Assessing the Learning Process of Transforaminal Endoscopic Discectomy for Sciatica

Is Close Supervision by a Senior Surgeon Necessary During the Initial Days of Performing Endoscopic Lumbar Discectomy? A Retrospective Comparative Study between Two Fellowship Trained Surgeons to Assess the Learning Curve

Objectives

Endoscopic lumbar discectomy is a minimally invasive technique with a steep learning curve. The studies in the literature base the learning curve on the operative duration. We conducted this study to determine the learning curve based on the presence or absence of supervision by an experienced surgeon.

Materials and Methods

This study involved two spine surgeons (surgeon A and surgeon B), who after their fellowship training from the same institute started practising in two different hospitals with different settings. The data of the first 80 patients operated by these two surgeons were extracted, and the patients were followed up for a minimum of 1 year. The data were split into first 30 cases and late 50 cases, which were compared to see the difference between the two surgeons.

Results

The first 30 cases were evaluated between the two surgeons, and the most significant difference between the two was the operative duration. There was difference between the two surgeons in approach towards migrated and foraminal/extra foraminal discs (P = 0.02). The surgeon B started operating on upper lumbar levels in his later 50 cases, but the foraminal and extraforaminal disc herniations were rarely treated by surgeon B.

Conclusions

Endoscopic discectomy when supervised by senior faculty helps to reduce the operative duration especially in the initial phases of a surgeon's career. The surgeon under the supervision of a senior faculty performs more of migrated and foraminal herniated discs.

Outcome of Percutaneous Endoscopic Lumbar Discectomy in Relation to the Surgeon's Experience: Propensity Score Matching

Percutaneous endoscopic lumbar discectomy (PELD) presents a challenging learning curve, and the correlation between surgeon experience and clinical outcomes remains contentious. This retrospective study aimed to compare the outcomes of PELD performed by a single surgeon at beginner and experienced stages. Propensity score matching selected 150 patients (75 per group) with a minimum 3-year follow-up. Clinical and radiological outcomes, perioperative complications, and adverse events were assessed. Baseline characteristics, pain improvement, patient satisfaction, and radiological outcomes did not differ between the groups. However, operation time was longer in the beginner group than in the experienced group (57.5 min [IQR, 50.0-70.0] versus 50.0 min [IQR, 45.0-55.0], p < 0.001). The beginner group had higher perioperative complication rates (eight patients [10.7%] versus one patient [1.3%], with a hazard ratio of 8.836 [95% CI, 1.077-72.514], p = 0.034) and lower 3-year survival without adverse events (19 patients [25.3%] in the beginner group and 10 patients [13.3%] in the experienced group, p = 0.045). Our findings indicate that the clinical outcomes were more favorable in patients operated on at the experienced stage compared to those treated at the beginner stage.

Validity Evidence for Procedure-specific Competence Assessment Tools in Orthopaedic Surgery: A Scoping Review

INTRODUCTION

Competency-based training requires frequent assessment of residents' skills to determine clinical competence. This study reviews existing literature on procedure-specific competence assessment tools in orthopaedic surgery.

METHODS

A systematic search of eight databases up to May 2023 was conducted. Two reviewers independently assessed validity evidence and educational utility of each assessment tool and evaluated studies' methodological quality.

RESULTS

Database searching identified 2,556 unique studies for title and abstract screening. Full texts of 290 studies were reviewed; 17 studies met the inclusion criteria. Bibliography review identified another five studies, totaling 22 studies examining 24 assessment tools included in the analysis. These tools assessed various orthopaedic surgery procedures within trauma, sports medicine, spine, and upper extremity. Overall validity evidence was low across all studies, and was lowest for consequences and highest for content. Methodological quality of studies was moderate. Educational utility assessment was not explicitly done for most tools.

DISCUSSION

The paucity of current procedure-specific assessment tools in orthopaedic surgery lacks the validity evidence required to be used reliably in high-stake summative assessments. Study strengths include robust methodology and use of an evidence-based validity evidence framework. Poor-quality existing evidence is a limitation and highlights the need for evidence-based tools across more subspecialties.