机器人辅助L_(4)、L_(5)椎弓根螺钉内固定术治疗腰椎滑脱症的学习曲线研究  

Learning curve of robot-assisted L_(4) and L_(5) pedicle screw insertion for lumbar spondylolisthesis

作　　者：范明星[1] 房彦名 安岩[1] 张琦 田伟[1] Fan Mingxing;Fang Yanming;An Yan;Zhang Qi;Tian Wei(Department of Spine Surgery,Beijing Jishuitan Hospital,Beijing 100035,China)

机构地区：[1]北京积水潭医院脊柱外科,北京100035

出　　处：《中华骨科杂志》2022年第6期341-348,共8页Chinese Journal of Orthopaedics

基　　金：北京市优秀人才培养资助青年骨干个人项目(2018000021469G225);北京积水潭医院院级科研基金项目(QN201903);北京积水潭医院人才培养计划(XKXX202104)。

摘　　要：目的研究机器人辅助L_(4)、L_(5)椎弓根螺钉内固定术治疗腰椎滑脱症的学习曲线及其拐点。方法回顾性分析2016年1月至2020年12月采用机器人辅助L_(4)、L_(5)椎弓根螺钉内固定术治疗43例腰椎滑脱症患者资料,男19例、女24例;年龄59(48,66)岁;按Meyerding分类,Ⅰ度滑脱23例,Ⅱ度滑脱18例,Ⅲ度滑脱2例。测量螺钉置入精度和螺钉准确性分级,记录患者手术时间、术中出血量、术中透视次数、术后并发症、术后住院时间等信息。采用累计求和法绘制学习曲线,根据形态将学习曲线分为前期和后期。对比学习前期和学习后期指标差异,采用t检验、Wilcoxon秩和检验进行统计学分析。结果43例腰椎滑脱症患者均顺利完成手术,置入L_(4)椎弓根螺钉60枚、L_(5)椎弓根螺钉70枚。L_(4)椎弓根螺钉置入精度在第23枚开始提高,L_(5)椎弓根螺钉置入精度在第20枚开始提高。以第23枚椎弓根螺钉(第14例患者)分割学习曲线为前期和后期,学习前期组与后期组在手术时间[(225.0±74.0)min vs.(207.0±81.2)min,t=0.65,P=0.521]、术中出血量[200(75,500)ml vs.100(60,200)ml,Z=1.30,P=0.195]、术中透视次数[10(6,10)次vs.10(6,10)次,Z=-0.37,P=0.712]、术后并发症发生率(8%vs.0,P=0.302)等的差异无统计学意义。学习后期较学习前期有更短的术后住院天数[4.5(3,6)d vs.6.0(5,9)d,Z=2.00,P=0.046]和更高的椎弓根螺钉置入精度[L_(4):1.33(1.06,1.79)mm vs.2.23(1.12,4.55)mm,Z=2.43,P=0.015;L_(5):1.47(0.98,1.87)mm vs.3.21(1.64,4.87)mm,Z=3.90,P=0.001]。前期和后期置钉准确率相近[L_(4):95%(21/22)vs.97%(37/38),P=1.000;L_(5):91%(20/22)vs.96%(46/48),P=0.585]。结论机器人辅助L_(4)、L_(5)椎弓根螺钉内固定术治疗腰椎滑脱症具有较明显的学习曲线,置入第23枚椎弓根螺钉时,螺钉置入精度开始提高。Objective To study the learning curve and inflection point of robot-assisted L_(4) and L_(5) pedicle screw insertion for lumbar spondylolisthesis.Methods A retrospective study was conducted on the data of 43 patients with L_(4) and L_(5) pedicle screw insertion for lumbar spondylolisthesis from January 2016 to December 2020 using surgical robot,including 19 males and 24 females,aging 59(48,66)years old.According to Meyerding classification,there were 23 grade I slippage,18 grade II slippage,and 2 grade III slippage.The screw deviation and screw accuracy grade were assessed.The operation time,intraoperative blood loss,the number of intraoperative fluoroscopies,postoperative complications,and postoperative hospital stay were recorded.Cumulative Sum(CUSUM)was used to analyze the learning curve,and the learning curve is divided into early and late learning stages according to morphology.T test and Wilcoxon rank-sum test were used for statistical analysis and comparison of indicators between early and late learning stages.Results 43 patients with lumbar spondylolisthesis successfully completed the operation,with 60 L_(4) pedicle screws and 70 L_(5) pedicle screws inserted.The accuracy of L_(4) pedicle screw placement began to improve since the 23rd placement,and the accuracy of L_(5) pedicle screw placement began to improve since the 20th placement.Using the 23rd pedicle screw(the 14th patient)to divide the learning curve as the early stage and the late stage.There was no statistically significant difference in the operation time(225.0±74.0 min vs.207.0±81.2 min,t=0.65,P=0.521),intraoperative blood loss[200(75,500)ml vs.100(60,200)ml,Z=1.30,P=0.195],the number of intraoperative fluoroscopies[10(6,10)vs.10(6,10),Z=-0.37,P=0.712]and postoperative complications(8%vs.0,P=0.302)between the early stage and late stage of learning curve.In the late stage of learning,the postoperative hospital stay was shorter[4.5(3,6)d vs.6.0(5,9)d,Z=2.00,P=0.046]and the pedicle screw insertion accuracy was higher[L_(4):1.33(1.06,1.79)mm vs

关 键 词：腰椎 脊椎滑脱 机器人手术 学习曲线 

分 类 号：R687.3[医药卫生—骨科学]