TRAINING IN VASCULAR NEUROSURGERY TRAINING IN VASCULAR NEUROSURGERY

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Genealogy of Training in Vascular Neurosurgery Shakeel A. Chowdhry, MD Robert F. Spetzler, MD Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona Correspondence: Robert F. Spetzler, MD, c/o Neuroscience Publications, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ 85013. E-mail: [email protected] Received, August 15, 2013. Accepted, October 11, 2013. Copyright © 2014 by the Congress of Neurological Surgeons

Remarkable advances and changes in the landscape of neurovascular disease have occurred recently. Concurrently, a paradigm shift in training and resident education is underway. This crossroad of unique opportunities and pressures necessitates creative change in the training of future vascular neurosurgeons to allow incorporation of surgical advances, new technology, and supplementary treatment modalities in a setting of reduced work hours and increased public scrutiny. This article discusses the changing landscape in neurovascular disease treatment, followed by the recent changes in resident training, and concludes with our view of the future of training in vascular neurosurgery. KEY WORDS: Education, Endovascular, Resident training, Simulator, Vascular neurosurgery Neurosurgery 74:S198–S203, 2014

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DOI: 10.1227/NEU.0000000000000225

he term genealogy is derived from the Greek genea (generation) and logos (knowledge). Commonly used to describe the study of family lines, the concept of genealogy in the context of vascular neurosurgery can describe the knowledge and advances that guided previous surgical treatment and training; this, coupled with modern technical and technological advances, an improved understanding of the pathophysiology of vascular lesions, and the recent paradigm shift in resident education, will shape the development and training of future vascular neurosurgeons. Modern medical trainees have witnessed a surge in medical literature, which has recently increased at an exponential rate. In the field of neurosurgery, and particularly within the subspecialty of vascular neurosurgery, remarkable advances continue at a feverish pace, driven by the common goals of improving care for patients with neurovascular disease. The beginning of the modern era of vascular microneurosurgery can be marked by the incorporation of the operating microscope and was followed shortly by the technical realization of the intracranial bypass.1-3 Over the subsequent decades, visualization and surgical instrumentation continued to improve, and surgical techniques and approaches were further developed to access all areas of the brain and spine. Advances in neuroanesthesia, neuroprotection, and monitoring techniques increased surgical safety and reduced morbidity. Routine use of adjuncts to assess vascular patency, including micro-Doppler ultrasound, catheter angiog-

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raphy, and later indocyanine green angiography, reduced operative morbidity, and increased surgical efficacy for several vascular lesions.4-6 As vascular microneurosurgery continued its development and refinement, certain vascular pathologies continued to carry higher morbidity. Concomitantly, alternative therapeutic modalities emerged and rapidly gained support among neurosurgeons as they were used to treat several of these lesions fraught with traditionally high microsurgical morbidity. As the new therapeutic modalities, endovascular neurosurgery and radiosurgery, were beginning to be established in the treatment portfolio for neurovascular disease, a profound change in the manner of educating residents had already begun to unfold, first in New York in the late 1980s and then nationwide. Initial changes were undertaken to address patient safety. However, the fundamental manner in which residents, including surgical residents, were trained was challenged, and the changes proposed would ultimately alter the core principles of surgical training. To incorporate the necessary changes for modern neurosurgical resident education along with the evolving changes within the treatment armamentarium for neurovascular disease meant definite, significant alterations in the training of vascular neurosurgeons. Here, we first address the changes in the therapeutic landscape for neurovascular disease and then discuss the recent changes in resident education. Finally, we discuss how these 2 factors affect the training of vascular neurosurgeons.

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GENEALOGY OF VASCULAR NEUROSURGERY TRAINING

ADVANCES AND CHANGES IN THE LANDSCAPE OF NEUROVASCULAR DISEASE In 1885, Sir Victor Horsley became the first surgeon to treat a cerebral aneurysm.7 Walter Dandy performed the first aneurysm clipping in 1937, 5 years after Olivecrona performed the first surgical excision of an intracranial arteriovenous malformation.8,9 Not surprisingly, in the early years, surgical treatment carried significant morbidity. Later, an improved understanding of disease pathophysiology was coupled with technical improvements, most notably incorporation of the operative microscope and refined surgical instrumentation, to reduce morbidity. Extensive exposures were developed and refined to minimize brain and spinal cord manipulation. Advances in neuroanesthesia, neuroprotection, and neurophysiologic monitoring increased safety.10 Micro-Doppler ultrasonography, temporary clipping, intraoperative angiography, indocyanine green angiography, image-guided stereotactic neuronavigation, and endoscopy represent only some of the important technical developments.4-6,11-13 Improved brain relaxation, ergonomic surgeon comfort with proper positioning, and the evolution of operative techniques to minimize iatrogenic injury (eg, dynamic retraction, otherwise known as retractorless surgery) contributed to improved outcomes.14 Anatomic studies and extensive surgical experience resulted in more focused surgical corridors; operative windows were tailored to minimize morbidity while maintaining critical exposure. As outcomes improved, standards began to develop. Having proven surgical feasibility and safety, the neurosurgical community moved efficacy to center stage. The natural history of neurovascular pathology, previously overlooked, was now critically important; data from early studies limited by confounding variables and biases were carefully analyzed to produce best estimates, and surgical efficacy was measured against these estimates. As the evolution of microneurosurgery progressed, endoluminal therapy was realized. Marked by Food and Drug Administration approval of Guglielmi detachable coils in 1995,15 coil embolization represented the collective realization of endovascular efforts that began in the 1970s during the era of Fjodor Serbineko’s proximal balloon occlusion. An exciting new approach to neurovascular disease, endovascular neurosurgery (or interventional neuroradiology), sought to treat the same vascular lesions but via an endoluminal approach within the blood vessel. Endovascular surgery gained rapid traction, with numerous reports demonstrating safety and efficacy in short-term windows. Requiring an entirely different skill set, endovascular surgery became particularly attractive when it was shown that it could be used to treat vascular lesions that carried high morbidity and mortality rates when treated by open microneurosurgery.16 The evolution and development of endovascular techniques have occurred at a frenetic pace, eclipsing those of microsurgery. Embolization coils have changed significantly since Guglielmi detachable coils received a humanitarian device exemption in

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1991, with the development of numerous coil designs and detachment apparatuses. Technological advances, including a variety of vascular remodeling devices (balloons, stents), improved access catheters, and a number of embolizates (polyvinyl alcohol, Onyx [Covidien, ev3 neurovascular, Irvine, California], and n-butyl cyanoacrylate [Codman Neurovascular, Raynham, Massachusetts]) have led to increased efficacy and breadth of treatment. Extracranial and intracranial stents have several iterations, and recently developed devices, including flow diversion stents (Pipeline, Covidien, ev3 neurovascular), have shown promise in numerous early studies. Adjuncts used in microneurosurgery such as neurophysiological monitoring also have contributed to reduced morbidity in endovascular neurosurgery. Endovascular surgery may be used in the treatment of myriad vascular lesions, including aneurysms, fistula, arteriovenous malformations, vascular tumors, and ischemic vascular disease. Wellpopularized studies,17,18 despite their significant limitations, have been cited as pivotal in driving the rapid and extensive shift to endovascular surgery, most prominently in Europe and most visibly with aneurysm treatment. It is important to note that as endovascular therapy has gained tremendous ground,19 it has done so despite limited data regarding its long-term efficacy. The longterm risks associated with partial or incomplete aneurysm treatment remain poorly understood. However, the quality of the available data continues to improve as refinements in studies are made on the basis of the apparent limitations of previous studies. As with large studies for vascular microneurosurgery,20,21 several endovascular studies22,23 have led to unexpected results, including the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis trial, in which the anticipated benefit of intracranial stenting was not realized because of the marked reduction in recurrent stroke seen in the arm receiving medical therapy. Trials such as these underscore the importance of rigorous scientific evaluation of therapeutic intervention. A unique pressure for bias that exists in modern era, particularly with endovascular surgery, is inherent in the collaborations critical to recent progress. The strong presence of industry is necessary for instrument and device design and development but invariably presents a significant source of bias. This bias is most evident in the cardiac literature in which a sprawling interventional cardiology industry grew to over $5 billion per year in 2005 on the basis of the perceived benefit of drug-eluting stents gleaned from data that included numerous industry-sponsored studies. More recent appraisals have indicated that these stents provide a more modest benefit with limitations, particularly in the long run. Only more recently have studies begun to compare numerous outcome measures between stenting and cardiac bypass.24,25 Colleagues26 have previously lamented that a closed view exists within vascular neurosurgery driven by a paradigm that revolves around microsurgery. This view, they argue, blinds practitioners to the best available treatments and retards progress. We would argue that a paradigm shift that emphasizes endovascular surgery over microneurosurgery, as evidenced in Europe, is not the solution.

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The dichotomous view of microneurosurgery and endovascular surgery as exclusive and diametrically opposing treatment modalities is counterproductive and serves only as a barrier to progress. Rather, the paradigm shift should be toward a disease-based focus, with incorporation of a strong understanding of all treatment modalities available and their benefits and limitations, both independently and as adjuncts to one another, measured against the natural history of the disease. The goal for microneurosurgery and endovascular surgery is naturally the same: to treat vascular disease effectively, efficaciously, durably, and with minimal morbidity. As the understanding of the benefits and limitations of a given modality continues to evolve, the use of a given technique must be couched in the current understanding of the pathophysiology and natural history of a particular vascular lesion and measured against the exclusive or combined use of other therapeutic modalities. Microneurosurgery and endovascular surgery, as well as radiosurgery, should be viewed as cooperative and supplementive, as opposed to exclusive, and training, as discussed below, must reflect that. As always, in determining the most appropriate treatment course, the relative morbidity of each treatment in the hands of a given practitioner or institution must be considered.

CHANGING LANDSCAPE IN TRAINING AND RESIDENT EDUCATION Surgical training, including neurosurgical training, followed the established halstedian model for the latter half of the 20th century. Dr William S. Halsted, chair of surgery at Johns Hopkins University, used a structure incorporating various aspects of the apprenticeship model that relied on a large surgical volume, a variety of cases, and extended time within the hospital. This system, which includes the well-known“see one, do one, teach one” corollary, successfully created a highly skilled surgical workforce.27 Unspoken contracts between the public, educators, institutions, residents, and students have long existed. However, increased public scrutiny, coupled with expectations in general society and the medical field for improved outcomes within a training environment couched in complex relationships between faculty, residents, hospitals, academic institutions, and industry, has necessitated a change in the training paradigm. Key examples of the limitations of the halstedian system were brought to light and resulted in a change in resident training driven by law first in New York and then nationwide. After the wellpublicized death of an 18-year-old woman in a New York City hospital in 1984, a commission headed by Dr Bertrand M. Bell offered recommendations that largely shaped Section 405 of the New York Health Code of 1989. The commission was concerned with several critical aspects of care that contributed to the patient’s death resulting from interactions between her home medication and prescribed medications that led to a lethal serotonin syndrome that resulted in cardiac arrest. The number of patients the admitting intern and supervising postgraduate year 2 resident carried overnight, the extent of hours worked consecutively, and the limited attending supervision were cited in what was viewed

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as a flawed system. A number of years later, the Health Care Reform Act of 2000 was introduced, ushered in by, among numerous other incidents, a fatal automobile accident involving a cardiology fellow after a night on call. These laws, along with the factors and influences cited above, contributed to the modern changes in resident education, which have resulted in restricted work hours and a reduction in operative experience against a backdrop of increased public scrutiny. These collective factors threaten, for the first time, to produce residents who may be less skilled than the previous generation. With regard to vascular neurosurgery, changes in operative exposure, coupled with a decrease in tertiary referrals for various vascular lesions, including posterior communicating artery aneurysms, have had a significant effect on resident training.28 In light of these pressures and changes, a necessary shift in resident education has been proposed. A new education matrix based on the attainment of specific competency milestones was proposed to replace the previous model. The old model was a timeintensive one of circumstantial practice in which residents were exposed to the cases and patients of a hospital or institution from which formative and summative tools were locally developed and experience was tracked. It required extensive time in the hospital for exposure, and education was measured in terms of experience tracking (cases logged). The new model, one of “intentional practice,” provides the trainee with a number of outcomes, or milestones, in various domains of clinical competency (Figure 1). Achievement of these milestones would necessitate designed educational experiences with nationally accepted and derived tools (summative and formative) for proficiency measurement, as well as for outcome (not just experience) tracking. The milestones, currently under development by the Senior Neurosurgical Society, would be specific for the field of training and based on the Accreditation Council for Graduate Medical Education core competencies of patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.29 An external accountability for outcomes would help to produce proficient physicians in the setting of these modern training requirements. In this new model of “matrixes and milestones,” assessment would remain embedded in the clinical setting with direct observation, but competencies would be expanded, curriculum would transition from random to deliberate, and nationally recognized milestones based on competency, not time, would be used. Again, achievement of these competency-based milestones must occur in the setting of reduced work hours and decreased operative experience. From a surgical perspective, this can realistically be achieved only with the use of training adjuncts to further trainees along the learning curve. Such adjuncts might include simulators, focused cadaveric dissections, and purposeful skills practice outside the operating room. These educational changes have been discussed among neurosurgery leaders and national medical boards for a number of years, and this educational paradigm shift has been championed by the Accreditation Council for Graduate Medical Education and

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and breadth of training for the vascular neurosurgeon. Appropriate training will invariably require exposure to microneurosurgical and skull base techniques, as well as angiography, endovascular neurosurgery, and radiosurgery. To achieve proficiency, trainees will require exposure to a number of cases and a variety of vascular lesions. In the past, operative proficiency was achieved through case exposure and extensive operative experience. The future will involve tailored experiences to ensure the appropriate breadth of experience, and competency will be measured by technical proficiency and complication avoidance and management as opposed to case volume. In the era of reduced operative experience, progression along the learning curve to operative proficiency will require either a marked extension of training time or, more reasonably, the sensible use of surgical adjuncts to further trainees along the learning curve. Such adjuncts include focused cadaveric dissection, animal procedures, and microsurgical and endovascular skills laboratories and simulators (Figures 2 and 3). Simulators are already in common use for endovascular surgical training and allow the trainee to attain certain technical skills and to rehearse for complication management. Operative simulators have proven to be more difficult to design, but several have been produced.31,32 Simulators allow technical rehearsal and purposeful practice, and as they evolve, they will likely assume a larger role in training (Figure 4).33 Animal procedures and laboratory work are critically important for

FIGURE 1. Circumstantial (A) and intentional (B) models of resident education. Training previously followed a circumstantial practice model that was based heavily on time spent in the hospital to allow sufficient breadth of exposure with experience tracking serving as a main form of assessment. The newer intentional practice model will use nationally recognized milestones in predetermined domains of clinical competency to drive intentional practice with a new focus on outcomes tracking to produce proficient physicians. Used with permission from Barrow Neurological Institute.

American Board of Neurological Surgery/Residency Review Committee.29 The initial phase for data collection to drive further development and implementation of this new system, known as the Next Accreditation System, began this past July.30

FUTURE OF VASCULAR NEUROSURGERY The previous training paradigm, couched in the halstedian apprenticeship model, has been replaced in the modern era by a model of purposeful training in the setting of restricted work hours and increased public scrutiny. Now, focused, goal-oriented training with expectations for lowering morbidity and improving outcomes is the system in which future vascular neurosurgeons will gain proficiency. As the educational framework has undergone monumental changes, so too has the landscape of neurovascular treatment. A marked increase in the operative and medical tools available for treating vascular disease necessitates wider exposure

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FIGURE 2. Photograph from a recent microneurosurgical course at Barrow Neurological Institute, St. Joseph’s Hospital, Phoenix, Arizona, May 2013. The participants are practicing microanastomosis using Silastic tubing and 9-0 suture. Used with permission from Barrow Neurological Institute.

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FIGURE 3. Photograph of a resident performing a dissection during a skull base surgery training course at Barrow Neurological Institute, St. Joseph’s Hospital, Phoenix, Arizona. Used with permission from Barrow Neurological Institute.

technical skill development for demanding procedures that are not frequently performed at most institutions, including vascular bypass (Figure 5). After formal training, vascular neurosurgeons must continue to commit to a rigorous and critical evaluation of their outcomes, diligently review operative video or angiography runs, and maintain discipline in continuing to hone and develop technical skills. Trainees in vascular neurosurgery will be expected to be proficient in all treatment modalities. Some neurosurgeons have argued that an inherent bias toward a treatment modality exists based on the practice of a given physician if that physician is trained exclusively as a microneurosurgeon or endovascular neurosurgeon. Although this may be true, the converse that such bias would be eliminated for a dually trained surgeon is not necessarily true. Rather, we would argue that a tendency will always exist for practitioners to favor one modality over the other on the basis of

FIGURE 4. Screen capture from a surgical simulator for aneurysm clipping (Selman Surgical Rehearsal Platform, Surgical Theater, Mayfield Village, Ohio). Used with permission from Surgical Theater.

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FIGURE 5. Photograph obtained via the intraoperative microscope during creation of a superficial temporal artery-to-posterior cerebral artery bypass for the treatment of a fusiform aneurysm. Temporary clips on the posterior cerebral artery can be seen on either side of the instruments. Used with permission from Barrow Neurological Institute.

their comfort with each treatment because equal mastery of both modalities may not be a realistic goal. Given the steeper learning curve for microneurosurgery and the arguably increased length of time required to reach mastery, it is easy to imagine that an initial bias in a young, dually trained surgeon toward endovascular surgery could easily emerge, particularly because endovascular fellowship is often undertaken after completion of neurosurgical residency. However, this effect may be partially offset by fellowships that incorporate both treatment modalities as part of the training. Several members of the neurosurgical community have encouraged the future generation of vascular neurosurgeons to maintain diligence in microsurgery both to preserve and to advance that treatment modality despite its steeper and longer learning curve because a tendency may truly emerge toward endovascular therapy if the future generation of microneurosurgeons is less skilled than the previous generation.34 This tendency may favor treatment toward endovascular therapy for lesions that would otherwise best be treated by microsurgical means (eg, blister aneurysms) because of a higher morbidity rate among the new generation of surgeons, effectively decreasing the level of care for that given lesion. Ultimately, although influences, including industry and the allure of the new, undoubtedly help shape the current treatment landscape, treatment modalities will be designed and selected on the basis of the risks of the treatment in the setting of our understanding of the natural history of the disease and the risks of other treatment options as delineated in current and future trials.

CONCLUSION The goal of vascular neurosurgery remains simple: to treat vascular disease effectively, efficaciously, durably, and with minimal

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GENEALOGY OF VASCULAR NEUROSURGERY TRAINING

morbidity. The reality of achieving this goal is anything but simple. When applying techniques and technology, one must measure new treatments against the gold standard treatment and the natural history of the disease. Measurements and statistical analyses can become complex, with numerous confounding variables, particularly with limited patient populations. New techniques and devices are exciting; they expand the arsenal with which to attack disease. Even with these technologies and advancements, there remain daunting lesions such as symptomatic fusiform vertebrobasilar aneurysms that continue to do poorly, reflecting our poor understanding of the underlying disease process.35,36 Training in vascular neurosurgery has undergone great changes in the modern era with the advent of endovascular therapy and the shift to intentional practice training in the setting of reduced work hours. The goal of producing a proficient neurosurgeon, one who has an intimate knowledge of the risks and benefits of all viable treatment options, can be accomplished by using surgical training adjuncts and intentional practice surgical and endovascular exposure. Through these measures, trainees can gain breadth of training in the setting of measured competency through achievement of national milestones. Ultimately, the posttraining transition from proficiency to mastery will rest, as before, in the hands of the given neurosurgeons who must remain committed to relentless objective, critical evaluation of outcomes and diligence in continuing to hone and develop technical skills. Disclosure The authors have no personal financial or institutional interest in any of the drugs, materials, or devices described in this article.

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Genealogy of training in vascular neurosurgery.

Remarkable advances and changes in the landscape of neurovascular disease have occurred recently. Concurrently, a paradigm shift in training and resid...
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