Determinants of Accuracy of Freehand, EVD Placement by Neurosurgical Trainees.

Abstract

Background: The insertion of an external ventricular drain (EVD) is a fundamental neurosurgical procedure predominantly performed by junior neurosurgical trainees. It is vital for managing conditions like hydrocephalus, intracranial hypertension, traumatic brain injury, and others. The procedure's success heavily relies on the precise identification of anatomical landmarks and the trainee's experience. Objective: This study aims to assess the precision and safety of EVD placement in patients treated by first-year (R1) and second-year (R2) neurosurgical residents, evaluating the impact of the residents' experience levels on the outcomes of the procedure. Methods: Conducted at the Neurosurgery Department of Jinnah Post Graduate Medical Center, Karachi, from February to July 2022, this prospective cohort study involved individuals aged 18 years or older undergoing EVD placement for hydrocephalus. Exclusion criteria included patients with more than 5mm midline shift on initial scans or those without a post-EVD placement scan. Procedures were performed under senior resident supervision, with postoperative CT scans assessing catheter tip placement and potential complications. Statistical analyses utilized IBM SPSS Statistics for Windows, Version 25.0, with Student’s t-test, Chi-square, and Fisher exact tests applied as appropriate. Results: The study comprised 152 patients (mean age: 39.4 ± 10.7 years; 52.6% male). The initial GCS scores varied, with 44.7% scoring above 8. Most EVD placements (60.5%) were by residents in their fourth or fifth year. The average procedure duration was 43 ± 8.7 minutes, with an average of 1.44 ± 0.12 passes. Optimal placement (Kakarla Grade 1) was achieved in 59.2% of cases, with significant differences in placement accuracy between R1 and R2 residents (p<0.05). Conclusion: The study highlights the significant role of experience and training in the successful placement of EVDs. The higher accuracy rates in more experienced residents underscore the need for enhanced training programs for junior neurosurgical trainees, focusing on anatomical landmark identification and procedural practice.