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Complications Associated With the Initial Learning Curve of Minimally Invasive Spine Surgery: A Systematic Review

  • Symposium: Minimally Invasive Spine Surgery
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

There is an inherently difficult learning curve associated with minimally invasive surgical (MIS) approaches to spinal decompression and fusion. The association between complication rate and the learning curve remains unclear.

Questions/purposes

We performed a systematic review for articles that evaluated the learning curves of MIS procedures for the spine, defined as the change in frequency of complications and length of surgical time as case number increased, for five types of MIS for the spine.

Methods

We conducted a systematic review in the PubMed database using the terms “minimally invasive spine surgery AND complications AND learning curve” followed by a manual citation review of included manuscripts. Clinical outcome and learning curve metrics were categorized for analysis by surgical procedure (MIS lumbar decompression procedures, MIS transforaminal lumbar interbody fusion, percutaneous pedicle screw insertion, laparoscopic anterior lumbar interbody fusion, and MIS cervical procedures). As the most consistent parameters used to evaluate the learning curve were procedure time and complication rate as a function of chronologic case number, our analysis focused on these. The search strategy identified 15 original studies that included 966 minimally invasive procedures. Learning curve parameters were correlated to chronologic procedure number in 14 of these studies.

Results

The most common learning curve complication for decompressive procedures was durotomy. For fusion procedures, the most common complications were implant malposition, neural injury, and nonunion. The overall postoperative complication rate was 11% (109 of 966 cases). The learning curve was overcome for operative time and complications as a function of case numbers in 20 to 30 consecutive cases for most techniques discussed within this review.

Conclusions

The quantitative assessment of the procedural learning curve for MIS techniques for the spine remains challenging because the MIS techniques have different learning curves and because they have not been assessed in a consistent manner across studies. Complication rates may be underestimated by the studies we identified because surgeons tend to select patients carefully during the early learning curve period. The field of MIS would benefit from a standardization of study design and collected parameters in future learning curve investigations.

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Authors and Affiliations

  1. Minimally Invasive Spine Center of Excellence, Spine Institute of San Diego, 6719 Alvarado Road, Suite 308, San Diego, CA, 92120, USA

    Joseph A. Sclafani MD & Choll W. Kim MD, PhD

Authors
  1. Joseph A. Sclafani MD
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  2. Choll W. Kim MD, PhD
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Corresponding author

Correspondence to Choll W. Kim MD, PhD.

Additional information

One of the authors (JAS) certifies that he, or a member of his immediate family, has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. One of the authors certifies that he (CWK), or a member of his immediate family, has received or may receive payments or benefits, during the study period, an amount less than USD 10,000 from Globus Medical (Audubon, PA, USA).

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

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Sclafani, J.A., Kim, C.W. Complications Associated With the Initial Learning Curve of Minimally Invasive Spine Surgery: A Systematic Review. Clin Orthop Relat Res 472, 1711–1717 (2014). https://doi.org/10.1007/s11999-014-3495-z

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  • DOI: https://doi.org/10.1007/s11999-014-3495-z

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