Keywords

Introduction

The objective of this chapter is to encapsulate the past, current, and future contribution to neurosurgical training in simulation from a European prospective. This chapter does not touch advances related to outside the European continent .

Comprehensive Healthcare Simulation from European Prospective

The Value of Simulation in Medical Practice

As a medical professional committed to “first do no harm,” some experts argue that it is an ethical imperative to develop and use simulators as a means to protect patients from being the “commodities to be used as conveniences of training” [1]. Neurosurgery ranks as the most liable specialty in all of medicine to malpractice, with 19.1% of neurosurgeons facing a claim a year [2]. A prospective study of 1108 elective neurosurgery cases showed that 78.5% of errors were preventable and that the most frequent errors were technical in nature [3]. Yet, in a field such as neurosurgery that requires such high level of technical expertise, with large consequences for error, there are even fewer opportunities for younger trainees to practice on the most complicated cases, which may only be possible after finishing a neurosurgical residency at the independent attending level [4].

Historically, trainees have developed operative neurosurgical skills through the surgical apprenticeship model, following the old adage “see one, do one, and teach one” [5]. However, in recent years many factors have challenged this traditional apprenticeship model:

  • Limitations on the working week hours of doctors were first started in the United States after the death of an 18-year-old female inpatient in 1984, determined by a grand jury to be partly a result of long hours worked by unsupervised interns and residents [6]. Similar changes occurred after the introduction of the European Working Time Directive, which limits the working week of junior doctors to 48 h [6].

  • The development of assistant surgical nurse practitioners has reduced learning opportunities in the operating room [7].

  • The introduction of modernizing medical careers and subspecialization has further reduced the surgical caseload of neurosurgical trainees [5].

  • There is a classical ethical dilemma inherent in training. The patients are best served when operated by a specialist rather than a trainee even if the trainee is supervised by the specialist [8].

  • Improving patient safety is obviously a very important ultimate goal; however even with the most established advances, there are no enough studies that simulation would affect the patient outcome [9,10,11].

Some authors have described the European Working Time Directive as a bureaucratic constraint hindering high-quality postgraduate training [12]. It may seem impossible to educate neurosurgeons to an even better standard than previously, with reduced training time and at the same time exponentially increasing complexity created by our scientific endeavors [8].

In the book Outliers, Malcolm Gladwell evaluated experts across multiple disciplines and concluded that the common theme among them is the accumulation of 10,000 h of repeated practice at a specific task [13]. Residency training in Europe with the current working hour restriction of 48 h per week over 6-year residency program will result in approximately 13,824 h of training, excluding 1 month vacation every year. However, most of this time is spent devoted to evaluating and treating patients and doing administrative work outside of the operating room.

Simulation has been postulated as a potential solution to the challenge of providing appropriate training in less time and represents a useful proxy measure for expert surgical performance [14].

Simulation in Neurosurgery

The tides of postgraduate medical education in Europe are changing [8, 15]. The increasing complexity of neurosurgery has surpassed the ability for a single neurosurgeon to master all theoretical and practical aspects of this specialty and pushed trainees toward subspecialization [8]. At the same time, there is a reduction in the resident/trainee working time to 48 h/week (including on calls) in the European Union [16], which contributes to a sense of need of additional training [12]. An additional challenge is that European residents in some countries have a less “hands-on” experience during residency than their counterparts in other European states [17]. In an international survey of neurosurgery program directors (PDs) , only 15% European PDs felt confident that their senior residents could manage aneurysm by craniotomy and clipping, in contrast to 75% of their North American counterparts [17]. Adding to the fact that some studies estimated that classical surgical training in the operating room can cost an upward of $50,000 per graduating resident [18], simulation training presents an attractive alternative including Europe. A recent article mentioned that Russia currently has 50 simulation centers in medicine, with plans to increase that number to 80 centers by 2017 [19]. Since simulation training sessions can be standardized and reproduced, it may be effectively included in testing, licensing, and credentialing processes [20].

Surgeons Are Made and Not Born

To answer the continuous debate about whether some surgeons are born great and experts or is it the hard work and commitment to continuous practice, Sadideen et al. questioned Galton’s innate talent theory. He mentioned that two studies conducted on novice medical students and surgical residents, respectively, have shown competency after repeated practice on a simulator [21, 22]. He also mentioned that testing the innate ability of an individual should be done to identify those who need extra training [23]. He concluded that although innate abilities play an important role in the development of surgical expertise, the literature suggests that the surgical experts are in fact “made,” not born which is the same conclusion given by Jasper Halpenny 100 years ago [24].

As to surgery, surgeons are made, not born. The making process we call education. Education should commence when the child begins to use its hands. It should be taught to use both hands equally well, as nearly as possible. As it grows, it should have its reasoning power developed, its ability to observe and record its observations, and its mechanical ability should be encouraged.

Practice Made Perfect

No one could argue the fact that in order to develop neurosurgical expertise, one should continuously practice the same procedure repeatedly. This was called by Ericsson and colleagues [25] as “deliberate practice .” The main characteristics of deliberate practice are motivation, detailed and immediate feedback, and the ability to perform the task repeatedly. Simulation provides the perfect learning tool for neurosurgical residents as it allows repeatedly performing the same task and also may provide immediate feedback using video recording and other tools such as the Imperial College Surgical Assessment Device which provide quantitative evaluation of the dexterity while performing core surgical skills [5, 26].

The Use of Simulation in Neurosurgical Residency Education

Medical educators have a very difficult task as medical knowledge is tremendously increasing in an exponential fast pattern and with the concern of patients being practiced upon by students [27]. A study which was conducted on 33 medical students in 2004 demonstrated that medical students value simulation-based learning highly and that they in particular value the opportunity to apply their theoretical knowledge in a safe and realistic setting [28]. Simulation has shown early success in helping junior residents learn the fundamentals of each operation, plan the approach, and rehearse the procedure [29]. However, for more senior residents, the advances in physical and virtual reality simulations were proved so far to be useful in training of intracranial endoscopy [30], tumor resection [31], and spine surgeries [32].

Europe’s Contribution to Advancement in Neurosurgical Simulation

Preop Planning

As early as 1998, a German group (Hassfeld S et al.) published a paper about the value of stereolithographic models for preoperative diagnosis of craniofacial deformities and planning of surgical corrections and concluded that using computer-assisted simulation and navigation systems improves quality and reduces risk of more extensive and radical interventions [33].

In another study which compared the simulated 3D virtual endoscopy images to the intraoperative endoscopic anatomy in terms of distortion and angle of view, suggested that both were comparable. According to this study, virtual endoscopy was found to be particularly useful for the preoperative depiction of (1) the nasal anatomy and its variations for choosing the side of the approach, (2) the sphenoid sinus septa and chambers for improved intraoperative orientation, and (3) the transparent 3D simulated visualization of the pituitary gland, tumor, and adjacent anatomic structures in relation to the sphenoid sinus landmarks for planning the opening of the sellar floor. Finally, they concluded that virtual endoscopy has the potential to become a valuable tool in endoscopic pituitary surgery for training purposes and preoperative planning, and it may add to the safety of interventions in case of anatomic variations [34].

It is well known that all surgical approaches are tailored specifically for each patient depending on the anatomy and pathology in the neurosurgical practice. Having that in mind, precise preoperative planning for these procedures is necessary to achieve optimal therapeutic effect. Therefore, multiple radiological imaging modalities are used prior to surgery to delineate the patient’s anatomy, neurological function, and metabolic processes. Beyer et al. from Vienna introduced an application that consists of three main modules which allow to (1) plan the optimal skin incision and opening of the skull tailored to the underlying pathology; (2) visualize superficial brain anatomy, function, and metabolism; and (3) plan the patient-specific approach for surgery of deep-seated lesions [35].

Stereolithographic Modeling

To the best of our knowledge one of the earliest papers about the stereolithographic modeling was published by a French group, Bouyssie JF et al., and it tested the accuracy of models derived from X-ray-computed tomography, which was found to be reliable enough to be used for surgical planning, for custom-made implants, and for surgical anatomy teaching [36].

Another study was conducted by a German group to assess the importance of stereolithographic models (SLMs) for preoperative diagnosis and planning in craniofacial surgery and to examine whether these models offer valuable additional information as compared to normal CT scans and 3D CT images [37].

Currently, 3D printing has been used primarily in neurosurgery for operative planning, teaching, practice, and prosthetics. Advances in 3D printing have enabled scientists, engineers, and physicians to create models for surgical planning and residency training based on patient-specific imaging studies [38]. High-fidelity 3D-printed models have the potential to assist clinical decision and allow surgeons to rehearse neurosurgical cases in a manner not previously possible [39].

Reality Training Applications

Virtual reality refers to the recreation of environments or objects as a complex, computer-generated image; haptic systems refer to those replicating the kinaesthetic and tactile perception (Fig. 22.1). Virtual reality and haptic systems are usually combined, and they are currently available to support vascular access training, endoscopy training, and laparoscopic surgical techniques [41].

Fig. 22.1
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The Sensorama was released in the 1950s (one of the earliest examples of immersive, multisensory multimodal technology) [40]

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Voxel-Man Group (Hamburg, Germany) developed virtual reality CT images, and the simulators were felt to improve the realism of surgical procedures in the middle ear and provided automatic skills assessment for each participant by the end of the procedure [42]. Kockro RA et al. from Germany have developed a highly interactive virtual environment that enabled collaborative examination of stereoscopic three-dimensional (3D) medical imaging data for planning, discussing, or teaching neurosurgical approaches and strategies. They found out that the system provides a highly effective way to work with 3D data in a group, and it significantly enhances teaching of neurosurgical anatomy and operative strategies [43].

The Human Brain Project

Decoding the human brain is perhaps the most fascinating scientific challenge in the twenty-first century. The Human Brain Project (HBP) is developing toward a European research infrastructure advancing brain research, medicine, and brain-inspired information technology [44].

Up to our knowledge, the earliest article written about the Human Brain Project was published in 1993, and it mentioned that an initiative of several NIH institutes and other US government agencies is being developed to provide a computer database that will allow neuroscientists’ access to information at all levels of integration, from genes to behavior [45]. However, the core idea of the Human Brain Project was first developed by Henry Markram and was based on the research developed for the Blue Brain Project [46]. On May 2005 Blue Brain Project was founded by the Brain Mind Institute of the École Polytechnique Fédérale de Lausanne (EPFL) in Switzerland with an interesting mission of using biologically detailed digital reconstruction and simulation of the mammalian brain to identify the fundamental principles of brain structure and function in health and disease [47]. Markram , in 2006, published a paper, and he proposed that “the time is right to begin assimilating the wealth of data that has been accumulated over the past century and start building biologically accurate models of the brain from first principles to aid our understanding of brain function and dysfunction” [48].

Henry Markram is a professor of neuroscience at the Swiss Federal Institute for Technology (EPFL). He is the founder of the Brain Mind Institute, founder and director of the Blue Brain Project, and the founder of the Human Brain Project [49]. Starting in 2010, Markram created and coordinated the partnership of around 80 European and international partners that developed the original HBP proposal. HBP is one of the two 10-year one billion Euro Flagship Projects selected in January 2013 by the European Commission. The project began operations in October of the same year [50].

The HBP has the following main objectives:

  • Create and operate a European scientific research infrastructure for brain research, cognitive neuroscience, and other brain-inspired sciences.

  • Gather, organize, and disseminate data describing the brain and its diseases.

  • Simulate the brain.

  • Build multi-scale scaffold theory and models for the brain.

  • Develop brain-inspired computing, data analytics, and robotics.

  • Ensure that the HBP’s work is undertaken responsibly and that it benefits society.

This project is exceptional in three respects: it is among the longest ever approved in the field of neuroscience (having a duration of 10 years), the most heavily financed (the HBP will receive about 1.1 billion euros), and the most transdisciplinary in nature [51].

The HBP has 12 subprojects (SP), and they are all interconnected (Table 22.1).

Table 22.1 The Human Brain Project subprojects [48, 52, 53]
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Our main concern in this chapter is related to subprojects 6 and 10 which will be discussed with further details below.

Brain Simulation Platform SP6

There are three main objectives for SP6 as stated by the Human Brain Project Framework Partnership Agreement (HBP FPA) :

  • Establish a generic strategy to reconstruct and simulate the multilevel organization of the brain for different brain areas and species.

  • Use this strategy to build high-fidelity reconstructions, first of the mouse brain and ultimately of the human brain.

  • Support community-driven reconstructions and simulations and to support comparisons between models based on different tools and approaches.

The platform will provide tools and services for the collaborative reconstruction and simulation of the brain, models of different brain areas and the whole brain (including models developed outside the HBP), and tools for in silico experimentation, supporting comparisons between different models and approaches. A key goal is to collaborate with SP1–SP4, SP9, and SP10 to develop simplified versions of high-fidelity brain models, for cognitive, behavioral, and clinical studies, and to participate in research using these models [52].

Collaborations with Other National, European, and International Initiatives

In the article “Creating a European Research Infrastructure to Decode the Human Brain” by Amuntus K et al., the author concluded that there are a growing number of well-publicized brain research initiatives around the world which are mobilizing unprecedented levels of funding for neuroscience and that there is a strong interest to maximize cooperation and coordination between the various initiatives and that the Human Brain Project (HBP) is keen to help lay the foundations for such interaction [44]. However, a particularly important collaboration is with the Allen Institute for Brain Science, Seattle, Washington, USA, on models of the visual and motor systems of the mouse ultimately leading to models of visuomotor behavior in mouse. Another collaboration with CENTER-TBI will provide data on specific traumatic brain injury lesions and multilevel data including electrophysiology, imaging, and cognitive measures that could be used to build models of brain injury [52].

Neurorobotics SP10

Neurorobotics can be defined as the science and technology of robots which are controlled by a simulated nervous system that reflects, at some level, the architecture and dynamics of the brain [54]. Probably the first researcher to develop a robot that fulfilled these criteria was Thomas Ross , who in 1933 devised a mobile robot with a small electromechanical brain, which could navigate through a maze in real time [55]. Researchers have also developed a large number of robots, three of the most advanced are iCub (Fig. 22.2) (a humanoid robot “child”) [57], Kojiro (a humanoid robot with about 100 “muscles”) [58], and ECCE (a humanoid upper torso that attempts to replicate the inner structure and mechanisms of the human body) [59].

Fig. 22.2
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An iCub robot mounted on a supporting frame. It was designed by the Robot Cub Consortium of several European universities and built by Italian Institute of Technology [56]

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The overall objective of SP10 is to provide tools allowing researchers to test the cognitive and behavioral capabilities of the brain models developed in SP6 and the neuromorphic implementations of these models from SP9. The Neurorobotics Platform will provide researchers with access to detailed brain models on the Brain Simulation Platform running slower than real time [52] (Fig. 22.3).

Fig. 22.3
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An assistance system for minimally invasive spinal surgery: robot-assisted positioning of screws on a model of the lumbar vertebrae at the Research Project Centre for Sensor Systems (ZESS), University of Siegen and Neurosurgery Karlsruhe (Used with permission [60])

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Recent European Contributions to Neurosurgical Simulators

European contribution to simulation training research is unfortunately somehow still limited. Limited operating room exposure to vascular neurosurgery for European trainees may be due to the consequences of reduced working week hours in the EU as well as a less “hands-on” approach as in the example of cerebral aneurysm clipping [8, 17]. This fact increases the need for training these valuable skills outside of the operating room. Practicing on animal tissue is an important aspect of neurosurgical training. Depending on the type of tissue, it offers trainees to practice on samples closely resembling realistic anatomy [61]. A recent article by the neurosurgeons from Turkey proposed a model of using fresh sheep cadavers to simulate microdiscectomy surgery [62]. Unfortunately, preservation of cadavers requires the use of harsh chemicals such as formaldehyde which alters tissue feel. To address the issue, British authors described embalming methods that realistically simulate the feel of the tissue or bone during pedicle placement [63]. Costs associated with setting up and maintaining animal labs present a general limitation to this teaching method. A Spanish team proposed a model of simulation of cerebral brain perfusion utilizing human brains instead of a more traditional use of decapitated heads [61]. For all the previous reasons, the development of alternative realistic training methods is vital (Fig. 22.4).

Fig. 22.4
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Dr. Giselle Coelho and her realistic model, a mimic of an infant with craniosynostosis (Used with permission [64])

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The Three Ways European Residents Can Access Simulators

In Europe, most of the simulation training that neurosurgery residents obtain comes from their respective residency site. The other sources include additional training at international simulation centers and participating in numerous training courses organized by national bodies or supranational organizations such as the European Association of Neurosurgical Societies (EANS) .

The situation regarding the use of simulators in Europe is heterogeneous. Despite the rising sentiment among the educators toward using more simulators [6], general trend suggests that simulation training continues to play only a minor role in the residency curriculum [65]. In a multinational study, PDs from 38 European countries (including Turkey and Israel) were surveyed on the state of neurosurgical education. Nine of the surveyed centers located in Western Europe and five surveyed centers in Eastern Europe had simulation facilities including either cadaveric labs, virtual labs, or phantoms (Fig. 22.5). Although the situation between different training sites within one country may vary, these preliminary results give an idea of the educational trends for the region as a whole. These findings corroborate results of a survey of 532 European neurosurgery residents, which indicated that less than half of European programs have simulation or cadaver labs [12]. Not surprisingly, only 13.4% of surveyed respondents were satisfied with their hands-on simulator training [12].

Fig. 22.5
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The availability of simulators in European countries [65] (Obtained with permission from the European survey study conducted by the postgraduate education committee of the European Association of Neurosurgical Societies 2016)

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Besta NeuroSim Center is the only European training site that contains several advanced neurosimulators under one roof. Located in Milan, Italy, the center has the latest virtual reality neurosimulators including NeuroTouch, ImmersiveTouch, Surgical Theater, and one 3D anatomical visualizer (Virtual Proteins) [66]. This training site has a close cooperation with McGill University (Canada). Besta NeuroSim Center offers postgraduate residency training, continuing medical education courses for practicing surgeons, and observerships for medical students in Europe [44].

The third source of simulation training for European residents comes from attending national and supranational courses – such as the EANS training courses. Founded in 2012, the EANS Hands-On Course is a 5-day biannual workshop. It offers trainees to practice cranial and spinal approaches and endoscopy techniques. Recently, there has been a push within EANS to include practical training aspects into courses that were previously exclusively theoretical [67]. For advanced trainees with interest in craniocervical junction, a special cadaveric workshop has been developed [68]. The course runs on an annual basis in Barcelona (Spain) and is taught by neurosurgical faculty from Europe and North America. This offers a unique chance for trainees to practice surgical skills under the guidance of international experts in both spine and skullbase approaches applying different techniques such as navigation, cadaveric models, virtual reality, and live 3D anatomy.

Finally, European trainees may get additional exposure to neurosimulators by doing an off-site rotation within their country or Europe at large [69].

SESAM Constitution

The name of the society is the “Society in Europe for Simulation Applied to Medicine,” known hereafter and registered as “SESAM”(Table 22.2).

Table 22.2 Society in Europe for Simulation Applied to Medicine (SESAM) Members. Used with permission [70]
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The purpose of SESAM is:

  • The development and application of simulation in education, research, and quality management in medicine and healthcare

  • Facilitation, exchange, and improvement of the technology and knowledge throughout Europe

  • Establishment of combined research facilities

SESAM has its registered office in Göttingen. SESAM is represented by an executive committee and a general assembly. The language used by SESAM is English [71].

Using Simulation for Certification and Board Exams

The Comprehensive Clinical Neurosurgery (CCN) review is becoming one of the most important pre-exam courses in Europe. Its importance comes from using very smart and innovative methods of teaching using simulation to help senior neurosurgery residents and fellows pass their board exams. The course was designed to simulate the oral exam environment by creating what is called “hot seat” sessions where candidates will be sitting on a chair in front of two faculty members of world-class experienced neurosurgeons, and they will be given case scenarios and examined just like if they were in a true final fellowship oral board exam (Fig. 22.6). At the end of each session, the candidates will be marked and will be given immediate feedback about their performance from the faculty members. These sessions are also videotaped so that each candidate accesses these videos and gets a performance feedback from the course director on not only academic knowledge but also on style of delivering information and use of body language [72].

Fig. 22.6
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(a, b) Hot seat session (board exam simulation) (Courtesy of CCN Review 2014 & 2015 (Krakow, Poland))

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The study which was conducted on candidates attending the CCN review over the past 4 years showed improvement in performance on the hot seat with the use of simulated hot seats provided there is at least moderate knowledge in theory (tested in the study using MCQ exam question style) [73]. In Europe, observed through the British Royal College Fellowship exam (FRCS) and the European Board of Neurological Surgery (EBNS), there was an improvement in candidates’ performance after being exposed to this simulation technique, and in fact the top performers in these exams are mainly candidates who took the simulation hot seat review course.

Where Is Simulation Heading in Europe?

Where will simulation go next? A question which was asked and answered by Walsh K . He proposed that a number of different themes will emerge.

  • Firstly, simulation will likely become much more closely linked to assessment in the future. The learner of the future will likely spend time in the simulator being continually assessed. The assessment may be by a person or by a machine. Regardless of this, the assessment will be against performance metrics that are important and that can be measured. In keeping with best practice generally in assessment, feedback will be continuous and specific to the task in hand [74].

  • Secondly, our vision of what constitutes simulation will change radically in the future. Currently simulation is often seen as a method of learning that can be defined by time and space. So a learner might spend a half-day in the local simulation suite learning a skill. In the future, the concept of simulation will become much more wide so that it captures a range of less well-defined but equally effective activities. For example, mobile simulation suites will enable simulation to happen on the wards or in the outpatient department [75]. Online simulations will enable learners to interact with simulations at a time and place that suits them [76]. Simulation centers themselves will become open access so that a learner can use them as and when they wish to.

  • Thirdly, the future of simulation in medical education will follow the same path as the future of healthcare [77].

  • Lastly, are we approaching the ultimate dream of simulating human brain? This will be the question to be yet answered .

Obstacles to Implementation of Simulation Training in Europe

Despite obvious benefits of using simulators to teach and assess neurosurgical trainees, there are several large obstacles. Firstly, a relatively high start-up cost [18] may be an important drawback to some European states. Secondly, facilitating an effective training session is a detailed process: a high number of steps involved in designing/planning effective simulation [69]. Thirdly, there may be hesitation of the part of educators to implement simulation training into the residency curriculum. One review [69] emphasized that, to gain full benefits of simulation training, the simulators must become a part of the teaching curriculum. Conversely, some trainees may perceive that simulation training is somehow less valuable or useful than more operative experience [69]. Finally, there is also a lack of access to the existing simulation facilities [64].