Original Article

Simulation Training Curricula for Neurosurgical Residents: Cervical Foraminotomy and Durotomy Repair Modules George M. Ghobrial1, Karl Balsara1, Christopher M. Maulucci2, Daniel K. Resnick3, Nathan R. Selden4, Ashwini D. Sharan5, James S. Harrop5

INTRODUCTION: Since 2010, the Congress of Neurological Surgeons (CNS) has offered a neurosurgical skills simulation course for residents and medical students. The authors describe their experience with incorporation of two neurosurgical skills simulation modules into the dedicated resident training curriculum of a single ACGMEaccredited training program, using lumbar dural repair (5) and posterior cervical laminoforaminotomy modules from the CNS simulation initiative (6).

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METHODS: Each of the available 22 neurosurgery residents at a single residency program was given two 20question pretests for a cervical laminoforaminotomy and durotomy repair module as a basic test of regional anatomy, general disease knowledge, surgical decision making, and recently published literature. This was followed by a faculty-directed skills simulation course and concluded with a final 20 question post-test.

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RESULTS: Posterior cervical laminoforaminotomy was performed once by each resident, and grading was conducted using the predetermined OSATs. The overall score was 56.1 (70%, range 26e76, maximum 80 points) with a trend towards higher scores with advanced levels of training. All residents completed the durotomy repair OSATs for a total of three trials. Of a maximum composite score of 60, a mean 37.2 (62%, range 15e58) was scored by the residents (Table 3). The mean OSAT scores for each durotomy trial was 2.66, 3.15, and 3.48 on each success test. A trend towards higher scores in advanced years of

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training was observed, but did not reach statistical significance (Figure 3). CONCLUSIONS: Duty hour limitations and regulatory pressure for enhanced quality and outcomes may limit access of neurosurgical residents to fundamental skills training. Fundamental skills training as part of a validated simulation curriculum can mitigate this challenge to residency education. National development of effective technical simulation modules for use in individual residency training programs is a promising strategy to achieve these goals.

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INTRODUCTION

I

ntroduction of work limitations in 2003 by the Accreditation Council for Graduate Medical Education (ACGME) has increased pressure on neurosurgical residency programs to provide adequate technical experience within limited duty hours (9). Public and regulatory demands for enhanced quality and outcomes may also limit the willingness of neurosurgical faculty to provide initial operative training to residents lacking fundamental technical skills. Simulation training may provide one method for mitigating these threats to resident education. Widespread use of simulation in medical education began with acute care resuscitation scenarios involving high-risk algorithms and critical team-based communication (13). Widespread success in the use of such cardiopulmonary resuscitation simulators has

Key words Cervical foraminotomy - Durotomy repair - Resident education - Simulation

School of Medicine and Public Health, Madison, Wisconsin, USA; 4Campagna Professor of Pediatric Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA; 5 Professor of Neurological Surgery, Thomas Jefferson University Hospital, Department of Neurological Surgery, Philadlephia, Pennsylvania, USA

Abbreviations and Acronyms ACGME: Accreditation Council for Graduate Medical Education CNS: Congress of Neurological Surgeons OSATs: Objective structured assessment tests

Citation: World Neurosurg. (2015) 84, 3:751-755. http://dx.doi.org/10.1016/j.wneu.2015.04.056 Supplementary digital content available online.

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1

From the Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA; 2Department of Neurological Surgery, Tulane University, New Orleans, Louisiana, USA; 3Department of Neurological Surgery, University of Wisconsin

WORLD NEUROSURGERY 84 [3]: 751-755, SEPTEMBER 2015

To whom correspondence should be addressed: George M. Ghobrial, M.D. [E-mail: [email protected]]

Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.

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ORIGINAL ARTICLE GEORGE M. GHOBRIAL ET AL.

SIMULATION TRAINING CURRICULA FOR NEUROSURGICAL RESIDENTS

evolved to interest in focused technical simulation for training, assessment, and rehearsal of procedural skills (2, 12). Since 2010, the Congress of Neurological Surgeons (CNS) has offered a neurosurgical skills simulation course for residents and medical students. The size and scope of this course has grown considerably each year to include simulation training in spine (3, 5, 6, 7, 8, 11) cranial (4, 22), endoscopic (10, 15-18), and endovascular techniques (14). One goal of this initiative has been to design and test simulation modules for ultimate incorporation into a comprehensive national residency curriculum. Effective technical simulation curricula generally require various specific components, including a pretest to quantify relevant baseline skills and knowledge, a didactic instructional session to outline course objectives, technical simulation training, and a posttest for summative evaluation (5, 6). Technical simulation curricula often employ objective structured assessment tests (OSATs) for evaluation. The authors describe their experience with incorporation of two neurosurgical skills simulation modules into the dedicated resident training curriculum of a single ACGME-accredited training program, using lumbar dural repair (5) and posterior cervical laminoforamenotomy modules from the CNS simulation initiative (6). METHODS Pretest Knowledge Assessment The Thomas Jefferson University Residency Program is a 7-year program training three residents per year with 22 residents at the time of writing. Each resident was given two 20-question pretests for each module as a basic test of regional anatomy, general disease knowledge, surgical decision making, and recently published literature (see Supplemental Materials). The questions were administered online by the CNS educational department and made available for a 2-day period before the July 18th Simulation Course. Simulation Course Before the start of each simulation exercise, the curriculum and answers to the pretest were explained in a didactic session. Next, all residents from postgraduate years 1e7 took part in a singlesession training program using two established simulators, the durotomy repair (5) and laminoforaminotomy (6) modules. The goal of the durotomy repair module is to close a 1-cm linear dural defect using 4-0 Nurolon in a continuous uninterrupted fashion (Ethicon, Somerville, New Jersey, USA). The lumbar defect is housed in a laminectomized spine model produced by Sawbones (Vashon Island, Washington, USA) (Figure 1). The laminoforaminotomy module involves a posterior cervical spine approach to a fabricated subaxial cervical spine, where selective laminoforaminotomies can be performed alone or in tandem with a cervical laminectomy (Figure 2). Residents completed one trial of the posterior cervical laminectomy and foraminotomy module and three trials on the durotomy closure module under close faculty supervision. Scoring Each test question was given a value of 1 point for a total of 20 points. For each module, the OSAT maximum score was 20 points

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Figure 1. Neurosurgical Simulation Lab, Durotomy Repair Module, Thomas Jefferson University.

per trial. Because three trials were performed with the durotomy repair module, the composite score for the OSAT was 60 points. The posterior cervical laminectomy and foraminotomy module had a maximum OSAT score of 80 points derived from one trial, with 16 components with a maximum score of 5 points per component (Supplementary Material). Scoring was standardized using OSATs that were evaluated by one faculty member for each simulator (Supplementary Material). Data recorded included the pretest and posttest scores, as well as resident specific OSAT scores for each trial. A Wilcoxon Rank Sum Test was used for statistical analyses, which were conducted with JMP 8.00 (SAS Institute, Cary, North Carolina, USA). RESULTS A total of 20 residents (90% participation) across all postgraduate levels of training (PGY1-7) completed the established academic curriculum (Table 1). Two residents abstained as they had previously administered the test at the CNS meeting (GG, KB). Examination All residents took the pretest within 48 hours of the simulation course and the posttest on completion of the simulation course.

Figure 2. Posterior cervical laminectomy and foraminotomy module.

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ORIGINAL ARTICLE GEORGE M. GHOBRIAL ET AL.

SIMULATION TRAINING CURRICULA FOR NEUROSURGICAL RESIDENTS

Table 1. Summary of Participants PGY

Number of Participants

Table 3. Summary of Obstructive Structured Assessment Test (OSAT) Performance PGY

PCF OSAT

CSF OSAT

1

3

2

3

1

39.3

17

3

2

2

38

24.3

4

3

3

43.5

27.5

5

2

4

61

41

6

2

5

57.5

49

7

5

6

65

49.5

20

7

72.75

56.3

Mean

53.86429

37.8

Total PGY, postgraduate year.

PCF, posterior cervical fusion; CSF, cerebrospinal fluid; PGY, postgraduate year.

The mean pretest scores for the durotomy repair and cervical laminectomy and foraminotomy simulation test were 11.7 and 15.1, respectively (20 points maximum), with performance on both the pretest and mean cumulative test scores (adding raw score from both tests) correlating directly with postgraduate year (P < 0.005) (Figure 2). Overall, the mean cumulative pretest and posttest scores were 13.4 and 16.475, indicating a significant improvement (P < 0.0001) (Table 2). Simulation Performance Posterior cervical laminoforaminotomy was performed once by each resident, and grading was conducted using the predetermined OSATs. The overall score was 56.1 (70%, range 26e76, maximum 80 points) with a trend toward higher scores with advanced levels of training. All residents completed the durotomy repair OSATs for a total of three trials. Of a maximum composite score of 60, a mean 37.2 (62%, range 15e58) was scored by the residents (Table 3). The mean OSAT scores for each durotomy trial were 2.66, 3.15, and 3.48 on each successive test. A trend toward higher scores in advanced years

Table 2. Summary of Examination Scoring Pretest

Posttest

Mean

Mean

1

13.83333

16.83333

0.054

2

12.33333

16.33333

0.008

3

12

13.75

0.19

4

13.66667

17

0.019

5

15.25

17.5

0.193

6

12.5

17

0.074

7

13.625

17

0.003

Mean

13.4

16.475

PGY

of training was observed but did not reach statistical significance (Figure 4). DISCUSSION Duty hour limitations and regulatory pressure for enhanced quality and outcomes may limit access of neurosurgical residents to fundamental skills training. Model-based technical simulation is ideally suited to teach, practice, and assess individual, isolated technical maneuvers necessary to carry out the complex and interdependent steps of entire neurosurgical operations (21). Demonstrated competence with these individual technical skills may also allow individual trainees to more greatly benefit from the experience of supervised live operative training, as well as increase the confidence of supervisory faculty in their ability to participate in surgical cases. The authors present their experience implementing two neurosurgical skills simulation modules within the recurring curriculum of an ACGME-accredited neurosurgical training program. The cervical laminoforaminotomy and spinal durotomy modules used were originally developed and validated by the national professional education society, the CNS, as part of a broader simulation initiative.

P

< 0.0001

PGY, postgraduate year.

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Figure 3. Combined pretest and posttest raw score by postgraduate year.

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ORIGINAL ARTICLE GEORGE M. GHOBRIAL ET AL.

SIMULATION TRAINING CURRICULA FOR NEUROSURGICAL RESIDENTS

Figure 4. Combined simulator mean performance by postgraduate year.

Online delivery of course preparatory materials and presimulation and postsimulation testing facilitated the educational benefit of the training, as well as detailed analysis of its impact on resident education. The residents demonstrated an overall improvement in their general knowledge base through their improved mean pretests and posttests, with a mean improvement in 3 points (P < 0.0001) (Figure 2). This is also demonstrated with a statistical improvement in 78% of didactic participants (P ¼ 0.005) in one prior report on the use of the posterior cervical module (6), as well as with prior implementation of the durotomy repair module (18.5% raw score improvement, P ¼ 0.02) (5). One difficulty with positively correlating test scores and module participation is that there is no ideal method to eliminate certain confounders. One source of bias in particular is examination improvement due to question familiarity from the pretest. Future examinations will include revised posttest questions in the attempt to see whether this change will have a significant impact on the significant examination improvement seen earlier. Residents conducted multiple trials pf the durotomy repair simulation module during the course. Across trials, the duration of time needed to close a 1-cm dural defect declined. Furthermore, the mean OSAT scores across the three trials increased from 2.66e3.48, demonstrating improvement in technical performance, shorter closer times, and increased closure integrity (reduced leak rate). There is evidence in other surgical disciplines, such as general surgery, of simulation training enhancing surgical skill more rapidly than conventional training. Aggarwal et al., in a randomized control trial, allocated 20 novice surgeons to either a laparoscopic cholecystectomy surgery virtual reality (VR) training module or conventional surgical training in vivo under the tutelage of a senior surgeon (1). The surgical ability of the VR-trained group on the third case was equivalent to that of the conventionally trained group on their fifth case. Zendejas et al. randomly assigned 50 PGY 1 through 5 general surgery residents to simulation-based learning or conventional training for laparoscopic hernia repair (23). Residents completing the simulator received higher operative performance scores, had fewer complications in vivo, and had patients who were less likely to require an overnight stay.

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The learning curve for a complex procedure, such as a laparoscopic Roux-en-Y gastric bypass, have been shown to range from 50 to 100 procedures (24). However, the typical surgeon requires approximately 400 procedures to reach a plateau, at which the time to complete the surgery with minimal complications occurs. As of yet, neurosurgeons have not defined this learning curve for any skill sets. More data need to be collected so that the most efficient and safe training environment can be achieved. Further study using our model could include retesting at 6-month or 12-month intervals to establish whether the short-term benefits of this simulation curriculum are sustained. A validated scoring system based on recorded video performance could be used to assess the impact of simulation training on both subsequent short- and long-term testing or even on live surgical performance. Such a system would also facilitate additional selfdriven resident practice, with separate or even remote mentor feedback. Neurosurgical skill simulation curricula may also be promulgated more systematically to broader groups of trainees through collaboration with residency program leadership organizations (19, 20). Limitations Carrying out the pretests and posttests remotely allows residents to look up answers during the test, limiting the accuracy of this approach in testing a priori knowledge. In the future, it may be possible to administer these assessments at the course site under direct supervision. Alternatively, posttest variations are being developed to limit bias attributed to participant’s familiarity with pretest questions. Nevertheless, the current results show performance varying by postgraduate training year (Figures 3 and 4), as would be expected on the basis of native performance ability. The pretest and posttest surveys used in the curriculum for this study have not been validated. The limited number of technical simulation modules investigated and the single-residency site for testing limit the generalizability of the conclusions reached. Nevertheless, the results reported here appear to justify a broader application of this approach across surgical skills and training sites in order to further validate this methodology.

FUTURE COURSE IMPLEMENTATION Due to time constraints, this current course experience is limited to 2 modules. The modules used were chosen due to the authors’ past experience with these modules as instructors at neurosurgical meetings. Future courses will need a variety of modules to maximize neurosurgical resident skill development. One planned improvement with the durotomy repair module will involve the use of tubes with corridors at oblique angles to the dural defect to restrict resident vision and movement in the attempt to increase the difficulty level and realism of the dural repair module. In the future cervical laminoforaminotomy module, the authors hope to provide models with varying degrees of pathology such as severe spondylosis or prior lateral mass fusion to increase the educational value for residents with prior course familiarity.

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SIMULATION TRAINING CURRICULA FOR NEUROSURGICAL RESIDENTS

CONCLUSION Duty hour limitations and regulatory pressure for enhanced quality and outcomes may limit access of neurosurgical residents to fundamental skills training. Fundamental skills training as part of

REFERENCES 1. Aggarwal R, Ward J, Balasundaram I, Sains P, Athanasiou T, Darzi A: Proving the effectiveness of virtual reality simulation for training in laparoscopic surgery. Ann Surg 246:771-779, 2007. 2. Bambakidis NC, Selman WR, Sloan AE: Surgical rehearsal platform: potential uses in microsurgery. Neurosurgery 73 (Suppl 1):122-126, 2013. 3. Chitale R, Ghobrial GM, Lobel D, Harrop J: Simulated lumbar minimally invasive surgery educational model with didactic and technical components. Neurosurgery 73 (Suppl 1):107-110, 2013. 4. El Ahmadieh TY, Aoun SG, El Tecle NE, Nanney AD 3rd, Daou MR, Harrop J, Batjer HH, Bendok BR: A didactic and hands-on module enhances resident microsurgical knowledge and technical skill. Neurosurgery 73 (Suppl 1):51-56, 2013. 5. Ghobrial GM, Anderson PA, Chitale R, Campbell PG, Lobel DA, Harrop J: Simulated spinal cerebrospinal fluid leak repair: an educational model with didactic and technical components. Neurosurgery 73 (Suppl 1):111-115, 2013. 6. Harrop J, Rezai AR, Hoh DJ, Ghobrial GM, Sharan A: Neurosurgical training with a novel cervical spine simulator: posterior foraminotomy and laminectomy. Neurosurgery 73 (Suppl 1): 94-99, 2013. 7. Hooten KG, Lister JR, Lombard G, Lizdas DE, Lampotang S, Rajon DA, Bova F, Murad GJ: Mixed Reality Ventriculostomy Simulation: Experience in Neurosurgical Residency. Neurosurgery 10: 576-581, 2014.

a validated simulation curriculum can mitigate this challenge to residency education. National development of effective technical simulation modules for use in individual residency training programs is a promising strategy to achieve these goals.

10. L’Orsa R, Macnab CJ, Tavakoli M: Introduction to haptics for neurosurgeons. Neurosurgery 72 (Suppl 1):139-153, 2013. 11. Luciano CJ, Banerjee PP, Sorenson JM, Foley KT, Ansari SA, Rizzi S, Germanwala AV, Kranzler L, Chittiboina P, Roitberg BZ: Percutaneous spinal fixation simulation with virtual reality and haptics. Neurosurgery 72 (Suppl 1):89-96, 2013. 12. Marcus H, Vakharia V, Kirkman MA, Murphy M, Nandi D: Practice makes perfect? The role of simulation-based deliberate practice and scriptbased mental rehearsal in the acquisition and maintenance of operative neurosurgical skills. Neurosurgery 72 (Suppl 1):124-130, 2013. 13. Mayer V, Schulz CM, Kreuzer M, Wagner KJ, Schneider G, Kochs EF: Cardiopulmonary resuscitation performance during simulator-based trainings: a comparative retrospective analysis of adherence to 2005 and 2010 guidelines. Minerva Anestesiol 79:264-273, 2013. 14. Mitha AP, Almekhlafi MA, Janjua MJ, Albuquerque FC, McDougall CG: Simulation and augmented reality in endovascular neurosurgery: lessons from aviation. Neurosurgery 72 (Suppl 1): 107-114, 2013. 15. Neubauer A, Wolfsberger S: Virtual endoscopy in neurosurgery: a review. Neurosurgery 72 (Suppl 1): 97-106, 2013. 16. Ray WZ, Ganju A, Harrop JS, Hoh DJ: Developing an anterior cervical diskectomy and fusion simulator for neurosurgical resident training. Neurosurgery 73 (Suppl 1):100-106, 2013.

8. Jabbour P, Chalouhi N: Simulation-based neurosurgical training for the presigmoid approach with a physical model. Neurosurgery 73 (Suppl 1): 81-84, 2013.

17. Rosseau G, Bailes J, del Maestro R, Cabral A, Choudhury N, Comas O, Debergue P, De Luca G, Hovdebo J, Jiang D, Laroche D, Neubauer A, Pazos V, Thibault F, Diraddo R: The development of a virtual simulator for training neurosurgeons to perform and perfect endoscopic endonasal transsphenoidal surgery. Neurosurgery 73 (Suppl 1):85-93, 2013.

9. Kirton OC: The Accreditation Council for Graduate Medical Education duty hour regulations: how do we make the best of an unpopular situation in training the surgeons of tomorrow? JAMA Surg 148:433-434, 2013.

18. Saito N, Kin T, Oyama H, Yoshino M, Nakagawa D, Shojima M, Imai H, Nakatomi H: Surgical simulation of cerebrovascular disease with multimodal fusion 3-dimensional computer graphics. Neurosurgery 60 (Suppl 1):24-29, 2013.

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19. Selden NR, Anderson VC, McCartney S, Origitano TC, Burchiel KJ, Barbaro NM: Society of Neurological Surgeons boot camp courses: knowledge retention and relevance of hands-on learning after 6 months of postgraduate year 1 training. J Neurosurg 119:796-802, 2013. 20. Selden NR, Origitano TC, Burchiel KJ, Getch CC, Anderson VC, McCartney S, Abdulrauf SI, Barrow DL, Ehni BL, Grady MS, Hadjipanayis CG, Heilman CB, Popp AJ, Sawaya R, Schuster JM, Wu JK, Barbaro NM: A national fundamentals curriculum for neurosurgery PGY1 residents: the 2010 Society of Neurological Surgeons boot camp courses. Neurosurgery 70:971-981; discussion 81, 2012. 21. Selden NR, Origitano TC, Hadjipanayis C, Byrne R: Model-based simulation for early neurosurgical learners. Neurosurgery 73 (Suppl 1): 15-24, 2013. 22. Stredney D, Rezai AR, Prevedello DM, Elder JB, Kerwin T, Hittle B, Wiet GJ: Translating the simulation of procedural drilling techniques for interactive neurosurgical training. Neurosurgery 73 (Suppl 1):74-80, 2013. 23. Zendejas B, Cook DA, Bingener J, Huebner M, Dunn WF, Sarr MG, Farley DR: Simulation-based mastery learning improves patient outcomes in laparoscopic inguinal hernia repair: a randomized controlled trial. Ann Surg 254:502-509; discussion 9-11, 2011. 24. Zevin B, Aggarwal R, Grantcharov TP: Simulationbased training and learning curves in laparoscopic Roux-en-Y gastric bypass. Br J Surg 99:887-895, 2012.

Conflict of interest statement: Partial financial support was received from the Congress of Neurological Surgeons. Received 26 February 2015; accepted 27 April 2015 Citation: World Neurosurg. (2015) 84, 3:751-755. http://dx.doi.org/10.1016/j.wneu.2015.04.056 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.

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APPENDIX CSF Leak/Durotomy Repair Quiz

A) Neurofilament protein (NFL) B) Albumin

1) The results of the multi-facility SPORT trials revealed surgical intervention for which of the following pathologies was associated with the highest rate of intraoperative durotomy (in p41, Desai et al. Neurosurgery 69:38-44, 2011)? A) Disc Herniation

C) b-2-transferrin D) Cell Count 7) What has been reported as the ideal distance between sutures when attempting a primary, watertight dural closure (In Ghobrial et al. S 115, Neurosurgery 73:S111-S115, 2013)?

B) Spinal Stenosis

A) 1-2mm

C) Spondylolysis

B) 2-3mm

D) Spondylolisthesis

C) 3-4mm

2) What is considered the gold-standard for repair of incidental durotomies (p44, Desai et al. Neurosurgery 69:38-44, 2011)? A) Watertight fascial closure B) Watertight primary repair C) Application of fibrin glue with watertight facial closure

D) 4-5mm E) 5-6mm 8) The second most common cited cause of malpractice lawsuits in spine surgery is incidental durotomy (In Ghobrial et al.S 112, Neurosurgery 73:S111-S115, 2013)? A) True

D) Synthetic patch with watertight fascial closure

B) False 3) Intraoperative dural injuries are approximately twice as common in revision degenerative lumbar spine surgery as compared with initial cases (In Williams et al, p 117 Neurosurgery 68:117-124, 2011). A) True

9) Which of the following are options for the conservative postoperative management of unrepaired durotomy of the lumbar cistern (In p922, Hutchinson et al. Neurosurgery 69:921-929, 2011)? A) Flat Bedrest for 1 e 3 days

B) False

B) Abdominal binders 4) In the multicenter, randomized Spine Patients Outcome Research Trials (SPORT) evaluating elective surgical decompression for lumbar stenosis, what was the incidence of durotomy (p41, Desai et al. Neurosurgery 69:38-44, 2011)?

C) Lumbar drain D) Percutaneous Fibrin Sealant E) All of the above

A) 4% 10) A cerebrospinal fluid leak should be suspected postoperatively after spine surgery in the setting of (In Ghobrial et al. S 112, Neurosurgery 73:S111-S115, 2013)?

B) 8% C) 11% D) 13%

A) Wound drainage

5.) What is the commonly reported occurrence rate of incidental durotomy in elective cervical spine surgery (In Williams et al, p 118 Neurosurgery 68:117-124, 2011)? A) 1%

C) Fluctuant subcutaneous fluid collection D) Subfascial collection E) All of the Above

B) 3%

11) In the setting of spinal cord injury, the presence of a neurological deficit makes a traumatic dural tear more likely (In Ghobrial et al.S 112, Neurosurgery 73:S111-S115, 2013).

C) 5% D) 7% E) 9%

A) True

6) A 71 year old male undergoes a decompression for spinal stenosis. On POD#2 persistent serosanguinous fluid is noted to drain from his incision. Which lab test is the most sensitive and specific for differentiating the presence of CSF (In Ghobrial et al. S 115, Neurosurgery 73:S111-S115, 2013)?

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B) Postural headache

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B) False 12) All of the following are possible complications that occur after a dural tear EXCEPT durotomies (p43, Desai et al. Neurosurgery 69:38-44, 2011)?:

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A) Spinal headache

A) Dorsal epidural blood patch

B) Subdural hemorrhage

B) Laminectomy and primary CSF closure

C) Hypokalemia

C) Laminectomy, dural repair, and fibrin sealant

D) Meningeal pseudocyst formation

D) Flat bed rest

E) Dural-cutaneous cerebrospinal fluid fistula 13) In a post hoc analysis of the SPORT study by Desai et al. (Neurosurgery 69:38-44, 2011), the presence of an unintended durotomy in the lumbar spine was found to increase the hospital LOS by approximately what percentage durotomies (p43, Desai et al. Neurosurgery 69:38-44, 2011)?

18) The administration of fibrin sealants in addition to primary closure has been shown to lower the rate of CSF leakage after repair (Sugawara et al, pONS-290, Neurosurgery 57[ONS Suppl 3] ONS-290-ONS-294, 2005). A) TRUE B) FALSE

A) 25-35% B) 10-15% C) 15-25% D) 35-45% 14) In a post hoc analysis of the SPORT study by Desai et al. (Neurosurgery 69:38-44, 2011), there was no significant difference between the durotomy and no-durotomy groups in the incidence of recurrent stenosis, development of listhesis, 1-4 year postsurgical reoperation rate, or Oswestry Disability Index at 1-4 years durotomies (p43, Desai et al. Neurosurgery 69:38-44, 2011)? A) TRUE B) FALSE 15) In an analysis of unintended durotomy for scoliotic procedures, which of the following etiologies was found to have an incidence of approximately double (2% vs. 1% in all indications for scoliosis) (In Williams et al, p 118, Table 1, Neurosurgery 68:117-124, 2011)? A) Congenital B) Neuromuscular C) Adolescent Idiopathic

19) In a registry of 108,478 surgical procedures held by the Scoliosis Research Society, the incidence of unintended durotomy as a percentage is most common in which types of degenerative pathology (order greatest>least) (In Williams et al, p 118, Table 1, Neurosurgery 68:117-124, 2011): A) Degenerative Disk Disease>Spondylotic Radiculopathy>Spinal Stenosis> Lumbar postlaminectomy Syndrome B) Lumbar Postlaminectomy Syndrome> Spondylotic Radiculopathy> Spinal Stenosis> Degenerative Disk Disease C) Spondylotic Radiculopathy> Degenerative Disk Disease> Spinal Stenosis> Lumbar Postlaminectomy Syndrome D) Spinal Stenosis> Spondylotic Radiculopathy> Lumbar Postlaminectomy Syndrome> Degenerative Disk Disease 20) In a registry of 108,478 surgical procedures held by the Scoliosis Research Society, the incidence of unintended durotomy as a percentage was most commonly encountered in which spinal region (In Williams et al, p 119, Table 3, Neurosurgery 68:117-124, 2011)? A. Thoracic B. Lumbar C. Cervical

D) Degenerative 16) In a Prospective multi-institutional spine registry, unintended durotomy was found to be associated with worsening functional outcomes (VAS back, VA leg, ODI) (In Adogwa et al. Neurosurgery 2013). A) TRUE B) FALSE 17) Spontaneous CSF leaks are the most common cause of Spontaneous intracranial hypotension, most commonly occurring at the spinal level. Which of the following statements best describes the preferred initial management of spontaneous CSF leak attributed to a spinal dural defect (In S239, In Cohen-Gadol et al. Neurosurgery 58[ONS Suppl 2] ONS-238-ONS245, 2006)?

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Answer Key 1 D (Desai et al. SPORT: Does Incidental Durotomy Affect Longterm outcomes in Cases of Spinal Stenosis? Neurosurgery 69:38-44, 2011) 2 B (Desai et al. SPORT: Does Incidental Durootmy Affect Longterm outcomes in Cases of Spinal Stenosis? Neurosurgery 69:38-44, 2011) 3 A (Williams et al. Incidence of Unintended Durotomy in Spine Surgery Based on 108,478 Cases. Neurosurgery 68:117-124, 2011) 4 A (Desai et al. SPORT: Does Incidental Durootmy Affect Long-term outcomes in Cases of Spinal Stenosis? Neurosurgery 69:38-44, 2011)

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SIMULATION TRAINING CURRICULA FOR NEUROSURGICAL RESIDENTS

5 A (Williams et al. Incidence of Unintended Durotomy in Spine Surgery Based on 108,478 Cases. Neurosurgery 68:117-124, 2011)

Laminectomy Repair Quiz 1) The arrow below is pointing to the?

6 C (Ghobrial et al. Simulated Spinal Cerebrospinal Fluid Leak Repair: An Educational Model With Didactic and Technical Components. Neurosurgery 73:S111-S115, 2013) 7 A (Ghobrial et al. Simulated Spinal Cerebrospinal Fluid Leak Repair: An Educational Model With Didactic and Technical Components. Neurosurgery 73:S111-S115, 2013) 8 A (Ghobrial et al. Simulated Spinal Cerebrospinal Fluid Leak Repair: An Educational Model With Didactic and Technical Components. Neurosurgery 73:S111-S115, 2013) 9 E (Hutchinson et al. Evaluation of Fibrin Sealants for Central Nervous System Sealing in the Mongrel Dog Durotomy Model. Neurosurgery 69:921-929, 2011) 10 E (Ghobrial et al. Simulated Spinal Cerebrospinal Fluid Leak Repair: An Educational Model With Didactic and Technical Components. Neurosurgery 73:S111-S115, 2013) 11 A (Ghobrial et al. Simulated Spinal Cerebrospinal Fluid Leak Repair: An Educational Model With Didactic and Technical Components. Neurosurgery 73:S111-S115, 2013) 12 C (Desai et al. SPORT: Does Incidental Durootmy Affect Longterm outcomes in Cases of Spinal Stenosis? Neurosurgery 69:38-44, 2011) 13 D (Desai et al. SPORT: Does Incidental Durootmy Affect Longterm outcomes in Cases of Spinal Stenosis? Neurosurgery 69:38-44, 2011)

A) C2-3 foramen

14 A (Desai et al. SPORT: Does Incidental Durootmy Affect Longterm outcomes in Cases of Spinal Stenosis? Neurosurgery 69:38-44, 2011) 15

C) C4 spinous process

15 D (Williams et al. Incidence of Unintended Durotomy in Spine Surgery Based on 108,478 Cases. Neurosurgery 68:117-124, 2011)

B) C3-4 foramen

D) C2 spinous process E) C3 spinous process 2) The T1 nerve root exits the spinal canal through the

16 B, FALSE (online only - Adogwa et al. Pain and Functional Outcomes After Incidental Durotomy in Lumbar Spine Surgery: A Propensity Matched Prospective, Multi-Institutional Longitudinal Study of 1741 Patients Oral Presentations 161, Neurosurgery 2013)

A) C6-7 foramen

17 D (Cohen-Gadol. Surgical Anatomy of Dural Defects in Spontaneous Spinal Cerebrospinal Fluid Laks. Neurosurgery 58 [ONS Suppl 2]ONS-238-ONS245, 2006)

D) Around the C7 pedicle

18 B (Sugawara et al. Novel Dural Closure Technique Using Polyglactin Acid Sheet Prevents Cerebrospinal Fluid Leakage after Spinal Surgery. Neurosurgery 57[ONS Suppl 3]ONS-290-ONS294, 2005) 19 A (Williams et al. Incidence of Unintended Durotomy in Spine Surgery Based on 108,478 Cases. Neurosurgery 68:117-124, 2011) 20 A (Williams et al. Incidence of Unintended Durotomy in Spine Surgery Based on 108,478 Cases. Neurosurgery 68:117-124, 2011)

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B) C7-T1foramen C) T1-2 foramen

E) None of the above 3) The C2 nerve root exits the spinal canal through (in Dewan et al. p475, Neurosurgery 74:475-481, 2014)? A) C2-3 foramen B) C1-2 foramen C) Above the C2 pedicle D) Below the C2 pedicle E) None of the above

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ORIGINAL ARTICLE GEORGE M. GHOBRIAL ET AL.

SIMULATION TRAINING CURRICULA FOR NEUROSURGICAL RESIDENTS

4) The arrow below is pointing to the? (in Ugur et al.p1163, Neurosurgery 48:1162, 2000)

7) The arrow below is pointing to the?

A) Spinous process B) Foramen transversarium C) Lateral mass D) Pedicle E) Laminae

A) Spinous process B) Foramen transversarium

5) How many paired cervical nerve roots are there? A) 7 B) 8 C) 14

C) Lateral mass D) Pedicle E) Laminae 8) The ligament that connects along this osseous ridge is the?

D) 6 E) 16

6) Using the Roy-Camille technique the longest “safe” lateral mass screw length for C3-6 is (in Horgan et al [PDF online only], p 1268, Neurosurgery 44(6)1267-1271, 1999): A) 10mm B) 12mm C) 14mm D) 16mm E) 20mm

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SIMULATION TRAINING CURRICULA FOR NEUROSURGICAL RESIDENTS

A) Ligamentum flavum

12) The arrow below is pointing to the (Menendez et al, in S1-106, Neurosurgery 60[Suppl 1]:!-103-111,2007)?

B) Anterior longitudinal ligament (ALL) C) Posterior longitudinal ligament (PLL) D) Only disc annulus present E) All the above 9) The arrow below is pointing to the (in A187 Fig 4 Finn et al. Neurosurgery 66:A184-192, 2010)?

A) Spinous process B) Foramen transversarium

A) C2-3 foramen

C) Lateral mass

B) C1-2 foramen

D) Pedicle

C) C2 pedicle

E) Laminae

D) C2 spinous process E) C3 spinous process

10) The cervical spine typically maintains a _________ position such to have no pressure on the Spinal cord (in Tang et al. Fig. 1 p664, Neurosurgery 71:662-669. 2012) A) Lordotic

13) What travels through this hole (in Finn et al, p187, Neurosurgery 66:A184-A192, 2010)?

B) Neutral C) Kyphotic D) None of the above E) All of the above 11) The C8 nerve root exits the spinal canal through the (in S1-96, Steinmetz et al. Neurosurgery 60[Suppl 1]:S-90-S-97, 2007): A) C6-7 foramen B) C7-T1foramen C) T1-2 foramen D) None of the above E) There is no C8 nerve

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SIMULATION TRAINING CURRICULA FOR NEUROSURGICAL RESIDENTS

A) C3 nerve B) C4 nerve C) C5 nerve D) Vertebral artery E) Sympathetic ganglion

16) What is the ideal laminectomy width (in Ishida et al, p219, Neurosurgery 24(2):215-222, 1989)? A) 12mm B) 15mm C) 18mm D) None of the above

14) During the operation, after removing the lamina you realize that the level count was off and instead of performing a C3-6 laminectomy you performed a C4-7 laminectomy. You should: A) Keep on going since it will not make a clinical difference B) Remove the C3 lamina and discuss with the patient and family C) Stop the case and awake the patient D) Remove the C3 lamina and never say anything 15) The arrow below is pointing to the (in 835 Cristante et al. Neurosurgery 70:835-839, 2012)?

E) All of the above

17) Which nerve root palsy is most common after PCDF (p595. Para 1, in Bydon et al. Neurosurgery 74:595-605, 2014)? A) C4 B) C6 C) C5 D) C8 E) C7

18) Using the Magerl technique of lateral mass screw placement, which of the following is the starting point of cervical lateral mass screws is (in Horgan et al, p 1268, Neurosurgery 44(6) 1267-1271, 1999):? A) Medial and rostral to the center of the lateral mass B) Medial and caudal to the center of the lateral mass C) Lateral and rostral to the center of the lateral mass D) Lateral and caudal to the center of the lateral mass

19) Using the Magerl technique of lateral mass screw placement, which of the following is the trajectory of cervical lateral mass screws placement is (in Horgan et al, p 1268, Neurosurgery 44(6)1267-1271, 1999):? A) Directed 10 degrees inclination

laterally,

with

no rostral-caudal

B) Directed 25 degrees laterally, with a rostral inclination that is parallel to the facet joint C) Directed straight forward, with a rostral inclination of 30 degrees A) C3 lateral mass

D) Directed 10 degrees medially, with caudal inclination of 25 degrees

B) C4 lateral mass C) C5 lateral mass D) C6 lateral mass E) C6-7 facet joint

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20) In the case of a myelopathic patient what is the ideal mean arterial pressure to maintain. (Lu et al. S1-p150, vol 60, no. 1, Jan 2007)

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ORIGINAL ARTICLE GEORGE M. GHOBRIAL ET AL.

SIMULATION TRAINING CURRICULA FOR NEUROSURGICAL RESIDENTS

A) >50

7) E

B) >60

8) C

C) >70

9) B

D) >80

10) A

E) >90

11) B 12) D 13) D

Answer Key

14) B

1) E

15) C

2) C

16) B

3) B

17) C

4) D

18) B

5) B

19) B

6) C

20) C

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Simulation Training Curricula for Neurosurgical Residents: Cervical Foraminotomy and Durotomy Repair Modules.

Since 2010, the Congress of Neurological Surgeons (CNS) has offered a neurosurgical skills simulation course for residents and medical students. The a...
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