椎间盘镜治疗腰椎间盘突出症初100例的学习曲线及经验

Microendoscopic lumbar discectomy: a learning curve and experience of first 100 cases

目的:分析椎间盘镜下腰椎间盘髓核摘除术的学习曲线,并对其手术经验进行总结。方法:2010年7月至2012年3月,通过椎间盘镜治疗最初100例单节段腰椎间盘突出症,按时间系列先后顺序分为4组(A、B、C、D组),前3组每组30例,D组10例,对各组手术中手术时间、手术出血、中转开放或再次手术、并发症、术后疗效进行比较和分析。结果:4组平均每例手术时间、出血量分别被统计,其中A组手术时间和出血量较B、C、D组差异有显著性(P﹤0.05),而B组较C、D两组差异无统计学意义(P>0.05);A组出现6例不利事件,B、C组各1例并发症,D组无手术并发症;4组患者术后1个月和12个月腿痛VAS、ODI评分均较术前有所改善(P<0.01)。结论:椎间盘镜下腰椎间盘髓核摘除术的学习曲线在30例左右达到平台期;穿刺定位、黄韧带切除、解剖标志的辨认和防范神经根硬脊膜损伤是初期操作椎间盘镜关键的步骤。

Objective To analyze the learning curve of microendoseopie lumbar discectomy （MED） and summarize the operative experience. Methods From July 2010 to March 2012, the first 100 patients with single level lumbar disc herniation managed with MED were divided into chronological groups （A, B, C and D）, 30 patients in group A, B, C and 10 patients in group D. The comparsons were conducted in terms of operative time, estimated blood loss, number of cases with transition from MED to open surgey or for reoperation, rate of complications and postoperative efficacy. Results The mean operative time and the mean estimated blood loss in each group was valuated respectively. In group A, the operative time and estimated blood loss were significantly decreased as compared with those in group B, C and D respectively （P 〈 0.05）, but those in group B were not significantly different from those in group C and D （P 〉 0.05）. There were 6 complications in group A, 1 complication in group B and C respectively and no complication in group D. The leg pain visual analogue scale and Oswestry disability index at the first month and the twelfth month postoperatively were all improved respectively as compared with those preoperatively （P 〈 0.01）. Conclusion The learning curve of microendoscopic lumbar discectomy generally may reach the plateau when about 30 cases are operated on. The key procedure to pass over the learning curve includes puncture and location, flavectomy, anatomy mark identification, and precaution of damage in dural sac.