TESSYS椎间孔镜治疗腰椎间盘突出症的学习曲线及经验

Tansforaminal endoscopic spine system for lumbar discectomy:the learning curve and our experiences

[目的]通过术中透视次数及手术时间、术前术后腿痛VAS评分及其改善、术后12个月基于患者手术经历和术后疗效的问卷调查及改良MacNab标准评定优良率，描述TESSYS椎间孔镜下腰椎间盘髓核摘除术的学习曲线并总结手术经验。[方法]2012年12月-2014年3月，通过后外侧人路TESSYS椎间孔镜治疗120例腰椎间盘突出症，按时间系列先后顺序分别纳入4组（A—D组），每组各30例；统计每例手术透视次数、手术时间，评估各组病例术前和术后3d、4周腿痛VAS、腿痛VAS评分改善值，以及评估术后12个月基于患者手术经历和术后疗效的问卷调查及改良MacNab标准的优良率，从而描述TESSYS椎问孔镜下腰椎间盘髓核摘除术的学习曲线，并总结手术经验。[结果]4组（A—D组）年龄、手术节段、突出类型及术前腿痛VAS评分比较差异无统计学意义（P〉0．05）；术中透视次数、手术时间A组与B、C、D组比较差异具有统计学意义（P〈0．05），B组与C、D组比较差异具有统计学意义（P〈0．05），而C、D组比较差异无统计学意义（P〉0．05）；术前和术后3d，术后4周腿痛VAS评分比较差异具有统计学意义（P〈0．01）；4组病例术后3d腿痛VAS评分组间比较差异无统计学意义（P〉0．05），而术后4周腿痛VAS评分及其改善值组间比较差异有统计学意义（P〈0．05）；基于患者术后12个月对椎间孔镜手术经历和疗效的问卷调查其优良率为90．83％，改良MacNab标准评定优良率为92．5％。[结论]TESSYS椎间孔镜的学习曲线在60～70例左右达到其平台期；椎间盘减压不彻底或复发是影响术后早期疗效的主要因素，学习曲线期TESSYS技术的手术经验是充分减压并完整切除椎间盘的突出部分、突出基底部分及游离椎间盘组织，探查椎管内是否有残余组织以及完成纤维环成形术。

[ Objective] To demonstrate the learning curve of transforaminal endoscopic spine system （TESSYS） and to summarize its experiences via the data of the frequency of intraoperative X - ray exposure, the length of operation time, the pre- operative and postoperative visual analogue scale of leg pain （ VAS - LP）, the improvement of the VAS - LP, and the evaluation of the patients＇ excellent or good outcomes rate via a patient - based outcome questionnaire and the modified MacNab criteria at 12- month follow- up postoperatively. [ Methods] One hundred and twenty consecutive cases of lumbar disc herniation who received transforaminal endoscopic spine system （TESSYS） through posterolateral transforaminal approach from November 2012 to March 2014 were divided into four sub - groups chronologically （front to back, sub - group A, B, C, D）, with 30 patients in each sub - group respectively. All the surgeries were acomplished by one same surgeon and treatment group. Each patient＇ s data of the frequency of intraoperative X - ray exposure, the length of operation time was recorded, the VAS - LP and the im- provement of the VAS - LP at preoperative and at 3 day, 4 - week postoperatively were evaluated. The excellent or good outcomes rate was evaluated based on two measurements, one was a patient - based outcome questionnaire of patient ＇ s operation experi- ence and its clinical efficacies at 12 - month follow - up postoperatively, the other was modified MacNab criteria evaluation at the same time point. By comparison the related outcomes, the learning curve of TESSYS was depicted, the clinical experience was also summarized. [ Results] For each sub- group （A, B, C, D）, the age, operative level, the type of disc herniation, and the preoperative VAS - LP were not statistically different （ P 〉 0. 05 ）. The comparison of the frequency of intraoperative X - ray ex- posure, the length of operation time demonstrated statistically significance （ P 〈 0. 05 ） between sub - group A and sub - group B, C, D, and between sub - group B and sub - group C, D, but were not statistically different between sub - group C and D （ P 〉 0. 05 ） . The VAS - LP in the preoperative and the 3 day, 4 - week postoperative periods demonstrated statistically signifi- cant （P 〈0. 01 ） in intra - group comparison. The comparison of the VAS - LP at the 3 day after operation was not statistically significant （ P 〉 0. 05 ）, but the comparison among the groups on the VAS - LP and its improvement at 4 - week postoperatively was statistically different respectively （ P 〈 0. 05 ） in each sub - group. The questionnaire based on the patients＇ experience of TESSYS and its effect at 12 - month follow - up postoperatively showed the patients excellent or good outcomes rate was 90. 83 %, and the patients＇ excellent or good outcomes rate evaluated by the modified MacNab criteria was 92. 5 %. [ Conclusion] The learning curve of TESSYS lumbar discectomy needs 60 -70 cases of repetitions to reach the plateau. The incomplete disc decompression or recurrence of disc is the main contributing factors for the early effect. The obtained experiences for better clinical efficacy are complete decompression including complete removal of the hernia mass, basal parts and sequestered parts, and the detection of the residual disc fragments in the vertebral canal, acomplishing of annuloplasty.