O型臂导航系统辅助胸椎椎弓根螺钉置入的准确性及学习曲线

The accuracy and learning curve of pedicle screw placement by using O-arm navigation in thoracic spine

中文关键词:  胸椎椎弓根螺钉置入  O型臂导航系统  学习曲线

英文关键词:Thoracic spine pedicle screw  O-arm intraoperative navigation  Learning curve

中文摘要:

  【摘要】 目的：探究应用O型臂导航系统辅助胸椎椎弓根螺钉置入的准确性及其学习曲线。方法：回顾性分析2015年5月~2018年5月我院行胸椎内固定手术的患者临床资料109例，其中男性49例，女性60例，年龄53.5±12.3岁（27～77岁）。根据是否使用O型臂导航系统辅助置钉分为导航组（A组，n=66）和非导航组（B组，n=43），置钉过程由医师1（具有3年脊柱外科手术经验）或医师2（具有20年脊柱外科手术经验）完成。导航组医师1完成35例（A1组），医师2完成31例（A2组）；非导航组医师1完成18例（B1组），医师2完成25例（B2组）。待引流管拔除后复查胸椎平扫CT，根据Neo′s法对术后椎弓根螺钉位置进行分级，统计各组的满意置钉（0级、1级螺钉）和螺钉穿透皮质（1级、2级、3级螺钉）的情况。比较各组的满意置钉率和皮质穿透率，并用皮质穿透率衡量同组内不同节段的置钉准确度。记录并比较各组的置钉时间，观察置钉时间随手术例数增加的动态变化，采用线性回归分析的方法探讨置钉时间与手术例数的关系。比较每组内不同阶段置钉时间和皮质穿透率的差异，评价术中应用O型臂导航系统的学习曲线。结果：共置入胸椎椎弓根螺钉668枚，其中，A1组置入螺钉222枚，满意置钉率97.3%，皮质穿透率10.8%；A2组置入螺钉188枚，满意置钉率97.9%，皮质穿透率10.1%；B1组置入螺钉120枚，满意置钉率91.7%；皮质穿透率20.0%；B2组置入螺钉138枚，满意置钉率97.8%，皮质穿透率9.4%。B1组的满意置钉率明显低于其他各组，且皮质穿透率也明显高于其他各组。B1组在胸椎不同节段（上胸段、中胸段、下胸段）的皮质穿透率存在显著差异（37.5%，28.6%，13.4%，P=0.02），而其余3组在胸椎不同节段的置钉准确率无统计学差异。B1组的单枚螺钉置钉时间（4.87±0.34min）明显高于其他3组（4.38±0.97min、4.40±1.00min、4.18±0.22min）。导航组（A组）的单枚螺钉置钉时间随着术者手术例数的增加而下降，线性回归分析显示A1组单枚螺钉置钉时间与手术例数呈显著线性负相关（F=123.3，P＜0.001），回归方程：置钉时间=5.88-0.084×手术例数，R2=0.79；A2组可得出相同结果（F=141.6，P＜0.001，置钉时间=6.01-0.10×手术例数，R2=0.83）。A1组的1~10例、11~20例、21~30例手术的皮质穿透率无统计学差异（P=0.97）；同样，A2组上述3个阶段的皮质穿透率也无显统计学差异（P=0.96）。结论：应用O型臂术中导航辅助胸椎椎弓根螺钉置入可以显著提高低年资医师的置钉准确率，增加手术安全性。随着手术例数增加O型臂导航下置钉时间显著下降；不同年资医师首次使用O型臂导航均能取得较高并且稳定的置钉准确度。

英文摘要:

  【Abstract】 Objectives: This study aimed to evaluate the accuracy andlearning curveof pedicle screw placement by using O-arm navigation versus C-arm guidance in thoracic spine. Methods: Retrospective analysis was performed on 109 cases of thoracic spine surgery performed by Peking University International Hospital from May 2015 to May 2018, including 49 males and 60 females. The age ranged from 27 to 77 years old, with an average age of 53.5±12.3 years. These cases were divided into navigation group(group A, n=66) and non-navigation group(group B, n=43) according to whether used of O-arm navigation. 35 cases of group A were completed by doctor 1 who had 3 years of experience in spinal surgery (group A1); 31 of group A were completed by doctor 2 who had 20 years of experience (group A2). On the other hand, 18 of group B were completed by doctor 1 (group B1) and 25 of group B were completed by doctor 2 (group B2). Postoperative pedicle screw position was graded according to Neo′s method, and satisfactory screw placement(grade 0 +1 screws) and screw penetration into the cortex (non-grade 0 screws) in each group were compared. The cortical perforation rate at different segment in the same group were compared. The screwsetting time of each group were recorded. Linear regression analysis was used to investigate the relationship between the screw setting time and operation numbers, and compare the difference of screw settingtime and cortical perforation rate in different stages, thus, to analyze the learning curves of O-arm navigation in thoracic spine. Results: A total of 668 thoracic pedicle screws were inserted in the 4 groups, of which 222 were inserted in group A1, with a satisfactory rate of 97.3% and a cortical perforation rate of 10.8%. In group A2, 188 screws were inserted, the satisfactory rate was 97.9%, and the cortical perforation rate was 10.1%. In group B1, 120 screws were inserted, with a satisfactory rate of 91.7%, and cortical perforation rate 20.0%. In group B2, 138 screws were inserted, with a satisfactory rate of 97.8%, and cortical perforation rate of 9.4%. The satisfactory rate of group B1 was significantly lower than the other groups, and the cortical perforation rate was also significantly higher than the other groups. Besides, there is significant difference of cortical perforation rates in different segments in thoracic pedicle in group B1(37.5%, 28.6%, 13.4%, P=0.02), and there is no significant difference in other 3 groups(A1/A2/B2). The setting time for each screw of group B1(4.87±0.34min) was significantly higher than the other respectively (4.38±0.97min, 4.40±1.00min, 4.18±0.22min). The setting time for each screw in the navigation group (A1, A2) decreased significantly with the increase of the number of surgical cases. Linear regression analysis showed that there was a significant negative linear correlation between the setting time and the number of surgical cases in group A1(F=123.3, P＜0.001), the setting time = 5.88-0.084×number of cases, R2=0.79). There was a same result in group A2(F=141.6, P＜0.001，the setting time = 6.01-0.10×number of cases, R2=0.83). Cortical perforationrates in the first 10, 11-20, and 21-30 cases of A1 group were not statistically significant(P=0.97), and the same results were found in the A2 group(P=0.96). Conclusions: The O-arm navigation assisted thoracicpedicle screw can significantly improve the accuracy of pedicle screw in young surgeon, which increased the safety of the operation. The screw setting time decreased significantly with the increase of the number of surgical cases,andearly application of O-arm by surgeonsat different seniority showed a high accuracy of screw placement.