Comparison of Single-Level Open and Minimally Invasive Transforaminal Lumbar Interbody Fusions Presenting a Learning Curve

Abstract

Background. Comparison of single-level open and minimally invasive transforaminal lumbar interbody fusions (O-TLIF and MI-TLIF) of a single surgeon and presentation of his MI-TLIF learning curve in a retrospective observational cohort study. Methods. 27 MI-TLIF and 31 O-TLIF patients, performed between 03/01/2013 and 03/31/2018, were compared regarding the operative time, blood loss, blood transfusion frequency, postoperative length of stay (LOS), and adverse events. An overall comparison of pre- and postoperative Oswestry Disability Index (ODI) results and Visual Analog Score (VAS) results of low back and leg pain was performed in the case of the two techniques. For a learning curve presentation, the MI-TLIF cases were compared and the optimal operative time was determined. Results. The gender ratio and age did not differ in the groups. Operative time showed no difference (P=0.88) between the MI-TLIF (161.2 ± 33.7 minutes) and O-TLIF groups (160 ± 33.6 minutes). Intraoperative blood loss was less (P≤0.001) in the MI-TLIF group (288.9 ± 339.8 mL) than in the O-TLIF group (682.3 ± 465.4 mL) while the incidence of blood transfusion was similar (P=0.64). The MI-TLIF group had shorter LOS (2.7 ± 1.1 days vs. 5 ± 2.7, P≤0.001). The frequencies of the surgical site infections (SSI), durotomy, new motor, and sensory deficit were not significantly different (P=0.17, 0.5, 0.29, 0.92). All the ODI, the VAS low back pain, and the VAS leg pain scores improved in both groups significantly (P≤0.001, P≤0.001, and P≤0.001 in the MI-TLIF group and P≤0.001, P≤0.001, and P≤0.001 in the O-TLIF group). The comparison of the pre- and postoperative results of the ODI and VAS questionnaires of the two techniques showed no significant difference regarding the improvement of these scores (MI-TLIF versus O-TLIF pre- and postoperative ODI difference p=0.64, VAS low back pain P=0.47, and VAS leg pain P=0.21). Assessing the MI-TLIF learning curve, operative time was shortened by 63 minutes (P=0.04). After the 14th MI-TLIF case, the surgical duration became relatively constant. Comparing the 14th and previous MI-TLIF cases to the later cases, LOS showed reduction by 1.03 days (P=0.01), while the other parameters did not show significant changes. Conclusions. Similar operative time and postoperative quality of life improvement can be achieved by MI-TLIF procedure as with O-TLIF, and additionally LOS and blood loss can be reduced. When comparing parameters, MI-TLIF can be an alternative option for O-TLIF with a similar complication profile. The learning curve of MI-TLIF can be steep, although it depends on the circumstances.

MIS-TLIF Procedure is Improving With Experience

“…A consistent theme among the studies was a gradual decrease in operative duration; 7 of the studies reported statistically significant decreases in operative duration from during the learning curve to after completion, 6,8,[15][16][17][18][19] confirming that surgeons become more efficient with experience. Furthermore, when comparing operative durations between studies, monotonic trends revealed a significant negative correlation between operative durations of cases during the learning curve and the year studies were published.…”

“…The number of patients in each study varied widely as well. For example, while Lee et al 8 included 90 patients and reported completion of the learning curve at 44 cases, Kovari et al 19 only included 27 patients and reported completion at 14 cases. It is difficult to directly compare these 2 endpoints when the overall cohort size of one study is smaller than the learning curve of the other.…”

Mobility-Maintaining Facet Arthroplasty of the Lumbar Spine With the Second-Generation TOPS System: A Case Series

“…This site's experience has been that the TOPS surgical technique allows implantation of the device without complications and minimal “fiddle factor.” The average operative time of 102 minutes found in this study is lower than reported durations of 1-level spinal fusion procedures of 142 to 200 minutes. 24-26…”

Physician-Related Variability in the Outcomes of an Invasive Treatment for Neck and Back Pain: A Multi-Level Analysis of Data Gathered in Routine Clinical Practice

“…Most reports on learning curves or variability across practitioners for invasive treatments for neck or low back pain focus on interventions other than NRT, many of which lack high quality evidence supporting their efficacy and effectiveness. Moreover, they are based on small samples (e.g., ≤150 patients or ≤3 practitioners), do not use multi-level analyses to adjust results for patient prognosis as established by previously validated models, or have been conducted either retrospectively or outside routine practice conditions (e.g., based on data gathered in randomized controlled trials) [ 8 , 9 , 10 , 11 , 12 , 13 , 40 , 41 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 ]. Therefore, it is inappropriate to compare such data with results from this study.…”