Ransom Nicholas A, Gollogly Sohrab, Lewandrowski Kai-Uwe, Yeung Anthony
Surgical Institute of Tucson, Tucson, AZ, USA.
Department of Surgery, Monterey Spine and Joint Center, Monterey, California, USA.
J Spine Surg. 2020 Jan;6(Suppl 1):S197-S207. doi: 10.21037/jss.2019.10.03.
Traditionally trained spine surgeons may want to transition from open spinal surgeries to endoscopic decompressions. The aspiring endoscopic spine surgeon may have to overcome multiple hurdles to master a learning curve without readily available training. Replacing traditional time-proven open spinal surgeries with endoscopic decompression may put the surgeons' reputation at risk and have an additional negative impact on his or her practice due to reduced revenue. The authors report on the utility of the mentor- and proctorship concepts to facilitate the transition from traditional open to endoscopic outpatient spine surgeries.
The study population (learning curve groups) was provided by two traditionally trained "apprentice" surgeons who have been in practice for 12 and 28 years, respectively. They trained with the remaining two authors under mentorship and proctorship arrangements. A VAS and Macnab outcomes analysis was performed by one surgeon laminectomy versus endoscopy in relationship to the case log representative of the initial learning curve. The second surgeon performed a postoperative narcotic utilization analysis as a representative way of favorable clinical outcomes in relation to his increasing case log with spinal endoscopy.
The learning curve study by the first author (NA Ransom-under the proctorship program) consisted of 40 patients with 20 patients each divided into the traditional laminectomy control group and 20 patients in the endoscopic group. There were 22 females and 18 males with an average age of 57.38 years and a mean follow-up of 38.58 months. The preoperative VAS for patients in both groups was 7.95 compared to the postoperative VAS at final follow-up of 4.01 with a statistically significant postoperative VAS reduction (P<0.001) but without any significant difference between open laminectomy control- and endoscopic decompression groups. The endoscopic learning curve group outcomes improved significantly after 15 cases (P<0.048). The second author (S Gollogly-under mentorship program) performed a similar review of his surgical cases log and noted a significant reduction of postoperative narcotic utilization as a result of improved outcomes after an initial learning curve of 15 cases. Clinical outcomes for both authors showed improved Macnab outcomes in the majority of patients (NA Ransom =65%; S Gollogly =57%) with a slightly higher success rate in the laminectomy group (70%) versus the endoscopy group (65%) at a statistical significant level (P=0.036).
The mentorship and proctorship approach is useful in helping traditionally trained spine surgeons to integrate spinal endoscopy into their well-established spine practices. Under the close guidance of an endoscopic master spine surgeon, the endoscopic learning curve may be comprehended by the experienced traditionally trained spine surgeon in approximately 15 lumbar decompression cases. During this initial 15-case learning curve, clinical outcomes with endoscopy may be slightly inferior to open laminectomy but may ultimately improve to equivalent levels.
接受传统培训的脊柱外科医生可能希望从开放性脊柱手术转向内镜减压手术。有抱负的内镜脊柱外科医生可能必须克服多个障碍，才能在没有现成培训的情况下掌握学习曲线。用内镜减压取代传统的经时间验证的开放性脊柱手术可能会使外科医生的声誉受到威胁，并且由于收入减少，还会对其业务产生额外的负面影响。作者报告了导师指导和监督概念在促进从传统开放性脊柱手术向内镜门诊脊柱手术过渡方面的效用。
研究人群（学习曲线组）由两位接受传统培训的“学徒”外科医生提供，他们分别从业12年和28年。他们在导师指导和监督安排下与其余两位作者一起培训。由一位外科医生对1例椎板切除术与内镜检查进行VAS和Macnab结果分析，以对照代表初始学习曲线的病例记录。第二位外科医生进行了术后麻醉药使用分析，以此作为脊柱内镜手术病例数增加后良好临床结果的一种代表性方式。
第一作者（NA·兰塞姆——在监督计划下）的学习曲线研究包括40例患者，每组20例，分别分为传统椎板切除术对照组和20例内镜检查组。有22名女性和18名男性，平均年龄57.38岁，平均随访38.58个月。两组患者术前VAS均为7.95，而最终随访时术后VAS为4.01，术后VAS有统计学意义的降低（P<0.001），但开放性椎板切除术对照组与内镜减压组之间无显著差异。内镜学习曲线组在15例手术后结果有显著改善（P<0.048）。第二作者（S·戈洛格利——在导师指导计划下）对他的手术病例记录进行了类似的回顾，并指出在最初15例的学习曲线后，由于结果改善，术后麻醉药使用显著减少。两位作者的临床结果均显示，大多数患者的Macnab结果有所改善（NA·兰塞姆=65%；S·戈洛格利=57%），椎板切除术组的成功率略高于内镜检查组（70%对65%），差异有统计学意义（P=0.036）。
导师指导和监督方法有助于帮助接受传统培训的脊柱外科医生将脊柱内镜技术融入其成熟的脊柱手术实践中。在经验丰富的内镜脊柱外科主刀医生的密切指导下，经验丰富的接受传统培训的脊柱外科医生可能在大约15例腰椎减压病例中理解内镜学习曲线。在最初的15例病例学习曲线期间，内镜手术的临床结果可能略逊于开放性椎板切除术，但最终可能改善到同等水平。
