Elsevier

World Neurosurgery

Volume 84, Issue 6, December 2015, Pages 1589-1597
World Neurosurgery

Original Article
Surgical Resident Education in Noninstrumented Lumbar Spine Surgery: A Prospective Observational Study with a 4.5-Year Follow-Up

https://doi.org/10.1016/j.wneu.2015.07.030Get rights and content

Objective

To review the outcomes of noninstrumented lumbar spine surgery performed by trainees as primary operators versus the outcomes of surgery performed by board-certified faculty neurosurgeons.

Methods

This prospective observational study involved patients undergoing noninstrumented surgery for lumbar disc herniation or lumbar spinal stenosis with a 4.5-year follow-up. Teaching cases (patients were operated on by neurosurgical residents in training) and nonteaching cases (patients were operated on by board-certified faculty neurosurgeons) were reviewed. Back and leg pain on a visual analog scale, functional disability using the Roland Morris Disability Questionnaire and Oswestry Disability Index, and health-related quality of life (HRQOL) using the 12-Item Short Form Survey and EuroQol 5D were assessed, and reoperations since the index surgery were recorded.

Results

Questionnaires were returned by 30 patients operated on by residents and 74 patients operated on by board-certified faculty neurosurgeons. On the 12-Item Short Form Survey physical component scale metric, teaching cases were 70% as likely as nonteaching cases (odds ratio = 0.70, 95% confidence interval = 0.25–1.98, P = 0.585) to achieve a favorable HRQOL response to surgery. Visual analog scale measures of back and leg pain were similar for teaching and nonteaching cases. The same was true for functional disability as measured by the Roland Morris Disability Questionnaire and Oswestry Disability Index and for HRQOL measured by the EuroQol 5D. The reoperation rate 4.5 years after the index surgery was also similar for both groups (∼10% for both groups).

Conclusions

The global outcome, as measured by HRQOL response after a mean follow-up of 4.5 years, was similar for teaching and nonteaching cases. Patients from both groups scored virtually equal results on various pain, functional, and HRQOL metrics, and the reoperation rate was similar.

Introduction

Surgical training is a required process in all surgical specialities. Every surgeon has to operate on a patient for the first time. Do operations in which a trainee is the primary operator achieve outcomes comparable to operations performed by board-certified faculty neurosurgeons (BCFNs)? The recent surgical education literature reveals that the outcomes after spinal procedures performed by supervised trainees are not inferior to the outcomes achieved by senior surgeons. A retrospective study on 287 patients undergoing anterior cervical discectomy with or without instrumentation demonstrated that complication rates and outcomes up to a mean follow-up of 6 months were similar for supervised residents compared with BCFNs (9). Concerning the lumbar spine, data from a prospective observational study showed that complication rates and 1-year health-related quality of life (HRQOL) outcomes of patients undergoing microscopic lumbar disc surgery performed by a supervised resident versus an experienced BCFN did not differ (10). Demographic changes as a result of increased life expectancy in developed countries are expected to lead to a higher prevalence of patients with degenerative disc disease. Although only a small percentage of such patients require a surgical intervention, a significant percentage of patients continue to live with pain or functional disability, and reoperation is reported in about 15% of patients after 5 years and up to 25% after 10 years 1, 8. Lumbar degenerative disc disease represents a particular challenge. The quality of the initial surgery may influence whether or not a patient has remaining symptoms and whether he or she needs to undergo reoperation at some point in the future.

We conducted a follow-up assessment approximately 4.5 years after patients had been enrolled in a prospective observational study to measure pain, functional disability, and HRQOL as well as to determine reoperation rates in patients undergoing noninstrumented lumbar spine surgery performed by residents or BCFNs. Our aim was to investigate whether surgical resident education had long-term negative effects on patients' outcomes.

Section snippets

Study Design and Patient Identification

This study was conducted as a prospective cohort study of consecutive patients with symptomatic and radiologically verified lumbar disc herniation (LDH) or lumbar spinal stenosis (LSS). Decisions about surgery, patient management, and exclusion criteria were previously reported for LDH (10). Surgical candidates for microscopic decompression surgery had neurogenic claudication or radicular leg pain with or without associated neurologic signs for at least 12 weeks. Spinal stenosis was diagnosed

Results

Between October 2010 and December 2010, 202 patients were selected as potentially eligible. All 202 patients were examined for eligibility. There were 22 patients who did not fulfill the inclusion criteria, and 8 patients refused consent. Therefore, 172 patients were included in the study; 58 were teaching cases (33.7%) and 114 were nonteaching cases (66.3%). Table 1 presents basic demographic parameters and the preoperative status of patients. Patients in the teaching group were ∼7.8 years

Discussion

The present study analyzed the medium-term to long-term outcomes of patients undergoing lumbar microdiscectomy for LDH or decompression surgery for LSS by neurosurgical residents and BCFNs. It was our intention not to overlook any unfavorable effects that surgery by a less experienced surgeon-in-training could have on pain, functional, and HRQOL outcomes as well as on the reoperation rate. The SF-12 PCS responder status up to 4.5 years after noninstrumented lumbar spine surgery did not differ

Conclusions

Patients operated on by supervised residents were as likely as patients operated on by senior surgeons to achieve a favorable HRQOL response at 4.5 years after noninstrumented lumbar spine surgery. The comprehensive long-term follow-up in this study revealed virtually equal results on various pain, functional, and HRQOL metrics as well as on the reoperation rate, indicating the noninferiority of outcomes of operations performed by residents supervised by BCFNs. The findings of this study are

Acknowledgments

We thank all patients who took part in this study and returned their follow-up questionnaire. We also thank Cornelia Lüthi, Study Nurse of the Neurosurgical Department, Kantonsspital St. Gallen, for her excellent work collecting the long-term follow-up questionnaires for this study. We thank Laetitia Smoll for critically revising the manuscript.

References (12)

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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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