Neurosurgery Exit Exam Preparation/ Basic Anatomy of Ventricles

Neurosurgery Exit Exam Preparation/ Basic Anatomy of Ventricles


Time: May 7, 202008:00 AM (US GMT -4)12:00 PM (GMT +0)01:00 PM (Coventry GMT +1)05:00 PM (Pak TIme GMT +5)


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Neurosurgical Training in Europe

Neurosurgical Training in Europe

Many proposals and guidelines have been published and recommended for neurosurgical training in Europe 1) 2) 3) 4)

Theoretical and practical aspects of neurosurgical training are highly variable throughout European countries, despite some efforts within the last decades to harmonize this.

Some countries are rated significantly above (and others significantly below) the current European average for several analyzed parameters 5).


Although there is a comparable duration of 4 to 6 years of neurosurgical residency across Europe, the content thereof varies widely.

The reason for these diverse training conditions could be explained by (1) the number of sovereign countries in Europe, (2) the unique historical educational concept in each of the European countries, and (3) the different socioeconomical setting of these countries. Another cause can be found in the cultural autonomy of each country and hence the ability of each country’s specific neurosurgical society to implement recommendations of the EANS for resident training only to a varying degree. There rarely is any specific or mandatory neurosurgical curriculum for any teaching hospital 6).


The US residency programs overall tend to be more structured when compared to the corresponding curricula in Europe, although exceptions may apply. This is evident especially via the well-organized monthly and/or yearly rotations, which advance the resident during the consecutive PGYs 7).


Country-specific composite scores for satisfaction with quality of theoretical and practical training, as well as working hours per week, were obtained from an electronic survey distributed among European neurosurgical residents between June 2014 and March 2015. These were related to anonymous country-specific results of the EBE-NS between 2009 and 2016, using uni- and multivariate linear regression analysis.

A total of n = 1025 written and n = 63 oral examination results were included. There was a significant linear relationship between the country-specific EBE-NS result in the written part and the country-specific composite score for satisfaction with quality of theoretical training [adjusted regression coefficient (RC) -3.80, 95 % confidence interval (CI) -5.43-7 -2.17, p < 0.001], but not with practical training or working time. For the oral part, there was a linear relationship between the country-specific EBE-NS result and the country-specific composite score for satisfaction with quality of practical training (RC 9.47, 95 % CI 1.47-17.47, p = 0.021), however neither with satisfaction with quality of theoretical training nor with working time.

With every one-step improvement on the country-specific satisfaction score for theoretical training, the score in the EBE-NS Part 1 increased by 3.8 %. With every one-step improvement on the country-specific satisfaction score for practical training, the score in the EBE-NS Part 2 increased by 9.47 %. Improving training conditions is likely to have a direct positive influence on the knowledge level of trainees, as measured by the EBE-NS. The effect of the actual working time on the theoretical and practical knowledge of neurosurgical trainees appears to be insignificant 8).

The European Training Courses in Neurosurgery

The EANS Training Committee and the Executive Director are responsible for arranging the European Training Courses in Neurosurgery.

What it is: 4 annual 4-day courses covering the key topics of: Vascular Neurosurgery

Tumour

Head Injury/Functional

Spine/Peripheral Nerves

History: Founded in the 1970s by Professors Brihaye, Pia and Vigoroux, the courses aim to serve the needs of neurosurgical trainees in the latter half of their training in neurosurgery.

The excellence of the courses and their scientific and social value is acknowledged throughout the neurosurgical community, and the current committee would like to acknowledge the tremendous part played by the founders, past chairmen of the Training Committee and previous Executive Administrator, Stephanie Garfield-Birkbeck, in bringing this about.

Fellowships

AOSpine Fellowships

AOSpine has compiled a comprehensive list of available fellowships. Please visit https://aospine.aofoundation.org/Structure/education/spine-centers/Pages/spine-centers.aspx for more information.

The Brain Prize

The Brain Prize of €1 million is awarded annually.

The Prize recognizes highly original and influential advances in research on the nervous system. If several researchers have contributed significantly to this achievement, more than one individual may receive the Prize. Nominees can be of any nationality but the research for which they are nominated must have been conducted in Europe or in collaboration with researchers in Europe. More information available on www.thebrainprize.org.

Fellowships in Portugal

The Portuguese Society of Neurosurgery is offering a number of clinical fellowships in accredited training programmes, lasting from six months to two years.

Further information is available from the SPNC secretariado@spnc.pt or www.spnc.pt

AANS Fellowships

The AANS also offer a range of fellowships.

Pain and Spine Fellowship

Scott & White Neuroscience Institute

The comprehensive Pain & Spine Fellowship at Scott & White is designed to provide educational experience in spinal and pain pathology to a graduate of a Neurosurgery training program or senior neurosurgery resident. Clinical and research experiences will be included. Both US and International candidates will be considered.

Contact: Vasilios A. Zerris, MD, MPH


Cervical Spine Research Society – European Section Research Grant

The Cervical Spine Research Society is a multidisciplinary organization that provides a forum for the exchange of ideas and promotes clinical and basic science research of the cervical spine. The organization values collegial interaction and strong scientific principles.

To faciliate research in the field of cervical spine the Cervical Spine Research Society – European Section (CSRS-ES) has the opportunity to offer € 25.000,- annually to research projects.

European Board Examination in Neurological Surgery

see European Board Examination in Neurological Surgery.

European Association of Neurosurgical Societies

see European Association of Neurosurgical Societies.

Working Time directive

The introduction of the European Working Time directive 2003/88/EC has led to a reduction of the working hours with distinct impact on the clinical and surgical activity of neurosurgical residents in training.

A survey was performed among European neurosurgical residents between 06/2014 and 03/2015. Multiple logistic regression was used to assess the relationship between responder-specific variables (e.g., age, gender, country, postgraduate year (PGY)) and outcome (e.g., working time).

A total of 652 responses were collected, of which n = 532 responses were taken into consideration. In total, 17.5, 22.1, 29.5, 19.5, 5.9, and 5.5 % of European residents indicated to work <40, 40-50, 51-60, 61-70, 71-80, or >80 h/week, respectively. Residents from France and Turkey (OR 4.72, 95 % CI 1.29-17.17, p = 0.019) and Germany (OR 2.06, 95 % CI 1.15-3.67, p = 0.014) were more likely to work >60 h/week than residents from other European countries. In total, 29 % of European residents were satisfied with their current working time, 11.3 % indicated to prefer reduced working time. More than half (55 %) would prefer to work more hours/week if this would improve their clinical education. Residents that rated their operative exposure as insufficient were 2.3 times as likely as others to be willing to work more hours (OR 2.32, 95 % CI 1.47-3.70, p < 0.001). Less than every fifth European resident spends >50 % of his/her working time in the operating room. By contrast, 77.4 % indicate to devote >25 % of their daily working time to administrative work. For every advanced PGY, the likelihood to spend >50 % of the working time in the OR increases by 19 % (OR 1.19, 95 % CI 1.02-1.40, p = 0.024) and the likelihood to spend >50 % of the working time with administrative work decreases by 18 % (OR 0.84, 95 % CI 0.76-0.94, p = 0.002).

The results of this survey on >500 European neurosurgical residents clearly prove that less than 40 % conform with the 48-h week as claimed by the WTD2003/88/EC. Still, more than half of them would chose to work even more hours/week if their clinical education were to improve; probably due to subjective impression of insufficient training 9).

Books

Training in Neurosurgery in the Countries of the EU: A Guide to Organize a Training Programme

Editors: Reulen, H.-J. (Ed.)

Agreed standards and guidelines are the heart and soul of improving the differing training systems and to harmonize neurosurgical training in the European countries. Such standards and guidelines have been laid down in the European Training Charter of the European Union of Medical Specialists and recently novellated. This book, written by experienced neurosurgeons, offers all those concerned with neurosurgical training – trainers and trainees – practical advice to implement the above mentioned standards and recommendations. It has been written as a manual: “How to do it”. It describes the tasks of a chairman (programme director), the tasks of the teaching staff, the organisation of a training curriculum, a rotation plan or a morbidity and mortality conference, the periodic progress evaluation, the course of an external audit and many more important topics. It contains a lot of practical tips, check lists and useful examples. Well educated young colleagues offer “safe neurosurgery” to our patients.

Table of contents (15 chapters) Introduction Antunes, J. Lobo Pages 1-2

UEMS charter on training of medical specialists in the EU — the new neurosurgical training charter Steers, J. (et al.) Pages 3-11

Neurosurgical training programme director position and responsibilities Neil-Dwyer, G. (et al.) Pages 13-16

Teaching staff Antunes, J. Lobo Pages 17-19

The ideal neurosurgical training curriculum Long, D. M. Pages 21-31

Internal regulations and general guidelines of a neurosurgical department and training programme Reulen, H.-J. (et al.) Pages 33-38

Principles of teaching in a structured training programme, the rotations, and the surgical training plan Steiger, H.-J. Pages 39-50

A structured neurosurgical training plan and the neurosurgical logbook in the UK Lindsay, K. W. Pages 51-57

The European Neurosurgical Log-Book (UEMS/EANS) Reulen, H.-J. Pages 59-66

Morbidity & mortality conferences — How can we do it? Brennum, J. (et al.) Pages 67-71

Problem-based learning in residency training and the tutorial process for training and education in neurosurgery Winkler, P. A. (et al.) Pages 73-76

Research rotation in a trainee’s curriculum Reulen, H.-J. (et al.) Pages 97-101

The accreditation of a training programme Reulen, H.-J. Pages 103-106

The European Examination — its present status and potential development Haase, J. Pages 107-114

Neurosurgical subspecialization: pros and cons Schackert, G. (et al.) Pages 115-119

PASSION Resident project

PASSION Resident project

Neurosurgical Training in Germany

Neurosurgical Training in Germany

Neurology

Kleineberg et al. found substantial variation among European countries in the duration of residency training programmes, and especially in the choice of obligatory rotations to external medical disciplines. Despite a presumably similar spectrum of patients, neurology residency training programmes across Europe are not harmonised. The structure of the programme should be determined by its relevance for neurologists today and in the future 10).

1)

Martin M, Burn SC. Neurosurgical residency in the United States: a trainee’s experience. Acta Neurochir (Wien) 2005;147(11):1211–1212. discussion 1212.
2)

Neil-Dwyer G, Lang DA, Trojanowski T. European Union of Medical Specialists. Neurosurgical training programme director position and responsibilities. Acta Neurochir Suppl. 2004;90:13–16.
3)

Steers J, Reulen HJ, Lindsay KW. European Union of Medical Specialists, Joint Residency Advisory and Accreditation Committee . UEMS charter on training of medical specialists in the EU—the new neurosurgical training charter. Acta Neurochir Suppl. 2004;90:3–11.
4)

Trojanowski T. Report of the JRAAC on the situation of the accreditation training programmes in Europe. Acta Neurochir (Wien) 2008;150(8):851–853.
5) , 8)

Stienen MN, Netuka D, Demetriades AK, Ringel F, Gautschi OP, Gempt J, Kuhlen D, Schaller K. Residency program trainee-satisfaction correlate with results of the European board examination in neurosurgery. Acta Neurochir (Wien). 2016 Oct;158(10):1823-30. doi: 10.1007/s00701-016-2917-y. Epub 2016 Aug 12. PubMed PMID: 27517689.
6)

Burkhardt JK, Zinn PO, Bozinov O, Colen RR, Bertalanffy H, Kasper EM. Neurosurgical education in Europe and the United States of America. Neurosurg Rev. 2010 Oct;33(4):409-17. doi: 10.1007/s10143-010-0257-6. Epub 2010 Apr 29. PubMed PMID: 20429023; PubMed Central PMCID: PMC3683626.
7)

American Board of Neurological Surgery (ABNS) ABNS Board Certification. 2009 http://www.abns.org/content/primary_certification_process.asp.
9)

Stienen MN, Netuka D, Demetriades AK, Ringel F, Gautschi OP, Gempt J, Kuhlen D, Schaller K. Working time of neurosurgical residents in Europe-results of a multinational survey. Acta Neurochir (Wien). 2016 Jan;158(1):17-25. doi: 10.1007/s00701-015-2633-z. Epub 2015 Nov 14. PubMed PMID: 26566781.
10)

Kleineberg NN, van der Meulen M, Franke C, Klingelhoefer L, Sauerbier A, Di Liberto G, Carvalho V, Berendse HW, Deuschl G; RRFS national representatives’ network. Differences in neurology residency training programmes across Europe – a survey among EAN-RRFS national representatives. Eur J Neurol. 2020 Apr 5. doi: 10.1111/ene.14242. [Epub ahead of print] PubMed PMID: 32248603.

Simulation-based training

Simulation-based training

Simulation is the imitation of the operation of a real-world process or system over time.

The recent emphasis on simulation-based training in neurosurgery has led to the development of many simulation models and training courses.

Simulation-based training is increasingly being used for assessment and training of psychomotor skills involved in medicine. The application of artificial intelligence and machine learning technologies has provided new methodologies to utilize large amounts of data for educational purposes. A significant criticism of the use of artificial intelligence in education has been a lack of transparency in the algorithms’ decision-making processes.

A study aimed to 1) introduce a new framework using explainable artificial intelligence for simulation-based training in surgery, and 2) validate the framework by creating the Virtual Operative Assistant, an automated educational feedback platform. Twenty-eight skilled participants (14 staff neurosurgeons, 4 fellows, 10 PGY 4-6 residents) and 22 novice participants (10 PGY 1-3 residents, 12 medical students) took part in this study. Participants performed a virtual reality subpial brain tumor resection task on the NeuroVR simulator using a simulated ultrasonic aspirator and bipolar.

Metrics of performance were developed, and leave-one-out cross validation was employed to train and validate a support vector machine in Matlab. The classifier was combined with a unique educational system to build the Virtual Operative Assistant which provides users with automated feedback on their metric performance with regards to expert proficiency performance benchmarks. The Virtual Operative Assistant successfully classified skilled and novice participants using 4 metrics with an accuracy, specificity and sensitivity of 92, 82 and 100%, respectively. A 2-step feedback system was developed to provide participants with an immediate visual representation of their standing related to expert proficiency performance benchmarks. The educational system outlined establishes a basis for the potential role of integrating artificial intelligence and virtual reality simulation into surgical educational teaching. The potential of linking expertise classification, objective feedback based on proficiency benchmarks, and instructor input creates a novel educational tool by integrating these three components into a formative educational paradigm 1).


Patel et al. aimed to identify the currently available simulators and training courses for neurosurgery, assess their validity and determine their effectiveness.

Both Medline and EMBASE were searched for English language articles that validate simulation models for neurosurgery. Each study was screened according to Messick’s validity framework, and rated in each domain. McGaghie’s model of translational outcomes was then used to determine a level of effectiveness (LoE) for each simulator or training course.

Upon screening of 6006 articles, 114 were identified either validating or determining a LoE for 108 simulation-based training models or courses. Achieving the highest rating for each validity domain were: six models and training courses for content validity; 12 for response processes; 4 for internal structure; 14 for relations to other variables and none for consequences. For translational outcomes, 6 simulators or training achieved a LoE of greater than 2 and thus demonstrated skills transfer beyond the simulation setting.

With the advent of increasing neurosurgery simulators and training tools, there is a need for more validity studies. Further attempts to investigate translational outcomes to the operating theatre when using these simulators are particularly warranted. Finally, more training tools incorporating full immersion simulation and non-technical skills training are recommended 2) 3).


The current simulation technology used for neurosurgical training leaves much to be desired. Significant efforts are thoroughly exhausted in hopes of developing simulations that translate to give learners the “real-life” feel. Though a respectable goal, this may not be necessary as the application for simulation in neurosurgical training may be most useful in early learners. The ultimate uniformly agreeable endpoint of improved outcome and patient safety drives these investments 4).


Medicine and surgery are turning towards simulation to improve on limited patient interaction during residency training. Many simulators today utilize virtual reality with augmented haptic feedback with little to no physical elements.

To optimize the learning exercise, it is essential that both visual and haptic simulators are presented to best present a real-world experience. Many systems attempt to achieve this goal through a total virtual interface.

Bova et al., approach has been to create a mixed-reality system consisting of a physical and a virtual component. A physical model of the head or spine is created with a 3-dimensional printer using deidentified patient data. The model is linked to a virtual radiographic system or an image guidance platform. A variety of surgical challenges can be presented in which the trainee must use the same anatomic and radiographic references required during actual surgical procedures.

Using the aforementioned techniques, they have created a ventriculostomy simulators, percutaneous stereotactic lesion procedure for trigeminal neuralgia, and spinal instrumentation.

The system has provided the residents an opportunity to understand and appreciate the complex 3-dimensional anatomy of the 3 neurosurgical procedures simulated. The systems have also provided an opportunity to break procedures down into critical segments, allowing the user to concentrate on specific areas of deficiency 5).


Multiple simulators have been developed for neurosurgical training, including those for minimally invasive procedures, vascular, skull base, pediatric, tumor resection, functional neurosurgery, and spine surgery.

Advances in imaging and computer technology have led to the development of different simulation models to complement traditional surgical training. Sophisticated virtual reality (VR) simulators with haptic feedback and impressive imaging technology have provided novel options for training in neurosurgery. Breakthrough training simulation using 3D printing technology holds promise for future simulation practice, proving high-fidelity patient-specific models to complement residency surgical learning 6).


Shakur et al., developed a real-time augmented reality simulator for percutaneous trigeminal rhizotomy using the ImmersiveTouch platform. Ninety-two neurosurgery residents tested the simulator at American Association of Neurological Surgeons Top Gun 2014. Postgraduate year (PGY), number of fluoroscopy shots, the distance from the ideal entry point, and the distance from the ideal target were recorded by the system during each simulation session. Final performance score was calculated considering the number of fluoroscopy shots and distances from entry and target points (a lower score is better). The impact of PGY level on residents’ performance was analyzed.

Seventy-one residents provided their PGY-level and simulator performance data; 38% were senior residents and 62% were junior residents. The mean distance from the entry point (9.4 mm vs 12.6 mm, P = .01), the distance from the target (12.0 mm vs 15.2 mm, P = .16), and final score (31.1 vs 37.7, P = .02) were lower in senior than in junior residents. The mean number of fluoroscopy shots (9.8 vs 10.0, P = .88) was similar in these 2 groups. Linear regression analysis showed that increasing PGY level is significantly associated with a decreased distance from the ideal entry point (P = .001), a shorter distance from target (P = .05), a better final score (P = .007), but not number of fluoroscopy shots (P = .52).

Because technical performance of percutaneous rhizotomy increases with training, they proposed that the skills in performing the procedure in there virtual reality model would also increase with PGY level, if this simulator models the actual procedure. The results confirm this hypothesis and demonstrate construct validity 7).


Simulation technology identifies neurosurgical residency applicants with differing levels of technical ability. These results provide information for studies being developed for longitudinal studies on the acquisition, development, and maintenance of psychomotor skills. Technical abilities customized training programs that maximize individual resident bimanual psychomotor training dependant on continuously updated and validated metrics from virtual reality simulation studies should be explored 8).


Surgical education is moving rapidly to the use of simulation for technical training of residents and maintenance or upgrading of surgical skills in clinical practice. To optimize the learning exercise, it is essential that both visual and haptic cues are presented to best present a real-world experience. Many systems attempt to achieve this goal through a total virtual interface.

To demonstrate that the most critical aspect in optimizing a simulation experience is to provide the visual and haptic cues, allowing the training to fully mimic the real-world environment.

Bova et al approach has been to create a mixed-reality system consisting of a physical and a virtual component. A physical model of the head or spine is created with a 3-dimensional printer using deidentified patient data. The model is linked to a virtual radiographic system or an image guidance platform. A variety of surgical challenges can be presented in which the trainee must use the same anatomic and radiographic references required during actual surgical procedures.

Using the aforementioned techniques, they have created simulators for ventriculostomy, percutaneous stereotactic lesion procedure for trigeminal neuralgia, and spinal instrumentation. The design and implementation of these platforms are presented.

The system has provided the residents an opportunity to understand and appreciate the complex 3-dimensional anatomy of the 3 neurosurgical procedures simulated. The systems have also provided an opportunity to break procedures down into critical segments, allowing the user to concentrate on specific areas of deficiency 9).

References

1)

Mirchi N, Bissonnette V, Yilmaz R, Ledwos N, Winkler-Schwartz A, Del Maestro RF. The Virtual Operative Assistant: An explainable artificial intelligence tool for simulation-based training in surgery and medicine. PLoS One. 2020 Feb 27;15(2):e0229596. doi: 10.1371/journal.pone.0229596. eCollection 2020. PubMed PMID: 32106247.
2)

Patel E, Aydin A, Cearns M, Dasgupta P, Ahmed K. A Systematic Review of Simulation-based Training in Neurosurgery, Part 1: Cranial Neurosurgery. World Neurosurg. 2019 Sep 18. pii: S1878-8750(19)32430-1. doi: 10.1016/j.wneu.2019.08.262. [Epub ahead of print] PubMed PMID: 31541755.
3)

Patel E, Aydin A, Cearns M, Dasgupta P, Ahmed K. A Systematic Review of Simulation-based Training in Neurosurgery, Part 2: Spinal and Paediatric Surgery, Neurointerventional Radiology and Non-Technical Skills. World Neurosurg. 2019 Sep 18. pii: S1878-8750(19)32442-8. doi: 10.1016/j.wneu.2019.08.263. [Epub ahead of print] PubMed PMID: 31541754.
4)

Konakondla S, Fong R, Schirmer CM. Simulation training in neurosurgery: advances in education and practice. Adv Med Educ Pract. 2017 Jul 14;8:465-473. doi: 10.2147/AMEP.S113565. eCollection 2017. Review. PubMed PMID: 28765716; PubMed Central PMCID: PMC5524176.
5) , 9)

Bova FJ, Rajon DA, Friedman WA, Murad GJ, Hoh DJ, Jacob RP, Lampotang S, Lizdas DE, Lombard G, Lister JR. Mixed-reality simulation for neurosurgical procedures. Neurosurgery. 2013 Oct;73 Suppl 1:138-45. doi: 10.1227/NEU.0000000000000113. PubMed PMID: 24051877.
6)

Rehder R, Abd-El-Barr M, Hooten K, Weinstock P, Madsen JR, Cohen AR. The role of simulation in neurosurgery. Childs Nerv Syst. 2016 Jan;32(1):43-54. doi: 10.1007/s00381-015-2923-z. Review. PubMed PMID: 26438547.
7)

Shakur SF, Luciano CJ, Kania P, Roitberg BZ, Banerjee PP, Slavin KV, Sorenson J, Charbel FT, Alaraj A. Usefulness of a Virtual Reality Percutaneous Trigeminal Rhizotomy Simulator in Neurosurgical Training. Neurosurgery. 2015 Sep;11 Suppl 3:420-5; discussion 425. doi: 10.1227/NEU.0000000000000853. PubMed PMID: 26103444.
8)

Winkler-Schwartz A, Bajunaid K, Mullah MA, Marwa I, Alotaibi FE, Fares J, Baggiani M, Azarnoush H, Zharni GA, Christie S, Sabbagh AJ, Werthner P, Del Maestro RF. Bimanual Psychomotor Performance in Neurosurgical Resident Applicants Assessed Using NeuroTouch, a Virtual Reality Simulator. J Surg Educ. 2016 Jul 6. pii: S1931-7204(16)30026-5. doi: 10.1016/j.jsurg.2016.04.013. [Epub ahead of print] PubMed PMID: 27395397.
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