经皮后路内镜下颈椎间盘切除术治疗神经根型颈椎病的学习曲线和临床疗效

The learning curve and clinical outcome of posterior percutaneous endoscopic cervical discectomy for cervical radiculopathy

中文关键词:  经皮后路内镜下颈椎间盘切除术  神经根型颈椎病  微创  学习曲线

英文关键词:Posterior percutaneous endoscopic cervical discectomy  Cervical radiculopathy  Minimally invasive  Learning curve

中文摘要:

  【摘要】 目的：探讨经皮后路内镜下颈椎间盘切除术治疗神经根型颈椎病的学习曲线和临床疗效。方法：回顾性分析我院2015年5月～2017年5月收治的54例行经皮后路内镜下颈椎间盘切除术治疗的单节段神经根型颈椎病患者，患者按照接受手术的时间先后顺序编号为1~54号，分为A（1~27号）、B（28~54号）两组，每组27例。对手术时间、手术并发症、住院花费、术后住院天数、翻修的例数以及术后临床疗效进行组间比较。临床结果的评估采用术前、术后1个月、术后半年和术后1年的颈肩部及上肢视觉疼痛模拟评分（visual analog scale，VAS）、颈椎功能障碍指数（neck disability index，NDI）和改良Macnab标准。学习曲线采用双变量回归曲线拟合出最优的立方模型（Y=b0+b1X+b2X2+b3X3）。结果：所有患者的平均随访时间为15.1±7.8个月，其中42例（A组27例，B组15例）例接受至少1年随访。两组患者术后1年随访时颈肩、上肢疼痛症状及NDI均有显著改善。两组患者经改良Macnab标准评价的临床疗效无明显统计学差异，总体优良率为90.7%。术前颈肩痛/患侧上肢痛VAS评分A组为7.1±0.9分/7.0±0.8分，B组为6.7±0.7分/7.2±1.0分；术后1个月时A组为2.1±1.5分/1.7±1.6分，B组为2.0±0.8分/1.3±0.5分；术后半年时A组为1.5±1.3分/1.2±1.2分，B组为1.1±1.0分/0.7±0.7分；术后1年时A组为0.4±0.9分/0.2±0.6分，B组为0.2±0.6分/0.1±0.3分。术前NDI A组为（55.3±13.7）%，B组为（56.9±8.4）%；术后1个月时A组为（25.5±14.9）%，B组为（17.0±7.1）%；术后半年时A组为（11.3±7.1）%，B组为（6.1±3.5）%；术后1年时A组为（4.9±8.0）%，B组为（1.8±3.9）%。A组和B组患者术前、术后半年及术后1年随访的颈肩部及上肢VAS评分及NDI无显著性差异（P＞0.05）。但A组患者术后1个月随访时颈肩部、上肢疼痛评分及NDI显著大于B组患者（P＜0.05）。两组患者术后共有4例患者出现一过性神经根炎，其中A组3例，B组1例，均在术后2周内恢复，无统计学差异（P=0.610）。两组患者的手术时间对比分析显示B组患者手术时间要显著低于A组（P=0.001）。通过两变量回归分析进行曲线拟合，建立立方模型（Y=141.85-5.592X+0.135X2-0.001X3，R2=0.939），发现随着病例数的增加，手术时间逐渐下降，且当患者例数为22例左右时，手术时间趋于平稳，平均67.76±5.15min。结论：经皮后路内镜下颈椎间盘切除术治疗神经根型颈椎病是安全、有效的，且具有显著的学习曲线和微创优势。随着手术患者例数的增加，手术时间逐步缩短，术后早期患者恢复更快，到22例趋于稳定，但学习曲线并不影响患者的中期临床疗效。

英文摘要:

  【Abstract】 Objectives: To investigate the learning curve and clinical outcome of posterior percutaneous endoscopic cervical discectomy for cervical radiculopathy. Methods: A retrospective analysis was performed on 54 patients who underwent single-level posterior percutaneous endoscopic cervical discectomy for cervical radiculopathy from May 2015 to May 2016. They were divided chronologically into 2 groups with 27 cases in each group(A and B). The duration of surgery, perioperative complication, hospitalization expense, postoperative hospitalization stay, reoperation rate and clinical outcome were evaluated and compared between the 2 groups. Clinical outcomes were assessed by the visual analogue scale(VAS), neck disability index(NDI) score and modified Macnab criteria in preoperative period as well as 1 month, 6 months and 1 year after surgery. The learning curve was characterized by using two variables regression analysis to establish a cube model(Y=b0+b1X+b2X2+b3X3). Results: The mean duration of follow-up was 15.1±7.8 months, and 42(group A 27 cases, group B 15 cases) patients achieved a minimum follow-up duration of 12 months. The VAS of radicular arm pain and neck pain improved significantly in all the patients at one-year follow-up, so did the NDI. According to Macnab assessment criteria, the surgical outcome was excellent and good in 90.6% patients. The preoperative VAS of neck pain and radicular arm pain of each group was as follows: A, (7.1±0.9)/(7.0±0.8), B, (6.7±0.7)/(7.2±1.0); which at 1 month after surgery was as follows: A, (2.1±1.5)/(1.7±1.6), B, (2.0±0.8)/(1.3±0.5); which at 6 months after surgery was as follows: A, (1.5±1.3)/(1.2±1.2), B, (1.1±1.0)/(0.7±0.7); which at 1 year after surgery was as follows: A, (0.4±0.9)/(0.2±0.6), B, (0.2±0.6)/(0.1±0.3). The preoperative NDI of each group was as follows: A, (55.3±13.7)%, B, (56.9±8.4)%; which at 1 month after surgery was as follows: A, (25.5±14.9)%, B, (17.0±7.1)%; which at 6 months after surgery was as follows: A, (11.3±7.1)%, B, (6.1±3.5)%; which at 1 year after surgery was as follows: A, (4.9±8.0)%, B, (1.8±3.9)%. There was no significantly difference of VAS between group A and group B postoperatively except for one-month after surgery. The improvement of VAS in group A was significantly less than that of group B. No intraoperative complication was observed in two groups. However, postoperative transient radiculitis occurred in 4 patients and was relieved within two weeks, and no significant difference was found between group A(3 cases) and group B(1 case, P=0.610). The duration of surgery of group A was significantly less than that of group B(P=0.001). The learning curve was characterized by using two variables regression analysis to establish a cube model(Y=141.85-5.592X+0.135X2-0.001X3，R2=0.939), which demonstrated that the duration of suegery decreased with the cases accumulation and reached plateau after 22 cases. Conclusions: Posterior percutaneous endoscopic cervical discectomy is a safe and effective option for cervical radiculopathy with its minimally invasive nature. A significant learning curve exists in the surgeon who performs PECD. Proficiency in surgical skill and better in early clinical recovery can be expected after finishing 22 cases, but longer duration of surgery has no impact on the medium-term surgical outcome before that.