Does the Specialty of the Surgeon Performing Elective Anterior/Lateral Lumbar Interbody Fusion for Degenerative Spine Disease Correlate with Early Perioperative Outcomes?

BACKGROUND: Comparative effectiveness research has a vital role in health reform and policies. Specialty training is one of these provider-side variables, and surgeons performing the same procedure who were trained in different specialties may have different outcomes. The objective of this study was to investigate the impact of spine surgeon specialty (neurosurgery vs. orthopedic surgery) on early perioperative outcome measures of elective anterior/lateral lumbar interbody fusion (ALIF/LLIF) for degenerative disc diseases. METHODS: In a retrospective, 1:1 propensity score-matched cohort study, 9070 patients were reviewed from the American College of Surgeons National Surgical Quality Improvement Program database. Propensity score matching and subgroup analysis were used. RESULTS: In both groups (single-level and multilevel ALIF/LLIF), patients operated on by neurosurgeons had longer operative time (188 minutes vs. 172 minutes/239 minutes vs. 221 minutes); shorter total hospital stay (71 hours vs. 90 hours/89 hours vs. 96 hours); and lower rates of return to the operating room (2.1% vs. 4.1%/2.4% vs. 4.2%), nonhome discharge (8.7% vs. 11.1%/10.1% vs. 14.9%), discharge after postoperative day 3 (22.0% vs. 30.0%/38.0% vs. 43.9%), and perioperative blood transfusion (2.1% vs. 5.1%/5.0% vs. 9.9%) (P < 0.05). In multilevel ALIF/LLIF, patients operated on by neurosurgeons had lower readmission rates (3.9% vs. 6.9%) (P < 0.05). Other outcome measures and mortality rates were similar between the single-level and multilevel ALIF/LLIF cohorts regardless of surgeon specialty. CONCLUSIONS: Our analysis found significant differences in early perioperative outcomes of patients undergoing ALIF/LLIF by neurosurgeons and orthopedic surgeons. These differences have significant clinical and cost implications for patients, physicians, program directors, payers, and health systems.

A Two-Surgeon Approach Improves Performance for Young Surgeons in Adolescent Idiopathic Scoliosis.

Adolescent idiopathic scoliosis (AIS) is a complex 3-dimensional deformity. Previous studies have suggested a learning curve in the successful execution of this technically demanding procedure. A 2-surgeon model may be helpful for less experienced surgeons by facilitating greater consistency in surgical metrics. The objective of this study was to show no significant difference in the parameters examined for surgeries done by inexperienced primary surgeons with a 2-surgeon model compared with those done by their more experienced cohorts. All surgeries with a primary diagnosis of AIS that were performed from January 2012 to December 2015 and had a minimum of 2-year follow-up were included for analysis. Three groups were created based on surgeon experience: inexperienced surgeons (IS) group, experienced surgeons (ES) group, and a third group where the primary surgeon was in the experienced group and the assistant surgeon was in the inexperienced group (EIS). Variables included for analysis were age, Lenke classification, number of levels fused, length of surgery, length of stay, percent curve correction, ratio of estimated blood loss to levels fused, surgical blood loss, and complications. There were no significant differences between the groups in terms of operative time, blood loss, number of levels fused, lower estimated blood loss ratio to the number of levels fused, or percent curve correction (P>.05). The IS group was found to have a significant shorter length of stay (P=.004). The 2-surgeon model is an effective tool for inexperienced surgeons to achieve consistent and reproducible operative performance that is comparable with their more experienced peers. [Orthopedics. 2021;44(3):e347-e352.].

Learning Curve for a Dual Attending Surgeon Strategy in Posterior Spinal Fusion (PSF): An Analysis of 105 Severe Adolescent Idiopathic Scoliosis Patients (Cobb Angle ≥90°).

STUDY DESIGN: Retrospective study. OBJECTIVE: To assess the learning curve of a dual attending surgeon strategy in severe adolescent idiopathic scoliosis patients. SUMMARY OF BACKGROUND DATA: The advantages of a dual attending surgeon strategy in improving the perioperative outcome in scoliosis surgery had been reported. However, the learning curve of this strategy in severe scoliosis had not been widely studied. METHODS: A total of 105 patients with adolescent idiopathic scoliosis with Cobb angle of 90° or greater, who underwent posterior spinal fusion using a dual attending surgeon strategy were recruited. Primary outcomes were operative time, total blood loss, allogeneic blood transfusion requirement, length of hospital stay from time of operation and perioperative complications. Cases were sorted chronologically into group 1: cases 1 to 35, group 2: cases 36 to 70, and group 3: case 71 to 105. Mean operative time (≤193.3 min), total blood loss (≤1612.2 mL), combination of both and allogeneic blood transfusion were the selected criteria for receiver operating characteristic analysis of the learning curve. RESULTS: The mean Cobb angle was 104.5°â€Š±â€Š12.3°. The operative time, total blood loss, and allogeneic blood transfusion requirement reduced significantly for group 1 (220.6 ±â€Š54.8 min; 2011.3 ±â€Š881.8 mL; 12 cases) versus group 2 (183.6 ±â€Š36.7 min; 1481.6 ±â€Š1035.5 mL; 3 cases) and group 1 versus group 3 (175.6 ±â€Š38.4 min; 1343.7 ±â€Š477.8 mL; 3 cases) (P < 0.05). There were six perioperative complications. Fifty-seven cases were required to achieve the preset criteria (mean operative time and mean total blood loss) (area under the curve 0.740; P < 0.001; sensitivity 0.675; specificity 0.662). CONCLUSION: There was significant improvement in operative time and total blood loss when comparing group 1 versus group 2 and group 1 versus group 3. The cut-off point for the learning curve was 57 cases when the preset criteria were fulfilled (≤193.3 min operative time and ≤1612.2 mL of total blood loss).Level of Evidence: 4.

Learning Curve and Clinical Outcome of Biportal Endoscopic-Assisted Lumbar Interbody Fusion.

Interbody fusion is a common surgical technique for diseases of the lumbar spine. Biportal endoscopic-assisted lumbar interbody fusion (BE-LIF) is a novel minimally invasive technique that has a long learning curve, which can be a barrier for surgeons. Therefore, we analyzed the learning curve in terms of operative time and evaluated the outcomes of BE-LIF. A retrospective study of fifty-seven consecutive patients who underwent BE-LIF for degenerative lumbar disease by a single surgeon from January 2017 to December 2018 was performed. Fifty patients underwent a single-level procedure, and 7 underwent surgery at two levels. The mean follow-up period was 24 months (range, 14-38). Total operative time, postoperative drainage volume, time to ambulation, and complications were analyzed. Clinical outcome was measured using the Oswestry Disability Index (ODI), Visual Analog Scale (VAS) score for back and leg pain, and modified Macnab criteria. The learning curve was evaluated by a nonparametric regression locally weighted scatterplot smoothing curve. Cases before the stable point on the curve were designated as group A, and those after the stable point were designated group B. Operative time decreased as the number of cases increased. A stable point was noticed on the 400th day and the 34th case after the first BE-LIF was performed. All cases showed improved ODI and VAS scores at the final follow-up. Overall mean operative time was 171.74 ± 35.1 min. Mean operative time was significantly lower in group B (139.7 ± 11.6 min) compared to group A (193.4 ± 28.3 min). Time to ambulation was significantly lower in group B compared to group A. VAS and ODI scores did not differ between the two groups. BE-LIF is an effective minimally invasive technique for lumbar degenerative disease. In our case series, this technique required approximately 34 cases to reach an adequate performance level.

Augmented Reality Supported Cervical Transpedicular Fixation on 3D-Printed Vertebrae Model: An Experimental Education Study.

AIM: To investigate the use of Augmented Reality (AR) technology as it contributes to spinal surgery education with the free-hand technique, and might reduce the error ratio. MATERIAL AND METHODS: Ten candidates, with anatomy education but no surgical experience, applied 36 pedicle screws with C2-C3 posterior transpedicular fixation technique to nine vertebrae models produced via a three-dimensional (3D) printer. RESULTS: Using AR to apply pedicle screws to the experimental vertebrae model increased the safety screw ratio significantly. In comparison of Grade 0 screws to other grades: 6/18 screws (33.3%) in the free-hand technique Group (n=18), and 14/18 screws (77.8%) in the AR Group (n=18), were measured for screw insertion safety ratios. The difference was statistically significant (p=0.018). The resemblance between our results and the results of previous studies researching supportive systems indicates our 3D printed vertebra model might be a helpful educational material. CONCLUSION: AR increases the safety ratio of cervical pedicle screw fixation significantly. The parameters investigated and used for the production of vertebrae models in this study can be used for experimental material production for future studies to investigate pedicle screw positioning.

Biomimetic 3-Dimensional-Printed Posterior Cervical Laminectomy and Fusion Simulation: Advancements in Education Tools for Trainee Instruction.

Surgical proficiency is classically acquired through live experience in the operating room. Trainee exposure to cases and complex pathologies is highly variable between training programs.1 Currently, there is no standard for neurosurgical skill assessment for specific operative techniques for trainees. Cadaveric simulation has been used to demonstrate surgical technique and assess resident skill but often presents a significant financial and facility burden.2-4 Three-dimensional (3D) printing is an alternative to cadaveric tissue in providing high-quality representation of surgical anatomy; however, this technology has significant limitations in replicating conductive soft tissue structures for the use of cauterization devices and haptic learning for proper tissue manipulation.5-7 Our team has combined novel synthesis methods of conductive thermoplastic polymerization and 3-dimensional-printed cervical spine models to produce a layered biomimetic simulation that provides cost-effective and anatomically accurate education for neurosurgical trainees (Video 1). This is accomplished through virtual modeling and layered simulator construction methods by placing the individual polymer layers according to anatomic location of the simulated in vivo structures. The consistency of the thermoplastics can be tailored according to the desired soft tissue structures (skin, fat, fascia, muscle) according to the degree of polymerization. This cost-effective simulation was designed to represent the material and biomechanical properties of the cervical spine cortico-cancellous interface, as well as individual soft tissue components with specific anatomic details of muscle tendinous and ligamentous insertion. These features allow for representative start-to-finish surgical simulation that has not yet been made widely available to neurosurgical training programs.

Pedicle Screw Instrumentation in Scoliosis Surgery: On Site Simulation Data on Accuracy and Efficiency With Different Techniques.

STUDY DESIGN: Prospective experimental study with on-site simulation. OBJECTIVE: To compare the accuracy and efficiency of different techniques for pedicle screw instrumentation (PSI). SUMMARY OF BACKGROUND DATA: Improving the safety and efficiency of PSI is a critical step to reduce the complication rates and the cost of scoliosis surgery. Innovative operative techniques for PSI have shown to safely improve efficiency, thereby reducing cost. Surgical simulation is a valuable tool to study different operative techniques. METHODS: Five spine fellows instrumented 20 simulation models of a scoliotic spine with 10 pedicle screws per model. Four techniques were studied, including the conventional pedicle probe and the innovative sequential drilling technique, with or without computed tomography (CT)-based navigation. Our primary outcome measures were efficiency and accuracy of PSI. We analyzed the data with bivariate analyses using the Chi-square test for categorical variables and the Student t test or ANalysis Of VAriance with Bonferroni post-hoc tests for continuous variables. RESULTS: The drilling techniques (free hand and navigated) were more efficient as compared with the pedicle probe techniques (P < 0.01). The navigated techniques resulted in better accuracy as compared with the free hand techniques (P = 0.036). Most pedicle breaches were medial (n = 32/52). The concave apical pedicle (T4 right side) had the highest incidence of breaches. There was no significant difference in efficiency comparing the free hand and the navigated pedicle probe techniques (P = 0.261) or comparing the free hand drilling and the navigated drilling techniques (P = 1.00). CONCLUSION: On site surgical simulation is a promising concept for teaching advanced procedural skills. Our findings suggest that navigation improves the accuracy of PSI while sequential drilling safely improves efficiency. Combining navigation with sequential drilling can significantly improve the accuracy and the efficiency of PSI in scoliosis surgery, as previously suggested with our published clinical data. LEVEL OF EVIDENCE: 4.

Impact of medical student involvement on outcomes following spine surgery: A single center analysis of 6485 patients.

Medical student (MS) observation and assistance in the operating room (OR) is a critical component of medical education. Though participation in the operating room has many benefits to the medical student, the potential cost of these experiences to the patients must be taken into account. Other studies have shown differences in outcomes with resident involvement, but the effect of medical students in the OR has been poorly understood. The objective of this study was to understand how medical students and residents impacted surgical outcomes in posterior spinal fusions, anterior cervical discectomy and fusions (ACDFs), and lumbar discectomies. We conducted a retrospective study of patients undergoing posterior spinal fusions, ACDFs, and lumbar discectomies over 15 years. There were 6485 patients met the inclusion criteria of either undergoing a posterior fusion, ACDF or lumbar discectomy (1250 posterior fusion, 1381 ACDF, 3854 lumbar discectomies). Overall, little difference was observed when a medical student was present for surgical outcomes including length of stay, infection, and readmission. For ACDFs, having a medical student present had a significantly longer procedure durations (OR = 1.612, p = 0.001) than cases without. Besides slightly longer operative time (in posterior fusions), there were no major differences in outcomes when a medical student was present in the OR.

Development of a Novel 3D Printed Phantom for Teaching Neurosurgical Trainees the Freehand Technique of C2 Laminar Screw Placement.

BACKGROUND: 3D printed models have grown in popularity for resident training. Currently there is a paucity of simulators specifically designed for advanced cervical instrumentation. Our institution created a unique simulator for the instruction of freehand placement of C2 laminar screws using a specific 3-dimensional printing technique to replicate the corticocancellous interface. This study was designed to determine the efficacy of the simulator for teaching neurosurgical residents the freehand technique of C2 laminar screw placement. METHODS: Ten participants with different experience levels participated in the study. The participants were separated into 2 groups based on experience level. Primary outcome assessments were breach rates, screw-screw interaction, and the ability to successfully place 2 screws in 1 model. Participants were graded based on a performance scoring system, and the outcomes of the 2 groups were compared. RESULTS: All participants in the novice group showed improved technical ability on repeated use of the simulator and were able to successfully place bilateral screws by the fourth attempt. Statistical analysis indicated an association between operative experience level and successful bilateral screw placement, implying that the simulator accurately represented an in vivo intraoperative scenario. CONCLUSIONS: By utilizing our novel 3D printing production method, we have created a unique simulator for the freehand placement of C2 laminar screws. To our knowledge, this is the first report of a study investigating the use of a 3-dimensional printed simulator specifically designed to teach the freehand placement of C2 laminar screws to neurosurgical trainees.

Navigation versus experience: providing training in accurate lumbar pedicle screw positioning.

PURPOSE: Accurate placement of spinal pedicle screws (PS) is mandatory for good primary segmental stabilization allowing consequent osseous fusion, requiring judgmental experience developed during a long training process. Computer navigation offers permanent visual control during screw manipulation and has been shown to significantly lower the risk of pedicle perforation. This study aims to evaluate whether safety, accuracy, and judgmental skills in screw placement, comparable to an experienced surgeon, can be developed during training using computer navigation. METHODS: Lumbosacral PS were placed in 18 patients in a prospective setting, in one segment side with conventional fluoroscopy by a senior spine-surgeon, and computer navigated on the other side by a trainee without prior experience in the technique. At the beginning and at the end of the study, PS were placed freehand in solid foam models by the trainee. PS placement time, intraoperative placement revisions, PS placement accuracy on postoperative CT scans, and postoperative complications were assessed. RESULTS: Significant improvement of trainee's PS placement accuracy (Sclafani score 8.2-8.83; p = 0.006) and time (13.3-6.8 min per screw; p = 0.005) to a similar level as the experienced surgeon state (5.2-4.1 min per screw; p = 0.39) was explored; similar improvement was explored in the foam models. The number of intraoperative placement revisions kept on a low level for surgeon (3.3-0.0%) and trainee (5.1-2.6%) during the whole study, no postoperative complications occurred. CONCLUSION: Navigated PS insertion allows safe teaching from the early beginning of surgical training, due to steady intraoperative control on PS placement. Adequacy of PS placement is similar to screws placed by an experienced surgeon. Progress in judgmental skills in screw placement can be gained rapidly by the trainee, which can also be transferred to non-computer navigated PS placement.

Development of a Spine Surgical Skills and Written Assessment for Orthopaedic Surgery Residents.

OBJECTIVE: The objective of this study was to develop an assessment module for orthopaedic spine surgery residents which is cost-effective and can reliably test knowledge and surgical skills. DESIGN: A ten-question multiple choice question and hands-on spine sawbones combination assessment was prospectively administered to consenting PGY-3 and PGY-4 residents before and after their 8-week spine rotation. Pre- and postrotation scores were compared using the paired t-test. SETTING: The Department of Orthopaedics, The Ohio State University Wexner Medical Center, a large academic medical centre providing primary and tertiary care. PARTICIPANTS: Orthopaedic resident physicians. RESULTS: A total of 21 residents (15 PGY-3, 6 PGY-4) participated in the study. The mean pre- and postrotation written test score was 7.38 ± 1.53 and 9.24 ± 0.83, respectively (p < 0.001). Corresponding surgical skills assessment scores were 95.4% ± 4.7 and 97.1% ± 2.6, respectively (p = 0.10). Overall, the postrotation written and surgical scores improved and showed less variation about the mean. CONCLUSIONS: This combination assessment measured improvement in below-average scoring residents and maintenance or improvement in residents with average and above average prerotation scores.

Surgical training in spine surgery: safety and patient-rated outcome.

PURPOSE: The aim of this study was to investigate the difference in patient-reported outcomes and surgical complication rates between lumbar procedures carried out either by experienced board-certified spine surgeons (BCS) or by supervised spine surgery residents (RES) in a large Swiss teaching hospital. METHODS: This was a single-center retrospective analysis of data collected prospectively within the framework of the EUROSPINE Spine Tango Registry. It involved the data of 1415 patients undergoing first-time surgery in our institution between the years 2004 and 2016. Patients were divided into three groups based on the surgical procedure: lumbar single-level fusion (SLF), single-level decompression (SLD) for lumbar spinal stenosis and disc hernia procedures (DH). Patient-reported outcome measures (primary outcome) included the multidimensional Core Outcome Measures Index (COMI) preoperatively and 3 and 12 months postoperatively plus single items concerning satisfaction with care and global treatment outcome (GTO). Secondary outcomes included surgical variables such as blood loss, duration of surgery, complication rates and length of stay. RESULTS: There were no significant differences between the RES and BCS patient groups for most of the demographic and baseline clinical variables with the exception of age in the SLD group (p = 0.012), BMI in the DH group (p = 0.02) and leg pain in the SLF group (p = 0.03). COMI scores improved significantly after all three types of procedure (p < 0.0001) without significant difference (p > 0.05) between the patients of RES and BCS. There was no significant difference (p > 0.05) between RES and BCS patients with regard to satisfaction and GTO. There were no significant differences between RES and BCS (p > 0.05) in the surgical or medical complication rates. CONCLUSION: In the given setting, surgical training of spine surgery residents under guided supervision by board-certified spine surgeons was shown to be safe, as it was not associated with greater morbidity or mortality. Furthermore, it had no detrimental influence on patient-reported outcomes. The findings can be used to give reassurance to prospective patients that are to be operated on by supervised spine surgery residents. These slides can be retrieved under Electronic Supplementary Material.

Learning Curve in Surgical Treatment of Odontoid Fixation for a Series of Type II C2 Fractures.

The craniovertebral junction (CVJ) is a complex anatomical area upon which most of the motion of the upper cervical spine depends [1]. Because of its unique range of motion, the CVJ is subject to several types of traumatic injury; it has been shown that odontoid fractures are the most common ones in the general population and are the most common isolated spinal fractures [2]. Accounting for up to 18% of all cervical fractures, odontoid fractures are the most common ones in elderly patients [3], in whom they account for up to 60% of spinal cord injuries [4].

Learning Curve of Minimally Invasive Surgery Oblique Lumbar Interbody Fusion for Degenerative Lumbar Diseases.

OBJECTIVE: To characterize the learning curve for a single surgeon during his initial phases of performing minimally invasive surgery oblique lumbar interbody fusion. METHODS: This was a prospective analysis of 49 consecutive patients who underwent a single-level minimally invasive surgery oblique lumbar interbody fusion performed by a single surgeon. Patients were divided into group A (first 24 patients) and group B (25 patients after initial 24 patients). The following data were compared between the 2 groups: surgical time, estimated blood loss, radiograph exposure time, clinical and radiographic results, and intraoperative and postoperative complications. The learning curve was assessed using a logarithmic curve-fit regression analysis. RESULTS: Average operative time was significantly longer in group A compared with group B. Compared with group B, group A had significantly more x-ray exposure time. Perioperative complications included thigh numbness and pain in 8 cases, psoas and quadriceps weakness in 3 cases, sympathetic nerve injury in 2 cases, and paralytic ileus in 1 case. All complications were transient and resolved within 3 months. The incidence of complications was 37.5% in group A and 20.0% in group B. Clinical and radiographic outcomes were basically identical in the 2 groups at last follow-up. CONCLUSIONS: Minimally invasive surgery oblique lumbar interbody fusion presents a learning curve to the practicing spine surgeon with regard to operative time, x-ray exposure time, and intraoperative and postoperative complications. Close attention to detail can minimize complications that may be associated with the learning curve.

Computer-assisted, minimally invasive transforaminal lumbar interbody fusion: One surgeon's learning curve A STROBE-compliant article.

Minimally invasive (MI) transforaminal lumbar interbody fusion (TLIF) is a challenging technique with a long learning curve. We combined computer-assisted navigation and MI TLIF (CAMISS TLIF) to treat lumbar degenerative disease. This study aimed to evaluate the learning curve associated with computer-assisted navigation MI spine surgery (CAMISS) and TLIF for the surgical treatment of lumbar degenerative disease. Seventy four consecutive patients with lumbar degenerative disease underwent CAMISS TLIF between March 2011 and May 2015; all surgeries were performed by a single surgeon. According to the plateau of the asymptote, the initial 25 patients constituted the early group and the remaining patients comprised the latter group. The clinical evaluation data included operative times, anesthesia times, intraoperative blood losses, days until ambulation, postoperative hospital stays, visual analog scale (VAS) leg and back pain scores, Oswestry disability index (ODI) values, Macnab outcome scale scores, complications, radiological outcomes, and rates of conversion to open surgery. The complexity of the cases increased over the series, but the complication rate decreased (12.00%-6.12%). There were significant differences between the early and late groups with respect to the average surgical times and durations of anesthesia, but no differences in intraoperative blood losses, days until ambulation, postoperative hospital stays, complication rate, VAS, ODI, Macnab outcome scale scores, or solid fusion rates. There was no need for conversion to open procedures in either group. Our study showed that a plateau asymptote for CAMISS TLIF was reached after 25 operations. The later patients experienced shorter operative times and anesthesia durations.

Impact of resident participation on outcomes following lumbar fusion: An analysis of 5655 patients from the ACS-NSQIP database.

The role of resident involvement on patient safety, morbidity, and mortality in lumbar spinal surgery has been poorly defined in the literature. The objective of this study is to investigate the relationship between resident involvement in the operating room and 30-day complication rates in patients undergoing lumbar spinal fusion procedures. We used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to retrospectively identify all patients who underwent a lumbar spinal fusion from 2006 to 2013. A propensity score matching algorithm was employed to minimize baseline differences. Multivariate logistic regression analysis of unadjusted and propensity-matched groups was performed to examine the effect of resident participation on operative details and 30-day complication rates. A total of 5655 patients met the inclusion criteria and propensity score matching yielded 1965 well-matched pairs. Resident involvement in lumbar fusion procedures was not found to be a significant predictor for mortality or reoperation. It was found to be a significant predictor for increased hospital stay (matched non-resident 4.0 ±â€¯5.8 days vs. resident 4.6 ±â€¯4.3 days, p < 0.001), operative time (matched non-resident 198 ±â€¯102 min vs. resident 243 ±â€¯118 min, p < 0.001), sepsis (matched OR 4.36, 95% CI 2.10-9.05, p < 0.001), development of DVT/PE (matched OR 2.02, 95% CI 1.10-3.70, p = 0.023), and superficial surgical site infections (matched OR 1.78, 95% CI 1.04-3.06, p = 0.037). In conclusion, this large-scale, population-based study found that resident participation in the operating room was safe but increased the risk of 30-day complications and increased operative duration and length of hospital stay.

Evaluation of C2 pedicle screw placement via the freehand technique by neurosurgical trainees.

OBJECTIVE Freehand placement of C2 instrumentation is technically challenging and has a learning curve due the unique anatomy of the region. This study evaluated the accuracy of C2 pedicle screws placed via the freehand technique by neurosurgical resident trainees. METHODS The authors retrospectively reviewed all patients treated at the LAC+USC Medical Center undergoing C2 pedicle screw placement in which the freehand technique was used over a 1-year period, from June 2016 to June 2017; all procedures were performed by neurosurgical residents. Measurements of C2 were obtained from preoperative CT scans, and breach rates were determined from coronal reconstructions on postoperative scans. Severity of breaches reflected the percentage of screw diameter beyond the cortical edge (I = < 25%; II = 26%-50%; III = 51%-75%; IV = 76%-100%). RESULTS Neurosurgical residents placed 40 C2 pedicle screws in 24 consecutively treated patients. All screws were placed by or under the guidance of Pham, who is a postgraduate year 7 (PGY-7) neurosurgical resident with attending staff privileges, with a PGY-2 to PGY-4 resident assistant. The authors found an average axial pedicle diameter of 5.8 mm, axial angle of 43.1°, sagittal angle of 23.0°, spinal canal diameter of 25.1 mm, and axial transverse foramen diameter of 5.9 mm. There were 17 screws placed by PGY-2 residents, 7 screws placed by PGY-4 residents, and 16 screws placed by the PGY-7 resident. The average screw length was 26.0 mm, with a screw diameter of 3.5 mm or 4.0 mm. There were 7 total breaches (17.5%), of which 4 were superior (10.0%) and 3 were lateral (7.5%). There were no medial breaches. The breaches were classified as grade I in 3 cases (42.9%), II in 3 cases (42.9%), III in 1 case (14.3%), and IV in no cases. There were 3 breaches that occurred via placement by a PGY-2 resident, 3 breaches by a PGY-4 resident, and 1 breach by the PGY-7 resident. There were no clinical sequelae due to these breaches. CONCLUSIONS Freehand placement of C2 pedicle screws can be done safely by neurosurgical residents in early training. When breaches occurred, they tended to be superior in location and related to screw length choice, and no breaches were found to be clinically significant. Controlled exposure to this unique anatomy is especially pertinent in the era of work-hour restrictions.

Effectiveness of the Thoracic Pedicle Screw Placement Using the Virtual Surgical Training System: A Cadaver Study.

BACKGROUND: The virtual simulation surgery has initially exhibited its promising potentials in neurosurgery training. OBJECTIVE: To evaluate effectiveness of the Virtual Surgical Training System (VSTS) on novice residents placing thoracic pedicle screws in a cadaver study. METHODS: A total of 10 inexperienced residents participated in this study and were randomly assigned to 2 groups. The group using VSTS to learn thoracic pedicle screw fixation was the simulation training (ST) group and the group receiving an introductory teaching session was the control group. Ten fresh adult spine specimens including 6 males and 4 females with a mean age of 58.5 yr (range: 33-72) were collected and randomly allocated to the 2 groups. After exposing anatomic structures of thoracic spine, the bilateral pedicle screw placement of T6-T12 was performed on each cadaver specimen. The postoperative computed tomography scan was performed on each spine specimen, and experienced observers independently reviewed the placement of the pedicle screws to assess the incidence of pedicle breach. RESULTS: The screw penetration rates of the ST group (7.14%) was significantly lower in comparison to the control group (30%, P < .05). Statistically significant difference in acceptable rates of screws also occurred between the ST (100%) and control (92.86%) group (P < .05). In addition, the average screw penetration distance in control group (2.37 mm ± 0.23 mm) was significantly greater than ST group (1.23 mm ± 0.56 mm, P < .05). CONCLUSION: The virtual reality surgical training of thoracic pedicle screw instrumentation effectively improves surgical performance of novice residents compared to those with traditional teaching method, and can help new beginners to master the surgical technique within shortest period of time.

Virtual surgery simulation versus traditional approaches in training of residents in cervical pedicle screw placement.

INTRODUCTION: The cervical screw placement is one of the most difficult procedures in spine surgery, which often needs a long period of repeated practices and could cause screw placement-related complications. We performed this cadaver study to investigate the effectiveness of virtual surgical training system (VSTS) on cervical pedicle screw instrumentation for residents. MATERIALS AND METHODS: A total of ten novice residents were randomly assigned to two groups: the simulation training (ST) group (n = 5) and control group (n = 5). The ST group received a surgical training of cervical pedicle screw placement on VSTS and the control group was given an introductory teaching session before cadaver test. Ten fresh adult spine specimens including 6 males and 4 females were collected, and were randomly allocated to the two groups. The bilateral C3-C6 pedicle screw instrumentation was performed in the specimens of the two groups, respectively. After instrumentation, screw positions of the two groups were evaluated by image examinations. RESULTS: There was significantly statistical difference in screw penetration rates between the ST (10%) and control group (62.5%, P < 0.05). The acceptable rates of screws were 100 and 50% in the ST and control groups with significant difference between each other (P < 0.05). In addition, the average screw penetration distance in the ST group (1.12 ± 0.47 mm) was significantly lower than the control group (2.08 ± 0.39 mm, P < 0.05). CONCLUSIONS: This study demonstrated that the VSTS as an advanced training tool exhibited promising effects on improving performance of novice residents in cervical pedicle screw placement compared with the traditional teaching methods.

Surgical skills: Can learning curves be computed from recordings of surgical activities?

PURPOSE: Surgery is one of the riskiest and most important medical acts that are performed today. The need to improve patient outcomes and surgeon training, and to reduce the costs of surgery, has motivated the equipment of operating rooms with sensors that record surgical interventions. The richness and complexity of the data that are collected call for new methods to support computer-assisted surgery. The aim of this paper is to support the monitoring of junior surgeons learning their surgical skill sets. METHODS: Our method is fully automatic and takes as input a series of surgical interventions each represented by a low-level recording of all activities performed by the surgeon during the intervention (e.g., cut the skin with a scalpel). Our method produces a curve describing the process of standardization of the behavior of junior surgeons. Given the fact that junior surgeons receive constant feedback from senior surgeons during surgery, these curves can be directly interpreted as learning curves. RESULTS: Our method is assessed using the behavior of a junior surgeon in anterior cervical discectomy and fusion surgery over his first three years after residency. They revealed the ability of the method to accurately represent the surgical skill evolution. We also showed that the learning curves can be computed by phases allowing a finer evaluation of the skill progression. CONCLUSION: Preliminary results suggest that our approach constitutes a useful addition to surgical training monitoring.