopedic and neurosurgery residents (N=72) as well as spine attending surgeons (N=26) participated from four different institutions. To test construct validity, performance metrics were compared between participants of different training status through one-way analysis of variance and linear regression analysis, with significance set at p<.05.
Spine attending surgeons consistently scored higher than the residents, in the screw trajectory task with triangular base (p=.0027) and defect probing task (p=.0035). In defect probing, performance improved with linear trend by number of residency training years with approaching significance (p=.0721). In that task, independent of institutional affiliation, PGY-2 residents correctly identified an average of 1.25±0.43 fewer locations compared with attending physicians (p=.0049). More than 80% of the spine attendings reported they would use the simulator for training purposes.
This low-cost fundamentals of spine surgery simulator detected differences in performances between spine attending surgeons and surgical residents. Programs should consider implementing a simulator such as fundamentals of spine surgery to assess and develop pedicle screw placement ability outside of the operating room.
A Scoping Review of Medical Education Research in Neurosurgery
2019, World Neurosurgery
Citation Excerpt :
Table 4 summarizes the results of 8 studies involving the statistical comparison of ≥2 simulators. Only 1 study used the focused interview in addition to surveys, which were employed by all studies.28 Two studies conducted with the largest sample size (99 and 100 program directors in the United States, respectively) revealed contradictive findings of the comparison between cadaveric and other types of simulation.24,26
Little is known about the state of medical education (ME) research in neurosurgery. As ME started to develop in neurosurgery in recent years, it is important to understand the current status and develop the theory for advancement in neurosurgery. The aim of this study was to undertake a scoping review of neurosurgery literature on ME research.
MEDLINE, SCOPUS, and PubMed databases were searched. Inclusion criteria were full-text articles in English published from January 2006 to December 2017. Research aspects included country of publication, annual number of publications, journal types, type of participants, frequently researched topics, and research design. Search terms included neurosurgery, medical education, teaching, training, learning, and curriculum.
A total of 9863 references were found across 3 databases. After duplicate removal and further screening, 533 references remained for coding analysis. ME research activity in neurosurgery is increasing and commonly observed in Western countries. Identified articles were mostly quantitative, with curriculum, assessment (especially simulation), and teaching and learning being the most dominant research themes.
This study highlights the need for enhanced quantity and quality of ME research in neurosurgery. It identifies areas of highest priority and aspects to be improved and provides us with a rationale for future development in ME in neurosurgery. These findings reveal future education research direction and programmatic research areas, while also establishing a benchmark to assess changes in educational scholarship over time.

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: Conflict of interest statement: Won Hyung A. Ryu received an Alberta Innovates Health Solutions Clinician Fellowship grant. Ahmed E. Mostafa received a Vanier Canada Graduate Scholarship. Navjit Dharampal received a University of Calgary Surgeon Scientist Program Scholarship. The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

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Original ArticleDesign-Based Comparison of Spine Surgery Simulators: Optimizing Educational Features of Surgical Simulators

Background

Methods

Results

Discussion

Introduction

Section snippets

Methods

Results

Promote Formation of Explicit and Implicit Memory

Discussion

Conclusion

Acknowledgments

J Surg Res

J Am Coll Surg

Am J Surg

Am J Surg

Am J Surg

Am J Surg

J Pediatr Surg

J Am Coll Surg

Systematic review of skills transfer after surgical simulation-based training

Br J Surg

Simulation in surgical education

CMAJ

Operative experience of residents in us general surgery programs: a gap between expectation and experience

Ann Surg

Does the introduction of duty-hour restriction in the United States negatively affect the operative volume of surgical trainees?

Interact Cardiovasc Thorac Surg

Does resident involvement effect surgical times and complication rates during laparoscopic appendectomy for uncomplicated appendicitis? An analysis of 16,849 cases from the ACS-NSQIP

Am J Surg

Teaching surgical skills—changes in the wind

N Engl J Med

Virtual reality training for surgical trainees in laparoscopic surgery

Cochrane Database Syst Rev

Simulation and resident education in spinal neurosurgery

Surg Neurol Int

Original Article
Design-Based Comparison of Spine Surgery Simulators: Optimizing Educational Features of Surgical Simulators