Abstract
Anterior cervical discectomy and fusion (ACDF) is a technique mainly used to treat cervical spondylosis, which is associated with radiculopathy or myelopathy. It is difficult to perform and has been associated with many clinical complications. ACDF training is time-consuming and potentially detrimental to the quality of patient care, thus it is important to clarify the essential skills and optimal training methods for ACDF. The findings of this study will help medical educators and researchers develop more effective training programs for ACDF. In this study, three ACDF experts developed a 37-question online survey, which was shared on 4 social media groups and presented at 2 academic conferences. As a result, one hundred and sixty survey responses were collected from 109 hospitals or institutes located in 24 provincial administrative districts across China. Surgical skills directly related to the surgical procedure and the identification of important anatomical structures were rated as essential skills for ACDF trainees. The mean duration of simulated ACDF training was 19.26 ± 39.31 h. Notably, younger surgeons received more training time than senior counterparts.
Supplementary Information
The online version contains supplementary material available at 10.1038/s41598-025-14675-9.
Keywords: Anterior cervical discectomy and fusion, Surgical education, Simulation training, Surgeon
Subject terms: Orthopaedics, Risk factors
Introduction
Anterior cervical discectomy and fusion (ACDF) was introduced more than 60 years ago and remains a technique used to treat cervical spondylosis with radiculopathy or myelopathy, as well as other pathologies requiring anterior cervical spine access and stabilization1. ACDF involves the resection of intervertebral disc material through the anterior approach and filling the disc space with a graft or implant to achieve osseous fusion2. The efficacy of ACDF is well-demonstrated by many long-term clinical studies3,4. However, the outcomes of ACDF may be unprecedented and the safety of ACDF may be compromised owing to the complex anatomy of the anterior cervical spine. The ACDF procedure is associated with various clinical complications, including neurological injuries, haematoma, postoperative dysphagia, laryngeal nerve palsy, and adjacent segment disease5–7.
Prior studies demonstrate that considerable ACDF experience correlates with favourable outcomes; based on the learning curve, approximately 60 procedures are typically required to achieve proficiency8. Surgeons with higher levels of proficiency can reduce the duration of the procedure as well as blood loss during the procedure. Experienced spine surgeons can avoid causing injury to the nerves and soft tissue during surgery, thereby reducing complication rates and postoperative pain9,10. Surgeons must become proficient in safely and effectively performing the procedure to achieve optimal clinical outcomes.
Owing to inherent challenges in spinal surgery and rapidly developing clinical technologies, novice spine surgeons require additional training before performing the actual surgery11. Medical simulations allow surgical trainees to practice their surgical skills in a risk-free environment12. In recent decades, various types of simulations have been used to train spine surgeons, and their educational value has been demonstrated13–16. However, despite its association with improved patient care and low cost, simulation training remains a source of concern, especially in terms of its integration into the surgical curricula17. The most suitable simulation method for trainees learning specific techniques should be selected carefully to enhance training efficiency and improve cost-effectiveness.
In this study, we solicited the participation of Chinese spine surgeons in an online survey, which aimed to investigate the most essential clinical skills for ACDF. Moreover, we attempted to identify cases in which simulation training is preferred and to ascertain the usage of such training programs for the ACDF procedure to ultimately help medical educators design more effective training programs.
Results
A total of 189 surgeons responded to the survey. After the exclusion of invalid data, responses from the participants who did not have prior experience of performing ACDF procedure, 160 valid responses from 109 medical institutions located in 24 provincial administrative districts across China, were included in the analysis. Cronbach’s alpha test revealed excellent internal consistency of the survey (α = 0.928). Of the 160 valid responses, 15 responses were from postgraduates/residents/fellows, 37 responses were from junior specialist surgeons, 69 responses were from consultants, and 39 responses were from senior consultants. The average duration of experience in performing the ACDF procedure for all participants was 7.60 ± 4.89 years, and the average number of surgeries performed per year was 34.54 ± 40.72. Table 1 shows the detailed demographic information of the participants.
Table 1.
Participants demographics.
| Postgraduates/ Residents/ Fellowsa |
Junior specialist surgeonb |
Consultantc | Senior consultantd |
All participants |
Welch F | P | |
|---|---|---|---|---|---|---|---|
|
Number of participants n |
15 | 37 | 69 | 39 | 160 | ||
|
Average ACDF per year mean ± SD |
20.93 ± 17.90 | 27.05 ± 29.03 | 39.51 ± 62.35 | 50.67 ± 53.58 | 34.54 ± 40.72 | 3.778 |
0.014 * |
|
Average years of performing ACDF mean ± SD |
5.27 ± 4.80 | 5.76 ± 5.21 | 6.87 ± 3.12 | 12.51 ± 6.41 | 7.60 ± 4.89 | 10.643 |
< 0.001 *** |
|
Total number of ACDF mean ± SD |
89.40 ± 102.13 | 175.78 ± 328.92 | 321.03 ± 720.12 | 738.46 ± 1079.55 | 331.17 ± 557.68 | 6.666 |
< 0.001 *** |
|
Total number of provincial administrative district in China |
34 |
Surveyed provincial administrative districts |
24 | Coverage 70.6% |
a compared with d, P = 0.004 **; b compared with d, P = 0.019 *.
*represents P < 0.05; **represents P < 0.01; ***represents P < 0.001.
Welch’s ANOVA tests were performed on the experience levels of the participants, and the results revealed significant differences. The results of the Tamhane T2 test indicated that, compared with junior surgeons, senior surgeons have more experience performing ACDF. The number of ACDF procedures performed increased with increasing experience among the surgeons.
General skills
Regarding the five general skills, as shown in Table 2, the results of Welch’s ANOVA revealed significant differences among the five skills. Of these, knowledge of gross anatomy and knowledge of imaging anatomy were the two most important skills. There were no significant differences in the ratings of the importance of each skill among surgeons with different levels of experience.
Table 2.
Five general surgical skills trainees should possess prior to performing in operating room.
| Postgraduate/ Residency/ Fellow |
Junior Specialist Surgeons |
Consultants | Senior Consultants |
All participants |
Welch F | P | |
|---|---|---|---|---|---|---|---|
| Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | |||
|
Knowledge of gross anatomya |
4.67 ± 0.72 | 4.78 ± 0.53 | 4.84 ± 0.41 | 4.85 ± 0.43 | 4.79 ± 0.53 | 0.367 | 0.777 |
|
Knowledge of imaging anatomyb |
4.73 ± 0.59 | 4.78 ± 0.48 | 4.81 ± 0.43 | 4.74 ± 0.55 | 4.77 ± 0.51 | 0.193 | 0.901 |
| Manual dexterityc | 4.53 ± 0.74 | 4.51 ± 0.77 | 4.65 ± 0.59 | 4.67 ± 0.53 | 4.59 ± 0.66 | 0.451 | 0.718 |
| Spatial perceptiond | 4.53 ± 0.64 | 4.43 ± 0.80 | 4.57 ± 0.65 | 4.56 ± 0.68 | 4.52 ± 0.69 | 0.267 | 0.849 |
| Tactile sensatione | 4.53 ± 0.64 | 4.38 ± 0.79 | 4.51 ± 0.70 | 4.49 ± 0.68 | 4.48 ± 0.70 | 0.266 | 0.849 |
a compared with c, P = 0.007 **; a compared with d, P < 0.001 ***; a compared with e, P < 0.001 ***; b compared with c, P = 0.023*; b compared with d, P = 0.037 *; b compared with e, P < 0.001***.
*represents P < 0.05; **represents P < 0.01; ***represents P < 0.001.
Specific skills
Among the three categories of specific skills, the surgical procedure and identification of important anatomical structures were more important than the preparation of the patient and instruments according to the results of Welch’s ANOVA and Tamhane T2 tests. The ratings of each category were consistent among the surgeons with different levels of experience. The details are presented in Table 3.
Table 3.
Categories of specific surgical skills important for trainees to possess prior to performing in operating room.
| Value | Postgraduate/ Residency/ Fellow |
Junior Specialist Surgeons |
Consultants | Senior consultants | All participants |
Welch F | P |
|---|---|---|---|---|---|---|---|
| Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | |||
|
Surgical procedurea |
4.65 ± 0.54 | 4.57 ± 0.54 | 4.75 ± 0.40 | 4.59 ± 0.51 | 4.64 ± 0.50 | 1.558 | 0.202 |
|
Identification of important anatomical structuresb |
4.71 ± 0.55 | 4.59 ± 0.51 | 4.65 ± 0.47 | 4.59 ± 0.49 | 4.63 ± 0.51 | 0.323 | 0.809 |
|
Preparation of the patient and instrumentsc |
4.48 ± 0.54 | 4.27 ± 0.65 | 4.50 ± 0.52 | 4.30 ± 0.65 | 4.39 ± 0.59 | 1.693 | 0.171 |
a compared with c, P < 0.001***; b compared with c, P < 0.001***.
*Represents P < 0.05; **represents P < 0.01; ***represents P < 0.001.
As shown in Table 4, participants consistently rated most specific skills, though only three skills differed significantly across groups with varied training levels. The participants added haemostasis of the posterior vertebral venous plexus and excision of the posterior longitudinal ligament as missing skills in the open-ended section.
Table 4.
Specific surgical skills trainees should possess prior to performing the procedure in the operating room.
| Postgraduates/ Residents/ Fellows |
Junior specialist surgeon |
Consultant | Senior consultant | All participants |
Welch F | P | |
|---|---|---|---|---|---|---|---|
| Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | |||
|
Cervical discectomy and nerve decompression |
4.73 ± 0.59 | 4.84 ± 0.44 | 4.86 ± 0.39 | 4.87 ± 0.34 | 4.83 ± 0.44 | 0.252 | 0.86 |
|
Using fluoroscopy to accurate localization of the surgical segment |
4.73 ± 0.59 | 4.70 ± 0.62 | 4.80 ± 0.47 | 4.95 ± 0.22 | 4.80 ± 0.48 | 3.168 | 0.032* |
|
Bluntly separating the space between the carotid sheath and trachea to expose the prevertebral fascia |
4.73 ± 0.59 | 4.76 ± 0.55 | 4.83 ± 0.45 | 4.85 ± 0.37 | 4.79 ± 0.49 | 0.331 | 0.803 |
|
Cleaning the incision and hemostasis |
4.67 ± 0.62 | 4.70 ± 0.57 | 4.83 ± 0.45 | 4.72 ± 0.60 | 4.73 ± 0.56 | 0.740 | 0.533 |
|
Palpating the carotid pulse |
4.73 ± 0.59 | 4.68 ± 0.58 | 4.78 ± 0.54 | 4.74 ± 0.55 | 4.73 ± 0.57 | 0.283 | 0.838 |
|
Implantation of anterior cervical plate |
4.80 ± 0.56 | 4.62 ± 0.59 | 4.77 ± 0.46 | 4.59 ± 0.64 | 4.70 ± 0.56 | 1.199 | 0.320 |
|
Using fluoroscopy to confirm the fusion device and plate position |
4.67 ± 0.62 | 4.62 ± 0.64 | 4.78 ± 0.48 | 4.67 ± 0.74 | 4.69 ± 0.62 | 0.757 | 0.524 |
|
Implantation of interbody fusion device |
4.53 ± 0.64 | 4.68 ± 0.63 | 4.80 ± 0.44 | 4.69 ± 0.61 | 4.68 ± 0.58 | 1.086 | 0.364 |
|
Patient positioning: Supine positioning with slight cervical extension to adequately expose the surgical area |
4.67 ± 0.62 | 4.59 ± 0.64 | 4.70 ± 0.49 | 4.67 ± 0.58 | 4.66 ± 0.58 | 0.226 | 0.878 |
|
Identifying the sternocleidomastoid muscle |
4.73 ± 0.59 | 4.49 ± 0.84 | 4.74 ± 0.59 | 4.62 ± 0.63 | 4.65 ± 0.66 | 1.038 | 0.384 |
|
Using a casper to open the intervertebral space |
4.67 ± 0.62 | 4.68 ± 0.63 | 4.64 ± 0.57 | 4.54 ± 0.68 | 4.63 ± 0.63 | 0.313 | 0.816 |
|
Longitudinally incising the prevertebral fascia to expose the vertebral bodies and intervertebral discs |
4.53 ± 0.64 | 4.59 ± 0.60 | 4.71 ± 0.55 | 4.62 ± 0.63 | 4.61 ± 0.61 | 0.575 | 0.634 |
|
Sterilizing the surgical areas and draping system |
4.67 ± 0.62 | 4.35 ± 0.79 | 4.70 ± 0.55 | 4.51 ± 0.68 | 4.56 ± 0.66 | 2.128 | 0.108 |
|
Placing drainage tube and drain strip |
4.67 ± 0.62 | 4.19 ± 0.88 | 4.78 ± 0.45 | 4.41 ± 0.91 | 4.51 ± 0.72 | 6.037 | 0.001** |
|
Incise the skin subcutaneous tissue and platysma muscle separately |
4.53 ± 0.64 | 4.35 ± 0.79 | 4.71 ± 0.60 | 4.36 ± 0.93 | 4.49 ± 0.74 | 2.814 | 0.048* |
|
Anatomical landmarking for surgical segment localization: Thyroid cartilage/ Cricoid cartilage/ C6 vertebral transverse process |
4.67 ± 0.62 | 4.54 ± 0.61 | 4.30 ± 0.79 | 4.41 ± 0.88 | 4.48 ± 0.73 | 1.657 | 0.187 |
|
Identifying and preserving the superior laryngeal and recurrent laryngeal nerves |
4.73 ± 0.59 | 4.51 ± 0.65 | 4.49 ± 0.80 | 4.18 ± 0.97 | 4.48 ± 0.75 | 2.138 | 0.106 |
| Suturing the incision | 4.67 ± 0.62 | 4.32 ± 0.97 | 4.61 ± 0.67 | 4.28 ± 0.79 | 4.47 ± 0.76 | 2.288 | 0.089 |
|
Patient anaesthesia: Nasotracheal intubation for general anesthesia |
4.40 ± 0.63 | 4.03 ± 0.96 | 4.45 ± 0.76 | 4.13 ± 1.06 | 4.25 ± 0.85 | 2.278 | 0.090 |
|
Operating room setup |
4.20 ± 0.68 | 4.11 ± 0.84 | 4.14 ± 0.77 | 3.90 ± 0.88 | 4.09 ± 0.79 | 0.850 | 0.472 |
Preferred types of simulation
Table 5 shows the ratings for the usefulness in skill training across common types of simulations, namely: (a) cadaveric specimens, (b) high-fidelity physical models (with accurate anatomy and haptic feedback enabling practice of specific steps using real instruments), (c) virtual reality (VR) simulators (computational programs providing interactive surgical step practice), (d) low-fidelity bench-top models (lacking anatomical accuracy, limited to fundamental skills). Statistical analyses revealed that cadaveric specimens were the most preferable type of simulation for improving surgeons’ surgical skills, and the rating was significantly higher than that of the other simulations. Low-fidelity bench-top models were rated as the least helpful simulation and had a significantly lower rating than any other type of simulation. For surgeons with different levels of experience, the perception of effectiveness was consistent across all simulation types.
Table 5.
Usefulness of the simulation type in Preparing trainees to perform in the operating room.
| Postgraduate/ Residency/ Fellow |
Junior Specialist Surgeons |
Consultants | Senior consultants | All participants |
Welch F | P | |
|---|---|---|---|---|---|---|---|
| Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | |||
|
Cadaveric specimensa |
4.53 ± 0.64 | 4.46 ± 0.77 | 4.51 ± 0.78 | 4.38 ± 0.91 | 4.47 ± 0.78 | 0.210 | 0.889 |
|
High-fidelity physical modelsb |
4.20 ± 0.86 | 4.22 ± 0.82 | 3.96 ± 1.02 | 4.13 ± 0.80 | 4.16 ± 0.87 | 0.232 | 0.874 |
|
Virtual reality (VR) simulatorsc |
4.20 ± 0.77 | 4.11 ± 0.84 | 4.07 ± 1.00 | 3.95 ± 0.76 | 4.06 ± 0.85 | 0.594 | 0.622 |
|
Low-fidelity bench-top modelsd |
3.93 ± 0.80 | 3.73 ± 0.96 | 3.57 ± 1.16 | 3.51 ± 1.00 | 3.69 ± 0.98 | 1.059 | 0.374 |
a compared with b, P = 0.024 *; a compared with c, P < 0.001 ***; a compared with d, P < 0.001 ***; b compared with d, P < 0.001 ***; c compared with d, P = 0.037 *.
*represents P < 0.05; **represents P < 0.01; ***represents P < 0.001.
Simulation training for ACDF
Table 6 shows the rating of surgeons’ prior experience using simulations to practice ACDF-related skills, with a score of 1 indicating the surgeon’s participation in such simulated training, and a score of 0 indicating that the surgeon had not participated in such simulated training. Cadaveric specimens were used significantly more frequently than the other three types of simulation; however, the use of the other three types of simulations was statistically similar. One-way ANOVA revealed significant differences in training duration, with senior surgeons receiving less training. The analysis revealed no statistically significant difference in simulated training duration across Tier 3 A and non-Tier 3 A hospitals (F = 0.673, P = 0.413). Cross-tabulation analysis demonstrated that cadaveric specimens training emerging as the universally dominant simulation method in different classifications of hospitals. VR simulator adoption diverged significantly, with non-Tier 3 A hospitals showing 22.0% utilization versus 12.73% in counterparts (χ2 = 2.254, P = 0.521).
Table 6.
Received simulation training for ACDF procedure.
| Postgraduate/ Residency/ Fellowe |
Junior Specialist Surgeonsf |
Consultantsg | Senior Consultantsh |
All participants |
Welch F | P | |
|---|---|---|---|---|---|---|---|
| Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | |||
|
Cadaveric specimensa |
0.60 ± 0.51 | 0.59 ± 0.50 | 0.75 ± 0.43 | 0.87 ± 0.34 | 0.70 ± 0.45 | 3.197 | 0.031* |
|
Virtual reality(VR) simulatorsb |
0.47 ± 0.52 | 0.24 ± 0.43 | 0.13 ± 0.34 | 0.08 ± 0.27 | 0.23 ± 0.39 | 3.334 | 0.027* |
|
High-fidelity physical modelsc |
0.13 ± 0.35 | 0.22 ± 0.42 | 0.19 ± 0.39 | 0.08 ± 0.27 | 0.16 ± 0.36 | 1.432 | 0.244 |
|
Low-fidelity bench-top modelsd |
0.27 ± 0.46 | 0.27 ± 0.45 | 0.12 ± 0.32 | 0.05 ± 0.22 | 0.18 ± 0.36 | 2.974 | 0.040* |
|
The duration of simulated training that previously received (hours) mean ± SD |
27.40 ± 53.68 | 21.19 ± 29.05 | 15.00 ± 41.47 | 13.44 ± 33.03 | 19.26 ± 39.31 | 0.630 | 0.599 |
a compared with b, P < 0.001 ***; a compared with c, P < 0.001 ***; a compared with d, P < 0.001 ***, f compared with g, P = 0.028 *; f compared with h, P = 0.031 *.
*Represents P < 0.05; **represents P < 0.01; ***represents P < 0.001.
Discussion
In this study, we identified the most important features of the ACDF procedure through a nationwide investigation. This provides medical educators with a more comprehensive understanding of the training needs specific to ACDF. By incorporating findings related to the relative importance of surgical skills, training programs can be restructured and focused more effectively, enabling educators and trainees to allocate limited training time with greater efficiency. Furthermore, the study elucidated current usage patterns and preferences regarding simulation in ACDF training, offering valuable insights for medical professionals seeking to understand its role in educating surgeons on this challenging procedure. These findings will also assist researchers in innovating simulation tools based on a deeper understanding of user requirements.
Regarding general skills, anatomical knowledge, including gross anatomy and imaging anatomy, is essential for learning the ACDF procedure. Anatomical knowledge of the anterior cervical spine, including the soft tissue, disc space, vertebral arteries, and associated bony structures, is crucial for the success of ACDF18. Moreover, clear visualization of the surgical field seems to play a critical role in minimizing iatrogenic injury.
The findings for the three subcategories of specific skills in this study differ from previous reported findings. Studies on arthroscopic surgery for knee and hip joints revealed consistently high ratings for identification of anatomical structures19–21. However, in this study, the rating for the surgical procedure was slightly higher than that for the identification of important anatomical structures. Typically, in arthroscopic surgery, surgeons experience difficulty in converting two-dimensional images into three-dimensional spatial data22,23, which requires a comprehensive understanding of the surgical space. As ACDF is an open surgery, surgeons have a clear view of the surgical site and can therefore identify the anatomical structures related to the operation quickly and easily, which reduces the cognitive load. Moreover, the ACDF procedure is intricate and involves manipulation of the vertebral artery and cervical root as well as the removal of posterior osteophytes via drilling24, which can easily cause iatrogenic injuries. Consequently, surgeons prioritized the proficiency of the surgical procedure in our present survey.
Analysis of specific ACDF skills revealed that surgeons across training levels reached consensus on their importance, with higher-ranked skills deemed particularly critical. Trainees should therefore focus greater attention on mastering these competencies. Earlier researches indicated that novice surgeons need relatively more time to achieve proficiency in ACDF surgery8,25. Thus, conventionally, trainees need to perform more procedures on real patients to achieve proficiency. However, this may compromise patient safety and lead to poor outcomes26. In earlier studies, patients express dissatisfaction when residents were involved in their operations27,28, thus reducing opportunities for surgical trainees to gain operational experience. This constraint would necessitate alternative skill-building methods.
Surgeons now have access to several medical simulators. Our study revealed that simulated training is popular among novice surgeons learning the ACDF procedure. According to the results, cadaveric specimens are the most preferred and commonly used method for practicing these skills. Owing to gross anatomic structures, minor anatomic variations, and haptic feedback during dissection, cadaveric specimens are considered the gold standard for practising complex surgical skills29,30. Despite these advantages, lack of specimen availability has reduced cadaveric ACDF simulation in recent years. Consequently, younger surgeons receive typically less such training.
According to the results, high-fidelity physical models and VR simulators are acceptable options when cadaveric specimens are not available. Many studies have revealed the positive effects of these simulation methods in training novice spine surgeons31–34. Compared with VR simulators, high-fidelity physical models are more representative of the actual surgery, and trainees are able to practice the complete surgical procedure, thus improving their requisite surgical skills. In terms of learning efficiency, an earlier study revealed that high-fidelity physical models are even better than cadaveric simulation for beginners35. This could explain why the rating for high-fidelity physical models is slightly higher than that of the VR simulator. Therefore, we recommend integrating high-fidelity physical models early in the training pathway when cadaveric simulation is not available. Interestingly, VR simulators fulfill a critical function in primary hospitals due to wider availability, reflecting resource disparities in China’s healthcare system. Future efforts should prioritize developing diverse simulation tools to provide educators with flexible training design options.
The international healthcare society has reached a consensus on the importance of medical simulation36,37. Simulations are key in improving the quality of care and should be continuously prioritized38. Currently, the duration of simulated ACDF training is relatively short in both Tier 3 A hospitals and non-Tier 3 A hospitals in China. Traditional apprenticeships are still dominant in the learning process of the surgical technique. To establish a safer and more effective training environment, it is necessary to refine the policies and regulations that encourage the utilization of simulation in medical training.
This study has several limitations in that the questionnaire that was used in this study lacked a pilot phase, and the research scope was restricted to China’s healthcare system, constraining global generalizability. Future studies could involve multinational comparative studies that would strengthen cross-regional applicability. Meanwhile, further investigations related to the comparison of independent performance metrics and cost-efficacy of various types of simulation would benefit evidence-based training optimization.
Methods
The survey was divided into 4 sections, with a total of 37 questions (Supplemental Table): (a) background information, (b) general skills, (c) specific skills, and (d) simulation for ACDF. The questions were adapted from earlier studies19–21 and modified by 3 experienced spine surgeons, each of whom has performed more than 250 ACDF procedures. The questions were modified based on the features of ACDF procedure, and additional sections, such as the usage of simulations for ACDF training, were added to address the study objectives. The online survey was developed using the website www.wenjuan.com, and the link was shared in 4 social media groups exclusively composed of spine surgeons in China. We also presented the survey at 2 national-level conferences held for orthopaedic surgeons. The data were collected from May to August 2024; all the participants joined this survey anonymously.
Informed consent was obtained from all participants. In the survey, the participants provided their basic information, including workplace, experience level, and ACDF clinical experience. The participants subsequently rated the general and specific skills on a 5-point Likert scale on the basis of their importance for trainees prior to performing ACDF in the operating room (scores ranged from 1 to 5, with 1 indicating the least important and 5 indicating the most important). Subsequently, participants reported and rated simulation training utility. Two open-ended sections were included to identify skills or simulation tools omitted from the survey.
Since the study did not involve patient or personal data, the Research Ethics Committee of Chongqing Medical University waived the requirement for formal ethics approval. This study was conducted in accordance with both institutional guidelines of Chongqing Medical University and the Declaration of Helsinki.
Analysis and statistics
To identify the trend of training for ACDF, the 20 specific skills were further divided into three subcategories: (a) preparation of the patient and instruments, (b) identification of anatomical structures, and (c) surgical procedure. Cronbach’s alpha test was used to determine the internal consistency of the questions, after which data were transformed for normal distribution to analyse the participants’ experience and hours of simulation training. One-way ANOVA with LSD post-hoc tests were applied when normality and homogeneity criteria were met; Welch’s ANOVA with Tamhane T2 tests addressed heteroscedasticity. One-way ANOVA compared simulation hours between Tier 3 A (China’s highest-tier institutions) and non-Tier 3 A hospitals to assess accessibility associations. Cross-tabulation quantified utilization rates of four simulation modalities stratified by hospital tier. The SPSS AU data science analysis platform (https://spssau.com) was used for statistical analysis.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
Authors wish to thank all the participants whom involved in this study. This study was financially supported by Chongqing Social Science Planning Talent Program (Grant No. 2022YC013), the Science and Technology Research Program of Chongqing Municipal Education Commission (Grant No. KJZD-K202301001), the Science and Technology Research Program of Chongqing Municipal Education Commission (Grant No. KJZD-M202301002), The 2024 Graduate Advisor Team Project of the First Clinical College, Chongqing Medical University (Grant No. CYYY-XKDFJH-DSTD-202404), and The Bayu Scholar Program (Grant No. YS2023074).
Author contributions
Bohong Cai, Xi Lyu, Jie Hao, Menghong Xia, Wei Jiang were responsible for study inception and design. Jie Hao, Menghong Xia, Wei Jiang, were responsible for the survey design. Xilin Cheng, Xi Lyu, Sihang Li, Baixiang Chen, Qi Yao, Hanhan Wu undertook data collection and analysis. Bohong Cai, Xi Lyu, Jie Hao, Menghong Xia, Wei Jiang, Hanhan Wu undertook data interpretation and preparation of the manuscript for publication. All the authors read and approved the final manuscript prior to submission.
Data availability
The datasets used and analysed during the current study are available from the corresponding author on reasonable request.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Jie Hao, Menghong Xia and Wei Jiang contributed equally to this work.
Contributor Information
Jie Hao, Email: hjie2005@aliyun.com.
Menghong Xia, Email: XMH_721218@163.com.
Wei Jiang, Email: jiangwei@cqmu.edu.cn.
References
- 1.Lindsey, R. W. Adjacent segment disease risk following anterior cervical discectomy and fusion: unknowns, or known unknowns, in our pursuit of an Evidence-Based risk determination. J. Bone Jt. Surg.104, 1959–1959 (2022). [DOI] [PubMed] [Google Scholar]
- 2.Martin, C. T., Pugely, A. J., Gao, Y. & Mendoza-Lattes, S. Thirty-Day morbidity after Single-Level anterior cervical discectomy and fusion: identification of risk factors and emphasis on the safety of outpatient procedures. J. Bone Jt. Surg.96, 1288–1294 (2014). [DOI] [PubMed] [Google Scholar]
- 3.Bohlman, H., Emery, S., Goodfellow, B. & Jones, P. Anterior cervical discectomy radiculopathy for cervical. J. Bone Jt. Surg.75–A, 1452 (1993). [DOI] [PubMed]
- 4.Buttermann, G. R. Anterior cervical discectomy and fusion outcomes over 10 years: a prospective study. Spine (Phila. Pa. 1976)43, 207–214 (2018). [DOI] [PubMed]
- 5.Nanda, A., Sharma, M., Sonig, A., Ambekar, S. & Bollam, P. Surgical complications of anterior cervical diskectomy and fusion for cervical degenerative disk disease: a single surgeon’s experience of 1576 patients. World Neurosurg.82, 1380–1387 (2014). [DOI] [PubMed] [Google Scholar]
- 6.Fountas, K. N. et al. Anterior cervical discectomy and fusion associated complications. Spine (Phila. Pa. 1976)32, 2310–2317 (2007). [DOI] [PubMed]
- 7.Robertson, J. T., Papadopoulos, S. M. & Traynelis, V. C. Assessment of adjacent-segment disease in patients treated with cervical fusion or arthroplasty: a prospective 2-year study. J. Neurosurg. Spine. 3, 417–423 (2005). [DOI] [PubMed] [Google Scholar]
- 8.Mayo, B. C. et al. Anterior cervical discectomy and fusion the surgical learning curve. Spine (Phila Pa. 1976). 41, 1580–1585 (2016). [DOI] [PubMed] [Google Scholar]
- 9.Lee, J. C., Jang, H. D. & Shin, B. J. Learning curve and clinical outcomes of minimally invasive transforaminal lumbar interbody fusion: Our experience in 86 consecutive cases. Spine (Phila. Pa. 1976)37, 1548–1557 (2012). [DOI] [PubMed]
- 10.Park, Y., Lee, S., Bin, Seok, S. O., Jo, B. W. & Ha, J. W. Perioperative surgical complications and learning curve associated with minimally invasive transforaminal lumbar interbody fusion: a single-institute experience. CiOS Clin. Orthop. Surg.7, 91–96 (2015). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Dvorak, M. F. et al. Confidence in spine training among senior neurosurgical and orthopedic residents. Spine (Phila. Pa 197631, 831–837 (2006). [DOI] [PubMed]
- 12.Dawe, S. R. et al. Systematic review of skills transfer after surgical simulation-based training. Br. J. Surg.101, 1063–1076 (2014). [DOI] [PubMed] [Google Scholar]
- 13.Stefan, P. et al. Three-dimensional-Printed computed Tomography-Based bone models for spine surgery simulation. Simul. Healthc.15, 61–66 (2020). [DOI] [PubMed] [Google Scholar]
- 14.Coelho, G. & Defino (ed, H. L. A.) The role of mixed reality simulation for surgical training in spine: phase 1 validation. Spine (Phila Pa. 1976)43 1609–1616 (2018). [DOI] [PubMed] [Google Scholar]
- 15.Unger, R. et al. Innovative growth and development of a neurological surgery residency cadaveric spine-simulation training program: a single-institution experience. J. Neurosurg. Spine2024, 1–10. 10.3171/2023.10.SPINE23273 (2024). [DOI] [PubMed]
- 16.Gasco, J. et al. Virtual reality spine surgery simulation: an empirical study of its usefulness. Neurol. Res.36, 968–973 (2014). [DOI] [PubMed] [Google Scholar]
- 17.Wang, Z. & Shen, J. Simulation training in spine surgery. J. Am. Acad. Orthop. Surg.30, 400–408 (2022). [DOI] [PubMed] [Google Scholar]
- 18.Petty, P., Pait, T. G. & Arnautovic, K. I. Surgical anatomy of the anterior cervical spine: the disc space, vertebral artery, and associated bony structures [3] (multiple letters). Neurosurgery41, 325 (1997). [DOI] [PubMed] [Google Scholar]
- 19.Safir, O. et al. What skills should simulation training in arthroscopy teach residents? Int. J. Comput. Assist. Radiol. Surg.3, 433–437 (2008). [DOI] [PubMed] [Google Scholar]
- 20.Hui, Y., Safir, O., Dubrowski, A. & Carnahan, H. What skills should simulation training in arthroscopy teach residents? A focus on resident input. Int. J. Comput. Assist. Radiol. Surg.8, 945–953 (2013). [DOI] [PubMed] [Google Scholar]
- 21.Cai, B. et al. Training surgical skills on hip arthroscopy by simulation: a survey on surgeon’s perspectives. Int. J. Comput. Assist. Radiol. Surg.17, 1813–1821 (2022). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Carr, A. J., Price, A. J., Glyn-Jones, S. & Rees, J. L. Advances in arthroscopy - Indications and therapeutic applications. Nat. Rev. Rheumatol.11, 77–85 (2015). [DOI] [PubMed] [Google Scholar]
- 23.Alvand, A., Auplish, S., Gill, H. & Rees, J. Innate arthroscopic skills in medical students and variation in learning curves. J. Bone Jt. Surgery-American Vol.93, e115(1)-e115(9) (2011). [DOI] [PubMed]
- 24.Barbagallo, G. M. V., Certo, F. & Three-Dimensional High-Definition exoscopic anterior cervical discectomy and fusion: a valid alternative to Microscope-Assisted surgery. World Neurosurg.130, e244–e250 (2019). [DOI] [PubMed]
- 25.Clifton, W. et al. Microanatomical considerations for safe uncinate removal during anterior cervical discectomy and fusion: 10-year experience. Clin. Anat.33, 920–926 (2020). [DOI] [PubMed] [Google Scholar]
- 26.Waisbrod, G. et al. Surgical training in spine surgery: safety and patient-rated outcome. Eur. Spine J.28, 807–816 (2019). [DOI] [PubMed] [Google Scholar]
- 27.Dutta, S. et al. And doctor, no residents please! J. Am. Coll. Surg.197, 1012–1017 (2003). [DOI] [PubMed] [Google Scholar]
- 28.Cowles, R. A. et al. Doctor-patient communication in surgery: attitudes and expectations of general surgery patients about the involvement and education of surgical residents. J. Am. Coll. Surg.193, 73–80 (2001). [DOI] [PubMed] [Google Scholar]
- 29.Au, J., Palmer, E., Johnson, I. & Chehade, M. Evaluation of the utility of teaching joint relocations using cadaveric specimens. BMC Med. Educ.18, 1–9 (2018). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Holla, S. J., Ramachandran, K., Isaac, B. & Koshy, S. Anatomy education in a changing medical curriculum in india: medical student feedback on duration and emphasis of gross anatomy teaching. Anat. Sci. Educ.2, 179–183 (2009). [DOI] [PubMed] [Google Scholar]
- 31.Jug, M., Tomaževič, M. & Cimerman, M. 3D model-assisted instrumentation of the pediatric spine: a technical note. J. Orthop. Surg. Res.16, 1–6 (2021). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Park, H. J., Wang, C., Choi, K. H. & Kim, H. N. Use of a life-size three-dimensional-printed spine model for pedicle screw instrumentation training. J. Orthop. Surg. Res.13, 1–8 (2018). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Luca, A. et al. Innovative educational pathways in spine surgery: advanced virtual Reality–Based training. World Neurosurg.140, 674–680 (2020). [DOI] [PubMed] [Google Scholar]
- 34.Alkadri, S., Maestro, D., Driscoll, M. & R. F. & Face, content, and construct validity of a novel VR/AR surgical simulator of a minimally invasive spine operation. Med. Biol. Eng. Comput.62, 1887–1897 (2024). [DOI] [PubMed] [Google Scholar]
- 35.Bohl, M. A. et al. Evaluation of a novel surgical skills training course: are cadavers still the gold standard for surgical skills training? World Neurosurg.127, 63–71 (2019). [DOI] [PubMed] [Google Scholar]
- 36.Fincher, R. M. E., White, C. B., Huang, G. & Schwartzstein, R. Toward hypothesis-driven medical education research: task force report from the millennium conference 2007 on educational research. Acad. Med.85, 821–828 (2010). [DOI] [PubMed]
- 37.Issenberg, S. B., Ringsted, C., Øostergaard, D. & Dieckmann, P. Setting a research agenda for simulation-based healthcare education a synthesis of the outcome from an Utstein style meeting. Simul. Healthc.6, 155–167 (2011). [DOI] [PubMed] [Google Scholar]
- 38.McGaghie, W. C., Issenberg, S. B., Petrusa, E. R. & Scalese, R. J. Revisiting ‘A critical review of simulation-based medical education research: 2003–2009’. Med. Educ.50, 986–991 (2016). [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and analysed during the current study are available from the corresponding author on reasonable request.