Assessing the Learning Process of Transforaminal Endoscopic Discectomy for Sciatica

Abstract

Objective: Percutaneous transforaminal endoscopic discectomy (PTED) is gaining popularity by both surgeons and patients as a less invasive treatment option for sciatica. Concerns, however, exist for its learning curve. No previous study has assessed the learning process of PTED. Hereby we present the learning process of 3 surgeons learning PTED.Methods: This analysis was conducted alongside a multicenter randomized controlled trial. After attending a cadaveric workshop, 3 spine-dedicated surgeons started performing PTED, initially under the supervision of a senior surgeon. After each 5 cases, and up to case 20, the learning process was evaluated using the validated questionnaires (objective structured assessment of technical skills [OSATS], global operative assessment of laparoscopic skills [GOALS]) and a 10-step checklist specifically developed for PTED.Results: In total, 3 learning curve surgeons performed a total of 161 cases. Based on self-assessment, surgeons improved mostly in the domains “time and motion,” “respect for tissue,” and “knowledge and handling of instruments.” Learning curve surgeons were more able to detect differences in performances on the OSATS than the senior surgeon. Based on the GOALS, the biggest improvements could be seen in “depth-perception” and “autonomy.” Based on the 10-item specific checklist, all surgeons performed all 10 steps by case 10, while only 1 surgeon performed all steps adequately by case 15.Conclusion: Based on these study results, PTED appears to be successfully adopted stepwise by 3 spine-dedicated surgeons. From 15 cases on, most steps are performed adequately. However, more cases might be necessary to achieve good clinical results. Validated tools are needed to determine the cutoff when a surgeon should be able to perform PTED independently.

Validity Evidence for Procedure-specific Competence Assessment Tools in Orthopaedic Surgery: A Scoping Review

“…We identified 22 studies using 24 procedure-specific surgical assessment tools (Table 1 ). 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 These tools assessed a variety of orthopaedic surgery procedures, including diagnostic knee arthroscopy and partial meniscectomy, 21 , 31 , 36 arthroscopic hip labral repair, 26 diagnostic shoulder arthroscopy, 21 , 29 arthroscopic rotator cuff repair and labral repair, 15 , 16 , 19 , 22 23 24 25 , 27 open surgical approaches to the shoulder (deltopectoral, lateral deltoid-splitting, and posterior), 28 shoulder arthroplasty, 20 arthroscopic hamstring anterior cruciate ligament reconstruction, 30 open carpal tunnel release, 34 , 35 trigger finger release, 34 percutaneous transforaminal endoscopic diskectomy, 17 and fracture fixation. 18 , 21 , 32 - 34 All tools included a checklist of critical steps that were graded categorically.…”

“…All tools except the Arthroscopic Bankart Metric and percutaneous transforaminal endoscopic diskectomy 10-step checklist were part of hybrid tools that also included a global rating scale. 17 , 22 23 24 25 All but five studies assessed tools in a simulation environment only; of the five, three assessed live operations 21 , 29 and two assessed arthroscopic recordings of operations. 15 , 16 Study participants included residents, fellows, and fellowship-trained attendings.…”

“…Twenty-one tools were designed to evaluate resident performance, two tools were designed to distinguish between novice and experienced orthopaedic surgeons, 15 , 16 , 22 , 25 and one tool was designed to evaluate spine surgeons learning a new technique. 17 Only two of the studies studying four different tools specified that the tool was intended for formative assessment 20 , 28 ; other studies did not distinguish whether the tool was meant for formative or summative assessment.…”

“… 19 All tools except five were developed by content experts (not specified in five tools). 15 16 17 18 19 20 Fourteen tools (58.3%) underwent the modified Delphi technique for revision.…”

Building a Successful Practice of Endoscopic Spine Surgery: Learning, Setting the Goal, and Expanding the Border

“…In this issue, Gadjradj et al [ 9 ] present a clear objective to evaluate the learning curve. The objective structured assessment of technical skill was proposed as a tool to evaluate surgical residents with 8 specific items [ 10 ].…”