Perioperative Surgical Complications and Learning Curve Associated with Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Single-Institute Experience

Abstract

BackgroundAs surgical complications tend to occur more frequently in the beginning stages of a surgeon's career, knowledge of perioperative complications is important to perform a safe procedure, especially if the surgeon is a novice. We sought to identify and describe perioperative complications and their management in connection with minimally invasive transforaminal lumbar interbody fusion (TLIF).MethodsWe performed a retrospective chart review of our first 124 patients who underwent minimally invasive TLIF. The primary outcome measure was adverse events during the perioperative period, including neurovascular injury, implant-related complications, and wound infection. Pseudarthroses and adjacent segment pathologies were not included in this review. Adverse events that were not specifically related to spinal surgery and did not affect recovery were also excluded.ResultsPerioperative complications occurred in 9% of patients (11/124); including three cases of temporary postoperative neuralgia, two deep wound infections, two pedicle screw misplacements, two cage migrations, one dural tear, and one grafted bone extrusion. No neurologic deficits were reported. Eight complications occurred in the first one-third of the series and only 3 complications occurred in the last two-thirds of the series. Additional surgeries were performed in 6% of patients (7/124); including four reoperations (two for cage migrations, one for a misplaced screw, and one for an extruded graft bone fragment) and three hardware removals (one for a misplaced screw and two for infected cages).ConclusionsWe found perioperative complications occurred more often in the early period of a surgeon's experience with minimally invasive TLIF. Implant-related complications were common and successfully managed by additional surgeries in this series. We suggest greater caution should be exercised to avoid the potential complications, especially when surgeon is a novice to this procedure.

Minimally invasive techniques for lumbar decompressions and fusions

“…Cited factors for nonadoption of MIS techniques include technical factors, limited training opportunities, and increased radiation exposure [74]. Specifically, the lack of training opportunities can lead to a steep learning curve, where earlier cases in a surgeon's experience may be associated with worse operative and clinical outcomes [75][76][77]. Studies investigating the learning curve in MIS techniques have identified earlier cases to be associated with increased operative times, radiation exposure, and complication risk [76][77][78].…”

“…Specifically, the lack of training opportunities can lead to a steep learning curve, where earlier cases in a surgeon's experience may be associated with worse operative and clinical outcomes [75][76][77]. Studies investigating the learning curve in MIS techniques have identified earlier cases to be associated with increased operative times, radiation exposure, and complication risk [76][77][78]. Sclafani et al, in a meta-analyis of 15 studies investigating learning curves, determined that 20-30 cases were required to overcome the learning curve for MIS procedures [75].…”

The National Neurosurgery Quality and Outcomes Database Qualified Clinical Data Registry: 2015 measure specifications and rationale

“…In the intraoperative phase, impeccable surgical aseptic technique, the timing and selection of antibiotic prophylaxis, and minimizing blood transfusions are key processes. 60,65,66,89,102,144 In the postoperative phase, aseptic wound care and early detection of wound inflammation or breakdown contribute to prevention of delayed contamination and subsequent infection.…”

“…9 Improvements in disability scores following spine surgery have been demonstrated in a number of conditions. 102,[106][107][108]122,150,151 One multicenter study investigated the outcomes of treatment for lumbar spinal stenosis, which represents the most common indication for surgery in patients over 65 years old. 151 In an as-treated analysis of 654 patients with 4-year follow-up, functional disability was found to be significantly reduced in patients who underwent surgery compared to those treated without surgery.…”

Learning Curve in Single-Level Minimally Invasive Tlif: Experience of a Neurosurgeon

“…11 Likewise, longer surgical times have been reported for MI, at least during the first cases, which could be a reflection of technical differences, but some authors associate this with a significant learning curve. [12][13][14][15][16][17][18] The objective of this study was to present and analyze the single level MI-TLIF learning curve for a single neurosurgeon (JASS). To this end, we evaluated various parameters, such as surgical time, amount of bleeding, and days of hospitalization.…”