球囊压迫术治疗三叉神经痛定位技术比较及Hartel穿刺法学习曲线探讨

Comparison of localization techniques in balloon compression surgery for trigeminal neuralgia and discussion of the learning curve of Hartel technique

目的比较经皮穿刺半月节球囊压迫术(PMC)治疗三叉神经痛不同定位技术的疗效,探讨Hartel穿刺法的学习曲线。方法回顾性分析2016年4月至2019年4月兰州大学第一医院神经外科收治的60例和中国人民武装警察部队特色医学中心神经外科收治的40例原发性三叉神经痛患者的临床资料。对3名神经外科医生进行3个阶段的手术培训,第一阶段分别采用Hartel穿刺法(Hartel穿刺组)、立体定向辅助穿刺法(立体定向组)及神经导航辅助穿刺法(神经导航组)各治疗20例患者,第二、三阶段分别采用Hartel穿刺法各治疗20例患者。比较第一阶段3种不同穿刺法的疗效,比较培训3个阶段Hartel穿刺法的手术疗效,并根据手术时间和穿刺次数绘制Hartel穿刺法的学习曲线。手术疗效的评价指标包括:穿刺次数、手术操作时间、手术有效率、并发症发生率、住院时间及住院费用。结果第一阶段:3组的性别、年龄、病程、手术操作时间、手术有效率及住院时间的差异均无统计学意义(均P>0.05),而手术穿刺次数、术后并发症发生率及住院费用方面的差异均有统计学意义(均P<0.05),其中Hartel穿刺组的穿刺次数最多,术后并发症发生率最高,但住院费用最少。Hartel穿刺法培训3个阶段,患者的性别、年龄、病程、手术有效率及住院费用的差异均无统计学意义(均P>0.05),但随着培训阶段增加,手术穿刺次数越来越少,操作时间越来越短,术后并发症发生率降低,住院时间缩短(均P<0.05)。通过绘制Hartel穿刺法的学习曲线发现,手术例数达到40例后,医生的的操作水平逐渐趋于平稳。结论对于手术初学者采用立体定向和神经导航的方式进行卵圆孔穿刺会显著降低三叉神经痛患者术后并发症的发生率,但会增加医疗费用。采用Hartel穿刺法手术例数达到40例后,术者的手术操作水平可趋于平稳。

Objective To compare the efficacy of percutaneous trigeminal ganglion balloon compression(PBC)in the treatment of trigeminal neuralgia(TN)with different localization assistance techniques,and to explore the learning curve of Hartel technique.Methods The clinical data of 60 patients of idiopathic TN admitted to Neurosurgery Department of Lanzhou University First Hospital and 40 patients admitted to Neurosurgery Department of Characteristic Medical Center of Chinese People′s Armed Police Force from April 2016 to April 2019 were retrospectively analyzed.We conducted three stages of surgical training for 3 neurosurgeons.In the first stage,20 patients were treated with Hartel puncture method(Hartel puncture group),20 with stereotaxy assisted puncture method(stereotactic group)and 20 with neuronavigation assisted puncture method(neuronavigation group).The Hartel puncture method was applied in the second and third stages and 20 patients were treated during the time period.We then compared the efficacy of 3 different puncture methods in the first stage,compared the surgical efficacy of Hartel puncture method in the 3 stages,and drew the learning curve of Hartel puncture according to the operation time and number of procedures.The evaluation indexes of surgical efficacy included number of punctures,operation time,operation efficiency,incidence of complications of hospital stay and hospitalization cost.Results For the first stage,there was no significant difference in gender,age,course of disease,operation time,operation efficiency or length of hospital stay among 3 groups(all P>0.05),while the number of surgical punctures,incidence of postoperative complications and hospitalization costs were statistically different(all P<0.05).The Hartel puncture group had the most punctures and highest postoperative complication rate,while the hospitalization cost was the least.There was no statistically significant difference in the gender,age,course of disease,surgical efficiency or hospitalization costs in the Hartel puncture training at three stages(all P>0.05),while as the training phase increased,the number of surgical punctures became less and less.The operation time became increasingly shorter,the operation efficiency was increasingly higher,the incidence of postoperative complications was increasingly lower,and the length of hospital stay was increasingly shorter(all P<0.05).By drawing the learning curve of Hartel′s puncture method,we found that after the number of surgical cases reached 40,the surgeon′s operation level gradually reached stability.Conclusions For beginners,stereotaxy and neuronavigation assisted methods are used in puncture of the foramen ovale,which could significantly reduce the incidence of postoperative complications while the medical cost would increase.After completing 40 cases of Hartel procedures,the operation level can be stabilized.