Gadjradj Pravesh S, Vreeling Arnold, Depauw Paul R, Schutte Pieter J, Harhangi Biswadjiet S
Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York, NY, USA.
Department of Neurosurgery, Park Medical Center, Rotterdam, The Netherlands.
Neurospine. 2022 Sep;19(3):594-602. doi: 10.14245/ns.2244342.171. Epub 2022 Sep 30.
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.
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.
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.
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.
全内镜脊柱手术作为一种治疗腰椎间盘突出症所致坐骨神经痛的侵入性较小的替代方法，正越来越受到关注。然而，由于经皮椎间孔内镜下椎间盘切除术（PTED）与其他技术相比似乎更难实施，因此存在学习曲线方面的问题。在本研究中，我们展示了3名初次接触PTED的外科医生在学习曲线期间及之后的临床结果。
在一项比较PTED与显微椎间盘切除术的随机对照非劣效性试验的第一阶段，3名外科医生由一位资深外科医生进行PTED手术培训。在接受监督完成多达20例手术之后，他们开始独立进行PTED手术。将早期病例的结果与后期病例（>20例）的结果进行比较。此外，对并发症和再次手术情况进行了比较。最后，比较了外科医生之间临床结果的差异。
在随访12个月时，87%的患者有可用的随访数据。总体而言，早期和后期PTED病例在患者报告的结果方面没有显著差异。此外，早期PTED病例的结果与显微椎间盘切除术的结果相当，而后期PTED病例与显微椎间盘切除术相比，结果虽小，但更有利。与资深外科医生或显微椎间盘切除术组相比，两名处于学习曲线阶段的外科医生在1年内再次手术的发生率显著更高。所有处于学习曲线阶段的外科医生的手术时间也更长。最后，在比较接受PTED与显微椎间盘切除术患者的临床结果时，资深外科医生与3名处于学习曲线阶段的外科医生之间的结果比较似乎存在一些统计学上的显著差异。
对于初次接触该手术的外科医生，在最初由经验丰富的资深外科医生监督的情况下，PTED似乎可以安全采用。在学习曲线期间，手术时间和再次手术的风险会增加，但患者报告的早期PTED病例的结果与后期PTED病例的结果相似，且与显微椎间盘切除术病例的结果相似。本研究强调了外科医生安全采用PTED需要有经验的指导者。
