A Structured Four-Phase Training Framework for Percutaneous Endoscopic Lumbar Discectomy: Literature Review and Survey-Based Pilot Study

Abstract

Percutaneous endoscopic lumbar discectomy (PELD) is a minimally invasive technique associated with reduced morbidity and faster recovery. Its adoption, however, is hindered by a steep learning curve and the absence of structured training frameworks. This study developed a four-phase training framework for PELD, grounded in educational theory and informed by trainer and trainee perspectives.

A targeted narrative review (2020–2025) was conducted to identify learning curve thresholds, training modalities, and educational frameworks in spinal endoscopy. In parallel, an exploratory pilot survey of 20 spine surgeons and trainees captured qualitative insights into perceived barriers, facilitators, and case thresholds for independence in transforaminal and interlaminar PELD.

Survey responses were summarized descriptively. Median case thresholds and interquartile ranges (IQR) were calculated for trainer estimates of proficiency.

The literature consistently reported a 30 to 40 case threshold for proficiency, with simulation, mentorship, and structured curricula as key accelerators. Survey respondents most frequently cited lack of structured training (60%), inadequate mentorship (40%), and operating room time pressure (40%) as barriers. Trainers estimated median thresholds of 25 cases (IQR 15–30) for transforaminal and 15 cases (IQR 10–30) for interlaminar PELD.

This study introduces a structured four-phase framework—simulation, observation, supervised lead cases, and independent practice—that directly addresses barriers identified by both trainers and trainees. By integrating literature synthesis with stakeholder perspectives, it provides a practical roadmap for competency-based training in PELD. This pilot study provides a foundational, globally relevant model for standardizing PELD training, which now warrants multicenter validation with objective performance metrics.