Retrospective cohort studyTo characterize the learning curve of a spine surgeon during the first 2 years of independent practice by comparing to an experienced colleague. To stratify learning curves based on procedure to evaluate the effect of experience on surgical complexity.The learning curve for spine surgery is difficult to quantify, but is useful information for hospital administrators/surgical programs/ new graduates, so appropriate expectations and accommodations are considered.Data from a retrospective cohort (2014-2016) were analyzed at a quaternary academic institution servicing a geographicallyisolated, mostly rural area. Procedures included anterior cervical discectomy and fusion, posterior cervical decompression and stabilization, single and 2-level posterior lumbar interbody fusion, lumbar discectomy, and laminectomy. Data related to patient demographics, after-hours surgery, and revision surgery were collected. Operative time was the primary outcome measure, with secondary measures including cerebrospinal fluid leak and early re-operation. Time periods were stratified into 6 month quarters (quarter [Q] 1-Q4), with STATA software used for statistical analysis.There were 626 patients meeting inclusion criteria. The senior surgeon had similar operative times throughout the study. The new surgeon demonstrated a decrease in operative time from Q1 to Q4 (158 minutes-119 minutes, P < .05); however, the mean operative time was shorter for the senior surgeon at 2 years (91 minutes, P < .05). The senior surgeon performed more revision surgeries (odds ratio [OR] 2.5 [95% confidence interval [CI] 1.7-3.6]; P < .001). Posterior interbody fusion times remained longer for the new surgeon, while laminectomy surgery was similar to the senior surgeon by 2 years. There were no differences in rates of cerebrospinal fluid leak (OR 1.2 [95% CI 0.6-2.5]; P > .05), nor reoperation (OR 1.16 [95% CI 0.7-1.9]; P > .05) between surgeons.A significant learning curve exists starting spine practice and likely extends beyond the first 2 years for elective operations.

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Background: There is significant variability in clinically important improvement (CII) criteria for spinal surgery that suggest population-and diagnosis-specific thresholds are required to determine surgical success using patient-reported outcome measures (PROMs). This study establishes surgical CII thresholds for 4 common lumbar degenerative spinal diagnoses using accepted anchor-based methodology and commonly used PROMs. Methods: CII analysis was conducted using baseline and 1-year data from participants in the Canadian Spine Outcomes and Research Network (CSORN) registry who underwent surgery for lumbar spinal stenosis (LSS), degenerative spondylolisthesis (DS), disc herniation (DH) or degenerative disc (DD) from 2015 to 2018. One-year CII thresholds were determined for the Oswestry Disability Index (ODI), and back and leg Numeric Pain Rating Scales (NPRS). At 1 year, patients reported whether they were much better, better, the same, worse or much worse compared with before their surgery. This was used as the anchor (improved: ≥ "better" v. not improved: ≤ "same") to determine CII thresholds for absolute change and percentage change for PROMs using a receiver operating characteristic (ROC) curve approach, with maximization of the Youden index as primary criterion. Correct classification rates were determined. Results: There were 856 participants with LSS (39.1% female, mean age 65.8 yr), 591 with DS (64.1% female, mean age 65.8 yr), 520 with DH (47.5% female, mean age 46.8 yr) and 185 with DD (43.8% female, mean age 50.9 yr). CII for ODI change ranged from -10.0 (DD) to -16.9 (DH). CII for back and leg NPRS change was -2 to -3 for each group. CII for percentage change varied by PROM and pathology group, ranging from -11.1% (ODI for DD) to -50.0% (leg NPRS for DH). Correct classification rates for all CII thresholds ranged from 72.1% to 89.4%. Conclusion: This work quantifies Canadian CII thresholds for the ODI and back and leg NPRS for 4 common lumbar spinal surgery cohorts, with high classification accuracy. Our results suggest that use of generic CII across different diagnoses in spine surgery is not advised. This study establishes the first comprehensive set of responder criteria in Canada for broader application and specificity in clinical and research settings and for surgical prognostic work.

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