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Table of Contents    
Year : 2017  |  Volume : 65  |  Issue : 6  |  Page : 1448-1449

Spinal model for teaching and training

Department of Neurosurgery, King Edward VII Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Parel, Mumbai, Maharashtra, India

Date of Web Publication10-Nov-2017

Correspondence Address:
Dr. Dattatraya Muzumdar
Department of Neurosurgery, King Edward VII Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Parel, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.217961

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How to cite this article:
Muzumdar D. Spinal model for teaching and training. Neurol India 2017;65:1448-9

How to cite this URL:
Muzumdar D. Spinal model for teaching and training. Neurol India [serial online] 2017 [cited 2019 Jun 26];65:1448-9. Available from:

Advanced techniques of spinal fusion and fixation require sound understanding of the three-dimensional anatomy of the spine. The anatomical knowledge of C1/C2 joint is complex. The orientation of the C1 and C2 along with alignment of the facets, comprehensive anatomy of ligaments, and the course of vertebral artery needs to be properly understood.[1],[2],[3] In the western countries, craniovertebral instability is commonly seen in rheumatoid arthritis and 10–30% of individuals with Down's syndrome. In the Indian subcontinent, the etiology is commonly congenital, traumatic, and also related to malnutrition.[1] It is relatively commonly seen in hospital practice and high volume academic centers. The patients usually belong to the lower socioeconomic strata and mainly solicit treatment in university academic teaching institutions, which provide surgical treatment at a subsidized cost. Hence, it is imperative that resident trainees and young consultants need to be well poised to tackle the intricacies in the management of these complex problems.

The current standard of teaching screw placement techniques to residents involves didactic lectures followed by lateral mass or transpedicular screw placement in the operating room under supervision.[1],[2],[3],[4],[5] This is usually preceded by cadaveric dissection, understanding spinal anatomy, and demonstration of fixation techniques. However, this practice has been largely subjective and has depended on an individual's interest, cooperation from the anatomy department, as well as special effort and mobilization skills. Consequently, the proficiency to perform this surgery has remained with a selected cohort of residents and consultants interested in spinal surgery. The attending of conferences, symposia, and workshops have added to the mastering of the surgical skills but this process has lacked objectivity.

Supervised training of residents and consultants in the techniques of spinal fixation in the operating room has its own limitations. It may be difficult to practice on a routine basis. The shrinking resident duty hours and limited surgical training also hinder adequate training. The insertion of these screws is technically demanding and the margin for error is small. It has multiple potential risks because of the proximity of eloquent vascular and neurological structures and the absence of visibility to subsurface anatomy during the insertion of screws.[6],[7],[8] Misplaced screws can result in construct failure or pseudarthrosis with the reported rates being in the range of 3.4–22%.[6],[8] Major errors can result in life-threatening hemorrhage or permanent neurological injury.[3],[9]

Simulation-based training is popular in general surgical training which involves laparoscopic methods.[10] However, three-dimensional anatomy of the spine is complex and difficult to visualize on the simulator. Virtual screw placement planning on two-dimensional computer screens has not shown to improve real time performance.[10] In such a situation, cadaveric specimens and navigation software would assume importance in improving accurate screw placement accuracy. The current method for resident screw insertion training includes didactic lectures coupled with exercise on the cadaveric or sawbones models. The mastering of spinal anatomy is achieved with supervision in the operating room.[1],[2],[4],[5],[6] Sundar et al., in their study found that supplementing the standard didactic-based curriculum with a single session of hands-on, cadaver-based anatomy instruction using navigation software with sawbone model visualization, and manipulation, significantly reduced the overall screw placement errors by 64% and suboptimal screw placement by 53%.[6]

Pedicle screw and lateral mass fixation techniques are the mainstay of spinal surgery. Spinal trauma and degenerative diseases are relatively common and are treated in peripheral hospitals in India. Hence, it is imperative that neurosurgical and orthopedic residents should be properly trained in screw placement techniques. In India, a uniform structured curriculum in spinal surgery as a teaching program is still lacking. Due to the high volume of patients and resource constraints, a dedicated approach towards screw placement techniques is not always possible. Although cadavers can be arranged easily, procuring of specimens for the demonstration of dedicated spinal anatomy is not always feasible. Sawbones and navigation software are expensive and their universal availability is also an issue. The wooden model for spinal anatomy teaching and screw placement is an excellent method for teaching. It is cheap, easily available, and user-friendly. It does not require a dedicated space and can be practiced in the clinic as well. It does not require any elaborate storage space or maintenance and can be assembled indigenously. Locally available glue can substitute for fixing wooden pieces to construct anatomy. Electric wires can be used to simulate vertebral arteries. It can possibly provide the residents a method to further advance through the residency program and for further acquisition of skills in the comfort of an operating room.[11]

In India, a dedicated spinal surgery program for proper screw placement aimed at Neurosurgery and Orthopedic surgeons should be the objective and such workshops should be conducted on a regular basis. It should be in alignment with the current trends in the spinal surgery training and practice. The economic constraints and the non-uniform practice patterns in India across training centers should be considered while formulating the programs. The role of cadaveric training in proper screw placement cannot be underestimated. The incorporation of sawbones models and virtual simulation has shown to decrease the screw placement error; however, their validation and the cost- issues involved in maintaining these programs may limit their universal acceptance. In such a situation, the incorporation of a wooden spinal model in addition to didactic sessions and cadaveric training would be ideal for training on a larger scale and especially in resource strained geographical regions.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Goel A, Shah A, Gupta SR. Craniovertebral instability due to degenerative osteoarthritis of the atlantoaxial joints: Analysis of the management of 108 cases. J Neurosurg Spine 2010;12:592-601.  Back to cited text no. 1
Kirkpatrick JS. A comparison C1-C2 transarticular screw placement after self-education and mentored education of orthopaedic residents. J Spinal Disord Tech 2012;25:E155-60.  Back to cited text no. 2
Sardhara J, Behari S, Mohan BM, Jaiswal AK, Sahu RN, Srivastava A, et al. Risk stratification of vertebral artery vulnerability during surgery for congenital atlanto-axial dislocation with or without an occipitalized atlas. Neurol India 2015;63:382-91.  Back to cited text no. 3
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Wu AM, Shao ZX, Wang JS, Yang XD, Weng WQ, Wang XY, et al. The accuracy of a method for printing three-dimensional spinal models. PLoS One 2015;10:e0124291.  Back to cited text no. 4
Li Z, Li Z, Xu R, Li M, Li J, Liu Y, et al. Three-dimensional printing models improve understanding of spinal fracture-A randomized controlled study in China. Sci Rep 2015;5:11570.  Back to cited text no. 5
Sundar SJ, Healy AT, Kshettry VR, Mroz TE, Schlenk R, Benzel EC. A pilot study of the utility of a laboratory-based spinal fixation training program for neurosurgical residents. J Neurosurg Spine 2016;24:850-6.  Back to cited text no. 6
Vaccaro AR, Rizzolo SJ, Balderston RA, Allardyce TJ, Garfin SR, Dolinskas C, et al. Placement of pedicle screws in the thoracic spine. Part II: An anatomical and radiographic assessment. J Bone Joint Surg Am 1995;77:1200-6.  Back to cited text no. 7
Suri A, Patra DP, Meena RK. Simulation in neurosurgery: Past, present, and future. Neurol India 2016;64:387-95.  Back to cited text no. 8
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Sindgikar P, Das KK, Sardhara J, Bhaisora KS, Srivastava AK, Mehrotra A, et al. Craniovertebral junction anomalies: When is resurgery required? Neurol India 2016;64:1220-32.  Back to cited text no. 9
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Chan S, Conti F, Salisbury K, Blevins NH. Virtual reality simulation in neurosurgery: Technologies and evolution. Neurosurgery 2013;72(Suppl 1):154-64.  Back to cited text no. 10
Jha DK. Wooden spinal model for teaching and training. Neurol India 2016;64:814-5.  Back to cited text no. 11
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