AUCTORES
Globalize your Research
Research Article | DOI: https://doi.org/10.31579/2578-8868/113
Neurosurgeon in Mexico City, Mexico
*Corresponding Author: Carlos Francisco Gutierrez Partida, Neurosurgeon in Mexico City, Mexico
Citation: Gutierrez Partida CF., Javier Q. Olvera., Velazquez Aleman AP., Ramirez leon. JF, Carlolina R Martinez. (2020) Minimally Invasive Transforaminal lumbar Interbody Fusion: when does the Learning Curve Begin?. J. Neuroscience and Neurological Surgery. 6(2); DOI:10.31579/2578-8868/113
Copyright: © 2020 Carlos Francisco Gutierrez Partida, This is an open-access article distributed under the terms of The Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Received: 19 December 2019 | Accepted: 22 January 2020 | Published: 03 February 2020
Keywords: minimally invasive; transforaminal lumbar
A recent studies have reported the learning curve in minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). Over the last two decades there has been a growing interest for the treatment of spinal disorders performed through the use of minimally invasive surgical procedures. The studies are based on clinical result such as blood loss, surgical time, or high rate of perioperative complications but none have studied the origin of these results. This study proposes a systematic learning skills method and a different perspective to evaluate the MI-TLIF learning curve.
Over the last two decades there has been a growing interest for the treatment of spinal disorders performed through the use of minimally invasive surgical procedures. [1,2] Actually, several manuscripts reported successful results associated with MI-TLIF. Also, differents authors evidenced that MI-TLIF procedures provide benefits regarding estimated blood loss, postoperative pain intensity, and length of hospital stay. [3,4,5] Some disadvantages of this technique are: the difficulty associated with working through a narrow surgical corridor that limits visualization of important anatomical landmarks and its steep learning curve. [6,7] A few articles report the existence of a learning curve applied to MI-TLIF, taking into account perioperative and postoperative data. [1,6,7,8] Furthermore, another studies refer that the rate of complications is the best indicator reflecting the experience of a spine surgeon; same studies that recommend to be cautious during initial MI-TLIF procedures to avoid complications associated to the learning effect. [6,7,8,9] However, no study answers the following questions: When does the learning curve originate? Does the curve only reflect the results of performing the technique repeatedly? Based on these concepts, we decided to evaluate the learning process of MI-TLIF technique by first using a systematic learning skills method and subsequently evaluating how that process determined the results of the learning curve in a minimally invasive spine fellow throughout his transition into becoming a minimally invasive spine surgeon.
Materials and Methods
Systematic learning skills method
This method proposes to organize the learning process of a complex minimally invasive spine technique, dividing it into tasks or steps that result in the complete implementation of such. These steps should be gradually learned in able to perform the complete technique fluidly. Surgical skills were evaluated using the OSATS global rating scale. [10] Evaluations were carried out by the surgeons who participated in the procedure. The first assessment of these tasks was developed at 18 months of such training. Subsequently, the last 6 months were also evaluated. The tasks that the MI-TLIF technique were divided into represent the key steps that compose it. These tasks were: [1] Patient placement, [2] Fluoroscopic planning, [3] Incision, [4] Tubular retractor docking, [5] Facetectomy with high-speed drill, [6] Microdiscectomy, (7) Endplate preparation, [8] Bone graft placement, [9] Cage introduction, [10] Pedicle screw placement. It is important to mention that the training period duration of the Minimally Invasive Spine Surgery (MISS)-fellow, who was assessed, lasted 2 years. During this period the MISS-fellow participated in courses, cadaver workshops, and academic sessions that strengthen the theoretical knowledge of the MI-TLIF technique.
The Learning Curve
The approval of local ethics committee was obtained. We retrospectively reviewed clinical records of all patients who underwent MI-TLIF procedures performed by the index author from February 2012 to March 2015. All patients included in the learning curve were operated after concluding the surgeon’s training period, therefore posterior to finalizing the systematic learning skills method described. Inclusion criteria were: adult patients, both genders, with degenerative lumbar spine disease, and without clinical improvement to conservative treatment for a least six months’ period prior to MI-TLIF. In addition, we excluded patients in which revision surgery was performed. With these selection criteria we included fifty-four patients as a discretionary sampling.
Measured parameters
Perioperative parameters included: patient demographics, operative time, estimated blood loss, perioperative and posoperative complications, and length of hospital stay. Visual Analogue Scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and the 36-Item Short Form Health Survey (SF-36) were preoperatively assessed and at 5 and 12 months after surgery.
Surgical technique
The patient will be in prone position under general anesthesia, continuous neurophysiologic monitoring (a really important tool), and fluoroscopic image guidance with C-arm, surgical approach was performed on the most symptomatic side. Progressive tubular retractors were used. Minimally invasive surgical procedure was performed through a 16 mm diameter working cannula. Complete lateral facetectomy and discectomy were performed; the endplates were prepared and bone graft was delivered in the lumbar intersomatic space. A rectangular bullet-nose cage was inserted. Cannulated transpedicular screws were placed afterwards.
Statistical analysis
Descriptive statistics was performed using SPSS version 17.0 statistical software. The clinical records were sequentially ordered according to date of surgery. Surgical time was properly adjusted on patients undergoing a multilevel MI-TLIF procedure. [12] The learning curve based on surgical time was calculated by piecewise regression analysis using the mathematical algorithm described by Muggeo, [13] (SigmaPlot statistical software version 12.3).
Results
Systematic learning skills method
The surgical tasks performed by the MISS-fellow during his learning process of MI-TLIF technique, during the first 18 months, were a total of 237 tasks on 32 patients. During the last 6 months he performed 220 tasks on 22 patients.
Consequently, the surgeon acquired more experience as he performed more tasks throughout the learning process. The evaluation of surgical skills with OSATS global rating scale rated 27 points in the first 237 tasks and 30 points in the subsequent 220 tasks. This means that the fluidity of the procedure improved in terms of task execution during the last 6 months analyzed. Table 1
The learning curve
Piecewise regression analysis evidenced that according to operative time in MI-TLIF, there is a break point at the 16th patient. Figure 1 The moving range chart demonstrated longer surgical time in patients 9, 26, and 36 despite the average operating time.
The Figure 2 of 54 patients evaluated from February 2012 to March 2015, 30 patients (55.5%) were female and 24 patients (44.4%) were male. Mean (SD) age of the patients was 68.917.18 years (range from 65-89 years). Two-level surgery was performed in 19 patients (35.18%) while 2 cases (3.7%) required a three-level fusion surgery. Mean (SD) operative time was 182.463.6 min (range 90-340 min) while the mean (SD) estimated blood loss was 43.834.1 mL (range 10-250 mL). The median hospital length stay was 3 days (IQR 2-10 days). VAS back and leg pain as well as ODI were assessed preoperatively and at the 6 and 12 month mark. SF-36 survey was evaluated preoperatively and at the final follow-up. Table 2 None of the cases required conversion to open surgery.
No perioperative complications occurred. The ability to treat conditions of the spine through the use of minimally invasive surgical techniques has gained interest amongst spine surgeons and their patients over the last two decades. [1,2] Web, et al assessed the arguments emitted by eighty-seven spine surgeons about limitations and disadvantages of MISS techniques and they concluded that there is a lack of effectiveness, technical difficulty, radiation exposure, and very few opportunities to learn these types of techniques; a fact that is more prominent in Latin American countries. [14] Specifically talking about MI-TLIF, the results of recent clinical studies and meta-analysis showed benefits regarding perioperative bleeding, postoperative pain, hospital length stays, infection rates, and overall costs. Other studies consider the rate of complications the best clinical indicator of the spine surgeon ́s experience and recommend to be cautious during the initial procedures to avoid potential complications related to the learning effect. [3,5,6,7,8,9] The learning curves in MI-TLIF published by authors like Nandyala, et al referred perioperative outcomes in sixty-five procedures of MI- TLIF and demonstrated longer surgical time, more blood loss, and increased anesthetic time in the first thirty-three cases. In addition, the frequency of complications and hospital length stay were similar to those operated by conventional open surgery. [15] Schizas, et al reported a learning curve in MI-TLIF that showed decreased surgical time after twelve patients were operated consecutively and also showed no increase in the frequency of complications associated to the learning effect. [8] Lee, et al reported a learning curve of MI-TLIF reached after 30 cases. They compared their first 30 cases with subsequent ones which had less operating time, estimated blood loss, and hospital length stay. [16] It is important to remember that the principle underlying the learning curve is well established: performing tasks in repetitive fashion reduces the time to complete them and increases the quality of those tasks. Therefore, the learning curve must be interpreted according to its specific context. In this study, a learning curve associated with surgical time was estimated in 54 patients who underwent MI-TLIF by a MISS-surgeon that completed his training period using a different learning process that, up until now, had not been described: the systematic learning skills method. The learning curve showed stabilization in surgical time after the 16th patient. Figure 1 piecewise regression analysis estimates the break point at the 16th patient.
A complications variable was not considered for the learning curve development because there were no complications reported in any of the 54 patients. This reinforces the fact that the learning method is crucial for good clinical results and that the surgical time depends on the clinical scenario characterized by performing the whole technique on real patients.
This demonstrates that the progressive acquisition of the surgical skills is needed to perform a fluid and safe MI-TLIF technique in a real clinical scenario. Applying the learning skills method when executing the technique ensures that the young MISS-Surgeon can avoid complications, and if any were to arise he would have the proper knowledge to approach them. Therefore, we think that the initial experience in MI-TLIF is acquired with the partial execution of numerous key tasks of the technique. The mastery of individual surgical tasks is verified by the fluency and ergonomics of movements, which leads to surgical proficiency throughout the whole procedure. Figure 3
When does the learning curve originate? We consider that the learning curve in MI-TLIF starts with sequential training and knowledge of every step that conforms the whole technique, beginning with the surgeon’s training. The learning curve is also influenced by the number and repetition of surgical tasks performed in particular clinical scenarios (patient individual setting). We determined that the learning curve is influenced by the application of the totality of the technique in his surgical practice as a faculty surgeon. In addition, the whole process of experience is completed by the academic labor of the surgeon. This was the proposed method in this article. After this analysis, we establish that the learning curve should be understood as a process that leads to clinical results. Therefore, the clinical results obtained after preforming the whole technique do not represent the totality of the learning curve, they are just a part of it. This article tries to change the paradigm established by previous literature which states that the learning curve is limited to just the clinical outcomes and instead to consider it as a measurement of the learning skills obtained up until the point when the whole procedure can be accomplished.
This method could be implemented in the teaching and learning process for future MIS-Surgeon´s training applied in each and every other minimally invasive spine surgery technique.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
