Evaluating educational outcomes of a structured virtual neurosurgical teaching program: The foundations in neurosurgery education study

Abstract

Background:

Access to neurosurgical education remains limited by geographic, institutional, and financial barriers. Virtual education offers a scalable approach, yet robust evaluations of structured programs remain limited.

Methods:

This prospective observational study evaluated the foundations in neurosurgery education (FINE) 2025/26 program, a 4-month international virtual teaching series comprising nine structured sessions delivered under the auspices of the Surgical Interest Group of Africa Neurosurgery Division. Pre- and post-program surveys assessed participant confidence, career interest, and educational value using five-point Likert scales. Within-session confidence changes were analyzed using Wilcoxon signed-rank tests with Bonferroni correction; pre–post-series comparisons used Mann–Whitney U-tests. Qualitative feedback underwent thematic analysis.

Results:

A total of 213 participants completed the pre-series survey and 54 the post-series evaluation, with 518 session-level responses recorded. Within-session confidence improved significantly across all nine sessions (mean gain Δ = +1.29; all p < 0.001, Bonferroni-corrected). Pre- to post-series comparisons demonstrated significant improvements in confidence managing neurosurgical conditions (Δ = +2.01, p < 0.001), neurosurgical emergencies (Δ = +2.04, p < 0.001), and understanding of training pathways (Δ = +1.62, p < 0.001). Session ratings were consistently high across clarity, usefulness, and engagement. Of post-series respondents, 74.1% reported increased likelihood of pursuing a career in neurosurgery.

Conclusion:

A structured, longitudinal virtual neurosurgical program significantly improved learner confidence, perceived preparedness, and understanding of training pathways. This model represents an effective and scalable approach to enhancing neurosurgical education and addressing disparities in early specialty exposure globally.

INTRODUCTION

Neurosurgery is a highly resource-intensive specialty characterized by significant global workforce disparities and inequitable access to care. Early exposure has been associated with increased career interest and preparedness to enter the specialty, yet opportunities remain constrained by limited clinical attachments, institutional variability, and financial or geographic barriers – particularly in low- and middle-income settings.[8]

While neurosurgical education has traditionally relied on in-person clinical and operative exposure, the expansion of digital learning has enabled scalable and geographically unrestricted access to teaching.[13,15,16] Emerging evidence supports digital learning’s role in improving learner engagement, confidence, and perceived knowledge acquisition.[3,7,10]

Despite these advances, robust evaluations of structured virtual neurosurgical programs remain limited, particularly regarding their impact on confidence, knowledge acquisition, and sustained career interest.[1,9,12] Many existing initiatives have taken the form of webinars or short-term interventions rather than longitudinal, integrated curricula; yet given the conceptual complexity of neurosurgery, structured and sequenced teaching is likely to be more effective in supporting holistic understanding among early learners.[14] Limited specialty exposure has also been associated with gaps in trainees’ understanding of training pathways and perceived barriers to entry,[1] underscoring the need for programs that integrate clinical teaching with career orientation.

The foundations in neurosurgery education (FINE) initiative

The FINE 2025/26 course was developed to address identified gaps through a structured, comprehensive virtual neurosurgical curriculum. The 4-month program, delivered from November 2025 to February 2026, was organized by the Neurosurgery Division of the Surgical Interest Group of Africa (SIGAF) and comprised a series of thematically integrated teaching sessions. Teaching covered core areas including neuroradiology, neurocritical care, cranial and spinal emergencies including trauma, atraumatic vascular pathologies, cerebrospinal fluid (CSF) disorders, and neurosurgical infections, complemented by sessions exploring training pathways in the United Kingdom (UK) and United States (US) and the lived experiences of neurosurgical trainees. The program was accredited for continuing professional development by the Royal College of Surgeons of England and endorsed by the Society of British Neurological Surgeons (SBNS).

The program was designed with five overarching learning objectives: (i) to develop foundational understanding of common neurosurgical emergencies; (ii) to build competency in interpreting neuroimaging relevant to acute and elective neurosurgical scenarios; (iii) to differentiate neurosurgical from medical causes of altered neurological status; (iv) to understand the key differences between UK and US neurosurgical training pathways; and (v) to support effective preparation for specialty applications and interviews. Teaching was delivered through Zoom/Microsoft Teams in a standardized 60-min session template comprising: A 5-min introduction with session objectives; 20 min of didactic teaching; a 20-min case-based learning segment with interactive polling and group discussion; a 5-min clinical pearls summary; and a 15-min live Q&A. Session slides, recordings, and pre- and post-session quizzes were made available to registered participants. Speakers included neurosurgical consultants, registrars, academic clinical fellows (ACFs), and experienced international medical graduates (IMGs), ensuring breadth and diversity of perspective.

This study evaluates the impact of the FINE 2025/26 course on participant-reported outcomes, including perceived usefulness, confidence in neurosurgical knowledge and training pathways, and career intentions. We assessed: (i) perceived educational value; (ii) changes in career interest; (iii) confidence in understanding training pathways; (iv) preferred teaching modalities; (v) behavioral intentions toward career progression; and (vi) perceived preparedness in clinical and career-related domains.

MATERIALS AND METHODS

Study design and setting

This study was a prospective observational assessment of the FINE 2025/26 teaching series, conducted from November 02, 2025, to February 21, 2026 under the auspices of the SIGAF Neurosurgery Division. Online pre- and post-program surveys, including post-session feedback, were distributed to attendees to assess baseline perceptions and course impact. Completion of the post-session feedback form served as the incentivized formal record of attendance at each session; session-level response counts were cross-referenced against Microsoft Teams attendance data to confirm participation. Responses were recorded using five-point Likert scales, with free-text questions exploring participants’ views on neurosurgery and neurosurgical training. Surveys were chosen as the primary data collection instrument due to their established utility in capturing learner perceptions and self-reported educational outcomes.

Participants

Participants were medical students, doctors (including foundation trainees, interns, and junior clinical fellows), neurosurgical trainees and registrars, and allied health professionals (including nurses, neuroscientists, and anatomists) who registered for and attended at least one FINE session. Recruitment took place through SIGAF social media platforms and the SBNS website. Participation was voluntary, and informed consent was obtained electronically for research and quality improvement purposes within the online survey. No identifying information was collected, and all responses were anonymized before analysis.

Program structure

The FINE 2025/26 curriculum comprised nine virtual sessions integrating core clinical topics (including neuroradiology, neurocritical care, CSF disorders, trauma, and neurosurgical infections) with professional development content (training pathways in the UK and US, and trainee experiences). Sessions incorporated lectures, case-based discussions, live Q&A, quizzes, and recorded materials, adopting a multimodal approach to enhance engagement and accommodate diverse learning preferences.

Sessions adhered to a standardized template to ensure consistency of delivery and learning experience: Each opened with a 5-min introduction outlining objectives, followed by 20 min of didactic teaching, a 20-min case-based learning segment incorporating interactive polling and group discussion, a 5-min summary of key clinical takeaways, and a 15-min live Q&A. Session materials (slides, pre- and post-session quizzes, and recordings) were made available to registered participants for asynchronous review.

The nine sessions and their primary learning objectives were as follows:

• Session 1 (Neuroradiology and neurocritical care): Participants were introduced to the interpretation of computed tomography and magnetic resonance imaging findings in neurosurgical patients, including hemorrhage, infarction, herniation, and space-occupying lesions. The session covered principles of neurocritical care and intracranial pressure (ICP) management, including external ventricular drain placement, medical strategies (mannitol, hypertonic saline), surgical decompression, and brain death testing.

• Session 2 (Subarachnoid Hemorrhage and Sodium Disturbances): This session addressed the differentiation and management of traumatic and spontaneous subarachnoid hemorrhage, including grading scales (WFNS, Fisher), aneurysm-securing strategies, nimodipine administration, and monitoring for vasospasm and delayed cerebral ischemia. Sodium disturbances in the neurosurgical patient were also covered, with a focus on distinguishing syndrome of inappropriate antidiuretic hormone secretion from cerebral salt-wasting syndrome.

• Session 3 (Hydrocephalus and CSF Pathologies): The session examined CSF physiology, including production, flow, and absorption; the classification of hydrocephalus (communicating versus noncommunicating); and clinical subtypes including acute, congenital, and normal pressure hydrocephalus. Management strategies were discussed in depth, covering shunt types (ventriculoperitoneal, ventriculopleural, ventriculoatrial, and lumboperitoneal shunts), shunt complications, and endoscopic third ventriculostomy, including its indications and outcomes. Idiopathic intracranial hypertension was also introduced.

• Session 4 (cranial trauma and cranial emergencies): This session covered initial assessment of traumatic brain injury (TBI) using ATLS principles and neuroimaging strategies. Topics included TBI classification by GCS, surgical thresholds for epidural hematoma, subdural hematoma, and contusions, ICP control strategies, prevention of secondary brain injury, and the recognition and management of postoperative complications including infection, seizures, tension pneumocephalus, and re-bleed.

• Session 5 (spinal trauma and spinal emergencies): Participants explored the management of acute spinal cord injuries, including ASIA classification and imaging approaches. The session addressed autonomic dysreflexia and spinal emergencies including cauda equina syndrome, metastatic spinal cord compression, and spinal hematoma (iatrogenic and spontaneous), supported by case-based discussions.

• Session 6 (neurosurgical infections): This session addressed intracranial infections, including brain abscess, subdural empyema, and postoperative infections (wound, shunt, and cranial hardware infections), as well as spinal infections, including spinal epidural abscess. Diagnostic approaches and surgical management principles were discussed using case-based scenarios.

• Session 7 (neurosurgery careers and academic pathways, UK Focus): This session outlined the UK neurosurgical application process, including the ST1/ST2 application timeline, eligibility criteria, and shortlisting matrix. Portfolio-building strategies were discussed across teaching, research, audit/quality improvement (QI), leadership, and psychomotor skills domains. Interview preparation and an overview of ACFs, including how to balance clinical work with research commitments, were also addressed.

• Session 8 (Pathways to neurosurgery training in the United States): This session provided an overview of US neurosurgery residency structure and timeline, USMLE Steps 1 and 2 CK preparation and score expectations, and the ERAS application process, covering CV structure, personal statements, and letters of recommendation. Topics also included research and observership opportunities, visa pathways for IMGs, and real-life insights from successful IMGs navigating the US application cycle, culminating in a comparative Q&A on UK versus US pathways.

• Session 9 (Life as a neurosurgical trainee, fireside chat): The final session took the form of a panel discussion featuring two neurosurgical trainees and a senior clinical fellow. Topics covered included workload, burnout, imposter syndrome, and examination stress; coping mechanisms, mentorship, and resilience strategies; and navigating CCT versus CESR pathways. The session concluded with an open live Q&A encouraging audience participation.

Data collection and outcome measures

Data were collected through online questionnaires (Google Forms) using five-point Likert scales unless otherwise specified.[2] Primary outcomes were: Changes in confidence in managing neurosurgical conditions and training pathways; self-reported career interest between pre- and post-program surveys; and perceived usefulness of the teaching series. Secondary outcomes included preferred and most effective teaching methods, likelihood of undertaking career-related actions, participant satisfaction, and thematic analysis of qualitative responses.

Data analysis

Data were analyzed using Microsoft Excel and RStudio (version 2026.01.2 + 418). Likert-scale responses were treated as ordinal data and summarized descriptively. Pre- and post-program comparisons were performed using the Wilcoxon signed-rank test; cross-tabulation analyses explored associations between engagement and perceived effectiveness of teaching methods. Qualitative responses were analyzed thematically. Statistical significance was set at p < 0.05.

Ethical considerations

This study was conducted as a service evaluation of an educational program. Data were collected as part of routine course feedback and anonymized before analysis. In accordance with UK Health Research Authority guidance, formal ethical approval was not required.

RESULTS

Participants

A total of 518 session-level responses were recorded across nine sessions, with attendance ranging from 39 (Session 9) to 91 (Session 1). Pre-series evaluation was completed by 213 participants and post-series evaluation by 54 participants. The pre-series cohort comprised predominantly medical students (n = 140, 65.7%), followed by foundation trainees or interns (n = 28, 13.1%) and junior clinical fellows or medical officers (n = 26, 12.2%). The majority of respondents were from Nigeria (n = 171, 80.3%), followed by the United Kingdom (n = 26, 12.2%), with further participation from Ghana, Kenya, Pakistan, and other countries. Of pre-series respondents, 133 (62.4%) reported no prior attendance at similar teaching sessions. Session-level evaluation data are presented in Table 1.

Table 1:

Session-level evaluation summary.

Perceived educational value

Overall session ratings were consistently high [Table 1]. Mean clarity of teaching ranged from 3.97 (Session 2) to 4.56 (Session 9), and mean usefulness from 4.12 (Session 4) to 4.56 (Session 9). Likelihood to apply content ranged from 4.21 (Session 2) to 4.54 (Session 1). Teaching delivery was rated between 4.28 (Session 2) and 4.70 (Session 8), and participant engagement between 4.04 (Session 4) and 4.51 (Session 9). Kruskal–Wallis analysis revealed significant between-session variation in clarity ratings (H = 26.4, p = 0.0009), but no significant variation in usefulness, likelihood to apply, teaching delivery, or engagement (all p > 0.05), indicating consistent quality across sessions regardless of topic.

Within-session confidence change

Pre-session confidence was uniformly low across all nine sessions (pooled mean 2.82 ± 1.25 on a five-point Likert scale). Post-session confidence was substantially higher (pooled mean 4.11 ± 0.89; [Figure 1]). The mean within-session confidence gain (Δ) was 1.29 points overall (range 1.11–1.42). Wilcoxon signed-rank testing demonstrated a statistically significant improvement at every individual session (all p < 0.001), all of which survived Bonferroni correction for nine comparisons (corrected threshold p < 0.0056). Pooled analysis across all 518 paired observations confirmed a highly significant improvement (W = 3421, p = 1.24×10^-55). Full per-session statistics are presented in Table 2.

Figure 1:

Pre- and post-session confidence across all nine sessions. Bars represent mean confidence rating (1–5 Likert scale) with error bars indicating ±1 standard error. Δ denotes the mean within-session confidence gain. ***p < 0.001 (Wilcoxon signed-rank test; all sessions survived Bonferroni correction, corrected α = 0.0056).

Table 2:

Wilcoxon signed-rank test results for pre- versus post-session confidence per session.

Baseline confidence was low, consistent with limited early exposure to neurosurgery, and the observed gains indicate that even short, focused virtual teaching can produce immediate educational benefit. These findings are consistent with comparable online neurosurgical teaching initiatives, including Martini et al.,[11] who demonstrated improvements in self-reported knowledge following a pandemic-era virtual neurosurgery course, and Ramos-Fresnedo et al.,[14] who reported high engagement and perceived educational value in a multidisciplinary interactive neurosurgical teaching series.

Pre- versus post-series outcomes

Baseline confidence in managing neurosurgical emergencies and critical care was low (mean 2.07 ± 1.30, n = 213). Post-series, mean preparedness in this domain was 4.11 ± 0.98 (n = 54; Δ = +2.04; Mann–Whitney U = 1515.5, p = 3.34 × 10^-18). Confidence in managing common neurosurgical conditions improved from a baseline mean of 2.10 ± 1.26 to 4.11 ± 0.95 post-series (Δ = +2.01; U = 1448, p = 1.61 × 10^-18). Understanding of career pathways and training improved from 2.31 ± 1.29 to 3.93 ± 1.03 post-series (Δ = +1.62; U = 2062.5, p = 7.50 × 10^-14). These comparisons are illustrated in Figure 2.

Figure 2:

Pre- versus post-series comparison of confidence and pathway understanding. Gray bars represent pre-series ratings (n = 213); blue bars represent post-series ratings (n = 54). Error bars indicate ±1 standard error. ***p < 0.001 (Mann–Whitney U-test, independent samples). Note: Pre-series measures confidence; post-series measures perceived preparedness – both on a 1–5 scale. Career interest item not shown (p = 0.360).

Career interest was high at baseline (mean 4.51 ± 0.86) and did not significantly differ at post-series evaluation (mean 4.26 ± 1.22; U = 6129, p = 0.360), though this should be interpreted with caution given the ceiling effect at baseline and the retrospective recall design of the post-series career interest item.

Career intention

Of 54 post-series respondents, 40 (74.1%) reported that participation made them more likely to pursue a career in neurosurgery [Figure 3]. Eight (14.8%) reported no change, 3 (5.6%) were unsure, and 3 (5.6%) reported being less likely to pursue neurosurgery. Among those indicating a preferred pathway, 22 (40.7%) identified UK training, 13 (24.1%) US training, and 18 (33.3%) were undecided.

Figure 3:

Self-reported change in career intention following the foundations in neurosurgery education program (post-series respondents, n = 54).

Career interest was high at baseline and did not change significantly following the program – likely because participants were already highly motivated, leaving limited room for further increase. However, the high proportion reporting an increased likelihood of pursuing neurosurgery, together with strong intention to undertake career-related actions, suggests the program reinforces and crystallizes existing interest rather than generating new interest.

Behavioral intention and preparedness

The mean likelihood of taking a concrete career-related step within 3 months was 3.94 ± 0.98 (n = 54). Overall perceived usefulness of FINE content for clinical practice was high (mean 4.63 ± 0.62). Participants rated the program as most effective for supporting further training (mean 3.37; 63.0% very effective) and career applications (mean 3.26; 51.9% very effective). Preparedness ratings across all six domains were predominantly in the moderately to very effective range, with fewer than 6% rating any domain as not applicable.

DISCUSSION

The expansion of virtual learning in neurosurgery, accelerated by the COVID-19 pandemic, has led to a sustained shift in educational delivery.[5] Digital platforms offer scalable and geographically unrestricted access to surgical education.[13] The observed improvements may be partly explained by established learning theory: E-learning draws on behaviorist, cognitivist, and constructivist principles and supports blended, interactive approaches that promote active, self-directed learning and facilitate knowledge application and clinical reasoning.[6] The longitudinal and structured design of the FINE program may explain the consistent engagement and improvements observed, facilitating a more coherent understanding of neurosurgery among early learners.

The international reach of the program, with over 80% of pre-series respondents from Nigeria and further representation across West Africa, East Africa, South Asia, and the UK, underscores its relevance across diverse settings, particularly where access to neurosurgical training is limited.[4] Sustained impact will require continued collaboration between educational institutions, professional bodies, and industry partners.

Limitations

This study has several limitations. Findings are based on participant-reported data, which may be influenced by subjective perception and may not accurately reflect true knowledge or clinical competence. Voluntary survey completion may have introduced selection bias, and the lower post-series response rate (n = 54 vs. n = 213 pre-series) may limit the representativeness of findings. Assessment relied on self-evaluation of confidence and understanding rather than objective testing. The absence of a comparison group limits direct attribution of improvements to the intervention. Finally, the diverse participant group, spanning different stages of training and professional backgrounds, may have introduced variability in baseline knowledge and learning needs, affecting generalizability.

CONCLUSION

The FINE 2025/26 program demonstrates that a structured, longitudinal virtual neurosurgical curriculum can deliver high perceived educational value and significantly improve participant confidence and preparedness across clinical and career-related domains. This model holds particular potential for addressing global disparities in neurosurgical education, providing structured specialty exposure to learners in settings where access to neurosurgical training remains limited.[4] Future research should incorporate objective measures of knowledge acquisition and evaluate long-term outcomes including retention, clinical competence, and career progression.

Data availability statement:

The datasets generated and analyzed during the present study are available from the corresponding author on reasonable request.

Ethical approval:

Institutional Review Board approval was not required for this study. The study was classified as a service evaluation of an existing educational programme using routine course feedback, confirmed using the UK Health Research Authority (HRA) online decision tool (hra-decisiontools.org. uk). As the programme was organised and delivered under the auspices of SIGAF and primarily involved voluntary participation via anonymous online survey with no clinical intervention, formal ethics committee review was not applicable under relevant national frameworks. The study was conducted in accordance with the Declaration of Helsinki. Informed consent was obtained electronically from all participants prior to participation.

Declaration of patient consent:

Patient’s consent was not required as there are no patients in this study. No patients were involved — only medical students, doctors, and allied health professionals, so patient-research oversight frameworks do not apply. Data were collected as routine course feedback as part of standard programme administration. All responses were anonymised before analysis, with no identifiable information collected. Voluntary informed consent was obtained electronically from all participants within the survey.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.\

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