Minimally Invasive Transforaminal Lumbar Interbody Fusion: Cost of a Surgeon's Learning Curve

Diogo Garcia, Bernardo Sousa-Pinto, Gaetano De Biase, Henry Ruiz-Garcia, Oluwaseun O. Akinduro, Ruchita Dholakia, Bijan Borah, W. Christopher Fox, Eric Nottmeier, H. Gordon Deen, Kingsley Abode-Iyamah, Alfredo Quinones-Hinojosa, Selby Chen

Research output: Contribution to journalArticlepeer-review


Background: Minimally invasive transforaminal interbody fusion has become an increasingly common approach in adult degenerative spine disease but is associated with a steep learning curve. We sought to evaluate the impact of the learning experience on mean procedure time and mean cost associated with each procedure. Methods: We studied the first 100 consecutive minimally invasive transforaminal interbody fusion procedures of a single surgeon. We performed multivariable linear regression models, modeling operating time, and costs in function of the procedure order adjusted for patients' age, sex, and number of surgical levels. The number of procedures necessary to attain proficiency was determined through a k-means cluster analysis. Finally, the total excess operative time and total excess cost until obtaining proficiency was evaluated. Results: Procedure order was found to impact procedure time and mean costs, with each successive case being associated with progressively less procedure time and cost. On average, each successive case was associated with a reduction in procedure time of 0.97 minutes (95% confidence interval 0.54–1.40; P < 0.001) and an average adjusted reduction in overall costs of $82.75 (95% confidence interval $35.93–129.57; P < 0.001). An estimated 58 procedures were needed to attain proficiency, translating into an excess procedure time of 2604.2 minutes (average of 45 minutes per case), overall costs associated with the learning experience of $226,563.8 (average of $3974.80 per case), and excess surgical cost of $125,836.6 (average of $2207.66 per case). Conclusions: Successive cases were associated with progressively less procedure time and mean overall and surgical costs, until a proficiency threshold was attained.

Original languageEnglish (US)
Pages (from-to)e1-e7
JournalWorld neurosurgery
StatePublished - Jun 2022


  • Costs
  • Health economic model
  • Minimally invasive
  • Spinal
  • Spine surgery
  • Transforaminal lumbar interbody fusion

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology


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