椎板间入路全内窥镜手术与传统显微镜下髓核摘除术治疗L_(5)-S_(1)椎间盘突出症的疗效及学习曲线分析

Efficacy and learning curve analysis of interlaminar endoscopic discectomy and traditional microscopic discectomy in the treatment of L_(5)-S_(1) disc herniation

目的探讨初学者开展椎板间入路全内窥镜手术(percutaneous endoscopic interlaminar lumbar discectomy,PEILD)与显微镜下髓核摘除术(open lumbarmicrodiscectomy,OLM)治疗L_(5)-S_(1)椎间盘突出症的疗效,并对两者的学习曲线进行分析。方法纳入同一初学者开展的56例L_(5)-S_(1)椎间盘突出症患者,依据其手术方案分为两组:OLM组(n=29,2016年5月-2017年9月)和PEILD组(n=27,2018年7月-2019年11月)。术后随访1年,对两组的疗效、手术时间和学习曲线进行分析。结果两组患者均成功完成PEILD和OLM手术,与术前相比,两组术后1年的VAS评分和ODI指数均获得显著改善(P<0.05),但无组间差异(P>0.05)。PEILD组和OLM组患者的手术并发症分别为2例(7.41%)和2例(6.90%),差异无统计学意义(P=0.656)。PEILD组术后复发3例(11.11%),再手术2例(7.41%);OLM组术后复发3例(10.34%),再手术2例(6.90%),两组差异无统计学意义(P=0.933)。PEILD组的手术时间显著少于OLM组,差异有统计学意义(P<0.05)。根据手术时间累积分析(PEILD组的熟练度临界值为第18例,而OLM组为第10例),以及线性回归分析(PEILD组手术时间减少的倾斜度为-0.922,而OLM组为-1.738),PEILD组的学习曲线更加困难。结论初学者开展PEILD和OLM手术治疗L_(5)-S_(1)腰椎间盘突出症时,其手术疗效和安全性、并发症均较为接近;PEILD的手术时间明显短于OLM,但其学习曲线则较为困难。

Objective To investigate the efficacy of percutaneous endoscopic interlaminar lumbar discectomy(PEILD)and open lumbar microdiscectomy(OLM)in the treatment of L_(5)-S_(1)disc herniation for beginners,and to analyze their learning curve.Methods Fifty-six patients with L_(5)-S_(1)disc herniation were enrolled and divided into OLM group(n=29,from May 2016 to September 2017)and PEILD group(n=27,from July 2018 to November 2019).The patients were followed up for 1 year,and the curative effect,operation time and learning curve of the two groups were analyzed.Results PEILD and OLM were successfully performed in both two groups.Compared with before operation,the VAS score and ODI index of the two groups were significantly improved at 1 year after operation(P<0.05),but there were no significant differences between the two groups(P>0.05).The operative complications in PEILD group and OLM group were 2 cases(7.41%)and 2 cases(6.90%),respectively,and the difference was not statistically significant(P=0.656).There were 3 cases of recurrence(11.11%)and 2 cases of reoperation(7.41%)in the PEILD group,and 3 cases of recurrence(10.34%)and 2 cases of reoperation(6.90%)in the OLM group.There was no significant difference between the two groups(P=0.933).The operation time of PEILD group was significantly shorter than that of OLM group(P<0.05).According to the cumulative analysis of operation time(the critical value of proficiency in the PEILD group was the 18th case,and was the 10th case in the OLM group),and linear regression analysis(the slope of operation time reduction in the PEILD group was-0.922 and-1.738 in the OLM group),the learning curve of the PEILD group was more difficult.Conclusion The curative effect,safety and complications of PEILD and OLM for L_(5)-S_(1)lumbar disc herniation are similar for beginners;the operation time of PEILD is significantly shorter than OLM,but its learning curve is more difficult.