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Unskilled unawareness and the learning curve in robotic spine surgery

  • Clinical Article - Spine
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript

Abstract

Background

Robotic assistance for the placement of pedicle screws has been established as a safe technique. Nonetheless rare instances of screw misplacement have been reported.The aim of the present retrospective study is to assess whether experience and time affect the accuracy of screws placed with the help of the SpineAssist™ robot system.

Methods

Postoperative computed tomography (CT) scans of 258 patients requiring thoracolumbar pedicle screw instrumentation from 2008 to 2013 were reviewed. Overall, 13 surgeons performed the surgeries. A pedicle breach of >3 mm was graded as a misplacement. Surgeons were dichotomised into an early and experienced period in increments of five surgeries.

Results

In 258 surgeries, 1,265 pedicle screws were placed with the aid of the robot system. Overall, 1,217 screws (96.2 %) were graded as acceptable. When displayed by surgeon, the development of percent misplacement rates peaked between 5 and 25 surgeries in 12 of 13 surgeons. The overall misplacement rate in the first five surgeries was 2.4 % (6/245). The misplacement rate rose to 6.3 % between 11 and 15 surgeries (10/158; p = 0.20), and reached a significant peak between 16 and 20 surgeries with a rate of 7.1 % (8/112; p = 0.03). Afterwards, misplacement rates declined.

Conclusions

A major peak in screw inaccuracies occurred between cases 10 and 20, and a second, smaller one at about 40 surgeries. One potential explanation could be a transition from decreased supervision (unskilled but aware) to increased confidence of a surgeon (unskilled but unaware) who adopts this new technique prior to mastering it (skilled). We therefore advocate ensuring competent supervision for new surgeons at least during the first 25 procedures of robotic spine surgery to optimise the accuracy of robot-assisted pedicle screws.

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Author notes

    Authors and Affiliations

    1. Department of Neurosurgery, University Medicine Göttingen, Göttingen, Germany

      Bawarjan Schatlo, Ramon Martinez, Awad Alaid, Kajetan von Eckardstein, Reza Akhavan-Sigari, Anina Hahn, Florian Stockhammer & Veit Rohde

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    1. Bawarjan Schatlo
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    2. Ramon Martinez
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    3. Awad Alaid
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    4. Kajetan von Eckardstein
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    5. Reza Akhavan-Sigari
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    6. Anina Hahn
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    7. Florian Stockhammer
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    8. Veit Rohde
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    Correspondence to Bawarjan Schatlo.

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    Comment

    The authors report the quality of screw placement using a robotic device. This article is well written and timely. Quality of provided healthcare should be shown to patients, insurance companies and healthcare-controlling instances. One of the issues to support quality is the number of patients who have been treated annually. This report shows that even for this technique a learning curve is present and a minimum number of patients should have been treated to gain experience. After that experience will not greatly improve (expressed as breaches of the pedicle).

    Ronald H.M.A. Bartels

    Nijmegen, The Netherlands

    Bawarjan Schatlo and Ramon Martinez contributed equally to this work

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    Schatlo, B., Martinez, R., Alaid, A. et al. Unskilled unawareness and the learning curve in robotic spine surgery. Acta Neurochir 157, 1819–1823 (2015). https://doi.org/10.1007/s00701-015-2535-0

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    • DOI: https://doi.org/10.1007/s00701-015-2535-0

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