title: A novel simulation model for minimally invasive spine surgery.
abstract: OBJECTIVE
  Minimally invasive spine surgery (MISS) is among the fastest growing technologies in general neurosurgical practice. In addition, great demand exists to teach these skills to neurosurgery residents. With newly enforced work hour restrictions, opportunities to acquire these skills are limited, necessitating development of alternative strategies of education. We describe a novel simulation model for MISS supplemented by resident self-assessment analysis and evaluation.
  
  
  METHODS
  The simulator was constructed using a nontransparent Plexiglas frame supplemented with a modified halo frame on which to affix spine specimens. Interchangeable copper tubing was affixed to a 360-degree pivot system to replicate a working portal. Deer skulls and spines were then collected and prepared accordingly. Laboratory exercises were based on the resident's level of training with emphasis on proper drilling techniques. Eight neurosurgery residents were asked to complete the exercises and complete a self-assessment survey regarding their competence level on a scale of 0 to 5, both before and after completing the skill sets. Additionally, they were asked to complete an exit survey that was used to assess the simulation exercises.
  
  
  RESULTS
  All exercises were completed successfully with the exception of placing 2 separate pedicle screws through the same portal, which posed difficulty on some specimens because of the of lack of lordosis of the specimens, leading to unfavorable trajectories using a free-hand technique. With regard to the resident self-assessment analysis, the mean confidence rating for performing an MISS laminectomy improved by a difference of 1.25 points (n = 8; 95% confidence interval, 0.66-1.84; P = 0.0015), from 2.50 to 3.75 before and after simulation exercises, respectively, and reached statistical significance. For the senior-level residents, the mean confidence rating for performing MISS placement of pedicle screws using a free-hand technique improved by a difference of 1.00 (n = 3; 95% confidence interval, -1.48-3.48; P = 0.225), from 3.33 to 4.33 before and after simulation exercises, respectively. Results of the exit survey were encouraging.
  
  
  CONCLUSIONS
  The MISS simulator is a feasible, inexpensive, and reproducible adjunct to neurosurgery resident training and provides a new teaching method for spine surgery. Further investigation of this technology is warranted, although multicenter, randomized, controlled trials assessing its validity may not be practical because of ethical constraints with regard to patient safety.
authors.affiliation: Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi 39216-4505, USA. jbwalker@neurosurgery.umsmed.edu
authors.forename: James B
authors.initials: JB
authors.lastname: Walker
authors.forename: Eddie
authors.initials: E
authors.lastname: Perkins
authors.forename: H Louis
authors.initials: HL
authors.lastname: Harkey
mesh_terms: D000818:Animals; D003670:Deer / Q000033:anatomy & histology / Q000601:surgery; D004389:Durable Medical Equipment; D004867:Equipment Design; D006801:Humans; D007396:Internship and Residency / Q000379:methods; D007796:Laminectomy / Q000295:instrumentation / Q000379:methods; D008866:Microsurgery / Q000193:education / Q000295:instrumentation / Q000379:methods; D019060:Minimally Invasive Surgical Procedures / Q000193:education* / Q000295:instrumentation* / Q000379:methods; D008953:Models, Anatomic; D019635:Neurosurgical Procedures / Q000193:education* / Q000295:instrumentation* / Q000379:methods; D013045:Species Specificity; D013123:Spinal Fusion / Q000295:instrumentation / Q000379:methods; D013131:Spine / Q000033:anatomy & histology / Q000601:surgery*; D013663:Teaching / Q000379:methods