Skill maintenance in neurosurgery: lessons from high-reliability professions and a plea to prioritize psychomotor skill retention, a mini-review

Microsurgical procedures in neurosurgery are characterized by steep learning curves, exceptional technical complexity, and limited tolerance for error. While considerable research has focused on microsurgical skill acquisition and the development of training models, substantially less attention has been directed toward skill retention and the mechanisms by which technical proficiency is maintained over time. This issue is particularly relevant for low-frequency, high-risk procedures such as extracranial-intracranial bypass surgery, aneurysm clip reconstruction, and complex skull base surgery. A mini-review was performed to examine the current understanding of skill retention in microsurgery and neurosurgery. Historical developments in microsurgical training were reviewed alongside contemporary evidence on skill decay, retraining strategies, and competency maintenance. Lessons from high-reliability professions, including military special operations, aviation, and motorsport, were analyzed for their potential applicability to neurosurgical practice. Challenges related to skill maintenance across different stages of a neurosurgical career and future directions for assessment and recertification were also explored. Microsurgical skill retention is influenced by procedural complexity, practice frequency, and initial proficiency. Although structured training programs can effectively facilitate skill acquisition, technical performance may deteriorate within weeks to months when skills are not regularly reinforced. Existing studies indicate that simulation-based rehearsal, cadaveric training, and deliberate practice can mitigate skill decay and accelerate skill reacquisition; however, optimal retraining intervals and ‘skill retention’ strategies in general remain poorly defined. Experiences from high-reliability professions demonstrate that structured maintenance of perishable skills, objective performance assessment, and recurrent training are essential for sustaining expertise. Similar principles may be applicable to neurosurgery, particularly for rare, technically demanding procedures. Skill retention is a critical yet underexplored component of surgical training. High-complexity procedures, low-volume procedures, and high-stakes scenarios demand structured skill maintenance strategies, informed by lessons from high-reliability professions. Across all neurosurgical career stages, retention-focused education, simulation, and assessment are essential for patient safety and procedural efficacy. Future research should define decay timelines, evaluate predictive validity of training, and optimize methods for preserving surgical competencies, ensuring that neurosurgeons remain proficient beyond their last case.