探討病人接受經皮內視鏡經椎間孔腰椎椎間盤切除手術照護品質相關因素

Exploring factors related to the quality of care for patients undergoing percutaneous endoscopic transforaminal lumbar discectomy

謝彥琳(Yen-Lin Shieh)

指導教授 ： 黃俊哲

義守大學/醫學院/醫務管理學系/碩士(2024年)

摘要

背景：脊椎內視鏡手術已成為實用的微創技術之一。腰椎間盤突出症及椎孔狹窄症病人接受經皮內視鏡經椎間孔腰椎椎間盤切除術前後疼痛變化及再復發將是重要的議題。
目的：本研究主要目的為(1)探討病人人口學和疾病相關因素與經皮內視鏡經椎間孔腰椎椎間盤切除手術總時間之相關性。(2)探討病人人口學和疾病相關因素與經皮內視鏡經椎間孔腰椎椎間盤切除術後疼痛分數、按時回診及固定復健之相關性。
方法：採回溯性世代研究設計，資料來源取自南部某地區醫院骨科手術病人照護資料檔，而主要研究對象為2021年11月至2023年2月期間年齡≥20歲、經確診為腰椎椎間盤突出或椎管狹窄，且接受經皮內視鏡經椎間孔腰椎椎間盤切除手術病人，最終研究樣本數為56筆。研究變項包括性別、年齡、是否從事工作、日常生活活動功能、主要疾病診斷、共病症數目、仰臥直抬腿測試、手術脊椎節數、術後疼痛分數，以及手術總時間、術後疼痛分數(含術後當日、一個月及三個月)、按時回診和固定復健等，並使用廣義線性模型和羅吉斯迴歸模式進行分析。
結果：腰椎椎間盤突出和腰椎管狹窄病人分別占53.6%及46.4%，而平均手術總時間為115.4分鐘，術後有按時回診和固定復健分別占89.3%及87.5%。在控制相關因素後，結果顯示67‒89歲者(coefficient [B]= 21.14，P= 0.016)和腰椎椎管狹窄者(B= 37.38，P <0.001)接受經皮內視鏡經椎間孔腰椎椎間盤切除手術總時間明顯較多於20‒66歲者和腰椎椎間盤突出者。此外，手術腰椎節數≥2者(B= 0.4，P= 0.049)接受經皮內視鏡經椎間孔腰椎椎間盤切除術後當日疼痛分數明顯較高於1節者。病人術前疼痛分數與術後當日(B= 0.67，P <0.001)和術後三個月疼痛分數(B= 0.41，P= 0.031)皆呈正向關係。病人術前疼痛分數(odds ratio [OR]= 71.18，P= 0.019)與其術後發生無按時回診明顯呈正向關係。
結論：本研究發現67‒89歲和罹患腰椎狹窄病人接受經皮內視鏡經椎間孔腰椎椎間盤切除手術總時間明顯較多，而手術腰椎節數≥2者術後當日疼痛分數明顯較高。此外，隨著病人術前疼痛分數愈高，其術後當日和術後三個月疼痛分數亦會隨之愈高，而術後發生無按時回診機率會明顯增加。本研究建議手術醫護團隊針對術前疼痛分數較高的椎間盤突出或椎管狹窄病人可擬定持續性疼痛監測和控制，以改善病人術後疼痛和照護品質。

關鍵字

腰椎椎間盤突出 ； 腰椎椎管狹窄 ； 經皮內視鏡經椎間孔腰椎椎間盤切除 ； 手術總時間 ； 照護品質

並列摘要

Background: Spinal endoscopic surgery has become one of the practical minimally invasive techniques. Pain changes and recurrence in patients with herniation of intervertebral disc and spine stenosis before and after percutaneous transforaminal endoscopic lumbar discectomy (PTELD) will be an essential issue.
Objective: The primary purposes of this study were (1) to explore the relationship between patient demographics and disease-related factors and the total operation time of PTELD; (2) to explore the relationship between patient demographics and disease-related factors, and pain scores, follow-up appointments on schedule and fixed rehabilitation after PTELD.
Methods: A retrospective cohort research design was adopted. This study retrieved the data from a southern local hospital's orthopedic patient surgical care data file. The main research subjects were those aged ≥20 years old between November 2021 and February 2023 who were diagnosed with herniation of intervertebral disc and spine stenosis who underwent percutaneous transforaminal endoscopic lumbar discectomy, and the final sample size consisted of 56 cases. The study variables included gender, age, employment status, activities of daily living, primary disease diagnosis, number of comorbidities, single leg raise test (SLRT), number of operated lumbar levels, total operation time, postoperative pain scores (including the day after surgery, one month and three months), timely follow-up visits and fixed rehabilitation. Generalized linear models and logistic regression models were used to analyze.
Results: Patients with herniation of intervertebral disc and spine stenosis accounted for 53.6% and 46.4%, respectively, and the average total operation time was 115.4 minutes. Postoperative follow-up visits and fixed rehabilitation accounted for 89.3% and 87.5%, respectively. After controlling for relevant factors, the results showed that patients aged 67 to 89 years (coefficient [B]= 21.14, P= 0.016) and those with spinal stenosis (B= 37.38, P<0.001) underwent percutaneous transforaminal endoscopic lumbar discectomy. The total time of resection surgery was significantly longer in patients aged 20 to 66 years and those with herniation of intervertebral disc. In addition, the pain scores on the day after undergoing percutaneous transforaminal endoscopic lumbar discectomy were significantly higher in patients with ≥2 lumbar levels (B= 0.4, P= 0.049) than those with one lumbar level.
The preoperative pain scores of patients showed a positive relationship with both the pain scores on the day of surgery (B= 0.67, P<0.001) and the pain scores three months postoperatively (B= 0.41, P= 0.031). Additionally, there was a significant positive relationship between preoperative pain scores (odds ratio [OR]= 71.18, P= 0.019) and the likelihood of patients not attending follow-up appointments on time postoperatively.
Conclusion: This study found that patients aged 67 to 89 years and those suffering from spine stenosis took significantly longer time to undergo percutaneous transforaminal endoscopic lumbar discectomy, and those who underwent surgery with ≥2 lumbar levels had significantly higher pain scores on the day after surgery. In addition, as the patient's preoperative pain score is higher, the pain score on the day after the operation and three months after the operation will also be higher, and the probability of missing a follow-up visit on time after the operation will be increased significantly. This study suggests that the surgical medical team can develop continuous pain monitoring and control for patients with disc herniation or stenosis who have high preoperative pain scores to improve patients' postoperative pain and quality of care

並列關鍵字

Herniation of intervertebral disc ； Spine Stenosis ； Percutaneous transforaminal endoscopic lumbar discectomy ； Operation time ； Care quality

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