Simulation in Endoscopic Spine Surgery: Systematic Review of Current Approaches and Educational Outcomes

Introduction: Endoscopic spine surgery (ESS) is a rapidly evolving field that offers a minimally invasive option for treating many spine pathologies. However, the limited availability of training programs and the steep learning curve have complicated the integration of ESS into surgical practice for many surgeons. This study summarizes the current status of surgical simulation in ESS training and aims to identify the strengths and limitations of current models

Methods: A systematic review was conducted following the PRISMA guidelines to assess the literature on simulation training in ESS. Studies from inception to April 2024 were systematically screened from five databases. Data were collected on simulator models, study design, training program components, and training outcomes.

Results: A total of 1,313 studies were identified, and ten met the inclusion criteria. The models used included animal models (20%), mixed reality (10%), self-made training models (60%), and synthetic or cadaveric models (10%). The most commonly simulated procedure was endoscopic discectomy (transforaminal and interlaminar) (40%), followed by endoscopic flavectomy (30%). Only two studies (2/10) attempted to validate the simulation training. Among the studies that included a training program, most employed pre-and post-training assessments in single or comparative cohorts (80%), with many (60%) using a multimodal approach in their training models. According to the Kirkpatrick classification, four studies assessed learners' reactions, and four measured learning outcomes. All studies reported improvements in learners' confidence, comfort, and satisfaction, as well as technical skills.

Conclusion : This review found that simulation training in ESS primarily utilizes multimodal approaches and surgical simulators, with improvements observed in learners' confidence and technical skills. However, there is a notable lack of a virtual reality (VR) simulator designed for ESS. Future research should focus on developing VR tools and creating standardized educational programs to reduce the steep learning curve in ESS training.