Open-access in spine surgery education: Developing and validating a free Transforaminal Lumbar Interbody Fusion (TLIF) virtual simulator.

Abstract

Background: Transforaminal Lumbar Interbody Fusion (TLIF) is a common but technically demanding procedure requiring extensive training. Existing simulators are costly and inaccessible, with no free online alternative. The goal of this study was to develop and validate the first free, online, computer-based interactive simulator for TLIF to teach surgical steps to residents.

Hypothesis: The hypothesis was that this computer simulator would perform better than a traditional PDF-based operative technique.

Patients and methods: A randomized controlled trial was conducted, including 42 orthopedic surgery residents from three academic centers, randomized into two groups: 21 trained using the computer-based TLIF simulator and 21 trained using the traditional PDF-based operative technique. They subsequently performed a TLIF procedure on a sawbone model. Performance was assessed using a specific TLIF checklist (primary outcome) and the Objective Structured Assessment of Technical Skills (OSATS) score (secondary outcome). Subspecialty, number of TLIF observed before the study and the sawbone model procedure time were recorded. Satisfaction was evaluated using a post-training questionnaire.

Results: Residents in the simulator group performed better on the checklist scores (mean 32.7/38.0 vs. 28.8/38.0; p = 0.01). OSATS score was slightly higher in the simulation group but without reaching significant difference (mean 26.7/35.0 vs. 23.3/35.0; p = 0.17). The simulator proved particularly beneficial for residents with less TLIF experience (N < 15), showing greater relative improvement compared to PDF traditional technique (with relative score differences of +16.5% for N < 5, +15.0% for 5 ≤ N < 15, and +6.3% for N ≥ 15). Participants rated the simulator highly for ease of use (mean 8.1/10 ± 1.6) and overall satisfaction (mean 8.7/10 ± 1.9).

Discussion: This new TLIF simulator provides a valuable tool for teaching procedural steps of a complex spinal surgery, especially for residents with limited experience or outside the spine specialty. Its free and accessible design eliminates barriers to surgical education, making it well-suited for use at home for daily training.

Level of evidence: II; Prospective, randomized, controlled educational study.