Background There is an inherently difficult learning curve associated with minimally invasive surgical (MIS) approaches to spinal decompression and fusion. The association between complication rate and the learning curve remains unclear. Questions/purposes We performed a systematic review for articles that evaluated the learning curves of MIS procedures for the spine, defined as the change in frequency of complications and length of surgical time as case number increased, for five types of MIS for the spine. Methods We conducted a systematic review in the PubMed database using the terms ''minimally invasive spine surgery AND complications AND learning curve'' followed by a manual citation review of included manuscripts. Clinical outcome and learning curve metrics were categorized for analysis by surgical procedure (MIS lumbar decompression procedures, MIS transforaminal lumbar interbody fusion, percutaneous pedicle screw insertion, laparoscopic anterior lumbar interbody fusion, and MIS cervical procedures). As the most consistent parameters used to evaluate the learning curve were procedure time and complication rate as a function of chronologic case number, our analysis focused on these. The search strategy identified 15 original studies that included 966 minimally invasive procedures. Learning curve parameters were correlated to chronologic procedure number in 14 of these studies. Results The most common learning curve complication for decompressive procedures was durotomy. For fusion procedures, the most common complications were implant malposition, neural injury, and nonunion. The overall postoperative complication rate was 11% (109 of 966 cases). The learning curve was overcome for operative time and complications as a function of case numbers in 20 to 30 consecutive cases for most techniques discussed within this review. Conclusions The quantitative assessment of the procedural learning curve for MIS techniques for the spine remains challenging because the MIS techniques have different learning curves and because they have not been assessed in a consistent manner across studies. Complication rates may be underestimated by the studies we identified because surgeons tend to select patients carefully during the early learning curve period. The field of MIS would benefit from a standardization of study design and collected parameters in future learning curve investigations.

The central neuroendocrine system in the Drosophila brain includes two centers, the pars intercerebralis (PI) and pars lateralis (PL). The PI and PL contain neurosecretory cells (NSCs) which project their axons to the ring gland, a complex of peripheral endocrine glands flanking the aorta. We present here a developmental and genetic study of the PI and PL. The PI and PL are derived from adjacent neurectodermal placodes in the dorso-medial head. The placodes invaginate during late embryogenesis and become attached to the brain primordium. The PI placode and its derivatives express the homeobox gene Dchx1 and can be followed until the late pupal stage. NSCs labeled by the expression of Drosophila insulin-like peptide (Dilp), FMRF, and myomodulin form part of the Dchx1 expressing PI domain. NSCs of the PL can be followed throughout development by their expression of the adhesion molecule FasII. Decapentaplegic (Dpp), secreted along the dorsal midline of the early embryo, inhibits the formation of the PI and PL placodes; loss of the signal results in an unpaired, enlarged placodeal ectoderm. The other early activated signaling pathway, EGFR, is positively required for the maintenance of the PI placode. Of the dorso-medially expressed head gap genes, only tailless (tll) is required for the specification of the PI. Absence of the corpora cardiaca, the endocrine gland innervated by neurosecretory cells of the PI and PL, does not affect the formation of the PI/PL, indicating that inductive stimuli from their target tissue are not essential for early PI/PL development.

The rapid adoption rate and integration of mobile technology (tablet computing devices and smartphones) by physicians is reshaping the current clinical landscape. These devices have sparked an evolution in a variety of arenas, including educational media dissemination, remote patient data access and point of care applications. Quantifying usage patterns of clinical applications of mobile technology is of interest to understand how these technologies are shaping current clinical care. A digital survey examining mobile tablet and associated application usage was administered via email to all ACGME training programs. Data regarding respondent specialty, level of training, and habits of tablet usage were collected and analyzed. 40 % of respondents used a tablet, of which the iPad was the most popular. Nearly half of the tablet owners reported using the tablet in clinical settings; the most commonly used application types were point of care and electronic medical record access. Increased level of training was associated with decreased support for mobile computing improving physician capabilities and patient interactions. There was strong and consistent desire for institutional support of mobile computing and integration of mobile computing technology into medical education. While many physicians are currently purchasing mobile devices, often without institutional support, successful integration of these devices into the clinical setting is still developing. Potential reasons behind the low adoption rate may include interference of technology in doctor-patient interactions or the lack of appropriate applications available for download. However, the results convincingly demonstrate that physicians recognize a potential utility in mobile computing, indicated by their desire for institutional support and integration of mobile technology into medical education. It is likely that the use of tablet computers in clinical practice will expand in the future. Thus, we believe medical institutions, providers, educators, and developers should collaborate in ways that enhance the efficacy, reliability, and safety of integrating these devices into daily medical practice.

No abstract

No abstract