International Orthopaedics

, Volume 41, Issue 2, pp 323–332 | Cite as

Navigation improves the learning curve of transforamimal percutaneous endoscopic lumbar discectomy

  • Guoxin Fan
  • Ruoshuang Han
  • Xin Gu
  • Hailong Zhang
  • Xiaofei Guan
  • Yunshan Fan
  • Teng Wang
  • Shisheng He
Original Paper



Beginners usually need increased punctures and dozens of fluoroscopy in learning transforamimal percutaneous endoscopic lumbar discectomy (tPELD). Navigator-assisted spinal surgery (NASS) is a novel technique that could induce a definite trajectory. The retrospective study aimed to investigate the impact of a definite trajectory on the learning curve of tPELD.


A total of 120 patients with symptomatic lumbar disc herniation who received tPELD between 2012 and 2014. Patients receiving tPELD with NASS technique by one surgeon were regarded as group A, and those receiving conventional methods by another surgeon were regarded as group B. Each group was divided into three subgroups (case 1–20, case 21–40, case 41–60).


The fluoroscopy times were 22.62 ± 3.80 in group A and 34.32 ± 4.78 in group B (P < 0.001). The pre-operative location time was 3.56 ± 0.60 minutes in group A and 5.49 ± 1.48 minutes in group B (P < 0.001). The puncture-channel time was 21.85 ± 4.31 minutes in group A and 34.20 ± 8.88 minutes in group B (P < 0.001). The operation time was 84.62 ± 9.20 minutes in group A and 101.97 ± 14.92 minutes in group B (P < 0.001), and the learning curve of tPELD in group A was steeper than that in group B. No significant differences were detected in patient-reported outcomes, hospital stay, patient satisfaction, and complication rate between the two groups (p > 0.05).


Definite trajectory significantly reduced the operation time, preoperative location time, puncture-channel time, and fluoroscopy times of tPELD by beginners, and thus reshaped the learning curve of tPELD and minimized the radiation exposure.


Definite trajectory Learning curve Lumbar location system NASS technique Radiation exposure Transforaminal percutaneous endoscopy lumbar discectomy 



We thanks the nurses who help us collect the clinical data, and further-education physicians who recorded the sequential fluoroscopy films. No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

Compliance with ethical standards



Conflict of interest



  1. 1.
    Fan G, Han R, Zhang H, He S, Chen Z (2015) Worldwide research productivity in the field of minimally invasive spine surgery: a 20-year survey of publication activities. Spine (Phila Pa 1976). doi: 10.1097/brs.0000000000001393 Google Scholar
  2. 2.
    Zheng C, Wu F, Cai L (2016) Transforaminal percutaneous endoscopic discectomy in the treatment of far-lateral lumbar disc herniations in children. Int Orthop. doi: 10.1007/s00264-016-3155-x Google Scholar
  3. 3.
    Wang K, Hong X, Zhou B-Y, Bao J-P, Xie X-H, Wang F, Wu X-T (2015) Evaluation of transforaminal endoscopic lumbar discectomy in the treatment of lumbar disc herniation. Int Orthop 39:1599–1604. doi: 10.1007/s00264-015-2747-1 CrossRefPubMedGoogle Scholar
  4. 4.
    Ahn Y, Lee SH, Park WM, Lee HY (2003) Posterolateral percutaneous endoscopic lumbar foraminotomy for L5-S1 foraminal or lateral exit zone stenosis. Technical note. J Neurosurg 99:320–323CrossRefPubMedGoogle Scholar
  5. 5.
    Du J, Tang X, Jing X, Li N, Wang Y, Zhang X (2016) Outcomes of percutaneous endoscopic lumbar discectomy via a translaminar approach, especially for soft, highly down-migrated lumbar disc herniation. Int Orthop. doi: 10.1007/s00264-016-3177-4 Google Scholar
  6. 6.
    Ahn Y, Kim CH, Lee JH, Lee SH, Kim JS (2013) Radiation exposure to the surgeon during percutaneous endoscopic lumbar discectomy: a prospective study. Spine (Phila Pa 1976) 38:617–625. doi: 10.1097/BRS.0b013e318275ca58 CrossRefGoogle Scholar
  7. 7.
    Choi G, Modi HN, Prada N, Ahn TJ, Myung SH, Gang MS, Lee SH (2013) Clinical results of XMR-assisted percutaneous transforaminal endoscopic lumbar discectomy. J Orthop Surg Res 8:14. doi: 10.1186/1749-799x-8-14 CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Ruetten S, Komp M, Merk H, Godolias G (2007) Use of newly developed instruments and endoscopes: full-endoscopic resection of lumbar disc herniations via the interlaminar and lateral transforaminal approach. J Neurosurg Spine 6:521–530. doi: 10.3171/spi.2007.6.6.2 CrossRefPubMedGoogle Scholar
  9. 9.
    Kafadar A, Kahraman S, Akboru M (2006) Percutaneous endoscopic transforaminal lumbar discectomy: a critical appraisal. Minim Invasive Neurosurg 49:74–79. doi: 10.1055/s-2006-932184 CrossRefPubMedGoogle Scholar
  10. 10.
    Lee DY, Lee SH (2008) Learning curve for percutaneous endoscopic lumbar discectomy. Neurol Med Chir (Tokyo) 48:383–388, discussion 388–389CrossRefGoogle Scholar
  11. 11.
    Wang H, Huang B, Li C, Zhang Z, Wang J, Zheng W, Zhou Y (2013) Learning curve for percutaneous endoscopic lumbar discectomy depending on the surgeon’s training level of minimally invasive spine surgery. Clin Neurol Neurosurg 115:1987–1991. doi: 10.1016/j.clineuro.2013.06.008 CrossRefPubMedGoogle Scholar
  12. 12.
    Wang B, Lü G, Patel AA, Ren P, Cheng I (2011) An evaluation of the learning curve for a complex surgical technique: the full endoscopic interlaminar approach for lumbar disc herniations. Spine J 11:122–130. doi: 10.1016/j.spinee.2010.12.006 CrossRefPubMedGoogle Scholar
  13. 13.
    Hsu H-T, Chang S-J, Yang SS, Chai CL (2012) Learning curve of full-endoscopic lumbar discectomy. Eur Spine J 22:727–733. doi: 10.1007/s00586-012-2540-4 CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Chaichankul C, Poopitaya S, Tassanawipas W (2012) The effect of learning curve on the results of percutaneous transforaminal endoscopic lumbar discectomy. J Med Assoc Thai 95(Suppl 10):S206–212PubMedGoogle Scholar
  15. 15.
    Gu G, Zhang H, He S, Jia J, Fu Q, Zhou X (2013) Preoperative localization methods for minimally invasive surgery in lumbar spine: comparisons between a novel method and conventional methods. J Spinal Disord Tech 26:E277–280. doi: 10.1097/BSD.0b013e31828677d8 CrossRefPubMedGoogle Scholar
  16. 16.
    Gibson JNA, Cowie JG, Iprenburg M (2012) Transforaminal endoscopic spinal surgery: the future ‘gold standard’ for discectomy? – a review. Surgeon 10:290–296. doi: 10.1016/j.surge.2012.05.001 CrossRefPubMedGoogle Scholar
  17. 17.
    Nellensteijn J, Ostelo R, Bartels R, Peul W, Van Royen B, Van Tulder M (2010) Transforaminal endoscopic surgery for symptomatic lumbar disc herniations: a systematic review of the literature. Eur Spine J 19:181–204. doi: 10.1007/s00586-009-1155-x CrossRefPubMedGoogle Scholar
  18. 18.
    Benzel EC, Orr RD (2011) A steep learning curve is a good thing! Spine J 11:131–132. doi: 10.1016/j.spinee.2010.12.012 CrossRefPubMedGoogle Scholar
  19. 19.
    Chakraverty RPP, Isaacs K (2007) Which spinal levels are identified by palpation of the iliac crests and the posterior superior iliac spines? J Anat 210:232–236CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Paolini S, Ciappetta P, Missori P, Raco A, Delfini R (2005) Spinous process marking: a reliable method for preoperative surface localization of intradural lesions of the high thoracic spine. Br J Neurosurg 19:74–76. doi: 10.1080/02688690500089209 CrossRefPubMedGoogle Scholar
  21. 21.
    Srinivasan D, Than KD, Wang AC, La Marca F, Wang PI, Schermerhorn TC, Park P (2014) Radiation safety and spine surgery systematic review of exposure limits and methods to minimize radiation exposure. World Neurosurg. doi: 10.1016/j.wneu.2014.07.041 PubMedGoogle Scholar
  22. 22.
    Hoogland T, Schubert M, Miklitz B, Ramirez A (2006) Transforaminal posterolateral endoscopic discectomy with or without the combination of a low-dose chymopapain: a prospective randomized study in 280 consecutive cases. Spine (Phila Pa 1976) 31:E890–897. doi: 10.1097/01.brs.0000245955.22358.3a CrossRefGoogle Scholar
  23. 23.
    Xin G, Shi-Sheng H, Hai-Long Z (2013) Morphometric analysis of the YESS and TESSYS techniques of percutaneous transforaminal endoscopic lumbar discectomy. Clin Anat 26:728–734. doi: 10.1002/ca.22286 CrossRefPubMedGoogle Scholar
  24. 24.
    Guan X, Gu X, Zhang L, Wu X, Zhang H, He S, Gu G, Fan G, Fu Q (2015) Morphometric analysis of the working zone for posterolateral endoscopic lumbar discectomy based on magnetic resonance neurography. J Spinal Disord Tech 28:E78–84. doi: 10.1097/bsd.0000000000000145 CrossRefPubMedGoogle Scholar
  25. 25.
    Fan G, Fu Q, Wu X, Guan X, Gu G, Yu S, Zhang H, He S (2015) Patient and operating room personnel radiation exposure in spinal surgery. Spine J 15:797–799. doi: 10.1016/j.spinee.2014.09.034 CrossRefPubMedGoogle Scholar
  26. 26.
    Buckland AJ, Baker JF, Roach RP, Spivak JM (2016) Cervical disc replacement - emerging equivalency to anterior cervical discectomy and fusion. Int Orthop 40:1329–1334. doi: 10.1007/s00264-016-3181-8 CrossRefPubMedGoogle Scholar

Copyright information

© SICOT aisbl 2016

Authors and Affiliations

  • Guoxin Fan
    • 1
  • Ruoshuang Han
    • 1
  • Xin Gu
    • 1
  • Hailong Zhang
    • 1
  • Xiaofei Guan
    • 1
  • Yunshan Fan
    • 1
  • Teng Wang
    • 1
  • Shisheng He
    • 1
  1. 1.Orthopedic Department, Shanghai Tenth People’s HospitalTongji University School of MedicineShanghaiChina

Personalised recommendations