- Department of Neuroscience, Winthrop Neuroscience, Winthrop University Hospital, Mineola, New York, USA
Nancy E. Epstein
Department of Neuroscience, Winthrop Neuroscience, Winthrop University Hospital, Mineola, New York, USA
DOI:10.4103/sni.sni_39_17Copyright: © 2017 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Nancy E. Epstein. Learning curves for minimally invasive spine surgeries: Are they worth it?. 26-Apr-2017;8:61
How to cite this URL: Nancy E. Epstein. Learning curves for minimally invasive spine surgeries: Are they worth it?. 26-Apr-2017;8:61. Available from: http://surgicalneurologyint.com/surgicalint-articles/learning-curves-for-minimally-invasive-spine-surgeries-are-they-worth-it/
Background:Minimally invasive surgery (MIS) spine procedures were developed to limit operative time, the extent of dissection, and reduce perioperative morbidity. Here, we asked what are the “learning curves” for these MIS spine procedures?
Methods:We reviewed studies in the literature that discussed the “learning curves” attributed to performing different MIS spine surgical procedures. Of interest, the majority were single-surgeon series.
Results:Very few articles assessed the learning curves for different MIS spine procedures. One study reported no learning curve for open vs. MIS discectomy/laminotomy. Another study indicated that 20–30 cases were required for a surgeon to become proficient in performing a variety of MIS spine fusions [e.g., cervical MIS fusions, MIS anterior lumbar interbody fusions (ALIF), MIS transforaminal lumbar interbody fusions (TLIF), and MIS pedicle/screw placement in the thoracic/lumbar spine]. Several other studies specifically cited that, to become proficient in the performance of TLIF, surgeons had to have performed between 10, to 32, to 40, to 44 such cases.
Conclusions:There is a very limited literature available that focuses on the “learning curves” associated with the performance of different types of MIS spine procedures. The number of cases required to satisfy the “learning curves” for different operations varied from 0 for MIS vs. open discectomy/laminotomy, to 20-30 for a variety of cervical-thoracic-lumbar procedures, and up to 44 cases for TLIF. Shouldn’t we ask whether better oversight measures and/or mentoring programs could limit the morbidity/AE occurring during these “learning curves” in the future?
Keywords: Adverse events, learning curve, minimally invasive spine surgery, minimizing, morbidity, mortality, under-reporting
Minimally invasive spine surgery (MIS) theoretically limits operative time/dissection, and reduces perioperative morbidity and mortality. Here, we focused on the “learning curves,” defined as the number of cases required to become proficient (e.g., reduce operative time, estimated blood loss, morbidity/adverse events) for performing various MIS spinal procedures. As some studies documented comparable long-term outcomes for open vs. MIS spinal operations, how do we determine wheter (not if) the “learning curve’ is “worth it”?
The adverse events (AE) attributed to MIS spine surgery need to be better recognized [
Several studies, most of which were single-surgeon series, identified “steep” learning curves for MIS spinal surgery [
In 2013, Silva et al., in another single-surgeon series, noted MIS-TLIF correlated with “a steep learning curve.”[
Subsequently, in 2014, Nandyala et al., again in a single-surgeon study, evaluated the learning curve for the first 32 cases of MIS TLIF vs. the latter 33 MIS TLIF performed for disc disease/lumbar spinal stenosis with grade I or II spondylolisthesis.[
Lee et al. in 2014 assessed the learning curve for 90 one-level MIS TLIF performed by one surgeon.[
In 2015, Jin-Tao et al. summarized the findings of 14 studies (12-month follow-up) involving MIS TLIF vs. open PLIF/TLIF.[
Sclafani and Kim in 2014 also discussed the learning curves found in 14 studies involving 966 MIS procedures that included MIS TLIF, percutaneous pedicle screw insertion (thoracic/lumbar), MIS anterior lumbar interbody fusion, and MIS cervical fusions.[
Two studies claimed no significant learning curves were associated with performing MIS vs. open lumbar discectomy, and MIS vs. open TLIF [
The spine literature documents different learning curves (e.g., complications/AE) for performing various types of MIS spinal surgical procedures.[
1. Ahn J, Iqbal A, Manning BT, Leblang S, Bohl DD, Mayo BC. Minimally invasive lumbar decompression-the surgical learning curve. Spine J. 2016. 16: 909-16
2. Epstein NE. How often is minimally invasive minimally effective: What are the complication rates for minimally invasive surgery?. Surg Neurol. 2008. 70: 386-8
3. Epstein NE. Spine surgery in geriatric patients: Sometimes unnecessary, too much, or too little. Surg Neurol Int. 2011. 2: 188-
4. Epstein NE. More nerve root injuries occur with minimally invasive lumbar surgery, especially extreme lateral interbody fusion: A review. Surg Neurol Int. 2016. 7: S83-95
5. Guyer RD, Foley KT, Phillips FM, Ball PA. Minimally invasive fusion: Summary statement. Spine. 2003. 28: S44-
6. Jin-Tao Q, Yu T, Mei W, Xu-Dong T, Tian-Jian Z, Guo-Hua S. Comparison of MIS vs. open PLIF/TLIF with regard to clinical improvement, fusion rate, and incidence of major complication: A meta-analysis. Eur Spine J. 2015. 24: 1058-65
7. Lau D, Lee JG, Han SJ, Lu DC, Chou D. Complications and perioperative factors associated with learning the technique of minimally invasive transforaminal lumbar interbody fusion (TLIF). J Clin Neurosci. 2011. 18: 624-7
8. Lee KH, Yeo W, Soeharno H, Yue WM. Learning curve of a complex surgical technique: Minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). J Spinal Disord Tech. 2014. 27: E234-40
9. Nandyala SV, Fineberg SJ, Pelton M, Singh K. Minimally invasive transforaminal lumbar interbody fusion: One surgeon's learning curve. Spine J. 2014. 14: 1460-5
10. Parker SL, Mendenhall SK, Shau DN, Zuckerman SL, Godil SS, Cheng JS. Minimally invasive versus open transforaminal lumbar interbody fusion for degenerative spondylolisthesis: Comparative effectiveness and cost-utility analysis. World Neurosurg. 2014. 82: 230-8
11. Phan K, Huo YR, Hogan JA, Xu J, Dunn A, Cho SK. Minimally invasive surgery in adult degenerative scoliosis: A systematic review and meta-analysis of decompression, anterior/lateral and posterior lumbar approaches. J Spine Surg. 2016. 2: 89-104
12. Sclafani JA, Kim CW. Complications associated with the initial learning curve of minimally invasive spine surgery: A systematic review. Clin Orthop Relat Res. 2014. 472: 1711-7
13. Silva PS, Pereira P, Monteiro P, Silva PA, Vaz R. Learning curve and complications of minimally invasive transforaminal lumbar interbody fusion. Neurosurg Focus. 2013. 35: E7-