单侧双通道内窥镜技术与经椎间孔入路经皮内窥镜下椎间盘切除术治疗腰椎椎间盘突出症的学习曲线比较

Comparison of learning curve between unilateral dual-channel endoscopic technique and percutaneous endoscopic transforamina discectomy for treatment of lumbar disc herniation

目的比较单侧双通道内窥镜(UBE)技术与经椎间孔入路经皮内窥镜下椎间盘切除术(PETD)治疗腰椎椎间盘突出症(LDH)的学习难点。方法回顾性分析2020年3月—2022年3月中国人民解放军联勤保障部队第923医院采用UBE技术(UBE组,n=66)和PETD(PETD组,n=66)治疗的LDH患者临床资料,记录2组手术时间、术中出血量、透视次数、住院时间及并发症发生情况。于术前、术后1个月及末次随访时采用疼痛视觉模拟量表(VAS)评分评估腰痛程度,采用Oswestry功能障碍指数(ODI)评估腰椎功能,末次随访时采用改良MacNab标准评价临床疗效。手术时间包括总手术时间(T0)、建立通道时间(T1)、术野显露时间(T2)及术中减压时间(T3),评估并分析比较2组各时间点及关键技术步骤的学习曲线。结果所有手术顺利完成。UBE组术中出血量高于PETD组,透视次数低于PETD组,差异均有统计学意义(P<0.05)。2组术后1个月和末次随访时腰痛VAS评分、ODI较术前明显改善,差异均有统计学意义(P<0.05)。2组疗效优良率和并发症发生率差异均无统计学意义(P>0.05)。2组T0、T2、T3阶段手术时间比较,差异均有统计学意义(P<0.05);L_(3)/L_(4)、L_(4)/L_(5)、L_(5)/S_(1)节段手术时间比较,差异均有统计学意义(P<0.05)。UBE组在25例左右时T0进入平台期,PETD组在60例左右时T0进入平台期;2组比较,UBE组学习曲线较陡峭,PETD组学习周期较长。UBE组术中T1、T2、T3阶段手术时间随手术例数增加均呈下降趋势,其中T1最短,T2最长;PETD组术中T1、T2、T3阶段手术时间随手术例数增加均呈下降趋势,其中T1最短,T3最长,T2变化幅度最大。结论2种术式疗效相当,与PTED相比,UBE技术具有学习周期短、减压效率高的特点,但在建立通道及术野显露用时方面不具有优势。

Objective To compare the difficulties in learning between unilateral biportal endoscopic(UBE)technique and percutaneous endoscopic transforaminal discectomy(PETD)for lumbar disc herniation(LDH).Methods The clinical data of LDH patients treated with UBE technology(UBE group,n=66)and PETD(PETD group,n=66)in the No.923 Hospital of the People’s Liberation Army Joint Security Force from March 2020 to March 2022 were retrospectively analyzed.And the operation time,intraoperative blood loss,fluoroscopy frequency,hospital stay and complications in the 2 groups were recorded.The intensity of low back pain was assessed by the visual analogue scale(VAS)score,and the Oswestry disability index(ODI)was used to assess the lumbar spine function at pre-operation,postoperative 1 month and the final follow-up.The clinical efficacy was evaluated by the modified MacNab criteria at the final follow-up.The operation time included total operative time(T0),channel establishment time(T1),surgical field exposure time(T2)and intraoperative decompression time(T3),and the learning curve of operation time and key technical steps were evaluated and analyzed to compare them between the 2 groups.Results All the operations were completed successfully.The intraoperative blood loss in the UBE group was higher than that in the PETD group,and the fluoroscopy frequency was lower than that in the PETD group,all with a statistically significant difference(P<0.05).The VAS score of low back pain and ODI at postoperative 1 month and the final follow-up were significantly improved compared with those before surgery in both groups,all with a statistical significance(P<0.05).There was no statistically significant differences in the rate of excellent and good efficacy and complication rate between the 2 groups(P>0.05).The difference in surgical time at T0,T2,and T3 stages between the 2 groups was statistically significant(P<0.05).The difference in surgical time at L_(3)/L_(4),L_(4)/L_(5),L_(5)/S_(1) segments was statistically significant(P<0.05).T0 entered the plateau at about 25 cases in the UBE group,and at about 60 in the PETD group.When comparing the 2 groups,the learning curve was steeper in the UBE group and longer in the PETD group.The operation time in the T1,T2,and T3 stages of UBE group showed a decreasing trend with the increase of surgical cases,with T1 being the shortest and T2 being the longest;and the operation time in the T1,T2,and T3 stages of in the PETD group also showed a decreasing trend with the increase of surgical cases,with T1 being the shortest,T3 the longest and T2 the most variable.Conclusion The surgical efficacy of the 2 methods is comparable.Compared with PTED,the UBE technique has a shorter learning period and higher decompression efficiency,but does not have advantages in establishing access and surgical field exposure.