AANS Neurosurgeon | Volume 28, Number 1, 2019


Technological Innovation Making Neurosurgical Training Better

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What would you do if you had to learn more information and achieve mastery of many technical skills, with significantly reduced hours allotted to training? For today’s neurosurgery residents, work-hour restrictions issued by the ACGME along with an intensifying medical-legal climate are decreasing operative autonomy for trainees in both supervised and unsupervised settings.1 Faced with these pressures, neurosurgeons have rallied to develop technologies that supplement intraoperative experiences and increase training efficiency.2

Innovative Technologies Effective

Recent advancements in technologies, such as augmented reality (AR), virtual reality (VR) and 3-D printing should provide vehicles for enhanced training. This year alone, studies have explored VR in neuroanatomy teaching 3, cranial vault anatomy 4, tumor resection 5, microsurgery 6, aneurysm clipping 7 and many other applications. Commercial entities have driven innovation in head-mounted display technologies, like Google Glass® and Microsoft HoloLens®, enabling projection of virtual graphics onto the user’s real-world environment, while others like CAE’s NeuroVR® (formerly NeuroTouch) have pushed the limits of tactile feedback and objective performance metrics in tumor resection. Applications of simulation technologies in neurosurgery have garnered attention from public media outlets (e.g., The Wall Street Journal) as well as professional societies, like the Congress of Neurological Surgeons (CNS), who chartered a Simulation Committee in 2010 to explore the role of simulation in resident education.

Neurosurgeons Fully Committed

Collaborations between researchers, surgeons and industry are pushing simulation technologies into the clinical domain. One such team, led by Duke neurosurgery residents Andrew Cutler, MD, and Shervin Rahimpour, MD, and faculty member Patrick Codd, MD, partnered with the Duke immersive Virtual Environment (DiVE) to develop AR applications for external ventricular drain (EVD) placement. The team has used the Microsoft HoloLens to project a 3-D brain graphic and virtual catheter onto the patient’s head, allowing the operator to guide the catheter from the surface to the frontal horn of the lateral ventricle. Similarly, a team at the University of Pennsylvania, led a neurosurgery resident Vivek Buch, MD, and faculty member H. Isaac Chen, MD, are helping pioneer new holographic applications for spinal fixation surgery. These patient-specific models provide insights into surgical anatomy and structural relationships, which may be useful as an educational resource and as a clinical tool to help formulate the surgical approach.

Questions Remain

As simulation technology races into the future, surgeons and trainees face difficult questions about its ultimate role in neurosurgical education and patient care. How realistic do simulations need to be for skills to translate to the surgical setting? How do we evaluate the cost/benefit of technologies like synthetic tissue, which has limited re-usability and high up-front expense? As regulatory policies drive residents out of the OR and into the simulation lab, how will we know the real impact on training quality? And most importantly, can we demonstrate that simulation leads to increased trainee competence and improved patient outcomes? Answering these questions will require a generation of large-scale randomized control trials (RCTs) in neurosurgical simulation. While institution-level efforts like the Neurosurgery Simulation Core (Icahn School of Medicine), Neurosurgery Simulation and Innovations Lab (Mayo Clinic), Neurosurgical Simulation and Virtual Reality Center (Stanford School of Medicine) and the Penn Medicine Clinical Simulation Center continue to lead the way, we anticipate a future of multi-institutional collaboration that unites researchers with complementary skills in AR/VR, image registration, synthetic tissue engineering and surgical expertise.

Training of the Future

Though challenges and questions remain, it is inevitable that a myriad of AR, VR, 3-D printing and other as yet unimagined applications will be fully incorporated into neurosurgery training over the coming decade, with benefits for patients, the public and all of neurosurgery.


1. Konakondla, S., Fong, R., & Schirmer, C. M. (2017). Simulation training in neurosurgery: Advances in education and practice. Advances in Medical Education and Practice, Volume 8, 465-473.

2. Bernardo, A. (2017). Virtual Reality and Simulation in Neurosurgical Training. World Neurosurgery, 106, 1015-1029.

3. Ekstrand, C., Jamal, A., Nguyen, R., Kudryk, A., Mann, J., & Mendez, I. (2018). Immersive and interactive virtual reality to improve learning and retention of neuroanatomy in medical students: A randomized controlled study. CMAJ Open, 6(1).

4. Hendricks, B. K., Patel, A. J., Hartman, J., Seifert, M. F., & Cohen-Gadol, A. (2018). Operative Anatomy of the Human Skull: A Virtual Reality Expedition. Operative Neurosurgery, 15(4), 368-377.

5. Sawaya, R., Alsideiri, G., Bugdadi, A., Winkler-Schwartz, A., Azarnoush, H., Bajunaid, K., . . . Maestro, R. D. (2018). Development of a performance model for virtual reality tumor resections. Journal of Neurosurgery, 1-9.

6. Choque-Velasquez, J., Colasanti, R., Collan, J., Kinnunen, R., Jahromi, B. R., & Hernesniemi, J. (2018). Virtual Reality Glasses and “Eye-Hands Blind Technique” for Microsurgical Training in Neurosurgery. World Neurosurgery, 112, 126-130.

7. Gmeiner, M., Dirnberger, J., Fenz, W., Gollwitzer, M., Wurm, G., Trenkler, J., & Gruber, A. (2018). Virtual Cerebral Aneurysm Clipping with Real-Time Haptic Force Feedback in Neurosurgical Education. World Neurosurgery, 112.

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