Department of Orthopaedics, Peking University Third Hospital, Beijing, China.
Engineering Research Center of Bone and Joint Precision Medicine, Beijing, China.
Orthop Surg. 2023 Sep;15(9):2318-2327. doi: 10.1111/os.13804. Epub 2023 Jul 5.
Despite rapid advances in minimally invasive surgery, en bloc laminectomy remains the most common surgical approach for treating thoracic ossification of the ligamentum flavum (TOLF). However, the learning curve of this risky operation is rarely reported. Therefore, we aimed to describe and analyze the learning curve of ultrasonic osteotome-based en bloc laminectomy for TOLF.
Among 151 consecutive patients with TOLF who underwent en bloc laminectomy performed by one surgeon between January 2012 and December 2017, we retrospectively analyzed their demographic data, surgical parameters, and neurological function. Neurological outcome was evaluated with the modified Japanese Orthopaedic Association (mJOA) scale, and the Hirabayashi method was used to calculate the neurological recovery rate. The learning curve was assessed with logarithmic curve-fitting regression analysis. Univariate analysis methods were used for statistical analysis, including t-test, rank sum test, and chi-square test.
A total of 50% of learning milestones could be reached in approximately 14 cases, and the asymptote in 76 cases. Therefore, 76 of the 151 enrolled patients were defined as the "early group," and the remaining 75 were delimitated as the "late group" for comparison. There was a significant intergroup difference in the corrected operative time (94.80 ± 27.77 vs 65.93 ± 15.67 min, P < 0.001) and the estimated blood loss (median 240 vs 400 mL, P < 0.001). The overall follow-up was 83.1 ± 18.5 months. The mJOA significantly increased from a median of 5 (IQR: 4-5) before the surgery to 10 (IQR: 9-10) at the last follow-up (P < 0.001). The overall complication rate was 37.1%, and no significant intergroup difference was found, except for the incidence of dural tears (31.6% vs 17.3%, p = 0.042).
Initially, mastering the en bloc laminectomy technique using ultrasonic osteotome for TOLF treatment can be challenging, but the surgeon's experience improves as the operative time and blood loss decrease. Improved surgical experience reduced the risk of dural tears but was not associated with the overall complication rate or long-term neurological function. Despite the relatively long learning curve, en bloc laminectomy is a secure and valid technique for TOLF treatment.
尽管微创外科技术发展迅速，但整块椎板切除术仍然是治疗胸椎黄韧带骨化症（TOLF）的最常见手术方法。然而，这种高风险手术的学习曲线却很少有报道。因此，我们旨在描述和分析超声骨刀整块椎板切除术治疗 TOLF 的学习曲线。
在 2012 年 1 月至 2017 年 12 月间，由同一位外科医生对 151 例 TOLF 患者进行了整块椎板切除术，我们对其进行了回顾性分析，记录了他们的人口统计学数据、手术参数和神经功能。采用改良日本骨科协会（mJOA）量表评估神经功能，采用 Hirabayashi 方法计算神经恢复率。使用对数曲线拟合回归分析评估学习曲线。采用 t 检验、秩和检验和卡方检验等单变量分析方法进行统计学分析。
大约 14 例患者中达到 50%的学习里程碑，76 例患者达到渐近线。因此，将这 151 例患者中的 76 例定义为“早期组”，其余 75 例定义为“晚期组”进行比较。两组之间的校正手术时间（94.80±27.77 分钟比 65.93±15.67 分钟，P＜0.001）和估计出血量（中位数 240 毫升比 400 毫升，P＜0.001）差异有统计学意义。总的随访时间为 83.1±18.5 个月。mJOA 评分从术前的中位数 5 分（IQR：4-5 分）显著提高到末次随访时的 10 分（IQR：9-10 分）（P＜0.001）。总的并发症发生率为 37.1%，除硬脑膜撕裂发生率（31.6%比 17.3%，P=0.042）外，两组之间无显著差异。
最初，掌握使用超声骨刀整块椎板切除术治疗 TOLF 的技术具有挑战性，但随着手术时间和出血量的减少，外科医生的经验会有所提高。手术经验的提高降低了硬脑膜撕裂的风险，但与总体并发症发生率或长期神经功能无关。尽管学习曲线相对较长，但整块椎板切除术是治疗 TOLF 的一种安全有效的技术。
