The Learning Curve of Subaxial Cervical Pedicle Screw Placement: How Can We Avoid Neurovascular Complications in the Initial Period?

BACKGROUND: Despite the biomechanical benefits of subaxial cervical pedicle screw (CPS) placement, possible neurovascular complications, including vertebral artery and nerve root injury, are of great concern. We have demonstrated many times the safety and efficacy of CPS deployments, even when using freehand technology. OBJECTIVE: To analyze the learning curve of CPS placement to determine the number of cases necessary for assuring safe CPS placement and to identify a reasonable accuracy rate. METHODS: From March 2012 to August 2018, a single surgeon performed posterior cervical fusion surgery using CPS placement on 162 consecutive patients. We classified whole surgical periods, 6 years, into 4 periods. We analyzed the screw breach rate, lateral mass screw conversion (LMSC) rate, and reposition rate. We also compared the CPS placement accuracy in the initial 15, 20, and 30 patients with the other 147, 142, and 132 patients, respectively, to assess the number of procedures necessary to reach the learning curve plateau and to identify a reasonable accuracy rate. RESULTS: The total number of planned CPS placements was 979. Our learning curve showed that the breach rate plateaus at 3% to 4%. The necessary numbers for safe and accurate CPS placement during learning curve were 30 patients and 170 screws. None of the patients undergoing CPS developed a neurologic or vascular complication. CONCLUSION: By following our 5 safety steps, the steady state for safety and accuracy can be reached without neurovascular complications even in the initial period of the learning curve.