Developing a 3D composite training model for cranial remodeling

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OBJECTIVE

Craniosynostosis correction, including cranial vault remodeling, fronto-orbital advancement (FOA), and endoscopic suturectomy, requires practical experience with complex anatomy and tools. The infrequent exposure to complex neurosurgical procedures such as these during residency limits extraoperative training. Lack of cadaveric teaching tools given the pediatric nature of synostosis compounds this challenge. The authors sought to create lifelike 3D printed models based on actual cases of craniosynostosis in infants and incorporate them into a practical course for endoscopic and open correction. The authors hypothesized that this training tool would increase extraoperative facility and familiarity with cranial vault reconstruction to better prepare surgeons for in vivo procedures.

METHODS

The authors utilized representative craniosynostosis patient scans to create 3D printed models of the calvaria, soft tissues, and cranial contents. Two annual courses implementing these models were held, and surveys were completed by participants (n = 18, 5 attending physicians, 4 fellows, 9 residents) on the day of the course. These participants were surveyed during the course and 1 year later to assess the impact of this training tool. A comparable cohort of trainees who did not participate in the course (n = 11) was also surveyed at the time of the 1-year follow-up to assess their preparation and confidence with performing craniosynostosis surgeries.

RESULTS

An iterative process using multiple materials and the various printing parameters was used to create representative models. Participants performed all major surgical steps, and we quantified the fidelity and utility of the model through surveys. All attendees reported that the model was a valuable training tool for open reconstruction (n = 18/18 [100%]) and endoscopic suturectomy (n = 17/18 [94%]). In the first year, 83% of course participants (n = 14/17) agreed or strongly agreed that the skin and bone materials were realistic and appropriately detailed; the second year, 100% (n = 16/16) agreed or strongly agreed that the skin material was realistic and appropriately detailed, and 88% (n = 14/16) agreed or strongly agreed that the bone material was realistic and appropriately detailed. All participants responded that they would use the models for their own personal training and the training of residents and fellows in their programs.

CONCLUSIONS

The authors have developed realistic 3D printed models of craniosynostosis including soft tissues that allow for surgical practice simulation. The use of these models in surgical simulation provides a level of preparedness that exceeds what currently exists through traditional resident training experience. Employing practical modules using such models as part of a standardized resident curriculum is a logical evolution in neurosurgical education and training.

ABBREVIATIONS ABS = acrylonitrile butadiene styrene; FDM = fused deposition modeling; FOA = fronto-orbital advancement; PA2200 = polyamide 2200; PGY = postgraduate year; PLA = polylactic acid; tPLA = Tough PLA.

Article Information

Correspondence Caitlin Hoffman: NewYork-Presbyterian Hospital, New York, NY. ceh2003@med.cornell.edu.

INCLUDE WHEN CITING Published online September 20, 2019; DOI: 10.3171/2019.6.PEDS18773.

Disclosures Du Cheng is supported by a Medical Scientist Training Program grant from the National Institute of General Medical Sciences of the National Institutes of Health, and he is the owner of a pending patent associated with the method of rendering CT scans and the method of manufacturing the 3D composite models described in this manuscript. He also reports ownership in the company CranialSim, which has not yet been formed. Medtronic provided surgical drill sets, Carl Storz provided endoscopic equipment, and Stryker provided surgical equipment and plating tools.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    3D printing of bone and soft tissue and associated equipment. A: Representative CT scans and 3D reconstruction used to create the bone and soft tissue of the model. B: The 3D printers used to create the bone and soft tissue. C: The completed model with the surgical setup of each course station. D: An attending physician demonstrates surgery to course participants. E: Completed cranial vault expansion with skin open, and a completed endoscopic suturectomy as seen through semitransparent skin.

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    Testing of materials for the 3D printed skull. Burr holes and craniotomy cuts were performed on ABS, PLA, tPLA, and PA2200 to assess fidelity to real bone and to minimize melting during craniotome cuts.

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    Surgical steps of an FOA on the 3D model (A–O). All surgical steps of the FOA for single-suture craniosynostosis repair were performed on the finalized 3D printed model.

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    Surgical steps of an endoscope-assisted craniectomy with strip suturectomy on the 3D model (A–I). All surgical steps of the endoscope-assisted craniectomy for single-suture craniosynostosis repair were performed on the finalized 3D printed model.

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    Experience with craniosynostosis surgery in course participants and nonparticipants. A–E: Course evaluation results showing the training level of the participants (A) and their experience with these surgical procedures (B) and participant evaluations of the overall simulation (C), lectures (D), and model (E). F: Current data from nonparticipants. Preparedness and understanding of residents who did not attend the course. G: Data from participant 1-year follow-up surveys. Preparedness and understanding of participants at the 1-year follow-up.

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    Course outline and station setup. A visual diagram of the course format including lecture contents, hands-on station setups, and workflows.

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