Simulation training in spinal endoscopic surgery: a systematic review of current status.

This systematic review aims to comprehensively evaluate the existing literature on endoscopic spine surgery (ESS) simulation. By assessing current designs, validation processes, and educational impacts in training of ESS simulators, our study aims to identify strengths and limitations, highlight critical gaps, and propose approaches to enhance simulator effectiveness. A systematic search identified 2,130 studies, with 10 meeting the inclusion criteria. The included studies comprised descriptive studies, randomized controlled trials, cohort studies, and a cross-sectional study. Data were extracted on simulator models, validation approaches, training strategies, and educational outcomes. Eleven simulator models were evaluated: animal (18%), mixed reality (9%), self-made (55%), synthetic (9%), and cadaveric (9%). Only six studies validated their simulators, revealing variable face, content, and construct validity. Simulator realism, particularly with respect to haptic feedback, spatial depth, and tissue interaction, was a central component of face validity across models, although these features were variably implemented and primarily evaluated using subjective measures. Among the included models, the mixed reality simulator demonstrated improvements in trainee performance, including faster puncture times, shorter overall operating duration, and reduced reliance on fluoroscopy. Multimodal teaching strategies combining didactic instruction and hands-on practice led to improvements in learner satisfaction, confidence, and technical performance. However, studies exhibited moderate to high risk of bias, with methodological quality rated as moderate (mean MERSQI score 9.8/18). Diverse ESS simulation models demonstrate potential to enhance surgical training. This review identified moderate methodological quality and substantial variability in study design, sampling, and validity across existing programs. Nevertheless, multimodal training approaches were commonly associated with improvements in technical performance and learner satisfaction. Despite these limitations, the available evidence supports the development of standardized simulation programs to enhance procedural proficiency by demonstrating objective improvements in procedural efficiency, task accuracy, and fluoroscopy utilization, alongside high levels of learner engagement and confidence, ultimately improving patient care.