Lower Learning Difficulty and Fluoroscopy
Reduction of Transforaminal Percutaneous
Endoscopic Lumbar Discectomy with an Accurate
Preoperative Location Method
Authors: He Shisheng 
Published: February 2021

Background: Transforaminal percutaneous endoscopic lumbar discectomy (tPELD) poses great
challenges for junior surgeons. Beginners often require repeated attempts using fluoroscopy
causing more punctures, which may significantly undermine their confidence and increase the
radiation exposure to medical staff and patients. Moreover, the impact of an accurate location on
the learning curve of tPELD has not been defined.
Objective: The study aimed to investigate the impact of an accurate preoperative location
method on learning difficulty and fluoroscopy time of tPELD.
Study Design: Retrospective evaluation.
Setting: Patients receiving tPELD by one surgeon with a novel accurate preoperative location
method were regarded as Group A, and those receiving tPELD by another surgeon with a
conventional fluoroscopy method were regarded as Group B.
Methods: From January 2012 to August 2014, we retrospectively reviewed the first 80 tPELD
cases conducted by 2 junior surgeons. The operation time, fluoroscopy times, preoperative location
time, and puncture-channel time were thoroughly analyzed.
Results: The operation time of the first 20 patients were 99.75 ± 10.38 minutes in Group A and
115.7 ± 16.46 minutes in Group B, while the operation time of all 80 patients was 88.36 ± 11.56
minutes in Group A and 98.26 ± 14.90 minutes in Group B. Significant differences were detected
in operation time between the 2 groups, both for the first 20 patients and total 80 patients (P
< 0.05). The fluoroscopy times were 26.78 ± 4.17 in Group A and 33.98 ± 2.69 in Group B (P
< 0.001). The preoperative location time was 3.43 ± 0.61 minutes in Group A and 5.59 ± 1.46
minutes in Group B (P < 0.001). The puncture-channel time was 27.20 ± 4.49 minutes in Group
A and 34.64 ± 8.35 minutes in Group B (P < 0.001). There was a moderate correlation between
preoperative location time and puncture-channel time (r = 0.408, P < 0.001), and a moderate
correlation between preoperative location time and fluoroscopy times (r = 0.441, P < 0.001).
Mild correlations were also observed between preoperative location time and operation time (r =
0.270, P = 0.001). There were no significant differences in preoperative back visual analogue scale
(VAS) score, postoperative back VAS, preoperative leg VAS, postoperative leg VAS, preoperative
Japanese Orthopaedic Association (JOA) score, postoperative JOA, preoperative Oswestry disability
score (ODI), or postoperative ODI (P > 0.05). However, significant differences were all detected
between preoperative abovementioned scores and postoperative scores (P < 0.05). Moreover,
there was no significant differences in Macnab satisfaction between the 2 groups (P = 0.179).
There were 2 patients with recurrence in Group A and 3 patients in Group B. Twelve patients with
postoperative disc remnants were identified in Group A and 9 patients in Group B. No significant
difference was identified between the 2 groups (P = 0.718).
Limitations: The preoperative lumbar location method is just a tiny step in tPELD, junior surgeons
still need to focus on their subjective feelings during punctures and accumulating their experienceConclusions: The accurate preoperative location method lowered the learning difficulty and reduced the fluoroscopy time of
tPELD, which was also associated with lower preoperative location time and puncture-channel time.
Key words: Learning difficulty, fluoroscopy reduction, transforamimal percutaneous endoscopic lumbar discectomy, preoperative
location
in endoscopic discectomy