Radiation Exposure in Minimally Invasive Transforaminal Lumbar Interbody Fusion: The Effect of the Learning Curve

Objective: The aim was to evaluate the learning curve of skinanchored intraoperative navigation (ION) for minimally invasive lumbar surgery.Summary of Background Data: ION is increasingly being utilized to provide better visualization, improve accuracy, and enable less invasive procedures. The use of noninvasive skin-anchored trackers for navigation is a novel technique, with the few reports on this technique demonstrating safety, feasibility, and significant reductions in radiation exposure compared with conventional fluoroscopy. However, a commonly cited deterrent to wider adoption is the learning curve.Methods: Retrospective review of patients undergoing 1-level minimally invasive lumbar surgery was performed. Outcomes were:(1) time for ION set-up and image-acquisition; (2) operative time;(3) fluoroscopy time; (4) radiation dose; (5) operative complications; (6) need for repeat spin; (7) incorrect localization. Chronologic case number was plotted against each outcome. Derivative of the nonlinear curve fit to the dataset for each outcome was solved to find plateau in learning.Results: A total of 270 patients [114 microdiscectomy; 79 laminectomy; 77 minimally invasive transforaminal lumbar interbody fusion (MI-TLIF)] were included. (1) ION set-up and image-acquisition: no learning curve for microdiscectomy. Proficiency at 23 and 31 cases for laminectomy and MI-TLIF, respectively. (2) Operative time: no learning curve for microdiscectomy. Proficiency at 36 and 31 cases for laminectomy and MI-TLIF, respectively. (3) Fluoroscopy time: no learning curve. (4) Radiation dose: proficiency at 42 and 33 cases for microdiscectomy and laminectomy, respectively. No learning curve for MI-TLIF. ( 5) Operative complications: unable to evaluate for microdiscectomy and MI-TLIF. Proficiency at 29 cases for laminectomy. ( 6) Repeat spin: unable to evaluate for microdiscectomy and laminectomy. For MI-TLIF, chronology was not associated with repeat spins. (7) Incorrect localization: none.Conclusions: Skin-anchored ION did not result in any wrong level surgeries. Learning curve for other parameters varied by surgery type, but was achieved at 25-35 cases for a majority of outcomes.

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“…Details regarding the technique for skin-anchored ION and surgical steps have been described in prior publications. [16][17][18][19][20][21][22]…”

Section: Surgical Techniquementioning

confidence: 99%

Time-demand, Radiation Exposure and Outcomes of Minimally Invasive Spine Surgery With the Use of Skin-Anchored Intraoperative Navigation

Vaishnav

Gang

Qureshi

2021

Clinical Spine Surgery: A Spine Publication

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“…TLIF was performed through a tubular retractor with unilateral facetectomy and placement of percutaneous pedicle screws. [15][16][17][18][19][20] LLIF was performed through a tubular retractor without resection of the anterior longitudinal ligament (ALL), with subsequent placement of percutaneous pedicle screws when needed. ALIF was performed through a retroperitoneal approach with the assistance of an access surgeon.…”

Section: Patient Samplementioning

confidence: 99%

Does interbody cage lordosis impact actual segmental lordosis achieved in minimally invasive lumbar spine fusion?

Lovecchio

Vaishnav

Steinhaus

et al. 2020

Neurosurgical Focus

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OBJECTIVEIn an effort to prevent loss of segmental lordosis (SL) with minimally invasive interbody fusions, manufacturers have increased the amount of lordosis that is built into interbody cages. However, the relationship between cage lordotic angle and actual SL achieved intraoperatively remains unclear. The purpose of this study was to determine if the lordotic angle manufactured into an interbody cage impacts the change in SL during minimally invasive surgery (MIS) for lumbar interbody fusion (LIF) done for degenerative pathology.METHODSThe authors performed a retrospective review of a single-surgeon database of adult patients who underwent primary LIF between April 2017 and December 2018. Procedures were performed for 1–2-level lumbar degenerative disease using contemporary MIS techniques, including transforaminal LIF (TLIF), lateral LIF (LLIF), and anterior LIF (ALIF). Surgical levels were classified on lateral radiographs based on the cage lordotic angle (6°–8°, 10°–12°, and 15°–20°) and the position of the cage in the disc space (anterior vs posterior). Change in SL was the primary outcome of interest. Subgroup analyses of the cage lordotic angle within each surgical approach were also conducted.RESULTSA total of 116 surgical levels in 98 patients were included. Surgical approaches included TLIF (56.1%), LLIF (32.7%), and ALIF (11.2%). There were no differences in SL gained by cage lordotic angle (2.7° SL gain with 6°–8° cages, 1.6° with 10°–12° cages, and 3.4° with 15°–20° cages, p = 0.581). Subgroup analysis of LLIF showed increased SL with 15° cages only (p = 0.002). The change in SL was highest after ALIF (average increase 9.8° in SL vs 1.8° in TLIF vs 1.8° in LLIF, p < 0.001). Anterior position of the cage in the disc space was also associated with a significantly greater gain in SL (4.2° vs −0.3°, p = 0.001), and was the only factor independently correlated with SL gain (p = 0.016).CONCLUSIONSCompared with cage lordotic angle, cage position and approach play larger roles in the generation of SL in 1–2-level MIS for lumbar degenerative disease.

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“…Cataract, bleeding, and other complications were included in the cumulative complication number in keeping with prior reports of learning curves. 30 The average complication rate was the total number of relevant complications over the entire case series. The derivatives of the association curves fitted to the overall datasets were calculated, and the corresponding case numbers were regarded as cutoff points.…”

Section: Methodsmentioning

confidence: 99%

The Learning Curve of Murine Subretinal Injection Among Clinically Trained Ophthalmic Surgeons

Huang

Narendran

Pereira

et al. 2022

Trans. Vis. Sci. Tech.

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Purpose Subretinal injection (SRI) in mice is widely used in retinal research, yet the learning curve (LC) of this surgically challenging technique is unknown. Methods To evaluate the LC for SRI in a murine model, we analyzed training data from three clinically trained ophthalmic surgeons from 2018 to 2020. Successful SRI was defined as either the absence of retinal pigment epithelium (RPE) degeneration after phosphate buffered saline injection or the presence of RPE degeneration after Alu RNA injection. Multivariable survival-time regression models were used to evaluate the association between surgeon experience and success rate, with adjustment for injection agents, and to calculate an approximate case number to achieve a 95% success rate. Cumulative sum (CUSUM) analyses were performed and plotted individually to monitor each surgeon's simultaneous performance. Results Despite prior microsurgery experience, the combined average success rate of the first 50 cases in mice was only 27%. The predicted SRI success rate did not reach a plateau above 95% until approximately 364 prior cases. Using the 364 training cases as a cutoff point, the predicted probability of success for cases 1 to 364 was 65.38%, and for cases 365 to 455 it was 99.32% ( P < 0.0001). CUSUM analysis showed an initial upward slope and then remained within the decision intervals with an acceptable success rate set at 95% in the late stage. Conclusions This study demonstrates the complexity and substantial LC for successful SRI in mice with high confidence. A systematic training system could improve the reliability and reproducibility of SRI-related experiments and improve the interpretation of experimental results using this technique. Translational Relevance Our prediction model and monitor system allow objective quantification of technical proficiency in the field of subretinal drug delivery and gene therapy for the first time, to the best of our knowledge.

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Radiation Exposure in Minimally Invasive Transforaminal Lumbar Interbody Fusion: The Effect of the Learning Curve

Cited by 40 publications

References 18 publications

Time-demand, Radiation Exposure and Outcomes of Minimally Invasive Spine Surgery With the Use of Skin-Anchored Intraoperative Navigation

Time-demand, Radiation Exposure and Outcomes of Minimally Invasive Spine Surgery With the Use of Skin-Anchored Intraoperative Navigation

Does interbody cage lordosis impact actual segmental lordosis achieved in minimally invasive lumbar spine fusion?

The Learning Curve of Murine Subretinal Injection Among Clinically Trained Ophthalmic Surgeons

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