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.

Keywords: Endoscopic discectomy; Lumbar disc herniation; Randomized controlled trial; Sciatica.

Fig. 1.

Flowchart with an overview of the enrollment and follow-up during the PTED-study. PTED, percutaneous transforaminal endoscopic discectomy; OM, open microdiscectomy.

Fig. 2.

Scores on the objective structured assessment of technical skills on performing percutaneous transforaminal endoscopic discectomy for the different surgeons as scored by themselves and by the experienced surgeon, are shown. LC, learning curve.

Fig. 3.

Number of items performed on the 10-task specific items list per surgeon.

Fig. 4.

Global operative assessment of laparo-/endoscopic skills of the trainee surgeons, as scored by the experienced surgeon. LC, learning curve.