经皮椎间孔镜(PETD/PEID)与微创通道下 MIS-TLIF治疗单节段腰椎间盘突出症的 疗效与成本效益比较

Comparison of Efficacy and Cost-Effectiveness between Percutaneous Endoscopic Transforaminal Discectomy (PETD/PEID) and Minimally Invasive Transforminal Lumbar Interbody Fusion (MIS-TLIF) in the Treatment of Single-Level Lumbar Disc Herniation

摘要: 目的：比较经皮椎间孔镜(PETD/PEID)与微创通道下经椎间孔腰椎间融合术(MIS-TLIF)治疗单节段腰椎间盘突出症(LDH)的临床疗效及成本效益，为临床手术方案的合理选择提供循证医学依据。方法：回顾性收集某单中心符合纳入标准的单节段LDH患者70例，根据手术方式分为PETD/PEID组(35例)和MIS-TLIF组(35例)。比较两组患者的手术相关指标(手术时间、术中出血量、术后引流管拔除时间、住院天数)、临床疗效指标(术前及术后3个月、12个月视觉模拟疼痛评分(VAS)、Oswestry功能障碍指数(ODI)、术后12个月椎间融合率、手术优良率)，并采用成本–效果比(CER)、增量成本–效果比(ICER)进行成本效益分析。结果：所有患者均完成12个月随访，无失访及严重并发症病例。PETD/PEID组手术时间、术中出血量、术后引流管拔除时间、住院天数均显著少于MIS-TLIF组(P < 0.05)。两组患者术前VAS评分、ODI指数比较差异无统计学意义(P > 0.05)；术后3个月、12个月，两组VAS评分、ODI指数均较术前显著改善(P < 0.05)，但组间比较差异无统计学意义(P > 0.05)。术后12个月，PETD/PEID组椎间融合率略低于MIS-TLIF组，手术优良率略高于MIS-TLIF组，但差异均无统计学意义(P > 0.05)。成本效益分析显示，PETD/PEID组CER值(239.56)显著低于MIS-TLIF组(377.69)，具有更优的成本效益；ICER分析提示，相较于PETD/PEID组，MIS-TLIF组每获得1个单位的疗效改善需额外投入成本，不具备经济学优势。结论：PETD/PEID与MIS-TLIF治疗单节段LDH均能获得良好的临床疗效，PETD/PEID具有创伤小、恢复快、住院周期短的优势，且成本效益更优，适合于单纯单节段LDH且无明显脊柱不稳的患者；MIS-TLIF则更适用于合并脊柱不稳、椎管狭窄等复杂情况的患者，临床需结合患者具体病情个体化选择手术方案。

Abstract: Objective: To compare the clinical efficacy and cost-effectiveness of percutaneous endoscopic transforaminal discectomy/interlaminar discectomy (PETD/PEID) and minimally invasive tubular transforaminal lumbar interbody fusion (MIS-TLIF) in the treatment of single-segment lumbar disc herniation (LDH), so as to provide evidence-based medical basis for the rational selection of clinical surgical schemes. Methods: A total of 70 patients with single-segment LDH who met the inclusion criteria in a single center were retrospectively collected and divided into the PETD/PEID group (35 cases) and the MIS-TLIF group (35 cases) according to the surgical method. Surgical-related indicators (operation time, intraoperative blood loss, postoperative drainage tube removal time, length of hospital stay), clinical efficacy indicators (Visual Analogue Scale (VAS) score, Oswestry Disability Index (ODI) before surgery and at 3 months and 12 months after surgery, intervertebral fusion rate at 12 months after surgery, excellent and good surgical rate) were compared between the two groups. Cost-effectiveness analysis was performed using cost-effectiveness ratio (CER) and incremental cost-effectiveness ratio (ICER). Results: All patients completed 12-month follow-up without loss to follow-up or severe complications. The operation time, intraoperative blood loss, postoperative drainage tube removal time and length of hospital stay in the PETD/PEID group were significantly less than those in the MIS-TLIF group (P < 0.05). There were no statistically significant differences in preoperative VAS score and ODI index between the two groups (P > 0.05); at 3 months and 12 months after surgery, the VAS score and ODI index of both groups were significantly improved compared with those before surgery (P < 0.05), but there were no statistically significant differences between the two groups (P > 0.05). At 12 months after surgery, the intervertebral fusion rate of the PETD/PEID group was slightly lower than that of the MIS-TLIF group, and the excellent and good surgical rate was slightly higher than that of the MIS-TLIF group, but the differences were not statistically significant (P > 0.05). Cost-effectiveness analysis showed that the CER value of the PETD/PEID group (239.56) was significantly lower than that of the MIS-TLIF group (377.69), indicating better cost-effectiveness; ICER analysis suggested that compared with the PETD/PEID group, the MIS-TLIF group required additional investment to obtain 1 unit of efficacy improvement, and did not have economic advantages. Conclusion: Both PETD/PEID and MIS-TLIF can achieve good clinical efficacy in the treatment of single-segment LDH. PETD/PEID has the advantages of less trauma, faster recovery, shorter hospital stay and better cost-effectiveness, which is suitable for patients with simple single-segment LDH without obvious spinal instability; MIS-TLIF is more suitable for patients with complex conditions such as combined spinal instability and spinal stenosis. Clinically, the surgical scheme should be selected individually according to the specific condition of the patient.