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Complications associated with the initial learning curve of minimally invasive spine surgery: a systematic review
Joseph A Sclafani1, Choll W Kim
1Minimally Invasive Spine Center of Excellence, Spine Institute of San Diego, 6719 Alvarado Road, Suite 308, San Diego, CA, 92120, USA.
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.
Insights
Minimally invasive spine surgery (MIS) has a learning curve, with complication rates decreasing after 20-30 cases. Standardized study designs are needed to accurately assess MIS learning curves.
Area of Science:
- Neurosurgery
- Orthopedic Surgery
- Spine Surgery
Background:
- Minimally invasive surgery (MIS) for the spine presents a steep learning curve for surgeons.
- The relationship between surgeon experience and complication rates in MIS spinal procedures is not well understood.
Purpose of the Study:
- To systematically review literature evaluating the learning curves of various MIS spinal procedures.
- To define learning curves by changes in complication frequency and surgical time with increasing case numbers.
Main Methods:
- Systematic review of PubMed and manual citation analysis for studies on MIS spine surgery learning curves.
- Categorization of clinical outcomes and learning curve metrics by procedure type (decompression, fusion, pedicle screw insertion, cervical).
- Analysis focused on operative time and complication rates as a function of case number.
Main Results:
- The learning curve for operative time and complication rates was overcome within 20-30 cases for most MIS techniques.
- Common complications included durotomy for decompression and implant malposition/neural injury for fusion.
- Overall postoperative complication rate was 11%.
Conclusions:
- Consistent assessment of MIS spinal surgery learning curves is challenging due to technique variability and inconsistent study designs.
- Complication rates may be underestimated due to careful patient selection during early learning phases.
- Standardization of study design and parameters is crucial for future MIS learning curve investigations.
