中国骨与关节杂志
中國骨與關節雜誌
중국골여관절잡지
Chinese Journal of Bone and Joint
2013年
4期
204-210
,共7页
董健文%戎利民%冯丰%刘斌%徐义春%王其友%陈瑞强%谢沛根
董健文%戎利民%馮豐%劉斌%徐義春%王其友%陳瑞彊%謝沛根
동건문%융이민%풍봉%류빈%서의춘%왕기우%진서강%사패근
椎间盘移位%腰椎%外科手术,微创性%椎间盘退行性变%椎间盘切除术,经皮%内窥镜%学习曲线
椎間盤移位%腰椎%外科手術,微創性%椎間盤退行性變%椎間盤切除術,經皮%內窺鏡%學習麯線
추간반이위%요추%외과수술,미창성%추간반퇴행성변%추간반절제술,경피%내규경%학습곡선
Intervertebral disk displacement%Lumbar vertebrae%Surgical procedure, minimally invasive%Intervetebral disc degeneration%Diskectomy, percutaneous%Endoscopes%Learning curve
目的研究椎间孔入路经皮内镜腰椎间盘髓核摘除术的学习曲线,并分析其主要影响因素.方法2011年2月至2012年12月,采用椎间孔入路经皮内镜技术治疗100例腰椎间盘突出症,按接受手术先后次序分别纳入5组( A~E 组),每组20例,男68例,女32例,平均年龄44岁.突出节段 L3~43例、 L4~5节段58例、L5~S1节段39例.后外侧突出78例、极外侧突出4例、中央型突出5例、混合型突出13例.合并侧隐窝与椎间孔狭窄15例、突出钙化7例,8例复发性突出,1例融合术后邻近节段突出.手术由具有开展显微内镜腰椎间盘髓核摘除术( MED )8年以上经验的同一组脊柱外科医师完成.对各组手术的通道建立时间、镜下操作时间、射线暴露量以及术后疗效、并发症进行记录、随访和比较.结果 L3~4、L4~5、 L5~S1各节段平均手术时间分别为(100.33±9.64) min、(106.31±31.01) min、(118.55±29.54) min.A~E 各组总手术时间依次为(152.20±24.48) min、(121.45±21.88) min、(103.30±15.79) min、(88.90±12.93) min、(88.05±17.83) min,D 组总手术时间与镜下操作时间均少于前3组( P<0.05),与 E 组比较差异无统计学意义;C 组建立通道时间及透视时间分别为(22.10±4.87) min、(82.45±18.23) s,较前2组均减少( P<0.05),与 D 组和 E 组比较差异均无统计学意义( P>0.05). B 组1例硬脊膜撕裂,术后无脑脊液漏;C 组1例导丝断裂,D 组1例神经根损伤,A 组与 B 组各1例术后一过性神经根痛.从 C 组开始,术后第1天改良 MacNab 疗效优良率达到或超过90%.平均随访时间9(1~23)个月,术后1个月腰痛 VAS、腿痛 VAS、JOA、ODI 评分均较术前改善( P<0.01).A 组1例因髓核摘除不足术后3个月行 MED,其余病例随访期内无复发与再手术.结论椎间孔入路经皮内镜腰椎间盘髓核摘除术学习曲线较长,通常在60~80例开始达到平台期,镜下操作较通道建立学习曲线更长,穿刺、镜下止血与减压技术的掌握是影响学习曲线的主要因素.
目的研究椎間孔入路經皮內鏡腰椎間盤髓覈摘除術的學習麯線,併分析其主要影響因素.方法2011年2月至2012年12月,採用椎間孔入路經皮內鏡技術治療100例腰椎間盤突齣癥,按接受手術先後次序分彆納入5組( A~E 組),每組20例,男68例,女32例,平均年齡44歲.突齣節段 L3~43例、 L4~5節段58例、L5~S1節段39例.後外側突齣78例、極外側突齣4例、中央型突齣5例、混閤型突齣13例.閤併側隱窩與椎間孔狹窄15例、突齣鈣化7例,8例複髮性突齣,1例融閤術後鄰近節段突齣.手術由具有開展顯微內鏡腰椎間盤髓覈摘除術( MED )8年以上經驗的同一組脊柱外科醫師完成.對各組手術的通道建立時間、鏡下操作時間、射線暴露量以及術後療效、併髮癥進行記錄、隨訪和比較.結果 L3~4、L4~5、 L5~S1各節段平均手術時間分彆為(100.33±9.64) min、(106.31±31.01) min、(118.55±29.54) min.A~E 各組總手術時間依次為(152.20±24.48) min、(121.45±21.88) min、(103.30±15.79) min、(88.90±12.93) min、(88.05±17.83) min,D 組總手術時間與鏡下操作時間均少于前3組( P<0.05),與 E 組比較差異無統計學意義;C 組建立通道時間及透視時間分彆為(22.10±4.87) min、(82.45±18.23) s,較前2組均減少( P<0.05),與 D 組和 E 組比較差異均無統計學意義( P>0.05). B 組1例硬脊膜撕裂,術後無腦脊液漏;C 組1例導絲斷裂,D 組1例神經根損傷,A 組與 B 組各1例術後一過性神經根痛.從 C 組開始,術後第1天改良 MacNab 療效優良率達到或超過90%.平均隨訪時間9(1~23)箇月,術後1箇月腰痛 VAS、腿痛 VAS、JOA、ODI 評分均較術前改善( P<0.01).A 組1例因髓覈摘除不足術後3箇月行 MED,其餘病例隨訪期內無複髮與再手術.結論椎間孔入路經皮內鏡腰椎間盤髓覈摘除術學習麯線較長,通常在60~80例開始達到平檯期,鏡下操作較通道建立學習麯線更長,穿刺、鏡下止血與減壓技術的掌握是影響學習麯線的主要因素.
목적연구추간공입로경피내경요추간반수핵적제술적학습곡선,병분석기주요영향인소.방법2011년2월지2012년12월,채용추간공입로경피내경기술치료100례요추간반돌출증,안접수수술선후차서분별납입5조( A~E 조),매조20례,남68례,녀32례,평균년령44세.돌출절단 L3~43례、 L4~5절단58례、L5~S1절단39례.후외측돌출78례、겁외측돌출4례、중앙형돌출5례、혼합형돌출13례.합병측은와여추간공협착15례、돌출개화7례,8례복발성돌출,1례융합술후린근절단돌출.수술유구유개전현미내경요추간반수핵적제술( MED )8년이상경험적동일조척주외과의사완성.대각조수술적통도건립시간、경하조작시간、사선폭로량이급술후료효、병발증진행기록、수방화비교.결과 L3~4、L4~5、 L5~S1각절단평균수술시간분별위(100.33±9.64) min、(106.31±31.01) min、(118.55±29.54) min.A~E 각조총수술시간의차위(152.20±24.48) min、(121.45±21.88) min、(103.30±15.79) min、(88.90±12.93) min、(88.05±17.83) min,D 조총수술시간여경하조작시간균소우전3조( P<0.05),여 E 조비교차이무통계학의의;C 조건립통도시간급투시시간분별위(22.10±4.87) min、(82.45±18.23) s,교전2조균감소( P<0.05),여 D 조화 E 조비교차이균무통계학의의( P>0.05). B 조1례경척막시렬,술후무뇌척액루;C 조1례도사단렬,D 조1례신경근손상,A 조여 B 조각1례술후일과성신경근통.종 C 조개시,술후제1천개량 MacNab 료효우량솔체도혹초과90%.평균수방시간9(1~23)개월,술후1개월요통 VAS、퇴통 VAS、JOA、ODI 평분균교술전개선( P<0.01).A 조1례인수핵적제불족술후3개월행 MED,기여병례수방기내무복발여재수술.결론추간공입로경피내경요추간반수핵적제술학습곡선교장,통상재60~80례개시체도평태기,경하조작교통도건립학습곡선경장,천자、경하지혈여감압기술적장악시영향학습곡선적주요인소.
Objective To study the learning curve of percutaneous endoscopic lumbar discectomy ( PELD ) via transforaminal approach, and to analyze its main contributing factors. Methods 100 consecutive patients with lumbar disc herniation who received PELD via transforaminal approach from February 2011 to December 2012 were divided into chronological groups ( group A-E ), with 20 patients in each group. There were 68 males and 32 females, with an average age of 44 years old. Disc protrusion was located at L3-4 in 3 cases, L4-5 in 58 cases and L5-S1 in 39 cases. Posterolateral herniation was in 78 cases, far lateral herniation in 4 cases, central herniation in 5 cases and mixed type herniation in 13 cases. Of 100 cases, there were 15 cases with lateral recess and/or foraminal stenosis, 7 cases with calcified disc herniation, 8 cases with recurrent herniation and 1 case with disc herniation at adjacent segments after fusion surgery. All the operations were performed by the same team of spine surgeons with over 8-year experience of microendoscopic discectomy ( MED ). The operation time of establishing working channel and endoscopic procedure, as well as the amount of X-ray exposure in each group were recorded. The surgical results and postoperative complications were also evaluated and compared. Results The mean operation time at L3-4, L4-5 and L5-S1 was ( 100.33±9.64 ), ( 106.31±31.01 ) and ( 118.55±29.54 ) minutes respectively. The mean total operation time in each group ( group A-E ) was ( 152.20±24.48 ), ( 121.45±21.88 ), ( 103.30±15.79 ), ( 88.90±12.93 ) and ( 88.05±17.83 ) minutes respectively. In group D, the total operation time and the operation time of endoscopic procedure was significantly decreased when compared with that in group A, B and C respectively ( P<0.05 ), which was not significantly different from that in group E. The operation time of establishing working channel and the fluoroscopy time was ( 22.10±4.87 ) minutes and ( 82.45±18.23 ) seconds respectively in group C, which was significantly decreased when compared with that in group A and B respectively ( P<0.05 ). There was no statistically significant difference in the operation time of establishing working channel and the fluoroscopy time between group D and E ( P>0.05 ). There was 1 case in group B with dural laceration without cerebrospinal fluid leakage postoperatively, 1 case in group C with guide wire breakage, and 1 case in group D with nerve root injuries. There was 1 case in group A and group B respectively with transient radiculalgia pain postoperatively. The excellent and good rate for clinical results reached at or above 90% according to the modified MacNab criteria from group C on the 1st day postoperatively. All patients were followed up for a mean period of 9 months ( range; 1-23 months ). The low back pain Visual Analogue Scale ( VAS ), leg pain VAS, Japanese Orthopedics Association ( JOA ) scale and Oswestry Disability Index ( ODI ) at the 1st month postoperatively were improved respectively when compared with that preoperatively ( P<0.01 ). 1 patient in group A received MED 3 months after the surgery due to insufficient discectomy, and there was no recurrence or reoperation for the other cases during the follow-up. Conclusions The learning curve of percutaneous transforaminal endoscopic discectomy is comparatively long. It generally needs 60 to 80 cases of repetitions for a spinal surgeon to be proficient. Endoscopic procedure needs much more repetitions when compared with that establishing working channel does. The main contributing factors to overcome the learning curve include puncture, endoscopic hemostasis and decompression.
