Alexander Winkler-Schwartz

Assessing bimanual performance in brain tumor resection with NeuroTouch, a virtual reality simulator.

BACKGROUND: Validated procedures to objectively measure neurosurgical bimanual psychomotor skills are unavailable. The NeuroTouch simulator provides metrics to determine bimanual performance, but validation is essential before implementation of this platform into neurosurgical training, assessment, and curriculum development. OBJECTIVE: To develop, evaluate, and validate neurosurgical bimanual performance metrics for resection of simulated brain tumors with NeuroTouch. METHODS: Bimanual resection of 8 simulated brain tumors with differing color, stiffness, and border complexity was evaluated. Metrics assessed included blood loss, tumor percentage resected, total simulated normal brain volume removed, total tip path lengths, maximum and sum of forces used by instruments, efficiency index, ultrasonic aspirator path length index, coordination index, and ultrasonic aspirator bimanual forces ratio. Six neurosurgeons and 12 residents (6 senior and 6 junior) were evaluated. RESULTS: Increasing tumor complexity impaired resident bimanual performance significantly more than neurosurgeons. Operating on black vs glioma-colored tumors resulted in significantly higher blood loss and lower tumor percentage, whereas altering tactile cues from hard to soft decreased resident tumor resection. Regardless of tumor complexity, significant differences were found between neurosurgeons, senior residents, and junior residents in efficiency index and ultrasonic aspirator path length index. Ultrasonic aspirator bimanual force ratio outlined significant differences between senior and junior residents, whereas coordination index demonstrated significant differences between junior residents and neurosurgeons. CONCLUSION: The NeuroTouch platform incorporating the simulated scenarios and metrics used differentiates novice from expert neurosurgical performance, demonstrating NeuroTouch face, content, and construct validity and the possibility of developing brain tumor resection proficiency performance benchmarks.

Neurosurgical Assessment of Metrics Including Judgment and Dexterity Using the Virtual Reality Simulator NeuroTouch (NAJD Metrics)

Advances in computer-based technology has created a significant opportunity for implementing new training paradigms in neurosurgery focused on improving skill acquisition, enhancing procedural outcome, and surgical skills assessment. NeuroTouch is a computer-based virtual reality system that can generate output data known as metrics from operator performance during simulated brain tumor resection. These measures of quantitative assessment are used to track and compare psychomotor performance during simulated operative procedures. Data output from the NeuroTouch system is recorded in a comma-separated values file. Data mining from this file and subsequent metrics development requires the use of sophisticated software and engineering expertise. In this article, we introduce a system to extract a series of new metrics using the same data file using Excel software. Based on the data contained in the NeuroTouch comma-separated values file, 13 novel NeuroTouch metrics were developed and classified. Tier 1 metrics include blood loss, tumor percentage resected, and total simulated normal brain volume removed. Tier 2 metrics include total instrument tip path length, maximum force applied, sum of forces utilized, and average forces utilized by the simulated ultrasonic aspirator and suction instrument along with pedal activation frequency of the ultrasonic aspirator. Advanced tier 2 metrics include instrument tips average separation distance, efficiency index, ultrasonic aspirator path length index, coordination index, and ultrasonic aspirator bimanual forces ratio. This system of data extraction provides researchers expedited access for analyzing the data files available for NeuroTouch platform to assess the multiple psychomotor and cognitive neurosurgical skills involved in complex surgical procedures.

Bimanual Psychomotor Performance in Neurosurgical Resident Applicants Assessed Using NeuroTouch, a Virtual Reality Simulator.

OBJECTIVE Current selection methods for neurosurgical residents fail to include objective measurements of bimanual psychomotor performance. Advancements in computer-based simulation provide opportunities to assess cognitive and psychomotor skills in surgically naive populations during complex simulated neurosurgical tasks in risk-free environments. This pilot study was designed to answer 3 questions: (1) What are the differences in bimanual psychomotor performance among neurosurgical residency applicants using NeuroTouch? (2) Are there exceptionally skilled medical students in the applicant cohort? and (3) Is there an influence of previous surgical exposure on surgical performance? DESIGN Participants were instructed to remove 3 simulated brain tumors with identical visual appearance, stiffness, and random bleeding points. Validated tier 1, tier 2, and advanced tier 2 metrics were used to assess bimanual psychomotor performance. Demographic data included weeks of neurosurgical elective and prior operative exposure. SETTING This pilot study was carried out at the McGill Neurosurgical Simulation Research and Training Center immediately following neurosurgical residency interviews at McGill University, Montreal, Canada. PARTICIPANTS All 17 medical students interviewed were asked to participate, of which 16 agreed. RESULTS Performances were clustered in definable top, middle, and bottom groups with significant differences for all metrics. Increased time spent playing music, increased applicant self-evaluated technical skills, high self-ratings of confidence, and increased skin closures statistically influenced performance on univariate analysis. A trend for both self-rated increased operating room confidence and increased weeks of neurosurgical exposure to increased blood loss was seen in multivariate analysis. CONCLUSIONS Simulation technology identifies neurosurgical residency applicants with differing levels of technical ability. These results provide information for studies being developed for longitudinal studies on the acquisition, development, and maintenance of psychomotor skills. Technical abilities customized training programs that maximize individual resident bimanual psychomotor training dependant on continuously updated and validated metrics from virtual reality simulation studies should be explored.

Clival fractures in a Level I trauma center

OBJECT Clival fracture (CF) is rare among head traumas. The aim of this study was to explore how radiological features observed in CF reflect the clinical picture and mechanism of injury in such cases. METHODS Radiological data for patients with skull base fracture admitted to the Montreal General Hospital between February 2002 and October 2012 were obtained from the Quebec Trauma Registry and reviewed for CF. Identified CF was categorized by orientation and quality. Injury mechanism, clinical presentation, and follow-up outcome were obtained through retrospective chart review. RESULTS Of the 1738 patients with skull base fractures, 65 exhibited CF, representing 1.2% of the 5416 patients with traumatic brain injuries admitted during the period studied. Thirty-nine (60%) of the 65 CFs were obliquely oriented, 17 (26.2%) were longitudinal, and 9 (14%) were transverse. Twenty-nine (45%) of the 65 patients demonstrated linear fracture, 17 (26%) hairline, 10 (15%) diastatic, and 9 (14%) displaced. Cranial nerve deficits and vascular injury occurred in 13.8% and 7.7% of cases, respectively. Twenty-five patients (38.5%) died in hospital. The long-term Extended Glasgow Outcome Scale score was significantly lower in transverse compared with longitudinal and oblique fractures (p = 0.03 and 0.03, respectively) and lower in diastatic compared with displaced fractures (p = 0.05). CONCLUSIONS This study provides information on the largest CF population studied to date, expands the current CF classification to include fracture quality as well as orientation, and underscores the existence of significant differences in pathogenesis and clinical presentation of CF subtypes.

Demographics, Interests, and Quality of Life of Canadian Neurosurgery Residents

BACKGROUND Neurosurgical residents face a unique combination of challenges, including long duty hours, technically challenging cases, and uncertain employment prospects. We sought to assess the demographics, interests, career goals, self-rated happiness, and overall well-being of Canadian neurosurgery residents. METHODS A cross-sectional survey was developed and sent through the Canadian Neurosurgery Research Collaborative to every resident enrolled in a Canadian neurosurgery program as of April 1, 2016. RESULTS We analyzed 76 completed surveys of 146 eligible residents (52% response rate). The median age was 29 years, with 76% of respondents being males. The most popular subspecialties of interest for fellowship were spine, oncology, and open vascular neurosurgery. The most frequent self-reported number of worked hours per week was the 80- to 89-hour range. The majority of respondents reported a high level of happiness as well as stress. Sense of accomplishment and fatigue were reported as average to high and overall quality of life was low for 19%, average for 49%, and high for 32%. Satisfaction with work-life balance was average for 44% of respondents and was the only tested domain in which significant dissatisfaction was identified (18%). Overall, respondents were highly satisfied with their choice of specialty, choice of program, surgical exposure, and work environment; however, intimidation was reported in 36% of respondents and depression by 17%. CONCLUSIONS Despite a challenging residency and high workload, the majority of Canadian neurosurgery residents are happy and satisfied with their choice of specialty and program. However, work-life balance, employability, resident intimidation, and depression were identified as areas of active concern.

Operative Landscape at Canadian Neurosurgery Residency Programs

Background Currently, the literature lacks reliable data regarding operative case volumes at Canadian neurosurgery residency programs. Our objective was to provide a snapshot of the operative landscape in Canadian neurosurgical training using the trainee-led Canadian Neurosurgery Research Collaborative. METHODS Anonymized administrative operative data were gathered from each neurosurgery residency program from January 1, 2014, to December 31, 2014. Procedures were broadly classified into cranial, spine, peripheral nerve, and miscellaneous procedures. A number of prespecified subspecialty procedures were recorded. We defined the resident case index as the ratio of the total number of operations to the total number of neurosurgery residents in that program. Resident number included both Canadian medical and international medical graduates, and included residents on the neurosurgery service, off-service, or on leave for research or other personal reasons. RESULTS Overall, there was an average of 1845 operative cases per neurosurgery residency program. The mean numbers of cranial, spine, peripheral nerve, and miscellaneous procedures were 725, 466, 48, and 193, respectively. The nationwide mean resident case indices for cranial, spine, peripheral nerve, and total procedures were 90, 58, 5, and 196, respectively. There was some variation in the resident case indices for specific subspecialty procedures, with some training programs not performing carotid endarterectomy or endoscopic transsphenoidal procedures. CONCLUSIONS This study presents the breadth of neurosurgical training within Canadian neurosurgery residency programs. These results may help inform the implementation of neurosurgery training as the Royal College of Physicians and Surgeons residency training transitions to a competence-by-design curriculum.

Is Virtual Reality Surgical Performance Influenced by Force Feedback Device Utilized

OBJECTIVE The study objectives were to assess if surgical performance and subjective assessment of a virtual reality simulator platform was influenced by changing force feedback devices. DESIGN Participants used the NeuroVR (formerly NeuroTouch) simulator to perform 5 practice scenarios and a realistic scenario involving subpial resection of a virtual reality brain tumor with simulated bleeding. The influence of force feedback was assessed by utilizing the Omni and Entact haptic systems. Tier 1, tier 2, and tier 2 advanced metrics were used to compare results. Operator subjective assessment of the haptic systems tested utilized seven Likert criteria (score 1 to 5). SETTING The study is carried out at the McGill Neurosurgical Simulation Research and Training Centre, Montreal Neurological Institute and Hospital, Montreal, Canada. PARTICIPANTS Six expert operators in the utilization of the NeuroVR simulator platform. RESULTS No significant differences in surgical performance were found between the two haptic devices. Participants significantly preferred the Entact system on all 7 Likert criteria of subjective assessment. CONCLUSIONS Our results show no statistical differences in virtual reality surgical performance utilizing the two bimanual haptic devices tested. Subjective assessments demonstrated that participants preferred the Entact system. Our results suggest that to maximize realism of the training experience educators employing virtual reality simulators may find it useful to assess expert opinion before choosing a force feedback device.

Subjective anxiety ratings before and after stressful neurosurgical virtual reality tumor resection task

Background: The availability of virtual reality (VR) surgical simulators affords the opportunity to assess the influence of stress on neurosurgical operative performance in a controlled laboratory environment. This study sought to examine the effect of a stressful VR neurosurgical task on the subjective anxiety ratings of participants with varying levels of surgical expertise. Methods: Twenty four participants comprised of six staff neurosurgeons, six senior neurosurgical residents (PGY4-6), six junior neurosurgical residents (PGY1-3), and six senior medical students took part in a bimanual VR tumor removal task with a component of sudden uncontrollable intra-operative bleeding. State Trait Anxiety Inventory (STAI) questionnaires were completed immediately pre and post the stress stimulus. The STAI questionnaire consisted of six items (calm, tense, upset, relaxed, content and worried) measured on a Likert scale. Results: Significant increases in subjective anxiety ratings were noted in junior residents (p=0.005) and medical students (p=0.025) while no significant changes were observed for staff and senior neurosurgical residents. Conclusions: Staff and senior residents more effectively mitigate stress compared to junior colleagues in a VR operative environment. Further physiological correlates are needed to determine whether this increased anxiety is paralleled by physiological arousal and altered surgical performance.

Autism Spectrum Disorder in a Term Birth Neonatal Intensive Care Unit Population

BACKGROUND Nonspecific perinatal risk factors have been revealed to be associated with the development of autism spectrum disorder. However, term at-risk infants, as a distinct population, are underrepresented in the literature. This study examines the incidence and neonatal risk factors for autism spectrum disorder in term neonatal intensive care unit survivors. METHODS We performed a retrospective analysis from a single university-practice database of neonates admitted to the neonatal intensive care unit and followed by a single pediatric neurologist. Term infants (≥ 37 weeks), born between 1991 and 2011, with at least 2 years (or 1 year if found to be neurologically normal) of follow-up were included. Principle outcomes were autism spectrum disorder, cerebral palsy, global developmental delay, and epilepsy. RESULTS One hundred eighty infants were included from a database of 564 neonates. Twelve (6.6%) developed autism spectrum disorder, 53 (29.4%) cerebral palsy, 77 (42.7%) global developmental delay, and 47 (26.1%) epilepsy. Seventy-one (39.4%) developed no adverse outcomes. Nine patients with autism spectrum disorder (75%) were diagnosed with at least one other adverse outcome. No neonatal or perinatal variables were evident to be significantly associated with later autism spectrum disorder. CONCLUSIONS In term neonatal intensive care unit survivors, autism spectrum disorder occurs at a greater frequency than in the general population and often develops alongside comorbid conditions. This highlights the importance of screening term neonatal intensive care unit survivors for autism spectrum disorder, particularly when comorbidities are present.