Lee Kong Hwee, Yeo William, Soeharno Henry, Yue Wai Mun
Singapore General Hospital, Singapore, Singapore.
J Spinal Disord Tech. 2014 Oct;27(7):E234-40. doi: 10.1097/BSD.0000000000000089.
Prospective cohort study.
This study aimed to evaluate the learning curve of minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).
Very few studies have evaluated the learning curve of this technically demanding surgery. We intend to evaluate the learning curve of MIS TLIF with a larger sample size and assess surgical competence based not only on operative time but with perioperative variables, clinical and radiologic outcomes, incidence of complications, and patient satisfaction.
From 2005 to 2009, the first 90 single-level MIS TLIF, which utilized a consistent technique and spinal instrumentation, performed by a single surgeon at our tertiary institution were studied. Variables studied included operative time, perioperative variables, clinical (Visual Analogue Scores for back and leg pain, Oswestry Disability Index, North American Spine Society Scores for neurogenic symptoms) and radiologic outcomes, incidence of complications and patient rating of expectation met, and the overall result of surgery.
The asymptote of the surgeon's learning curve for MIS TLIF was achieved at the 44th case. Comparing the early group of 44 patients to the latter 46, the demographics were similar. For operative parameters, only 3 variables showed differences between the 2 groups: mean operative duration, fluoroscopy duration, and usage of patient-controlled analgesia. At the final follow-up, for clinical outcome parameters, the 2 groups were different in 3 parameters: VAS scores for back, leg pain, and neurogenic symptom scores. For radiologic outcome, both groups showed similar good fusion rates. For complications, none of the MIS TLIF cases were converted to open TLIF intraoperatively. In the early group, there were 3 complications: 1 incidental durotomy and 2 asymptomatic cage migrations; and in the latter group, there was 1 asymptomatic cage migration.
In our study, technical proficiency in MIS TLIF was achieved after 44 surgeries, and the latter patients benefited from shorter operative duration and radiation, less pain, and more relief in their back, leg, and neurogenic symptoms.
前瞻性队列研究。
本研究旨在评估微创经椎间孔腰椎椎间融合术（MIS TLIF）的学习曲线。
极少有研究评估这种技术要求较高的手术的学习曲线。我们打算以更大的样本量评估MIS TLIF的学习曲线，并不仅根据手术时间，还依据围手术期变量、临床和影像学结果、并发症发生率以及患者满意度来评估手术能力。
对2005年至2009年期间由我们三级医疗机构的一名外科医生采用一致技术和脊柱内固定器械实施的前90例单节段MIS TLIF进行研究。所研究的变量包括手术时间、围手术期变量、临床（背部和腿部疼痛的视觉模拟评分、Oswestry功能障碍指数、北美脊柱协会神经源性症状评分）和影像学结果、并发症发生率、患者对预期达成情况的评分以及手术的总体结果。
该外科医生MIS TLIF学习曲线的渐近线在第44例手术时达到。将早期的44例患者与后46例患者进行比较，人口统计学特征相似。在手术参数方面，两组之间只有3个变量存在差异：平均手术持续时间、透视时间以及患者自控镇痛的使用情况。在末次随访时，就临床结果参数而言，两组在3个参数上存在差异：背部、腿部疼痛的视觉模拟评分以及神经源性症状评分。在影像学结果方面，两组的融合率均良好且相似。在并发症方面，所有MIS TLIF病例术中均未转为开放TLIF。早期组有3例并发症：1例意外硬脊膜切开和2例无症状的椎间融合器移位；后期组有1例无症状的椎间融合器移位。
在我们的研究中，经过44例手术后实现了MIS TLIF的技术熟练，后期患者受益于更短的手术持续时间和辐射暴露、更少的疼痛以及背部、腿部和神经源性症状的更多缓解。
