Mixed reality neurosurgical simulations and adult learning theories: a systematic review

Neurosurgical education relies on rigorous training to help learners develop technical proficiency and neuroanatomical comprehension. Traditional teaching methods, such as cadaveric dissections and live surgical observations, face limitations associated with accessibility, cost, and ethical concerns. Mixed reality (MR), an emerging technology within extended reality, offers an interactive and immersive approach to surgical training. This review examines the effectiveness of MR in neurosurgical education through established adult learning theories, aiming to determine the optimal integration model for enhancing trainee skill acquisition and knowledge retention.

A systematic literature search of MEDLINE, Scopus, Embase, and Cochrane databases was conducted. The search included studies of MR applications in neurosurgical education aligned with adult learning theories. A total of 341 articles were identified, with 18 meeting the inclusion criteria after screening. Studies were categorized based on their integration of adult learning theories, including experiential learning, constructivism, behaviorism, cognitivism, and self-directed learning. Data extraction focused on MR applications, assessment metrics, and performance improvements among trainees.

The review found that MR-based neurosurgical training improved spatial understanding, procedural accuracy, and trainee engagement. Experiential learning was the most frequently applied model (18 studies), followed by constructivism (15 studies), behaviorism (7 studies), and cognitivism (6 studies). Studies on cranial procedures demonstrated enhanced spatial cognition and motor skills, whereas studies exploring spinal procedures, such as pedicle screw placement, showed increased precision and greater trainee confidence. Although no studies explicitly emphasized andragogy or connectivism, MR's integration of feedback mechanisms and real-time simulation was found to facilitate skill refinement and knowledge retention.

MR-based neurosurgical training aligns effectively with theories of adult learning, particularly experiential and constructivist learning. The technology enhances procedural accuracy and spatial awareness, contributing to improved neurosurgical education. Although MR accelerates the learning curve, randomized controlled trials are needed to evaluate its long-term impact on surgical performance. Incorporating MR into neurosurgical curricula could revolutionize training by fostering active learning, optimizing skill acquisition, and improving patient safety.