C型臂X线机引导下腰椎间盘阻滞术的学习曲线分析

Analysis of the learning curve for lumbar discoblock guided by C-arm fluoroscopy

中文关键词:  腰痛  腰椎间盘阻滞术  学习曲线

英文关键词:Low back pain  Lumbar discoblock  Learning curve

中文摘要:

  【摘要】 目的：分析C型臂X线机引导下腰椎间盘阻滞术的学习曲线，并比较L2～L5与L5/S1椎间隙学习曲线的不同。方法：回顾性分析我科在2017年10月～2019年12月分别由2名主治医师连续完成的C型臂X线机透视下的单间隙腰椎间盘阻滞术的腰痛患者的手术信息，基于手术时间、术中透视次数两大评估脊柱微创手术操作的重要指标分别绘制学习曲线，并使用学习曲线累积求和法（learning curve cumulative summation，LC-CUSUM）基于预定的手术成功标准进行分析处理。手术成功的标准定为：在L2～L5椎间隙手术时间不超过20min，L5/S1椎间隙不超过25min；透视次数分别在L2～L5椎间隙不超过5次，L5/S1椎间隙不超过7次。同时比较掌握腰椎间盘阻滞术在L2~L5与L5/S1椎间隙及不同学习阶段手术时间、术中透视次数、术后VAS改善率、术中神经根刺激症状发生次数等方面的差异。结果：腰椎间盘阻滞术在L2~L5与L5/S1组相比，其手术时间（17.9±3.7min vs 24.1±3.8min）、术中透视次数（5.0±1.5次 vs 6.0±1.6次）及术中神经根刺激症状发生次数（3.2±1.5次 vs 4.1±1.6次）均明显减少（P＜0.05）。在L2~L5组，通过LC-CUSUM分析的学习提高阶段、学习掌控阶段，其手术时间（19.2±4.2min vs 16.0±1.6min）、术中透视（5.5±1.8次 vs 4.4±0.7次）及术中神经根刺激症状发生次数（4.1±1.2次 vs 1.9±1.0次）均具有显著差异（P＜0.05）。在L5/S1组，前后两个学习阶段其手术时间（25.3±4.0min vs 21.7±1.8min）、术中透视（6.4±1.7次 vs 5.1±0.8次）及术中神经根刺激症状发生次数（4.9±1.3次 vs 2.6±1.2次）均具有显著差异（P＜0.05）。但是VAS改善率在L2~L5与L5/S1组[（63.5±9.5）% vs （64.5±8.5）%，P=0.52]及各组相应前后两个学习阶段相比[L2~L5：（63.8±8.9）% vs （62.6±10.5）%，P=0.65；L5/S1：（64.0±9.7）% vs （64.8±5.5）%，P=0.7]无明显统计学差异。结论：通过基于手术操作时间和术中透视次数的LC-CUSUM精确分析，C型臂X线机透视下的腰椎间盘阻滞术在L2~L5椎间隙熟练掌握通常需要33~36例，在L5/S1椎间隙由于其解剖的相对复杂性则需要40~44例。

英文摘要:

  【Abstract】 Objectives: The purpose of the present study was to determine the learning curve for lumbar discoblock guided by C-arm fluoroscopy using a learning curve cumulative summation test(LC-CUSUM), and compare the differences between L2-L5 and L5/S1 segment. Methods: A retrospective design was used. This study comprised 120 patients who underwent a single level lumbar discblock from October 2017 to December 2019. Patients were divided into group L2-L5 and group L5/S1 according to the operation segment and each group was operated by different orthopedic surgeon. Surgery success was defined as: operative time of group L2－L5 <20 minutes, group L5/S1 ＜25 minutes, and accordingly the acceptable procedure was completed within 5 and 7 times of C-arm fluoroscopy. The LC-CUSUM was used to analyze the data. The operative time, numbers of radioactive exposure, numbers of nerve root irritation syndromes during operation and VAS improvement rate between the two groups were compared respectively, and the differences of these indexes between the different learning stage were compared respectively either. Results: The mean operative time in the two groups was 17.9±3.7min vs 24.1±3.8min respectively(P＜0.05). The average numbers of radioactive exposure in the two groups were 5.0±1.5 vs 6.0±1.6 respectively(P＜0.05). The average numbers of nerve root irritation syndromes during operation in the two groups were 3.2±1.5 vs 4.1±1.6(P＜0.05). The mean operative time(19.2±4.2min vs 16.0±1.6min), the average numbers of radioactive exposure(5.5±1.8 vs 4.4±0.7), the average numbers of nerve root irritation syndromes(4.1±1.2 vs 1.9±1.0) between the early and late learning stage of L2-L5 segment showed significant differences respectively(P＜0.05). The mean operative time(25.3±4.0min vs 21.7±1.8min), the average numbers of radioactive exposure(6.4±1.7 vs 5.1±0.8), the average numbers of nerve root irritation syndromes(4.9±1.3 vs 2.6±1.2) between the early and late learning stage of L5/S1 segment showed significant differences respectively(P＜0.05). No significant differences were found in the VAS improvement rate of the two groups[(63.5±9.5)% vs (64.5±8.5)%, P=0.52] and the two learning stage[L2-L5: (63.8±8.9)% vs (62.6±10.5)%, P=0.65; L5/S1: (64.0±9.7)% vs (64.8±5.5)%, P=0.7]. Conclusions: The LC-CUSUM analysis demonstrated that a substantial learning period maybe necessary before an adequate level of performance is achieved for the discoblock technique guided by C-arm fluoroscopy in L2-L5 and L5/S1 segment: 33-36 and 40-44 cases respectively.