Division of Neurosurgery, National Naval Medical Center, Bethesda, Maryland 20889, USA.
Neurosurg Focus. 2010 May;28(5):E21. doi: 10.3171/2010.1.FOCUS1011.
Minimal-access transforaminal lumbar interbody fusion (TLIF) has gained popularity as a method of achieving interbody fusion via a posterior-only approach with the aim of minimizing injury to adjacent tissue. While many studies have reported successful outcomes, questions remain regarding the potential learning curve for successfully completing this procedure. The goal of this study, based on a single resident's experience at the only Accreditation Council for Graduate Medical Education-approved neurosurgical training center in the US military, was to determine if there is in fact a significant learning curve in performing a minimal-access TLIF.
The authors retrospectively reviewed all minimal-access TLIFs performed by a single neurosurgical resident between July 2006 and January 2008. Minimal-access TLIFs were performed using a tubular retractor inserted via a muscle-dilating exposure to limit approach-related morbidity. The accuracy of screw placement and operative times were assessed.
A single resident/attending team performed 28 minimal-access TLIF procedures. In total, 65 screws were placed at L-2 (1 screw), L-3 (2 screws), L-4 (18 screws), L-5 (27 screws), and S-1 (17 screws) from the resident's perspective. Postoperative CTs were reviewed to determine the accuracy of screw placement. An accuracy of 95.4% (62 of 65) properly placed screws was noted on postoperative imaging. Two screws (at L-5 in the patient in Case 17 and at S-1 in the patient in Case 9) were lateral, and no revision was needed. One screw (at L-4 in Case 24) was 1 mm medial without symptoms or the need for revision. In evaluating the operative times, 2 deformity cases (Grade III spondylolisthesis) were excluded. The average operating time per level in the remaining 26 cases was 113.25 minutes. The average time per level for the first 13 cases was 121.2 minutes; the amount of time decreased to 105.3 minutes for the second group of 13 cases (p = 0.25).
In summary, minimal-access TLIF can be safely performed in a training environment without a significant complication rate due to the expected learning curve.
微创经椎间孔腰椎体间融合术（TLIF）作为一种仅通过后路实现椎间融合的方法已得到广泛应用，其目的是使相邻组织的损伤最小化。虽然许多研究报告了成功的结果，但对于成功完成该手术的潜在学习曲线仍存在疑问。本研究基于美国军队中唯一一家经研究生医学教育认证委员会认可的神经外科培训中心的一名住院医师的经验，旨在确定微创经椎间孔 TLIF 是否确实存在显著的学习曲线。
作者回顾性分析了 2006 年 7 月至 2008 年 1 月期间由一名神经外科住院医师实施的所有微创经椎间孔 TLIF。微创经椎间孔 TLIF 通过管状牵开器插入，通过肌肉扩张暴露来限制与入路相关的发病率。评估螺钉放置的准确性和手术时间。
一名住院医师/主治医生团队共完成 28 例微创经椎间孔 TLIF 手术。从住院医师的角度来看，总共在 L-2（1 个螺钉）、L-3（2 个螺钉）、L-4（18 个螺钉）、L-5（27 个螺钉）和 S-1（17 个螺钉）放置了 65 个螺钉。术后 CT 检查以确定螺钉放置的准确性。术后影像学检查显示，28 个螺钉中有 95.4%（62/65）位置正确。2 个螺钉（病例 17 的 L-5 和病例 9 的 S-1）位置偏侧，无需修正。1 个螺钉（病例 24 的 L-4）位置偏内侧 1 毫米，无症状，无需修正。在评估手术时间时，排除了 2 例畸形病例（III 度滑脱）。在其余 26 例中，每个节段的平均手术时间为 113.25 分钟。前 13 例的平均每节段时间为 121.2 分钟；第二组 13 例的时间减少到 105.3 分钟（p = 0.25）。
综上所述，微创经椎间孔 TLIF 可以在培训环境中安全进行，由于预期的学习曲线，其并发症发生率没有显著增加。
