机器人辅助经皮内镜下腰椎间盘切除术的初步疗效报告

目的探讨机器人辅助下经皮内镜椎间盘切除术(transforaminal percutaneous endoscopic lumbar discectomy,tPELD)治疗腰椎间盘突出症的可行性及其临床疗效。方法回顾性分析接受天玑TM骨科手术机器人辅助下tPELD手术治疗单节段腰椎间盘突出症14例连续病例的病历资料(机器人组),男7例,女7例;年龄为(46.6±14.8)岁(范围16~72岁)。机器人组在术中获取实时三维影像并在机器人系统内规划穿刺路径,再由机械臂引导术者进行精准穿刺和工作通道建立完成手术。选取同期接受传统"C"型臂X线透视辅助下tPELD手术的25例连续病例作为对照组,年龄(45.5±13.7)岁(范围16~68岁)。所有患者均完成至少12个月的随访。主要观察指标为术中透视次数、疼痛视觉模拟评分(visual analog scale,VAS)、Oswestry腰椎功能障碍指数(Oswestry disability index,ODI),以及采用改良Macnab分级评估临床疗效,记录并发症发生情况。结果两组患者的年龄、性别分布、腰椎间盘突出类型、手术节段、术前VAS和ODI的差异均无统计学意义(P>0.05)。机器人组除1例由于技术原因术中转为开放手术外,余13例均成功完成机器人辅助tPELD手术。机器人组术中透视(8.8±5.5)次明显低于对照组(21.3±8.3)次,差异有统计学意义(t=4.842,P<0.01)。机器人组术后即刻VAS为(2.85±1.79)分,末次随访时为(1.50±1.04)分均较术前(7.62±0.92)分有明显下降(F=69.747,P<0.01);末次随访时ODI为18.89%±12.16%较术前71.19%±12.12%有明显下降(t=15.430,P<0.01)。两组间术后即刻VAS(t=0.568,P=0.574)、末次随访VAS(t=0.713,P=0.481)及末次随访ODI(t=0.171,P=0.865)的差异均无统计学意义;末次随访时改良Macnab分级优良率机器人组92.30%,对照组84.00%,差异无统计学意义(χ²=0.517,P=0.472)。两组均未出现神经根损伤、硬膜损伤、颅内压升高等严重并发症,机器人组出现复发1例(复发率7.7%),对照组出现复发2例(复发率8.3%),差异无统计学意义(χ²=0.001,P=0.973)。结论机器人辅助经皮内镜下腰椎间盘切除技术能够协助术者简单、准确、安全地建立工作通道,并取得良好的临床效果。

Clinical outcomes of robot-assisted transforaminal percutaneous endoscopic lumbar discectomy

Objective To introduce a new TIANJI robot assisted targeted puncture technique,and discuss the feasibility and clinical effect of transforaminal percutaneous endoscopic lumbar discectomy(tPELD)using this technique.Methods The first 14 consecutive cases of single level lumbar disc herniation who underwent robot assisted tPELD procedure were retrospectively analyzed.The mean age was 46.3±16.0 years old(ranged from 16-72).After data transferred from C-arm to robot system and automatic registration,surgeons made plans of the trajectory on robot system based on intraoperative 3-dimensional images of lumbar spine.Move robotic arm to planned position,guide an accurate puncture pathway and establish working cannula.25 consecutive patients who underwent conventional C-arm assisted tPELD surgery during the same period of time were assessed as the controlled group.The mean age was 45.5±13.7 years old(ranged from 16-68).All patients were followed up for 12 months.Clinical effect was assessed by visual analogue scale(VAS),Oswestry disability index(ODI)and Modified Macnab criteria.Intraoperative parameters and surgery-related complications were recorded.Results The baseline data of age,surgical level,types of herniation,preoperative VAS scores and ODI had no significant difference between two groups(P>0.05).In robot group,one case was converted to open microdiscectomy during operation due to technical failure.The other thirteen cases had successful robot assisted tPELD surgeries and were assessed accordingly.The new technique had good clinical outcomes.The immediate post-operative VAS score 2.85±1.79 and the last follow-up VAS score 1.50±1.04 were both significantly decreased than that before surgery 7.62±0.92(F=69.747,P<0.01);the last follow-up ODI 18.89%±12.16%was significantly reduced from the pre-operative ODI 71.19%±12.12%(t=15.430,P<0.01).Between two groups,the immediate post-operative VAS score(t=0.568,P=0.574),the last follow-up VAS score(t=0.713,P=0.481),and last follow-up ODI had no significant difference(t=0.171,P=0.865).The excellent or good rate of modified Macnab criteria at the last follow-up was 92.30%in robot group,comparing to 84.0%in controlled group.The fluoroscopic times during surgery of robot group 8.8±5.5 was significantly lowered the in controlled group 21.3±8.3(P<0.01).One case in robot group and two cases in controlled group had recurrence during follow-up period(recurrence rate 7.7%vs.8.3%).However,there was no significant complications such as nerve root injury,dura injury or increased intracranial pressure in both groups.Conclusion This study confirmed the feasibility of this new technique.Preliminary results indicated that TIANJI robot could help to build an easy,accurate and safe procedure of tPELD surgery.