后路显微内窥镜下腰椎间盘髓核摘除术学习曲线及其影响因素

Learning curve of microendoscopic lumbar discectomy and its contributing factors

目的分析后路显微内窥镜下腰椎间盘髓核摘除术的学习曲线,并对其影响因素进行探讨。方法通过后路显微内窥镜治疗50例腰椎间盘突出症,按时间序列先后顺序分为五组(A^E组),每组10例,对各组手术时间、手术通道建立时间、椎间盘切除时间、术中出血量、并发症、术后疗效进行比较和分析。结果五组(A^E组)中各组总手术时间分别为(137.20±23.72)min、(109.30±12.88)min、(84.40±6.99)min、(68.20±9.36)min、(67.80±5.16)min。D组总手术时间和手术通道建立时间均少于前三组(P<0.05),但与E组比较差异无统计学意义(P>0.05);C组椎间盘切除时间和出血量分别为(26.40±5.30)min、(68.50±13.13)ml,较A组和B组均减少(P<0.05),但与D组和E组比较差异均无统计学意义(P>0.05);A组有2例并发症,均为术后脑脊液漏;B组有2例并发症,其中1例硬膜囊撕破,1例术后硬膜外血肿形成。五组患者术后3个月的腿痛VAS、ODI评分均较术前改善(P<0.01)。从C组开始,术后第1个月改良Mac Nab评分达到90%。结论后路显微内窥镜下腰椎间盘髓核摘除术的学习曲线被描述,通常在20~30例开始达到平台期,手术通道建立时间较椎间盘切除时间长;穿刺定位、镜下止血、黄韧带的辨认切除和防范神经根硬脊膜损伤是影响学习曲线的关键步骤;后路显微内窥镜下腰椎间盘髓核摘除术是安全有效的微创治疗方式。

Objective To analyze the learning curve of microendoscopic lumbar discectomy（MED） via posterior interlaminar endoscopic approach,and to discuss its main contributing factors.Methods Fifty consecutive patients with lumbar disc herniation who received MED via posterior interlaminar endoscopic approach were divided into chronological groups（group A,B,C,D,E）,with 10 patients in each group.The operation time,the operation time of establishing working channel and discectomy,as well as estimated blood loss,the complications,postoperative efficacy were compared and evaluated.Results The mean total operation time in each group（from A to E） was（137.20±23.72） min,（109.30±12.88） min,（84.40±6.99） min,（68.20±9.36） min,（67.80±5.11） min respectively.In group D,the total operation time and the operation time of establishing working channel were significantly decreased when compared with those in group A,B and C respectively（P〈0.05）,but they were not significantly different from those in group E（P〈0.05）.The time of discectomy and the operative blood loss were（26.40 ± 5.30） min,（68.50 ± 13.13） ml in group C, which were significantly decreased when compared with those in group A and B respectively （P〈0.05）, but not significantly different from those in group D, E （P〉0.05）. There were 2 cases of complications in group A with ce- rebrospinal fluid leakage postoperatively. There were 2 cases of complications in group B with 1 case of dural lacera- tion, and 1 case of epidural hematoma postoperatively. The leg pain Visual analogue scale （VAS） and Oswestry disabil- ity index （ODI） in five groups at the third month postoperatively were all improved respectively when compared with that preoperatively （P〈0.01）. From group C, the excellent-good rate for clinical results reached 90% according to the modified Macnab criteria at the first month postoperatively. Condusi0n The learning curve ofmicroendoscopic lum- bar discectomy via posterior interlaminar endoscopic approach is depicted. It generally needs 20 to 30 cases of repeti- tions to reach the plateau. The establishing working channel needs much more repetitions or learning time than discectomy. The key procedures to overcome the learning curve include puncture and location, endoscopic hemostasis, lig- menmm flavum identification and flavectomy, precaution tearing in dural sac and root. The microendoscopic lumbar discectomy via posterior interlaminar endoscopic approach is a safe, effective and minimally invasive procedure to deal with lunabar disc herniation.