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Brief description/objective

Background:
It is a well-established dogma in times of high surgical specialisation that residents gain their first years of clinical experience on the surgical ward and during assistances. Only in the minority of highly specialized clinics, residents are introduced to commonly performed surgeries in a standardized manner during the first years of training. In contrast, many surgeons do not reach a quintessential level of their technical operative skills until successful completion of their residency. Furthermore, less experience could protract the surgical program by longer surgery- and anaesthesia time, or could even harm the patient by higher blood loss, operation time, and higher complication rates with subsequent morbidity. As any surgical procedure, also microscopic lumbar disc surgery requires a course of instruction and considerable number of surgeries under supervision by experienced surgeons. Additionally, early intensive training of the manual skills is helpful to shorten the learning curve. Frequent theoretical, as well as practical tuition has been implemented at the first author’s institution in order to train residents earlier in important neurosurgical procedures and foster autonomous decision-making. Moreover, all residents are assisted during any surgical procedure by a responsible specialized consultant who supervises and guides the residents’ steps carefully to warrant high quality patient care during the procedure.

Objective:
Both patient’s and resident’s satisfactory rates have been high using this program during the past years. However, surgeon’s experience has recently been identified as a factor that might influence clinical outcomes following spine surgery. The aim of this study was to test the hypothesis that complication rates and post-operative changes to health-related quality of life (HrQoL) are similar when performed by supervised resident surgeons compared to that of more experienced consultant surgeons.

Methods:
A prospective study on 102 patients receiving surgery for lumbar disc herniation (LDH) was performed at the Kantonsspital St.Gallen. Baseline pain levels (VAS) and health-related quality of life (HrQoL; 12-Item short-form health survey (SF-12)) were measured at 4 weeks and 1 year postoperatively and patients were divided into responders and non-responders to surgery based on validated criteria associated with SF-12 score changes. The surgeons level of experience was dichotomised into two groups: residents (group A) and consultants (group B). In addition, data concerning the operation (length, estimated blood loss) and the postoperative course including common complications like incidental durotomy, bleeding, wound infection, and a need for re-operation were assessed.

Results:
- Patients of both groups achieved equal results in terms of pain reduction after 4 weeks (mean VAS change -3.8 (A) vs. -3.1 (B), p=0.25) and 1 year postoperatively (mean change in VAS -3.5 (A) vs. -3.37 (B), p=0.84).
- Residents were 100% as likely as consultants to achieve a favourable HrQoL response to lumbar disc hernia surgery (pPCS=0.85; pMCS=0.99).
- We are 95% confident that this value lies between 0.32 and 4.02 (PCS) and 0.37 and 2.67 (MCS), indicating that consultant surgeons, when compared to supervised residents, are not more likely to achieve a favourable response in a patient as measured by HrQoL.
- Intraoperative blood loss, length of surgery, intra- and postoperative complications (none in both groups), length of hospital stay, post-operative consumption of pain medication and dependency between the study groups did not differ.

Conclusion
- If professionally instructed by dedicated senior surgeons, less experienced trainee surgeons provide an equally high quality of patient care with similar postoperative results after LDH surgery.
- There were no higher rates of short-term complications and similar results in terms of postoperative pain and quality of life were achieved until one year after the intervention.
- However, a structured education program in which the important anatomical landmarks and surgical steps are recognized by the resident is of paramount importance to warrant high quality patient care.


Conflict of interest / funding:
The authors declare no conflicts of interest. There was no funding received for this study.