Surgeons Learning Curve of Transforaminal Endoscopic Discectomy for Sciatica

Abstract

Objective: Full-endoscopic spine surgery is gaining interest as a less-invasive alternative to treat sciatica caused by a lumbar disc herniation. Concerns, however, exist with the learning curve as percutaneous transforaminal endoscopic discectomy (PTED) appears to be more difficult to be performed compared to other techniques. In this study, the clinical outcomes during and after the learning curve are presented of 3 surgeons naïve to PTED.Methods: In the first phase of a randomized controlled, noninferiority trial comparing PTED with microdiscectomy, 3 surgeons were trained in the PTED-procedure by a senior surgeon. After performing up to 20 cases under supervision, they started performing PTED on their own. Results of the early cases were compared to the later cases (>20). Furthermore, complications and reoperations were compared. Finally, differences in clinical outcomes between surgeons were compared.Results: At 12 months of follow-up, 87% of the patients had follow-up data available. In general, there were no significant differences in patient-reported outcomes between the early and later PTED cases. Furthermore, outcomes of the early PTED cases were comparable to the outcomes of microdiscectomy, while the later PTED cases had small, but more favorable outcomes compared to microdiscectomy. Two learning curve surgeons had substantially higher rates of reoperations within 1 year, compared to the senior surgeon or the microdiscectomy group. Duration of surgery was also longer for all learning curve surgeons. Finally, when comparing clinical outcomes of patients undergoing PTED versus microdiscectomy, there appears to be some statistically significant differences in outcomes compared between the senior and 3 learning curve surgeons.Conclusion: PTED appears to be safe to be adopted by surgeons naïve to the procedure when they are initially supervised by an experienced senior surgeon. Duration of surgery and risk of repeated surgery are increased during the learning curve, but patient-reported outcomes of the early PTED cases are similar to the outcomes of later PTED cases, and similar to the outcomes of microdiscectomy cases. This study underlines the need for an experienced mentor for surgeons to safely adopt PTED.

Training to be a spinal endoscopic surgeon: What matters?

“…Gadjradj et al conducted a study by observing the clinical outcomes during and after the learning curve (20 cases) presented by three surgeons new to spinal endoscopy. They later determined that spinal endoscopic surgery had a relevant steep learning curve and that young spinal surgeons should use the endoscope under the supervision of a senior surgeon ( 17 ).…”

“…However, they should be patient and persevere rather than be dejected in order to add to their experiences regularly. There is also evidence that the situation will improve over time ( 17 ). According to the surgeons, the most difficult aspect of mastering this technique is the disparate surgical view ( 21 ).…”

Education for Being A Spine Endoscopic Surgeon: What Matters?

“…Pravesh S Gadjradj et al had conducted a study by observing the clinical outcomes during and after the learning curve (20 cases) presented of 3 surgeons naive to spine endoscopy. They later came up with the point that spine endoscopic surgery had a relevant steep learning curve and the young spine surgeons should use endoscope under the monitoring from a senior surgeon [17].…”

“…However, they should have adequate patience and perseverance instead of dejection, in order to accumulate their experience constantly. And there is evidence showing that the situation will get improved over time [17]. According to the surgeons, the most di cult aspect to master this technique is disparate surgical view [21].…”

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

“…This study is important because it is more apparent than the evaluation based on the operation time or complications, and both the trainee and the supervisor can evaluate objectively. In another paper by the same authors [ 11 ], learning curve surgeons trained in the same way showed lower performance than expert surgeons in the first year of operation time and recurrence rate but reported results that were comparable in patient satisfaction and progress. This suggests that endoscopic surgery can achieve reproducible and stable results even for beginners when well-trained and educated.…”