Residents' Learning Curve of Lumbar Transforaminal Epidural Steroid Injections

Abstract

Background and Study Aims There is a paucity of literature on beginners' training and on its connection with patient safety for transforaminal epidural steroid injections (TFESIs). This study retrospectively assessed the learning curves and associated complications of neurosurgery residents never previously exposed to TFESI and compared them with experienced board-certified faculty neurosurgeons (BCFNs). Material and Methods Procedure time in minutes, dose-area product (DAP) in cGy*cm2, periprocedural observations, and complications in 354 TFESIs for radicular pain secondary to lumbar disk herniation or lumbar spinal stenosis were extracted from operative notes and the electronic infiltration logbook in the per-injection format. Learning curves for 238 residents and 116 BCFN TFESIs in terms of procedure time and DAP were estimated using monotone regression. Results Residents' TFESI procedure time and DAP reached BCFN level (4.7 minutes and 140.2 Gy*cm2) after 67 and 68 cases, respectively. Residents' TFESIs were unsuccessful in 1.7%, mostly for severe obesity and hypertrophied facet joints, but no severe complications were noted. Obesity, however, did not result in increased procedure times or radiation exposure in general. Residents were faster and required less fluoroscopy in TFESI of the upper lumbar nerve roots than for L5 or S1 in particular. Conclusion The residents' learning curve for TFESIs in terms of procedure time and radiation exposure can be overcome safely after < 70 TFESIs. An outcome analysis correlating to the interventionalist's training level would be worth investigating in future studies.

Comparison between anteroposterior and oblique “Scotty dog” approach during S1 transforaminal epidural steroid injection

“…In one study of residents’ learning curve with lumbar TFESI, residents took more time and required more fluoroscopy in TFESI of S1 than for the upper lumbar nerve roots. [ 13 ] In our study, an OS approach to the S1 foramen was effective, easy, and faster than the AP approach. In the report that first introduced the oblique approach, researchers mentioned potential advantages of it, including reduced procedure time and radiation exposure.…”

Creation of a three-dimensional printed spine model for training in pain procedures

“… 8 , 11 During spinal procedures, especially when performing STEB at the L5/S1 level, it is often difficult to identify the target point and secure the entry path of the needle because of the pelvic bone. 10 Therefore, the phantom designed in the present study could also be useful for training and simulating transforaminal endoscopy or other procedures in which the pelvic bones may cause difficulty.…”

“…Several studies have demonstrated the efficacy of using phantoms to teach procedures. 5 , 8 , 10 – 13 However, to the best of our knowledge, this is the first study to evaluate the efficacy of simulation phantoms for training in the performance of selective transforaminal epidural block (STEB), medial branch block (MBB), and lumbar sympathetic ganglion block (LSGB) procedures. In addition, standard tools to evaluate the learning effects of these procedures are lacking.…”

Physician-Related Variability in the Outcomes of an Invasive Treatment for Neck and Back Pain: A Multi-Level Analysis of Data Gathered in Routine Clinical Practice

“…Most reports on learning curves or variability across practitioners for invasive treatments for neck or low back pain focus on interventions other than NRT, many of which lack high quality evidence supporting their efficacy and effectiveness. Moreover, they are based on small samples (e.g., ≤150 patients or ≤3 practitioners), do not use multi-level analyses to adjust results for patient prognosis as established by previously validated models, or have been conducted either retrospectively or outside routine practice conditions (e.g., based on data gathered in randomized controlled trials) [ 8 , 9 , 10 , 11 , 12 , 13 , 40 , 41 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 ]. Therefore, it is inappropriate to compare such data with results from this study.…”