Joswig Holger, Haile Sarah Roberta, Hildebrandt Gerhard, Stienen Martin Nikolaus
Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.
Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.
J Neurol Surg A Cent Eur Neurosurg. 2017 Sep;78(5):460-466. doi: 10.1055/s-0037-1599056. Epub 2017 Mar 24.
There is a paucity of literature on beginners' training and on its connection with patient safety for transforaminal epidural steroid injections (TFESIs). This study retrospectively assessed the learning curves and associated complications of neurosurgery residents never previously exposed to TFESI and compared them with experienced board-certified faculty neurosurgeons (BCFNs). Procedure time in minutes, dose-area product (DAP) in cGycm, periprocedural observations, and complications in 354 TFESIs for radicular pain secondary to lumbar disk herniation or lumbar spinal stenosis were extracted from operative notes and the electronic infiltration logbook in the per-injection format. Learning curves for 238 residents and 116 BCFN TFESIs in terms of procedure time and DAP were estimated using monotone regression. Residents' TFESI procedure time and DAP reached BCFN level (4.7 minutes and 140.2 Gycm) after 67 and 68 cases, respectively. Residents' TFESIs were unsuccessful in 1.7%, mostly for severe obesity and hypertrophied facet joints, but no severe complications were noted. Obesity, however, did not result in increased procedure times or radiation exposure in general. Residents were faster and required less fluoroscopy in TFESI of the upper lumbar nerve roots than for L5 or S1 in particular. The residents' learning curve for TFESIs in terms of procedure time and radiation exposure can be overcome safely after < 70 TFESIs. An outcome analysis correlating to the interventionalist's training level would be worth investigating in future studies.
关于经椎间孔硬膜外类固醇注射（TFESI）初学者培训及其与患者安全之间联系的文献较少。本研究回顾性评估了从未接触过TFESI的神经外科住院医师的学习曲线及相关并发症，并将其与经验丰富的获得委员会认证的神经外科教员（BCFN）进行比较。从手术记录和每次注射格式的电子浸润日志中提取了354例因腰椎间盘突出症或腰椎管狭窄继发神经根性疼痛而进行的TFESI的手术时间（分钟）、剂量面积乘积（DAP，单位为cGycm）、围手术期观察结果及并发症。使用单调回归估计了238例住院医师和116例BCFN的TFESI在手术时间和DAP方面的学习曲线。住院医师的TFESI手术时间和DAP分别在67例和68例后达到BCFN水平（4.7分钟和140.2 Gycm）。住院医师的TFESI成功率为1.7%，主要原因是严重肥胖和关节突关节肥大，但未观察到严重并发症。然而，一般而言，肥胖并未导致手术时间延长或辐射暴露增加。特别是在上腰椎神经根的TFESI中，住院医师的操作速度更快，所需的荧光透视更少。住院医师在进行少于70次TFESI后，就可以安全地克服其在手术时间和辐射暴露方面的学习曲线。未来的研究值得对与介入医生培训水平相关的结果分析进行调查。
