In the spotlight also at GSC 2022: High-fidelity training simulators improve skills and confidence in minimally invasive lumbar decompression
Simulation-inspired spine surgery
Härtl says that the study builds on—and adds to—the AO’s legacy of pioneering new educational methods in order to advance patient care.
“What we’ve been trying to do with this project and with others is to really increase access to valuable and effective training using surgical simulation, online training, blended learning, and so forth. The AO has certainly spearheaded that,” says Härtl, senior author of the paper and leader of the AO Spine Minimally Invasive Spine Surgery (MISS) Task Force. “We’ve used MISS really as a mechanism to explore these new ways of teaching.”
Not only is the study unique in that it is the first such study of using a state-of-the-art simulator that could realistically simulate the soft tissue, bone, bleeding, and dura routinely encountered during standard lumbar spine surgery, Härtl says it is unique terms of the preparation that went into it.
“We took an MIS operation, really analyzed it in detail using experts, and tried to define the individual steps that really make up the procedure—that are necessary for trainees to master in order to get good at performing this procedure,” he says. “Once we had defined those steps, we used surgical simulation to replicate them and have surgeons replicate them multiple times in sequence.”
The procedures were recorded to gauge whether the surgeons’ performance improved.
“That was unique because this type of surgical-simulation-inspired surgery has never been done before,” says Härtl. He noted that such state-of-the-art training is a far cry from his own training which relied on cadavers, which are expensive and in limited supply—and cadaver training often requires traveling great distances; all of these factors are obstacles, particularly in low- and middle-income countries.
Spine surgery has a steep learning curve
“Spine surgery has a very steep learning curve and—of course—in this study, we saw errors where people decompressed in areas where they shouldn’t have, but what we saw mainly was that people were so focused that they actually forgot about the little things like adjusting the table height or the microscope,” she explains.
Another takeaway from the study was that surgical time decreased during each of the three procedures performed on the simulator and sentinel errors—such as injury to the facet joint during drilling and dural tear—decreased over the course of subsequent procedures. Participants’ skills improved in each of the domains observed, with the greatest increase among the inexperienced and very inexperienced participants. Furthermore, overall surgical proficiency improved over the course of three trials with the simulator.
Simulation accelerates learning
The study found that simulation for performing MISS can accelerate learning and provide a safe environment for exploration and practice prior to intervention on live patients, and that using high-fidelity simulator models may have the most impact early in training. All participants, regardless of their training background, showed improvement in every measure and test, from the first procedure onward with fewer errors and skipped steps and less operating room time.
Melcher says simulation has the potential to transform education and prompt more hospitals to adopt MISS.
“It could be a great chance to bring more people to MISS and convince hospital management of its value, because surgeons will be able to say, ‘Listen, I’ve done this on a simulator and I know exactly what I’m doing,’” Melcher says, adding that in her opinion, the simulator offers a superior training experience compared to cadavers.
Härtl adds that surgical simulators are not being used by academic institutions, they are being used by other entities—including the AO—to train surgeons.
“The AO certainly has extensive experiencing using it for some AO activities, but there is still some limitation [to wider use] due to the cost of the technology,” he says, explaining that—for example—AO North America sent surgical simulation models to six institutions where local surgeons performed ULBD and MISS transforaminal lumbar interbody fusion (TLIF), with faculty participating remotely.
What does the future hold?
Härtl sees production costs as the real challenge to affordability of the technology and hopes prices will come down as the technology matures. Another challenge is communicating the technology’s benefits—as demonstrated by the study—to AO surgeons and course chairpersons spearheading AO education worldwide.
“I think the traditional concept of surgical meetings and congresses, where surgeons come together in one location, will continue to be very important. But I think these activities can be supplemented—and surgical simulation could be a very powerful supplement,” he says. “I think the future is going to hold a combination of traditional learning and innovation with surgical simulation, decentralizing, and blended learning.”
A follow-up study, funded in part by the AO, is in the works with Weill Cornell Brain and Spine Center surgeon and researcher Ibrahim Hussain, to explore how high-fidelity simulator training translates into the operating room.