PT  - JOURNAL ARTICLE
AU  - KUMAR, ABHISHEK
AU  - MERRILL, ROBERT K.
AU  - OVERLEY, SAMUEL C.
AU  - LEVEN, DANTE M.
AU  - MEAIKE, JOSHUA J.
AU  - VAISHNAV, AVANI
AU  - GANG, CATHERINE
AU  - QURESHI, SHEERAZ A.
TI  - Radiation Exposure in Minimally Invasive Transforaminal Lumbar Interbody Fusion: The Effect of the Learning Curve
AID  - 10.14444/6006
DP  - 2019 Feb 01
TA  - International Journal of Spine Surgery
PG  - 39--45
VI  - 13
IP  - 1
4099  - https://www.ijssurgery.com/content/13/1/39.short
4100  - https://www.ijssurgery.com/content/13/1/39.full
SO  - Int J Spine Surg2019 Feb 01; 13
AB  - Background Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) has comparable fusion rates and outcomes to the open approach, though many surgeons avoid the technique due to an initial learning curve. No current studies have examined the learning curve of MI-TLIF with respect to fluoroscopy time and exposure. Our objective with this retrospective review was to therefore use a repeatable mathematical model to evaluate the learning curve of MI-TLIF with a focus on fluoroscopy time and exposure.Methods We conducted a retrospective review of single level, primary fusions performed by a single surgeon during his initial experience with minimally invasive spine surgery. Chronologic case number was plotted against variables of interest, and learning was identified as the point at which the instantaneous rate of change of a curve fit to the data set equaled the average rate of change of the data set.Results One hundred nine cases were reviewed. Proficiency in operative time was achieved at 38 cases with the first 38 requiring a median of 137 minutes compared to 104 minutes for the latter 71 cases (P < .0001). Mastery of fluoroscopy use occurred at case 51. The median fluoroscopy time for the first 51 cases was 2.8 minutes, which dropped to 2.1 minutes for cases 52 to 109 (P < .0001). The complication rate plateaued after 43 cases, with 3 of 11 total complications occurring in the latter 76 cases.Conclusions Our results demonstrate the most gradual learning occurred with respect to fluoroscopy time and exposure, and operative time improved the quickest.Level of Evidence IV.Clinical Relevance These findings may guide spine surgeon education and training in minimally invasive techniques, and help determine safe case loads for radiation exposure during the initial learning phase of the technique. The model used to identify the learning curve can also be applied to several fields and surgical techniques.