내시경을 이용한 경피적 요추 절제술에서의 학습곡선 Learning curve for percutaneous endoscopic lumbar discectomy

Brief review

이 논문은 PELD에서의 learning curve에 대한 논문 입니다.

요새 계속 PELD learning curve에 대한 논문을 보고 있는데, 각 논문별로 언급된 항목에 조금씩 차이가 있네요. 여기서는 수술시간, 1년 후의 임상적 결과, 수술 성공률, 수술 실패율, 합병증 발생률, 재발률 등의 항목을 조사하였습니다. 

이 논문이 2008년에 출판되었는데, 최근에 출판된 PELD learning curve관련 논문들과 큰 차이는 없어보입니다.

Clinical success를 아래의 기준으로 판단했습니다.

1. 통증지수(VAS)의 향상률이 2점 이상

2. 장애지수(ODI)의 향상률이 25% 이상

3. 환자의 주관적인 회복률이 50% 이상

4. 주요한 합병증이 없음

그런데 주관적인 회복률을 어떻게 평가했는지 안나와있네요.. clinical outcome 평가 시 처럼 환자에게 전화하여 환자가 느끼는 회복률을 적용한 것 일까요

그리고 특이한점은 일반적으로 의학통계에 널리 사용되는 SPSS가 아니라 SAS라는 프로그램을 사용하여 분석을 했습니다.

아래의 링크 따라가셔서 전체 내용 확인하세요^^

*Title: Learning curve for percutaneous endoscopic lumbar discectomy

내시경을 이용한 경피적 요추 절제술에서의 학습곡선

*Authors: Lee DY, Lee SH

*Bibliography: Neurol Med Chir (Tokyo). 2008Sep;48(9):383-8; discussion 388-9.

Background of data

Percutaneous endoscopic lumbar discectomy (PELD) is one of the surgical options for soft lumbar disk herniation, but the learning curve is perceived to be steep.

Methods

▶Subjects: 51 PELD cases performed for single-level intracanalicular lumbar disk herniation causing radiculopathy.

▶Divided into 3 groups: each 17 patients

▶Evaluating parameters: operating time, failure rate, complication rate, and 1-year reherniation rate.

▶1 year clinical success rate was assessed by telephone interviews

Results

▶4 patients required subsequent open discectomy due to PELD failure.

▶2 minor complications.

▶1 year clinical success: achieved in 42 of the 47 patients

▶Reherniation developed in 5 patients

-A significant reduction in operating time was observed after 17 patients had been treated (p = 0.0004).

▶Failure rate, complication rate: no significant differences between the 3 groups

▶1year clinical success rate, reherniation rate: no significant differences

Conclusion

The PELD learning curve seems to be stable and acceptable with proper pre-PELD training.

합병증은 최소침습 척추수술의 초기 학습곡선과 연관성이 있다 Complications associated with the initial learning curve of minimally invasive spine surgery: a systematic review

Brief review

최소침습적인 척추수술의 Learning curve(학습곡선)을 주요 항목으로 하여 체계적 문헌고찰을 시행한 연구 입니다.

Pubmed에서 검색된 논문을 정해진 프로토콜대로 리뷰하여 최종적으로 15개의 논문이 선택되었습니다.

각 연구별로 complication, procedure time, fusion rate, estimated blood loss, level of evidence, sample size, intervention, study design등을 조사하여 정리하였습니다.

decompressive procedure에서는 durotomy, 그리고 fusion에서는 implant malposition,neural injury, and nonunion가 가장 흔한 합병증이라는 결과가 나왔습니다.

또 수술 후의 전체적인 합병증 발병률은 11%입니다.

아래 링크 따라가시면 전문 보실 수 있습니다^^

*Title: Complications associated with the initial learning curve of minimally invasive spine surgery: a systematic review

합병증은 최소침습 척추수술의 초기 학습곡선과 연관성이 있다: 체계적 문헌고찰

*Authors: Sclafani JA, Kim CW

*Bibliography: Clin Orthop Relat Res. 2014Jun;472(6):1711-7.

BACKGROUND

-There is an inherently difficult learning curve associated with minimally invasive surgical (MIS) approaches to spinal decompression and fusion.

-The association between complication rate and the learning curve remains unclear.

QUESTIONS/PURPOSES

-Evaluated the learning curves of MIS procedures for the spine

-Defined as the change in frequency of complications and length of surgical time as case number increased, for five types of MIS for the spine.

METHODS

▶Searching protocol: PubMed database

-terms: "minimally invasive spine surgery AND complications AND learning curve”

▶Clinical outcome and learning curve metrics were categorized for analysis by surgical procedure (MIS lumbar decompression procedures, MIS transforaminal lumbar interbody fusion, percutaneous pedicle screw insertion, laparoscopic anterior lumbar interbody fusion, and MIS cervical procedures).

▶Procedure time and complication rate: the most consistent parameters to evaluate the learning curve

▶total 15 original studies are remained.

 

RESULTS

-The most common learning curve complication for decompressive procedures was durotomy.

-For fusion procedures, the most common complications were implant malposition, neural injury, and nonunion.

-The overall postoperative complication rate was 11% (109 of 966 cases).

-The learning curve was overcome for operative time and complications as a function of case numbers in 20 to 30 consecutive cases for most techniques discussed within this review.

CONCLUSIONS

-The quantitative assessment of the procedural learning curve for MIS techniques for the spine remains challenging because the MIS techniques have different learning curves and because they have not been assessed in a consistent manner across studies.

-Complication rates may be underestimated by the studies we identified because surgeons tend to select patients carefully during the early learning curve period.

-The field of MIS would benefit from a standardization of study design and collected parameters in future learning curve investigations.

An Institutional Six-year Trend Analysis of the Neurological Outcome After Lateral Lumbar Interbody Fusion: A 6-Year Trend Analysis of a Single Institution.

Brief review

*Title: An Institutional Six-year Trend Analysis of the Neurological Outcome After Lateral Lumbar Interbody Fusion: A 6-Year Trend Analysis of a Single Institution.

측부요추체 유합술 후의 신경학적 결과의 6년간 기관 동향 분석: 단일 기관의 6년간의 동향 분석

*Author: Alexander Aichmair, Marios G. Lykissas, Federico P. Girardi, Andrew A. Sama, Darren R. Lebl, Fadi Taher, Frank P. Cammisa, and Alexander P. Hughes

*Bibliography: Spine (Phila Pa 1976). 2013Nov 1;38(23):E1483-90.

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To evaluate the proportional trend of neurological deficits after lateral lumbar interbody fusion (LLIF) at a single institution.

SUMMARY OF BACKGROUND DATA

Lumbar nerve roots are prone to iatrogenic damage during the transpsoas approach in LLIF, and postoperative neurological sequelae remain a major concern.

METHODS

▶Subject number: 451 patients (undergone LLIF)

▶Period: 2006.03~2012.04

-The electronic medical records and office notes were retrospectively reviewed.

(For reports on postoperative neurological deficits)

RESULTS

>>The number of included patients who underwent LLIF

(mean follow up period: 15.4±9.2 months)

-2006~2008: 47 patients (group A)

-2009~2010: 155 patients (group B)

-2011~2012: 91 patients (group C)

>>Indicate a decreasing proportional trend or postoperative sensory deficits (SDs), motor deficits (MDs), and anterior thigh pain (TP).

-SDs- immediate postoperative: statistically significant in decreasing proportion (P=0.018)

         - last follow-up: close to statistically significant in decreasing proportion (P=0.126)

-TP -immediate postoperative: close to statistically significant in decreasing proportion 

         (P = 0.098)

  -last follow-up: close to statistically significant in decreasing proportion (P = 0.136)

CONCLUSION

The present data indicate a decreasing proportional trend for SDs, MDs, anterior TP

(Institutional learning curve during a 6-year time period of performing LLIF)