Learning curve of trans-sacral epiduroscopic laser decompression in herniated lumbar disc disease

Abstract

Background Trans-sacral epiduroscopic laser decompression (SELD) using slender epiduroscope and a holmium YAG laser is one of the minimally invasive surgical options for lumbar disc herniation. However, the learning curve of SELD and the effect of surgical proficiency on clinical outcome have not yet been established. We investigated patients with lumbar disc herniation undergoing SELD to report the clinical outcome and learning curve. Methods Retrospective analysis of clinical outcome and learning curve were performed at a single center from clinical data collected from November 2015 to November 2018. A total of 82 patients who underwent single-level SELD for lumbar disc herniation with a minimum follow-up of 6.0 months were enrolled. Based on the findings that the cut-off of familiarity was 20 cases according to the cumulative study of operation time, patients were allocated to two groups: early group (n = 20) and late group (n = 62). The surgical, clinical, and radiological outcomes were retrospectively evaluated between the two groups to analyze the learning curve of SELD. Results According to linear and log regression analyses, the operation time was obtained by the formula: operation time = 58.825–(0.181 × [case number]) (p < 0.001). The mean operation time was significantly different between the two groups (mean 56.95 min; 95% confidence interval [CI], 49.12–64.78 in the early group versus mean 45.34 min; 95% CI, 42.45–48.22 in the late group; p = 0.008, non-parametric Mann–Whitney U test). Baseline characteristics, including demographic data, clinical factors, and findings of preoperative magnetic resonance imaging, did not differ between the two groups. Also, there was no significant difference in terms of surgical outcomes, including complication and failure rates, as well as clinical and radiological outcomes between the two groups. Conclusion The learning curve of SELD was not as steep as that of other minimally invasive spinal surgery techniques, and the experience of surgery was not an influencing factor for outcome variation.

Factors Predicting the Clinical Outcome After Trans-sacral Epiduroscopic Laser Decompression for Lumbar Disc Herniation

“…However, in our previous study, both the surgical outcome and clinical outcome were not different between the early and late surgery groups. 28 Therefore, we speculated that the patient characteristics could affect clinical outcomes after SELD. For example, differences in detailed baseline characteristics such as demographic data, disc level, morphology of pathology could cause varied clinical outcomes.…”

Expanded Indications of Full Endoscopic Spine Sugery

“…Central and paracentrally located herniations are classical indications. Similarly presence of discal cysts, HIZ and fibrosis around the nerve fibres are also indications for SELD [187][188][189] .…”

“…Profound motor weakness, CES, hard disc herniations, lateral and foraminal disc herniations, instability, known haemorrhagic disorders and anatomic abnormalities of the sacral hiatus are known contraindications 189) . Severe stenosis remains a contraindication.…”

“…There are unique complications such as a ventral dural tear, injury to the exiting nerve root, instrument breakage, seizures and increased radiation exposure 94,[202][203][204][205][206] . The learning curve is quite steep for foraminal approach and flatter for interlaminar approach 114,189,[207][208][209] . Systematic training in ESS techniques and anatomical knowledge are canty at university and spine organisation levels which are dominated by conventional teachers.…”

Trans sacral Endoscopic Laser Decompression – A Case Report, Technical Note and Literature review

“…The concept of SELD is based on the introduction of a steerable catheter in the sacral hiatus, followed by the insertion of a fiberoptic laser system into the ventral side of the epidural disc space with an epiduroscope. This procedure enables the direct decompression of the ruptured annulus as the laser vaporizes the bulging disc in the herniated part, cauterization of the sinuvertebral nerve, adhesiolysis of structures nearby the nerve root, and irrigation of inflammation with saline and steroids [ 1 , 2 , 3 , 4 , 5 ]. Literature about the SELD procedure is scarce, with limited studies demonstrating positive clinical and radiological outcomes with good safety in patients with lower back pain and radicular leg pain due to lumbar disc herniation [ 6 , 7 , 8 , 2 , 9 , 10 ].…”