Transforaminal Lumbar Interbody Fusion with Rigid Interspinous Process Fixation: A Learning Curve Analysis of a...

Studies have shown that a significant learning curve may be associated with adopting minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) with bilateral pedicle screw fixation (BPSF). Accordingly, several hybrid TLIF techniques have been proposed as surrogates to the accepted BPSF technique, asserting that less/fewer fixation(s) or less disruptive fixation may decrease the learning curve while still maintaining the minimally disruptive benefits. TLIF with interspinous process fixation (ISPF) is one such surrogate procedure. However, despite perceived ease of adaptability given the favorable proximity of the spinous processes, no evidence exists demonstrating whether or not the technique may possess its own inherent learning curve. The purpose of this study was to determine whether an intraoperative learning curve for one- and two-level TLIF + ISPF may exist for a single lead surgeon.

Seventy-four consecutive patients who received one- or two-Level TLIF with rigid ISPF by a single lead surgeon were retrospectively reviewed. It was the first TLIF + ISPF case series for the lead surgeon. Intraoperative blood loss (EBL), hospitalization length-of-stay (LOS), fluoroscopy time, and postoperative complications were collected. EBL, LOS, and fluoroscopy time were modeled as a function of case number using multiple linear regression methods. A change point was included in each model to allow the trajectory of the outcomes to change during the duration of the case series. These change points were determined using profile likelihood methods. Models were fit using the maximum likelihood estimates for the change points. Age, sex, body mass index (BMI), and the number of treated levels were included as covariates.

EBL, LOS, and fluoroscopy time did not significantly differ by age, sex, or BMI (p ≥ 0.12). Only EBL differed significantly by the number of levels (p = 0.026). The case number was not a significant predictor of EBL, LOS, or fluoroscopy time (p ≥ 0.21). At the time of data collection (mean time from surgery: 13.3 months), six patients had undergone revision due to interbody migration. No ISPF device complications were observed.

Study outcomes support the ideal that TLIF + ISPF can be a readily adopted procedure without a significant intraoperative learning curve. However, the authors emphasize that further assessment of long-term healing outcomes is essential in fully characterizing both the efficacy and the indication learning curve for the TLIF + ISPF technique.