C型臂X线机引导下腰椎间盘阻滞术的学习曲线分析

科技工作者之家 2021-08-27

张  科,吴卉乔,王建喜,石长贵,刘  洋,袁  文

(海军军医大学长征医院脊柱外科 200003 上海市)

基金项目:国家自然科学基金面上项目(编号:81972090)

第一作者简介:男(1991-),硕士在读,

研究方向:脊柱外科

电话:(021)82886806  

E-mail:zhangkespine@163.com

通讯作者:刘洋  

E-mail:liuyangspine@hotmail.com

 

【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。

【关键词】 腰痛;腰椎间盘阻滞术;学习曲线

doi:10.3969/j.issn.1004-406X.2021.01.08

中图分类号:R681.5    

文献标识码:A   

文章编号:1004-406X(2021)-01-0056-07

 

Analysis of the learning curve for lumbardiscoblock guided by C-arm fluoroscopy/ZHANG Ke, WU Huiqiao, WANG Jianxi, etal//Chinese Journal of Spine and Spinal Cord, 2021, 31(1): 56-62

【Abstract】  Objectives: The purpose ofthe present study was to determine the learning curve for lumbar discoblockguided by C-arm fluoroscopy using a learning curve cumulative summationtest(LC-CUSUM), and compare the differences between L2-L5 and L5/S1 segment.Methods: A retrospective design was used. This study comprised 120 patients whounderwent a single level lumbar discblock from October 2017 to December 2019.Patients were divided into group L2-L5 and group L5/S1 according to theoperation 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 theacceptable 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 ofradioactive exposure, numbers of nerve root irritation syndromes duringoperation and VAS improvement rate between the two groups were comparedrespectively, and the differences of these indexes  between the different learning stage werecompared respectively either. Results: The mean operative time in the twogroups was 17.9±3.7min vs 24.1±3.8min respectively(P<0.05). The average numbers of radioactive exposure in the two groupswere 5.0±1.5 vs 6.0±1.6 respectively(P<0.05). The average numbers of nerve root irritation syndromes duringoperation 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 segmentshowed significant differences respectively(P<0.05). The mean operative time(25.3±4.0min vs 21.7±1.8min), the average numbers of radioactiveexposure(6.4±1.7 vs 5.1±0.8), the average numbers of nerve root irritationsyndromes(4.9±1.3 vs 2.6±1.2) between the early and late learning stage ofL5/S1 segment showed significant differences respectively(P<0.05). No significant differences werefound in the VAS improvement rate of the two groups[(63.5±9.5)% vs (64.5±8.5)%, P=0.52] and the two learningstage[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 thata substantial learning period maybe necessary before an adequate level ofperformance is achieved for the discoblock technique guided by C-armfluoroscopy in L2-L5 and L5/S1 segment: 33-36 and 40-44 cases respectively.

【Key words】 Low back pain; Lumbar discoblock; Learning curve

【Author′s address】 Department of Spine Surgery, Changzheng Hospital, Naval MedicalUniversity, Shanghai, 200003, China

 

图1  L2~L5组LC-CUSUM分析  a 基于手术时间的失败病例累计数 b 基于手术时间的学习曲线累积求和分析 c 基于放射次数的失败病例累计数 d 基于放射次数的学习曲线累积求和分析

Figure 1 LC-CUSUM of group L2-L5  a Cumulative counting of failure cases based on operative time in group L2-L5 b Learning curves of group L2-L5 b ased on operative time c Cumulative counting offailure cases based on radiation exposure in group L2-L5 d Learning curves ofgroup L2-L5 b ased radiation exposure

图2  L5/S1组LC-CUSUM分析  a 基于手术时间的失败病例累计数 b 基于手术时间的学习曲线累积求和分析 c 基于放射次数的失败病例累计数 d 基于放射次数的学习曲线累积求和分析

Figure 2 LC-CUSUM of group L5/S1  a Cumulative counting of failure cases based on operative time in group L5/S1 b Learning curves of group L5/S1 b ased on operative time c Cumulative counting offailure cases based on radiation exposure group L5/S1 d Learning curves of group L5/S1 b ased radiation exposure

来源:gh_9f19453ed2d0 中国脊柱脊髓杂志

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