1156 Autonomy Development in Pediatric Neurosurgery: Implications for Resident Training

INTRODUCTION: Pediatric neurosurgery presents distinct challenges in training and evaluating competency of neurosurgical residents due to the uniquely vulnerable population, breadth of surgical procedures, and delicate neonatal tissue. METHODS: Data from neurosurgery residents across 12 institutions were compared for five procedures (ventriculo-peritoneal shunt, craniotomy for tumor (supratentorial), craniotomy for tumor (infratentorial), craniotomy for trauma, and endoscopic third ventriculocisternostomy). TAGS scores, ranging from 1 (lowest autonomy) to 4 (highest), measured surgical autonomy. The study also tracked ZPD transitions across four stages: ZPD1 (positioning and opening), ZPD2 (second most complex portion), ZPD3 (most critical/complex portion), and ZPD4 (closing). Results were analyzed with descriptive statistics. RESULTS: Our analysis depicted an overall trend of increased autonomy with higher PGY level. Notably, for pediatric cases, there was a drop in reported autonomy level from PGY-1 to PGY-2 that may be explained by variation in case complexity from intern year to PGY-2. Interestingly, despite lower autonomy scores compared to adult cases from PGY-2 to PGY-4, pediatric and adult autonomy ratings were similar from PGY-5 to PGY-7. In both, there was a trend toward increasing focus on ZPD3, the most complex portion of the case, in later PGY levels, though adult neurosurgery data demonstrated higher proportions of ZPD3 focus overall. CONCLUSIONS: These findings demonstrate the unique developmental trajectory of surgical autonomy within pediatric neurosurgery. By recognizing varying trends in autonomy and ZPD transitions among neurosurgical subspecialties, more nuanced benchmarks and educational interventions can be implemented. These insights can inform tailored educational strategies, enhancing the training and readiness of neurosurgery residents to fellowships and independent practice.