经皮内固定术与传统后路开放内固定术治疗胸腰椎骨折不良事件比较的Meta分析

Comparison of the adverse events of percutaneous pedicle screw fixation and traditional open pedicle screw fixation for thoraco lumbar fractures:a Meta-analysis

目的系统评价经皮椎弓根螺钉内固定术(PPSF)与传统后路开放内固定术(TOPSF)治疗胸腰椎骨折时出现的不良事件,为胸腰椎骨折治疗方法安全性的评估提供科学依据。方法计算机检索从建库至2016年3月Pub M ed、EM base、Cochrane图书馆等中英文数据库。手工检索《The Journal of Bone and Joint Surgery》、《Spine》、《European Spine Journal》等期刊。英文检索词为thoracolumbar fracture、lumbar fracture、percutaneous pedicle screw fixation、open fixation、posterior surgery、sextant、traditional fixation、conventional fixation、minimally invasive surgery、comparative study、randomized controlled trail、clinical trail等;中文检索词为经皮内固定术、后路内固定术、胸腰段骨折等。根据纳入标准进行筛选、数据提取、质量评价。采用Rev Man 5.3进行Meta分析。结果最后纳入18项研究,其中随机对照试验4项,前瞻性对比研究3项,回顾性对比研究11项,共计1 034例,其中PPSF组501例,TOPSF组533例。M eta分析显示:与TOPSF组相比,PPSF组手术时间短(WMD=-0.95,95%CI:-1.33^-0.57,P<0.001)、术中出血量少(WMD=-2.97,95%CI:-3.69^-2.25,P<0.001)、术后引流量少(WMD=-2.43,95%CI:-3.04^-1.83,P<0.001)、住院时间短(WMD=-5.37,95%CI:-6.69^-4.05,P<0.001)、下床活动时间早(WMD=-2.51,95%CI:-3.66^-1.36,P<0.001)、总体术后VAS评分低(WMD=-1.14,95%CI:-1.62^-0.66,P<0.001)、术后ODI评分低(WMD=-1.78,95%CI:-3.00^-0.55,P=0.004)、术后Cobb角矫正度丢失低(WMD=-0.52,95%CI:-0.93^-0.11,P=0.01)、术中辐射暴露时间长(WMD=5.12,95%CI:2.89~7.34,P<0.001)、两种术式椎弓根螺钉位置异常差异无统计学意义(OR=1.04,95%CI:0.43~2.56,P=0.92),术后感染差异无统计学意义(OR=0.39,95%CI:0.12~1.26,P=0.12)。结论 PPSF能够缩短手术时间、减少手术出血量、减小手术创伤等,能够达到与TOPSF相似的置钉准确度,保证手术安全性,有效的保护周围软组织,减少术后Cobb角矫正度的丢失,降低术后疼痛及功能恢复异常等不良事件的发生率。

Objective To systematically reviewthe adverse events of percutaneous pedicle screwfixation（PPSF） and traditional open pedicle screwfixation（TOPSF） for thoracolumbar fracture,in order to provide more evidence for the effective treatment of thoracolumbar fracture. Methods Databases including Pubmed,Cochrane Central Register of Controlled Trails（CENTRAL）,and Embase were retrieved with computer. Journal of Bone and Joint Surgery,Spine,and European Spine Journal were manually searched. The searching terms were thoracolumbar fracture,lumbar fracture,percutaneous pedicle screwfixation,open fixation,posterior surgery,sextant,traditional fixation,conventional fixation,minimally invasive surgery,comparative study,randomized controlled trail,and clinical trail. Data were then screened,extracted,assessed,and analyzed with Rev Man 5. 3 software. Results A total of 18 studies including 4 randomized controlled trials,3 prospective comparative studies,11 retrospective comparative studies were enrolled,involving 1,034 patients. Meta-analysis showed that the PPSF group,compared with the TOPSF group,had shorter surgery time（WMD =- 0. 95,95% CI：- 1. 33-- 0. 57,P 〈 0. 001）,less intraoperative blood loss（WMD =- 2. 97,95%CI：- 3. 69-- 2. 25,P 〈 0. 001）,less postoperative drainage amount（WMD =- 2. 43,95% CI：- 3. 04-- 1. 83,P 0. 001）,shorter hospital stay（WMD =- 5. 37,95% CI：- 6. 69-- 4. 05,P 〈 0. 001）,less time from surgery to walking（WMD =- 2. 51,95% CI：- 3. 66-- 1. 36,P 〈 0. 001）,less overall postoperative visual analogue scale（WMD =- 1. 14,95% CI：- 1. 62-- 0. 66,P 〈 0. 001）,lower postoperative Oswestry disability index（WMD =- 1. 78,95%CI：- 3. 00-- 0. 55,P = 0. 004）,less postoperative Cobb angle correction loss（WMD =- 0. 52,95% CI：- 0. 93-- 0. 11,P = 0. 01）,longer intraoperative exposure to radiation（WMD = 5. 12,95% CI： 2. 89-7. 34,P 〈 0. 001）.However,no significant difference was found between the two groups with regard to the rate of screwmisplacement（OR = 1. 04,95% CI： 0. 43-2. 56,P = 0. 92） and the rate of infection（OR = 0. 39,95% CI： 0. 12-1. 26,P = 0. 12）.Conclusion PPSF can not only shorten surgery time,hospital stay,and time from surgery to walking,but also lessen intraoperative blood loss,postoperative drainage amount,postoperative visual analogue scale,postoperative Oswestry disability index,and postoperative Cobb angle correction loss,but achieve the same accuracy in pedicle screwplacement as TOPSF and secure the operation. Meanwhile,PPSF can protect the surrounding soft tissues,and reduce the rate of adverse events.