Safety of intracranial aneurysm surgery performed in a postgraduate training program: implications for training.

Abstract

Patient care and educational experience have long formed a dichotomy in modem surgical training. In neurosurgery, achieving a delicate balance between these two factors has been challenged by recent trends in the field including increased subspecialization, emerging technologies, and decreased resident work hours. In this study the authors evaluated the experience profiles of neurosurgical trainees at a large Canadian academic center and the safety of their practice on patient care. Two hundred ninety-three patients who underwent surgery for intracranial aneurysm clipping between 1993 and 1996 were selected. Prospective data were available in 167 cases, allowing the operating surgeon to be identified. Postoperative data and follow-up data were gathered retrospectively to measure patient outcomes. In 167 cases, a total of 183 aneurysms were clipped, the majority (91%) by neurosurgical trainees. Trainees performed dissections on aneurysms that were predominantly small (< 1.5 cm in diameter; 77% of patients) and ruptured (64% of patients). Overall mortality rates for the patients treated by the trainee group were 4% (two of 52 patients) and 9% (nine of 100 patients) for unruptured and ruptured aneurysm cases, respectively. Patient outcomes were comparable to those reported in historical data. Staff members appeared to be primary surgeons in a select subset of cases. Neurosurgical trainees at this institution are exposed to a broad spectrum of intracranial aneurysms, although some case selection does occur. With careful supervision, intracranial aneurysm surgery can be safely delegated to trainees without compromising patient outcomes. Current trends in practice patterns in neurosurgery mandate ongoing monitoring of residents' operative experience while ensuring continued excellence in patient care.