退行性腰椎侧凸后路长节段固定不同上端固定椎选择比较的Meta分析

A meta-analysis of the outcomes of posterior long-segment fi xation with different upper instrumented vertebrae for degenerative lumbar scoliosis

目的对退行性腰椎侧凸后路长节段融合内固定不同上端固定椎选择进行Meta分析,探讨不同上端固定椎对临床疗效的影响。方法计算机检索Cochrane图书馆(2014年第8期)、Pub Med(1966年至2014年8月)、EMbase(1966年至2014年8月)、中国生物医学文献数据库(1978年至2014年8月)、万方数据库(1998年至2014年8月)、中国期刊全文数据库(1999年至2014年8月)、维普期刊(1998年至2014年8月),并人工检索期刊《The Journal of Bone and Joint Surgery》、《中华骨科杂志》、《中国脊柱脊髓杂志》。由2名评价者按纳入与排除标准选择文献、提取资料和质量评价后,采用Rev Man 5.2软件进行Meta分析。结果最终纳入6篇回顾性研究文献,共453例,其中融合至上胸椎(upper thoracic,UT)208例(T10及以上),融合至下胸椎(lower thoracic,LT)245例(T10以下)。Meta分析结果显示:成人退行性腰椎侧凸后路长节段融合内固定选择上胸椎与选择下胸椎相比,手术操作时间更长[WMD=0.94,95%CI(0.50,1.38),P<0.0001],术中出血更多[WMD=0.60,95%CI(0.34,0.86),P<0.00001],而两者术后Oswestry功能障碍指数(oswestry disability index,ODI)[WMD=0.83,95%CI(-3.45,5.10),P=0.70],术后腰椎前凸角(lumbar lordosis,LL)[WMD=-0.94,95%CI(-3.39,5.27),P=0.67],术后交界性后凸角(proximal junctional kyphosis,PJK)[WMD=-1.93,95%CI(-4.65,0.79,P=0.16],术后矢状位垂直轴(sagittal vertical axis,SVA)[WMD=-1.13,95%CI(-4.19,1.92),P=0.47],术后胸椎后凸角(thoracic kyphosis,TK)[WMD=1.51,95%CI(-2.76,55.78),P=0.49]相比,差异均无统计学意义。结论对退行性腰椎侧凸长节段固定患者,选择T10为近端固定椎能达到与T10以上椎相似的脊柱矢状面参数矫正效果,且具有手术时间短、出血量少的优势。

Objective To investigate the clinical outcomes of posterior long-segment fi xation with different upper instrumented vertebrae for degenerative lumbar scoliosis based on a meta-analysis. Methods Computer retrieval was performed on Cochrane Library（ 8th Quarter 2014）, Pubmed（ 1966 to August, 2014）, Embase（ 1966 to August, 2014）, China Biological Medicine Database（ 1978 to August, 2014）, Wanfang database（ 1998 to August, 2014）, China National Knowledge Internet（ CNKI）（ 1999 to August, 2014） and VIP（ 1998 to August, 2014）. Manual searching of ＂The Journal of Bone and Joint Surgery＂, ＂Chinese Journal of Orthopeadics＂ and ＂Chinese Journal of Spine and Spinal Cord＂ was also carried out. Literatures were selected, data were extracted and qualities were evaluated by 2 reviewers independently with a designed extraction form. Rev Man 5.2 software was used for the meta-analysis. Results Six retrospective studies involving 453 patients were included. There were 208 patients with the fusion from the upper thoracic（ UT） spine（ above T10） to L5 or S1（ UT group） and 245 patients with the fusion from the lower thoracic（ LT） spine（ below T10） to L5 or S1（ LT group）. The meta-analysis results were stated as following. The operation time [ weighted mean difference（ WMD）=0.94, 95% confi dence interval（ CI）（ 0.50, 1.38）, P〈0.0001 ] was longer and the intraoperative bleeding amount [ WMD=0.60, 95% CI（ 0.34, 0.86）, P〈0.00001 ] was more in UT group than that in LT group. While there were not statistically signifi cant differences betwee the 2 groups inpostoperative Oswestry Disability Index（ ODI） [ WMD=0.83, 95% CI（-3.45, 5.10）, P=0.70 ], postoperative lumbar lordosis（ LL） [ WMD=-0.94, 95% CI（-3.39, 5.27）, P=0.67 ], postoperative proximal junctional kyphosis（ PJK） [ WMD=-1.93, 95% CI（-4.65, 0.79, P=0.16 ], postoperative sagittal vertical axis（ SVA） [ WMD=-1.13, 95% CI（-4.19, 1.92）, P=0.47 ] and postoperative thoracic kyphosis（ TK） [ WMD=1.51, 95% CI（-2.76, 55.78）, P=0.49 ]. Conclusions Fusion from the lower thoracic spine（ below T10） is as effective as the fusion from the upper thoracic spine（ above T10） in posterior long-segment fi xation for degenerative lumbar scoliosis, with the advantages of shorter operation time and less blood loss. In addition spinal sagittal deformity correction can be improved.