长节段固定治疗成人退变性腰椎侧凸不同近端固定椎患者手术并发症和翻修情况的Meta分析

The effect of the proximal instrumented vertebrae on complications and revision rate in long fusion correction of degenerative adult lumbar scoliosis: a Meta analysis

目的 :分析长节段固定治疗成人退变性腰椎侧凸不同近端固定椎患者的手术并发症和翻修情况。方法:于2018年3月15日通过计算机系统检索Pubmed、Embase、Cochrane、维普、万方数据库、中国知网数据库,截止时间为2018年3月15日。根据上端内固定椎的不同分为两组:近端固定到T10及以上节段为高位椎(upper vertebra,UV)组,近端固定到T10以下节段为低位椎(lower vertebra,LV)组。纳入标准:(1)国内外公开发表比较后路长节段不同上端内固定椎治疗成人退变性腰椎侧凸文献;(2)随机或者非随机对照研究;(3)患者年龄≥18岁;(4)随访时间≥1年。提取文献基本信息,并发症[围手术期及非围手术期术后并发症:硬脊膜破裂,深静脉血栓形成,创口深部感染,创口浅表感染,神经系统并发症,近端邻近节段退变性疾病,近端交界处后凸畸形(proximal junctional kyphosis,PJK),内固定失败,假关节形成,总并发症等],术中出血量和翻修情况(如PJK、假关节形成、内固定失败、感染等不同原因导致的翻修情况)。并通过非随机实验方法学指数法(methodological index for non-randomised studies,MINORS)评价方法对最终纳入文献进行质量评分,Begg法评估发表偏倚。通过STATA 12.0软件进行Meta分析。结果:最终纳入10篇文献,中文2篇,英文8篇,共883例患者,其中UV组353例,LV组530例。所有文献MINORS评分为16~20分,Begg法分析无明显发表偏倚。并发症包括围手术期并发症和非围手术期并发症两大类。其中围手术期并发症中,UV组患者术中出血量显著多于LV组,权重均数差(weight mean difference,WMD)(95%CI)为409.33ml(288.74,529.92),而硬脊膜破裂、深静脉血栓形成、创口深部感染、创口浅表感染、神经系统并发症和围手术期总并发症对比无显著性差异(P>0.05)。非围手术期术后并发症中,UV组近端邻近节段退变性疾病发生率低于LV组,风险比(relative risk,RR)(95%CI)为0.26(0.11,0.63),P<0.05;PJK、内固定失败、假关节形成和非围手术期术后总并发症对比无显著性差异(P>0.05);PJK、假关节形成、内固定失败、感染等原因引起翻修及总翻修率均无统计学差异(P>0.05)。结论:长节段固定治疗成人退变性腰椎侧凸近端固定椎向中上胸椎延长可能有利于降低近端邻近节段退变性疾病的发生,但患者术中出血量更多,在其他并发症和翻修率方面尚未发现优势。

Objectives: To investigate the effect of the proximal instrumented vertebrae on complications and revision rate in long fusion correction of degenerative adult lumbar seoliosis.Methods:The databases of Pubmed,Embase,Cochrane library,VIP,Wanfang and CNKI were searched at March 15th,2018to identify studies that;compared outcome measures of the upper and lower proximal instrumented vertebrae (UV,upper vertebrae to T10 and above region;LV,lower vertebrae to lower than T10region)in correction of degenera- tive adult lumbar scoliosis with long fusion.The included criteria were:(1)the studies focusing on comparisonof outcome measures of the upper and lower proximal instrumented vertebrae in long fusion correction of degenerative adult lumbar scoliosis;(2)randomised or non-randomised controlled studies;(3)age ≥18years old;(4)follow up ≥1year.The general information,complieations[peri-operative and later post-operative complications:dural tear,deep vein thrombosis,deep wound infection,superficial wound infection,neurologic complications,proximal adjacent degenerative diseases,proximal junctional kyphosis (PJK),implant failure, pseudarthrosis and total complications],blood loss and revision rate (different reasons for revision,PJK, pseudarthrosis,implant failure and infection)were extracted.Methodological index for non-randomised studies (MINORS)was used to assess the quality of included studies,and Begges test was used to assess the publication bias.The Meta analysis was performed by using STATA 12.0.Results:Ten articles (2in Chinese and 8in English)were enrolled in this meta analysis,with total 883cases(UV=353cases;LV=530cases). The MINORS scores ranged from 16to 20,no significant publication bias was observed by using Beggs test. The complications included perioperative complications and later post-operative complications.For perioperative complications,the blood loss of UV group was significant more than that of LV group[weight mean difference (WMD):409.33ml (95%CI:288.74,529.92)],however,no significant difference was found in deep vein throm- bosis,deep wound infection,superficial wound infection,neurologic complications and total perioperative complications between two groups.For later post-operative complications,the incidence of proximal adjacent degenerative disease in UV group was lower than that in LV group[relative risk(RR):0.26(95%CI:0.11,0.63)], however,no significant difference was found in PJK,implant failure,pseudarthrosis and total later post-opera tive complications between two groups.No significant difference was found in the total revision and revison caused by PJK,pseudarthrosis,implant failure and infection.Conclusions:Selection of the upper thoracic region as the proximal instrumented vertebrae in the correction of degenerative adult lumbar scoliosis with long fusion may reduce the rate of proximal adjacent degenerative disease,however,present no advantage in terms of blood loss,other complications and revision rate.