Learning curve for biportal endoscopic posterior cervical foraminotomy determined using the cumulative summation test

Abstract

Background Learning curves describe the rate of performance improvements corresponding to the surgeon’s caseload, followed by a plateau where limited further improvements are observed. This study aimed to determine the learning curve for biportal full-endoscopic posterior cervical foraminotomy (BE-PCF) for the unilateral cervical foraminal disc. Methods The learning curve was evaluated using a learning curve cumulative summation test (LC-CUSUM). The goal for the operation time was set to 78 min, which is the mean operation time (mOT) of percutaneous full-endoscopic posterior cervical foraminotomy (PE-PCF) performed by a senior surgeon. Moreover, clinical outcomes and post-operative complications were compared between the early and late learning periods 1 year post-operatively. Results This study enrolled the first 50 patients who underwent single-level BE-PCF, performed by a single surgeon. The LC-CUSUM signalled competency for surgery at the 20th operation, indicating that sufficient evidence was obtained to prove that the surgeon was competent. The mOT was 71.29 ± 11.69 min in BE-PCF, 71.84 ± 12.61 min in the early learning period, and 67.83 ± 10.31 min in the late learning period (p = 0.254). There was no statistical difference in clinical outcomes, visual analogue scale scores, and neck disability index between both periods (p > 0.05). Four complications were recorded throughout the whole period, with three in the early period and one in the late period (p = 0.285). Conclusion Our study shows that BE-PCF has a learning curve of 20 caseloads to achieve 90% proficiency, and it significantly reduces the operation time based on the performance of a senior surgeon proficient in PE-PCF.

Outcomes and Complications Associated With the Learning Curve for Endoscopic Cervical Foraminotomy

“…A total of three articles were included from a total of 792 articles initially retrieved from the three databases. [5][6][7] Refer to Figure 1 for the PRISMA diagram for this study. The mean MINORS score for the three included articles was 16.3 2.9 points.…”

“…The mean MINORS score for the three included articles was 16.3 2.9 points. [5][6][7] Refer to Table 1 for more information on quality grading.…”

“…While numerous studies have examined the effectiveness of various endoscopic cervical spine surgeries, the literature suggests that there is hesitancy to adopt these techniques due to the steep learning curve. [5][6][7][8][9][10] However, before this study, only individual studies have examined the learning curve for endoscopic cervical spine foraminotomy, limiting the generalizability of the results. While there are numerous ways to assess the learning curve for a surgical technique, this study utilized meta-analysis to compare various common outcome measures (ie, operative time, intraoperative blood loss, complication rate) to assess the differences between the learning phase and the competency phase of the learning curve.…”

“…2,3 Despite this fact, endoscopic cervical spine procedures, such as endoscopic cervical foraminotomy, are innovative minimally invasive surgical techniques emerging in the literature for surgical management of cervical pathology without the use of open incision. [4][5][6][7][8][9][10] Although numerous benefits have been ascribed to endoscopic surgical management of cervical conditions, endoscopic cervical spine surgery is believed to have a steep learning curve, which may impact patient outcomes and discourage surgeon utilization. [4][5][6][7] The impact of the learning curve has been established in the literature for other minimally invasive techniques and has been examined in multiple studies regarding lumbar endoscopic surgery.…”

“…[4][5][6][7][8][9][10] Although numerous benefits have been ascribed to endoscopic surgical management of cervical conditions, endoscopic cervical spine surgery is believed to have a steep learning curve, which may impact patient outcomes and discourage surgeon utilization. [4][5][6][7] The impact of the learning curve has been established in the literature for other minimally invasive techniques and has been examined in multiple studies regarding lumbar endoscopic surgery. [11][12][13][14][15] However, no systematic review and meta-analysis exists that examines the impact of the learning curve on patient outcomes and complications with endoscopic cervical foraminotomy to date in the literature, although several individual observational studies have been published recently, indicating interest in this specific topic.…”