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McNamee C, Keraidi S, McDonnell J, Kelly A, Wall J, Darwish S, Butler JS. Learning curve analyses in spine surgery: a systematic simulation-based critique of methodologies. Spine J 2024:S1529-9430(24)00269-9. [PMID: 38843955 DOI: 10.1016/j.spinee.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 05/13/2024] [Accepted: 05/15/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND CONTEXT Various statistical approaches exist to delineate learning curves in spine surgery. Techniques range from dividing cases into intervals for metric comparison, to employing regression and cumulative summation (CUSUM) analyses. However, their inherent inconsistencies and methodological flaws limit their comparability and reliability. PURPOSE To critically evaluate the methodologies used in existing literature for studying learning curves in spine surgery and to provide recommendations for future research. STUDY DESIGN Systematic literature review. METHODS A comprehensive literature search was conducted using PubMed, Embase, and Scopus databases, covering articles from January 2010 to September 2023. For inclusion, articles had to evaluate the change in a metric of performance during human spine surgery across time/a case series. Results had to be reported in sufficient detail to allow for evaluation of individual performance rather than group/institutional performance. Articles were excluded if they included cadaveric/nonhuman subjects, aggregated performance data or no way to infer change across a number of cases. Risk of bias was assessed using the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tool. Surgical data were simulated using Python 3 and then examined via multiple commonly used analytic approaches including division into consecutive intervals, regression and CUSUM techniques. Results were qualitatively assessed to determine the effectiveness and limitations of each approach in depicting a learning curve. RESULTS About 113 studies met inclusion criteria. The majority of the studies were retrospective and evaluated a single-surgeon's experience. Methods varied considerably, with 66 studies using a single proficiency metric and 47 using more than 1. Operating time was the most commonly used metric. Interval division was the simplest and most commonly used method yet inherent limitations prevent collective synthesis. Regression may accurately describe the learning curve but in practice is hampered by sample size and model choice. CUSUM analyses are of widely varying quality with some being fundamentally flawed and widely misinterpreted however, others provide a reliable view of the learning process. CONCLUSION There is considerable variation in the quality of existing studies on learning curves in spine surgery. CUSUM analyses, when correctly applied, offer the most reliable estimates. To improve the validity and comparability of future studies, adherence to methodological guidelines is crucial. Multiple or composite performance metrics are necessary for a holistic understanding of the learning process.
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Affiliation(s)
- Conor McNamee
- National Spine Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland; University College Dublin School of Medicine, Dublin, Ireland.
| | - Salman Keraidi
- National Spine Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland; University College Dublin School of Medicine, Dublin, Ireland
| | - Jake McDonnell
- National Spine Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Andrew Kelly
- University of Galway School of Medicine, Galway, Ireland
| | - Julia Wall
- National Spine Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Stacey Darwish
- National Spine Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland; Department of Orthopaedics, Saint Vincent's University Hospital, Dublin, Ireland
| | - Joseph S Butler
- National Spine Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland; University College Dublin School of Medicine, Dublin, Ireland
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Silva PS, Pereira P. Answer to the Letter to the Editor of Bansal Tungish, et al. concerning "Minimally invasive fusion surgery for patients with degenerative spondylolisthesis and severe lumbar spinal stenosis: a comparative study between MIDLIF and TLIF" by Pedro Santos Silva, et al. (Eur Spine J [2023]; doi:10.1007/s00586-023-07847-6). EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:1306-1308. [PMID: 38286910 DOI: 10.1007/s00586-023-08081-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 11/29/2023] [Indexed: 01/31/2024]
Affiliation(s)
- Pedro Santos Silva
- Spine Unit, Neurosurgery Department, Centro Hospitalar Universitário São João, Porto, Portugal.
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal.
- Neuroscience Unit, Hospital CUF Porto, Porto, Portugal.
| | - Paulo Pereira
- Spine Unit, Neurosurgery Department, Centro Hospitalar Universitário São João, Porto, Portugal
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal
- Neuroscience Unit, Hospital CUF Porto, Porto, Portugal
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Silva PS, Jardim A, Pereira J, Sousa R, Vaz R, Pereira P. Minimally invasive fusion surgery for patients with degenerative spondylolisthesis and severe lumbar spinal stenosis: a comparative study between MIDLIF and TLIF. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:3210-3217. [PMID: 37422769 DOI: 10.1007/s00586-023-07847-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 03/30/2023] [Accepted: 06/25/2023] [Indexed: 07/11/2023]
Abstract
PURPOSE This study aims to compare midline lumbar interbody fusion (MIDLIF) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for treatment of patients with severe stenosis and lumbar degenerative spondylolisthesis (DS), focusing on dural tears rates, other complications, clinical and radiological outcomes. METHODS This cohort study included patients with severe lumbar spinal stenosis (Shizas C or D) and lumbar DS who underwent MIDLIF or MIS-TLIF. Propensity score matching was done and the groups were compared regarding surgery time, length of stay, perioperative complications, clinical results and radiological outcomes, at 1 year of follow-up. RESULTS The study included initially 80 patients, and 72 patients after matching, 36 in each group. Six patients had dural tears, four in the MIDLIF group and two in the MIS-TLIF group (p = 0.67). General complication rates and reoperations were not significantly different between the groups. Good or excellent clinical was achieved in 75% of the MIDLIF patients and 72% of the MIS-TLIF patients (p = 0.91). Radiological parameters showed small but statistically significant (p < 0.01) improvements after surgery, particularly in segmental lordosis and lumbar lordosis (2.0° and 1.7°), while pelvic tilt and global tilt decreased (1.6° and 2.6°). These findings were similar for both groups. CONCLUSION Our study confirms that MIDLIF is a safe and reliable minimally invasive alternative for lumbar interbody fusion in DS, even in patients with severe stenosis and previous spine surgery. It seems to offer similar results to MIS-TLIF regarding clinical results, radiological outcomes and complications.
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Affiliation(s)
- Pedro Santos Silva
- Spine Unit, Neurosurgery Department, Centro Hospitalar Universitário São João, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal.
- Neuroscience Unit, Hospital CUF Porto, Porto, Portugal.
| | - Ana Jardim
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Joana Pereira
- Serviço de Ortopedia, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Rita Sousa
- Serviço de Ortopedia e Traumatologia, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Rui Vaz
- Spine Unit, Neurosurgery Department, Centro Hospitalar Universitário São João, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal
- Neuroscience Unit, Hospital CUF Porto, Porto, Portugal
| | - Paulo Pereira
- Spine Unit, Neurosurgery Department, Centro Hospitalar Universitário São João, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal
- Neuroscience Unit, Hospital CUF Porto, Porto, Portugal
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Peng SB, Yuan XC, Lu WZ, Yu KX. Application of the cortical bone trajectory technique in posterior lumbar fixation. World J Clin Cases 2023; 11:255-267. [PMID: 36686364 PMCID: PMC9850973 DOI: 10.12998/wjcc.v11.i2.255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/29/2022] [Accepted: 01/05/2023] [Indexed: 01/12/2023] Open
Abstract
The cortical bone trajectory (CBT) is a novel technique in lumbar fixation and fusion. The unique caudocephalad and medial-lateral screw trajectories endow it with excellent screw purchase for vertebral fixation via a minimally invasive method. The combined use of CBT screws with transforaminal or posterior lumbar interbody fusion can treat a variety of lumbar diseases, including spondylolisthesis or stenosis, and can also be used as a remedy for revision surgery when the pedicle screw fails. CBT has obvious advantages in terms of surgical trauma, postoperative recovery, prevention and treatment of adjacent vertebral disease, and the surgical treatment of obese and osteoporosis patients. However, the concept of CBT internal fixation technology appeared relatively recently; consequently, there are few relevant clinical studies, and the long-term clinical efficacy and related complications have not been reported. Therefore, large sample and prospective studies are needed to further reveal the long-term complications and fusion rate. As a supplement to the traditional pedicle trajectory fixation technique, the CBT technique is a good choice for the treatment of lumbar diseases with accurate screw placement and strict indications and is thus deserving of clinical recommendation.
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Affiliation(s)
- Shi-Bo Peng
- Department of Orthopedics, Chongqing Nanchuan Hospital of Traditional Chinese Medicine, Chongqing 408400, China
| | - Xi-Chuan Yuan
- Department of Orthopedics, Chongqing Nanchuan Hospital of Traditional Chinese Medicine, Chongqing 408400, China
| | - Wei-Zhong Lu
- Department of Orthopedics, Chongqing Hospital of Traditional Chinese Medicine, Chongqing 400021, China
| | - Ke-Xiao Yu
- Department of Orthopedics, Chongqing Hospital of Traditional Chinese Medicine, Chongqing 400021, China
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Guo S, Zhu K, Yan MJ, Li XH, Tan J. Cortical bone trajectory screws in the treatment of lumbar degenerative disc disease in patients with osteoporosis. World J Clin Cases 2022; 10:13179-13188. [PMID: 36683619 PMCID: PMC9850985 DOI: 10.12998/wjcc.v10.i36.13179] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/05/2022] [Accepted: 11/28/2022] [Indexed: 12/26/2022] Open
Abstract
Lumbar degenerative disc disease (DDD) in the elderly population remains a global health problem, especially in patients with osteoporosis. Osteoporosis in the elderly can cause failure of internal fixation. Cortical bone trajectory (CBT) is an effective, safe and minimally invasive technique for the treatment of lumbar DDD in patients with osteoporosis. In this review, we analyzed the anatomy, biomechanics, and advantages of the CBT technique in lumbar DDD and revision surgery. Additionally, the clinical trials and case reports, indications, advancements and limitations of this technique were further discussed and reviewed. Finally, we concluded that the CBT technique can be a practical, effective and safe alternative to traditional pedicle screw fixation, especially in DDD patients with osteoporosis.
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Affiliation(s)
- Song Guo
- Department of Orthopedics Surgery, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai 200080, China
| | - Kai Zhu
- Department of Orthopedics Ⅱ, Qingdao No. 8 People’s Hospital, Qingdao 266121, Shandong Province, China
| | - Mei-Jun Yan
- Department of Orthopedics Surgery, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai 200080, China
| | - Xin-Hua Li
- Department of Orthopedics Surgery, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai 200080, China
| | - Jun Tan
- Department of Orthopedics, United Family Healthcare, Shanghai 200336, China
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Samal F, Sterba A, Haninec P, Jurek P, Waldauf P, Filip M, Linzer P. Long-Term Outcome After Midline Lumbar Fusion for the Treatment of Lumbar Spine Instability Due to Degenerative Disease. World Neurosurg 2021; 154:e641-e648. [PMID: 34332153 DOI: 10.1016/j.wneu.2021.07.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Midline lumbar fusion (MIDLF) is one promising new surgical technique that has been developed to minimize perioperative damage to the paravertebral stabilizing musculotendinous system. The aim of this study was to assess long-term clinical and radiological effects of MIDLF. METHODS This prospective cohort study evaluated patients who underwent MIDLF for degenerative spinal instability. Clinical and radiological examinations were performed before and after surgery. Perioperative and postoperative complications were recorded. Follow-up was 2 years. P ≤ 0.05 was considered statistically significant. RESULTS The study included 64 patients (mean age 58.9 ± 10.7 years; 41 women [64.1%]). The most frequent indication for MIDLF was degenerative spondylolisthesis grade I (28 cases [43.8%]); the prevalent spinal segment to be fused was L4-L5 (35 cases [54.7%]). Mean duration of surgery was 148.2 ± 28.9 minutes. Relief of low back pain and leg pain was significant and stable in the postoperative period as assessed by visual analog scale (P < 0.001). Of patients, 86.9% reported fair, good, or excellent outcomes in terms of pain relief based on MacNab score 2 years after surgery. Patients' level of function in activities of daily living improved significantly based on Oswestry Disability Index score: from 66.8 ± 9.8 before surgery to 33.9 ± 16.5 2 years after surgery (P < 0.001). X-rays and computed tomography at 12 months showed interbody fusion in 46 cases (73.4%), inconclusive results in 13 cases (20.3%), and no fusion in 4 cases (6.3%). No damage to neural or vascular structures and no failure of hardware or screw loosening were recorded. CONCLUSIONS MIDLF is a safe, efficient method for surgical treatment of lumbar spine instability. Its limited invasiveness contributes to better preservation of paravertebral muscles and enhanced postoperative spinal stability.
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Affiliation(s)
- Filip Samal
- Neurosurgical Clinic, Kralovske Vinohrady University Hospital, Prague, Czech Republic; Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Albert Sterba
- Neurosurgical Clinic, Kralovske Vinohrady University Hospital, Prague, Czech Republic; Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Pavel Haninec
- Neurosurgical Clinic, Kralovske Vinohrady University Hospital, Prague, Czech Republic; Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Patrik Jurek
- Department of Neurosurgery, Tomas Bata Regional Hospital, Zlin, Czech Republic
| | - Petr Waldauf
- Third Faculty of Medicine, Charles University, Prague, Czech Republic; Clinic of Anesthesiology and Resuscitation, University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Michal Filip
- Department of Neurosurgery, Tomas Bata Regional Hospital, Zlin, Czech Republic; Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Petr Linzer
- Department of Neurosurgery, Tomas Bata Regional Hospital, Zlin, Czech Republic.
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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. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18083855. [PMID: 33916951 PMCID: PMC8067591 DOI: 10.3390/ijerph18083855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 04/04/2021] [Accepted: 04/05/2021] [Indexed: 11/21/2022]
Abstract
Neuro-reflexotherapy (NRT) is a proven effective, invasive treatment for neck and back pain. To assess physician-related variability in results, data from post-implementation surveillance of 9023 patients treated within the Spanish National Health Service by 12 physicians were analyzed. Separate multi-level logistic regression models were developed for spinal pain (SP), referred pain (RP), and disability. The models included all patient-related variables predicting response to NRT and physician-related variables. The Intraclass Correlation Coefficient (ICC) and the Median Odds Ratio (MOR) were calculated. Adjusted MOR (95% CI) was 1.70 (1.47; 2.09) for SP, 1.60 (1.38; 1.99) for RP, and 1.65 (1.42; 2.03) for disability. Adjusted ICC (95%CI) values were 0.08 (0.05; 0.15) for SP, 0.07 (0.03; 0.14) for RP, and 0.08 (0.04; 0.14) for disability. In the sensitivity analysis, in which the 6920 patients treated during the physicians’ training period were excluded, adjusted MOR was 1.38 (1.17; 1.98) for SP, 1.37 (1.12; 2.31) for RP, and 1.25 (1.09; 1.79) for disability, while ICCs were 0.03 (0.01; 0.14) for SP, 0.03 (0.00; 0.19) for RP, and 0.02 (0.00; 0.10) for disability. In conclusion, the variability in results obtained by different NRT-certified specialists is reasonable. This suggests that current training standards are appropriate.
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Delgado-Fernández J, Frade-Porto N, Blasco G, Gonzalez-Tarno P, Gil-Simoes R, Pulido P, Sola RG. Simulation with 3D Neuronavigation for Learning Cortical Bone Trajectory Screw Placement. J Neurol Surg A Cent Eur Neurosurg 2020; 82:262-269. [PMID: 33260245 DOI: 10.1055/s-0040-1715485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND OBJECTIVE Learning a new technique in neurosurgery is a big challenge especially for trainees. In recent years, simulations and simulators got into the focus as a teaching tool. Our objective is to propose a simulator for placement of cortical bone trajectory (CBT) screws to improve results and reduce complications. METHODS We have created a platform consisting of a sawbone navigated with a 3D fluoroscope to familiarize our trainees and consultants with CBT technique and later implement it in our department. Objective Structured Assessment of Technical Skills (OSATS) and Physician Performance Diagnostic Inventory Scale (PPDI) were obtained before and after the use of the simulator by the five participants in the study. Patients who were operated on after the implementation of the technique were retrospectively reviewed. RESULTS During the simulation, there were 4 cases of pedicle breach out of 24 screws inserted (16.6%). After having completed simulation, participants demonstrated an improvement in OSATS and PPDI (p = 0.039 and 0.042, respectively). Analyzing the answers to the different items of the tests, participants mainly improved in the knowledge (p = 0.038), the performance (p = 0.041), and understanding of the procedure (p = 0.034). In our retrospective series, eight patients with L4-L5 instability were operated on using CBT, improving their Oswestry Disability Index (ODI) score (preoperative ODI 58.5 [SD 16.7] vs. postoperative ODI 31 [SD 13.4]; p = 0.028). One intraoperative complication due to a dural tear was observed. In the follow-up, we found a case of pseudoarthrosis and a facet joint violation, but no other complications related to misplacement, pedicle fracture, or hardware failure. CONCLUSION The simulation we have created is useful for the implementation of CBT. In our study, consultants and trainees have valued very positively the learning obtained using the system. Moreover, simulation facilitated the learning of the technique and the understanding of surgical anatomy. We hope that simulation helps reducing complications in the future.
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Affiliation(s)
| | | | - Guillermo Blasco
- Division of Neurosurgery, University Hospital La Princesa, Madrid, Spain
| | | | - Ricardo Gil-Simoes
- Division of Neurosurgery, University Hospital La Princesa, Madrid, Spain
| | - Paloma Pulido
- Division of Neurosurgery, University Hospital La Princesa, Madrid, Spain
| | - R G Sola
- Department of Innovation in Neurosurgery, Universidad Autónoma de Madrid, Madrid, Spain.,Neurosurgical Department Hospital Nuestra Señora del Rosario, Madrid, Spain
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Rohde V. How much "real world" data is needed for clinical decision-making? Acta Neurochir (Wien) 2019; 161:2421-2422. [PMID: 31642997 DOI: 10.1007/s00701-019-04082-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 09/17/2019] [Indexed: 12/12/2022]
Affiliation(s)
- V Rohde
- Department of Neurosurgery, Medical Faculty, University of Goettingen, Göttingen, Germany.
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