Introduction
The coronavirus disease 2019 (COVID-19) was declared a pandemic on 11 March 2020, after which millions of lives were lost and healthcare systems around the world were restructured. In real clinical practice, we discovered that acute diseases could be managed by several different medical specialties [
1]. Unfortunately, elective surgeries and many other surgical procedures were canceled or postponed in China. The overall orthopedic case volume has also been drastically scaled back. Therefore, as an in-person activity, teaching has been challenging during the COVID-19 pandemic. Although there has been increasing investigation of the orthopedic potential role of multiple education methods, the emergence of the high-risk potential of injury to the spinal cord and vascular structures as well destroying destruction of landmark bony structures due to tumors invading nature, has led to the dilemma in orthopedic oncology teaching. Therefore, because of the challenges associated with the COVID-19 pandemic, alternative surgical methods that allow students the opportunity to gain knowledge and skills are in demand.
With the advent of artificial intelligence and mechanical automation, imaging and computer-assisted robotic navigation (CARN) techniques have been adopted in multidisciplinary surgery. Robotic surgery was first introduced in neurosurgery in 1995, and a robot was first introduced into spinal surgery in the mid-2000s [
2,
3]. The robotic system was initially applied in spinal surgery because the freehand technique had a relatively high rate of suboptimal pedicle screw placement (PSP). Several studies [
4‐
6] have already shown the promising outcomes, accuracy, and precision of PSP with computer-assisted robotic systems. Although it has, in theory, shown satisfactory results in training novice surgeons in accurate PSP, this technology is relatively new and has never been used in spinal oncology education.
The objective of this study was to show the application of this technology in spinal oncology education. This new CARN training program for novice orthopedists was developed based on precise screw placement in the real world. To address this, in our present study, we retrospectively explored the learning curve and cumulative summation (CUSUM) for the time to PSP proficiency among trainees.
Discussion
There used to be several complex barriers facing an intern to become a real orthopedist. In addition, the advent of the COVID-19 pandemic has led to a sharp reduction in surgical ability, and opportunities to practice orthopedic surgeries. It has now become more difficult for interns to learn procedures in clinical practice than previously during residency training. Admittedly, adapting to the “post-COVID-19 Era” is still a stressful and ongoing challenge. Therefore, the approach to teaching should also be changed in terms of methods, especially for surgical interns.
As a spinal surgeon, PSP is a fundamental surgical technology that provides multidimensional protection and significant rigidity for further treatment [
15]. Traditionally, pedicle screws in spinal oncology patients have been inserted by hand, but pedicle screws inserted by hand are often inaccurately placed due to the complex anatomical structure of the spinal tumor based on the anatomical site. Therefore, inaccurate placement of pedicle screws may damage vital tissues, leading to serious surgical complications, including pedicle fracture or penetration, nerve root or spinal cord injury, vascular injury, dural rupture, and epidural hematoma. In patients with spinal tumors, radiation and chemotherapy also severely impair osseous healing and reduce bone quality. Therefore, once screws are malposition in frail patients, the risks of spinal fracture and instability are even higher. The desire to decrease the time to proficiency and the incidence of surgical complications while increasing efficiency and accelerating training seem to be more critical and urgent than at any time before the COVID-19 pandemic.
In a previous study of spinal surgery, the safety of PSP by primary surgeons using the freehand technique was acceptable under appropriate supervision [
16]. Some studies also reported that as PSP training began, accuracy and operation time finally tended to reach a plateau [
17]. However, because of differences in medical education and surgical practice, the turning point was also different in different studies. Gonzalvo et al. [
18] showed that a significant decline in complication rate and a sharp reduction in the operation time of PSP occurred after approximately 80 screws were placed, approximately in the 25th patient. In another study, according to the LC-CUSUM analysis, the turning point on the learning curve marking adequate placement was approximately 114 screws in the 17th patient. K. J. Ryu [
19] also described a continuous decreasing trend in accurate screw placement until 23–25 patients were operated on. Other papers [
20‐
22] also showed a similar learning curve for spinal surgeries to correct a deformed spine, but they did not report a definitive number of PSPs needed to achieve proficiency. They also focused more on scoliosis surgery but seldom on tumor surgery.
Computer-assisted navigation techniques have shown promising results by increasing the accuracy of spinal instrumentation, reducing the risk of potential complications, and reducing radiation exposure [
23,
24]. It is also possible to achieve a high degree of precision with the technology and repetitive tasks can be completed without diminishing performance. However, although there are limitations in visibility and surgeons’ experience after participating in a traditional training program, computer-assisted robotic systems may be an ideal teacher for PSP. Our most important finding was the steeper learning curve seen in studies examining surgical training methods associated with the robotic program. We found that the CARN training program helped novice orthopedists become proficient in PSP with fewer pedicle screws and fewer patients. Furthermore, the learning curve associated with the CARN training program was steeper than both the traditional PSP training program and the post-report [
25] according to our findings. In addition, the decline in the time to PSP proficiency in the early stage was more visible in CARN education than in traditional education even if the difference did not reach statistical significance. Compared with the traditional education group, the participants in the CARN group were able to reduce the time to proficiency for spinal surgery. However, the mean time to proficiency was longer in the CARN group. It seems that spine surgeons with experience in PSP would not benefit so much from the CARN training program.
As expected, the CUSUM test was successful in evaluating the quality of our new educational model. In our research, these plots did cross the satisfactory level of h. The results may indicate that the CARN training program and the traditional freehand training program would lead to accurate PSP. Even if CARN was a new training system for surgeons, implementation of this novel training program showed a favorable result considering that all the trainees were less experienced spine surgeons. In the early stage of LC-CUSUM, pedicle screw failure was observed more often in our study in both trainees. Therefore, learning curves would be flattened as they started from a well-educated point in real surgical practice than students did in our study. The safety of the CARN training program was also evaluated by the accuracy of pedicle screws. The rate of perfect trajectory, Grade A, was statistically higher in the CARN training program group than in the traditional group. In our research, no adverse events or revision surgeries were recorded.
We acknowledge the following limitations of our study. First, it was based on only two trainees’ surgical practices at a single institution. In addition, the two spinal surgeons were familiar with this new robotic-assisted training program. Therefore, this learning curve and CUSUM curve may be more appropriate for those well-versed in courses focusing on computer-assisted robotic systems. Second, all the procedures performed in this study were open surgeries with full exposure of the relevant anatomy. Therefore, we were unable to evaluate the accuracy of the CARN training program when used for percutaneous or minimally invasive spine procedures.
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