The concept of SELD is an intermediate step between intervention (such as, nerve block or neuroplasty) and surgery (such as, microdiscectomy or full endoscopic surgery). In other words, when nerve block is ineffective or a more effective procedure is needed, but the operation is over-treatment, the SELD can be an option for disc herniation. In terms of this position of SELD, its indication or role is similar with annular modulation or annuloplasty. However, the advantages of SELD includes availibility of real endoscopic vision of target lesion, direct ablation of herniated disc, adhesiolysis, and drug injection. In addition, in terms of simple minimally invasive procedure under local anesthesia, the indications of SELD need not to be too heavy like a microdiscectomy or full endoscopic surgery.
According to previous studies, the clinical or surgical outcomes of SELD were found to be favorable in various lumbar spine diseases [3–7, 12-17]. In particular, several recent papers regarding the clinical outcome of SELD for disc herniation have reported that the clinical outcome was favorable as there was significant improvement in low back pain or radiating leg pain, patient satisfaction rate of more than 70%, and low rates of surgical failure or recurrence [8, 18-21].
However, according to the result of this study and author’s previous report, the clinical outcome was inconsistent with that in previous reports as the patient satisfaction rate was 58.5% according to Odom’s criteria and the surgical failure or recurrence rate was 17.1% during 6 months of follow-up . This result was not favorable compared to not only previous studies on SELD but also the results of other surgical techniques for lumbar disc herniation [22-24].
After considering the reason for these discordances, we hypothesized that surgeon’s learning curve of SELD could affect the outcome. In other words, we speculated that the result may not be favorable in the early stage of clinical application compared to that at the adapted stage; as a result, the overall clinical outcome could be unfavorable.
SELD is considerably different from conventional microsurgery or full endoscopic surgery because of the different access route and equipment used. The obstacles in starting SELD include different access methods via the sacral hiatus, unfamiliarity to a steerable guide catheter, difficulty in reaching the target lesion, the use of a very narrow and magnified endoscopic view, the presence of a vague or obscured view owing to epidural bleeding or fat, fear of intradural insertion of a catheter, or uncertainty of successful decompression. The trainee should have worked on at least a certain number of cases to become accustomed to the trans-sacral approach and very narrow two-dimensional steerable endoscopic vision. These barriers may pose challenges for a surgeon at the beginner stage and might result in a steep learning curve and cause unfavorable and inconsistent clinical outcomes.
Operation time is a major parameter to assess the technical proficiency of surgeons . A trend of operation time is an effective statistical tool to assess whether a trainee has achieved acceptable proficiency . Surgeon’s comfort and technical proficiency is correlated to a decrease in procedure length in chronological case series, and the traditional evaluation of the learning curve has focused on operation time according to the number of cases .
In our study, as the number of cases accumulated, the operation time was shortened as a result of familiarity with the surgical technique. The cumulative analysis identified a threshold of 20 cases after which the operation time was consistent. In other words, the operation time approached an asymptote in the 20th case and decreased from a mean 56.95 minutes in the initial 20 cases to a mean 45.34 minutes in the later 62 cases (decrease of 20%). On the basis of the asymptote point, we found out that the learning curve of SELD is similar to 10–30 cases of other spinal surgeries, such as microsurgery using tubular retractor or full endoscopic surgery [27–31]. Also, based on the 20% decrease of operation time and proportional constant of -0.181 in the formula of operation time, the rate of decline is not steep compared to the 23% to 58% decrease in operation time during the initial series of cases between the 10th and 30th case of other minimally invasive spinal surgeries [27–31]. These findings imply that the entry barriers for beginners to start SELD are easier or similar compared to those for other techniques.
Another clinically relevant parameter used to assess proficiency of surgeon through the learning curve is the complication or failure rate. Incompetence is inevitable when learning a new surgical technique, particularly minimally invasive surgery; thus, majority of surgery-related complications, failure, or conversions to open techniques usually occurred within the beginner stages of the learning process . The lack of clear anatomic knowledge or orientation and unfamiliarity of new instruments appears to be a significant limitation, and this may cause serious injury to neurologic structures or unintended adverse events in the initial series of patients . Multiple studies on minimally invasive spine surgery have reported that the complication rate is higher and the clinical outcome is poorer at the beginner level than at the expert level [23, 27, 33, 34].
However, in our study, both the clinical outcomes and the surgical outcomes, including complication rate and failure or recurrence rate, were similar between the early and late groups. Based on previous studies, the complication rate of 10% in the early group was favorable compared to the complication rate of 14%–40% in the novice stage of other minimally invasive spinal surgeries [26, 35–37]. Furthermore, the overall incidence of complications was only 8.5% (7 of 82 patients) and complications were only mild-to-moderate. Among the complications, the transient nuchal pain is related to increase of intracranial pressure due to excessive epidural injection of normal saline for irrigation during surgery. In addition, we speculate that transient motor weakness is related to temporary irritation of nerve root by catheter or laser ablation. These findings suggest that, compared to other minimally invasive spinal surgeries, SELD is relatively easy to learn and is a safe procedure with less complications.
This study has several limitations. Because of its retrospective study design, it was impossible to control for all variations. Moreover, the number of patients in the final cohort was relatively small, and the research was conducted at a single center. However, this single-center study could maintain the quality of follow-up and exclude the factor related to the diversity of surgeons.
To the best of our knowledge, this study is the first to evaluate the learning curve and related outcome of SELD in lumbar disc herniation. More complete studies with a prospective design are required to establish SELD as an easy to learn and safe procedure.