单侧双通道脊柱内镜技术治疗腰椎管狭窄症的临床疗效和学习曲线研究

Clinical efficacy and surgical learning curve study of unilateral biportal endoscopy unilateral laminec-tomy bilateral decompression technique in the treatment of lumbar spinal stenosis

目的单侧双通道脊柱内镜(UBE)技术被广泛应用于腰椎间盘突出症和腰椎管狭窄症的治疗。本研究通过分析该技术的学习曲线,旨在为此类手术方式的实施和学习流程提供参考。方法回顾性分析了2021年6月至2023年12月期间在首都医科大学附属北京友谊医院骨科中心脊柱外科接受UBE的腰椎管狭窄症患者情况。收集所有患者的基线信息、手术时间、失血量、并发症以及主观评分。采用累积总和法(CUSUM)对学习曲线进行评估。结果共纳入122例接受单节段UBE-ULBD手术的患者。平均随访时间为(10.51±2.44)个月(8~20个月),手术节段包括L2/3(3例)、L3/4(13例)、L4/5(85例)和L5/S1(21例)。根据手术时间曲线拟合的结果,对患者队列根据不同的掌握熟练度进行分组。即学习阶段组(第1~38例)和掌握阶段组(第39~122例)。学习阶段组的手术时间长于掌握阶段组[(153.3±44.0)min与(129.2±34.5)min,t=2.978,P<0.05],失血量高于掌握阶段组[(62.4±42.3)min与(53.1±31.5)min,t=1.209,P>0.05],但隐性失血量低于掌握阶段组[(207.1±140.5)min与(211.2±110.9)min,t=-0.160,P>0.05]。学习阶段组的引流量多于掌握阶段组[(64.1±43.1)min与(29.4±34.4)min,t=-4.752,P<0.05]。两组患者术前、术后即刻、末次随访时进行重复测量设计的方差分析显示两组患者的ODI评分不同组别间差异无统计学意义(F=3.502,P=0.062),不同时间点间差异有统计学意义(F=347.190,P<0.001),组别与时间点间无交互作用(F=0.071,P=0.931);腰痛的VAS评分方面发现不同组别间差异有统计学意义(F=32.691,P=0.000),不同时间点间差异有统计学意义(F=866.102,P<0.001),组别与时间点间无交互作用(F=0.665,P=0.862)。腿痛的VAS评分方面发现不同组别间差异有统计学意义(F=24.980,P<0.001),不同时间点间差异有统计学意义(F=693.920,P<0.001),组别与时间点间无交互作用(F=1.986,P=0.139)。结论作为一种治疗腰椎管狭窄症的有效的微创脊柱内镜技术,UBE-ULBD手术需要大约38例才能克服学习曲线。如果能成功克服学习曲线,该技术将具有手术微创、操作灵活高效、术后恢复快等优点。

Objective Unilateral biportal endoscopy(UBE)technique is widely used in the treat-ment of lumbar disc herniation and lumbar spinal stenosis.By analyzing the learning curve of this technique,this study aims to inform the implementation and learning process of such surgical modalities.Methods Pa-tients with lumbar spinal stenosis who underwent UBE between June 2021 and December 2023 in the Depart-ment of Spine Surgery,Orthopaedic Center,Beijing Friendship Hospital,Capital Medical University,were retrospectively analyzed.Baseline information,operative time,blood loss,complications,and subjective scores were collected from all patients.The learning curve was evaluated using the cumulative sum(CU-SUM)method.Results A total of 122 patients who underwent single-segment UBE-ULBD were included.The mean follow-up time was(10.51±2.44)months(8-20 months),and the operated segments included L2/3(3 patients),L3/4(13 patients),L4/5(85 patients),and L5/S1(21 patients).Based on the results of surgical time curve fitting,the patient cohort was divided into groups according to different levels of mastery proficiency.Namely,the learning phase group(1-38 cases)and the mastery phase group(39-122 cases).The learning stage group had a longer operative time than the mastery stage group(153.3±44.0 min与129.2±34.5 min,t=2.978,P<0.05),higher blood loss than the mastery stage group(62.4±42.3 min与53.1±31.5 min,t=1.209,P>0.05),but lower hidden blood loss than the mastery stage group(207.1±140.5 min与211.2±110.9 min,t=-0.160,P>0.05).There was more drainage in the learning stage group than in the mastery stage group(64.1±43.1 min与29.4±34.4 min,t=-4.752,P<0.05).ANOVA with repeated measures design at preoperative,imme-diate postoperative,and final follow-up showed no statistically significant difference in ODI scores between the two groups(F=3.502,P=0.062),statistically significant difference between different time points(F=347.190,P=0.000),and no interaction between group and time point(F=0.071,P=0.931);For VAS scores for low back pain a statistically significant difference was found between groups(F=32.691,P=0.000),be-tween time points(F=866.102,P=0.000)and no interaction between groups and time points(F=0.665,P=0.862).In terms of VAS scores for leg pain a statistically significant difference was found between different groups(F=24.980,P=0.000),between different time points(F=693.920,P=0.000),and no interaction be-tween groups and time points(F=1.986,P=0.139).Conclusions As an effective minimally invasive spinal endoscopic technique for the treatment of lumbar spinal stenosis,the UBE-ULBD procedure requires approx-imately 38 cases to overcome the learning curve.If the learning curve can be successfully overcome,the tech-nique will have the advantages of minimally invasive surgery,flexible and efficient operation,and fast post-operative recovery.