峡部裂伴轻度腰椎滑脱原位融合与复位融合临床疗效的Meta分析

A meta-analysis of the clinical outcomes of arthrodesis in situ or after reduction for low-grade lumbar isthmic spondylolisthesis

目的系统评价原位融合与复位融合治疗轻度(I、II度)峡部裂型腰椎滑脱症的临床疗效。方法计算机全面检索Pub Med、Cochrane Library、Emabse databases、Sinomed、中国知网数据库、万方数据库、维普数据库,检索时间截止至2016年4月。纳入峡部裂伴轻度腰椎滑脱症术中原位融合与复位融合的随机对照研究(randomized controlled trial,RCT)和队列研究,对RCT研究采用改良Jarad评分进行质量评价,对非RCT研究采用NOS评价方法,由2名作者(陈佳海、白雪东)独立提取及分析数据,采用Review Manager 5.3软件对所得的数据进行Meta分析。结果经过系统检索和筛选,共有4篇符合条件的文献纳入本研究,包括2篇RCT以及2篇队列研究。Meta分析结果表明,复位后融合患者其滑脱程度较原位融合者明显改善[SMD=-1.58,95%CI(-2.09^-1.06),P<0.00001],并在2年以上的随访时得到有效维持[MD=20.05,95%CI(17.71~22.38),P<0.00001],差异有统计学意义;然而,在Oswestry功能障碍指数(oswestry disability index,ODI)[MD=1.136,95%CI(-1.34~3.60),P=0.37]、疼痛视觉模拟评分(visual analogue scale,VAS)[MD=0.06,95%CI(-0.21~0.32),P=0.67]、优良率[RR=1.01,95%CI(0.92~1.10),P=0.87]、融合率[RR=0.99,95%CI(0.93~1.06),P=0.81]以及手术并发症发生率方面[RR=0.78,95%CI(0.36~1.72),P=0.54],复位后融合组与原位融合组之间差异无统计学意义。结论在峡部裂伴轻度腰椎滑脱症的手术方式选择上,复位后融合可使滑脱椎体良好复位并得到有效维持复位,但与原位融合相比在临床疗效方面差异无统计学意义。两种手术方式均能减轻患者腰痛程度、获得良好的椎间融合率,提高患者治疗满意度。选择何种治疗方式应根据患者的具体病情以及手术医师对具体技术的熟练程度而定,远期临床疗效及矢状平衡问题需进一步深入研究。

Objective To systematically evaluate the clinical outcomes of arthrodesis in situ or after reduction for low-grade （ I and II ） lumbar isthmic spondylolisthesis. Methods A comprehensive search of both randomized clinical trials （ RCTs ） and cohort studies on arthrodesis in situ or after reduction for low-grade lumbar isthmic spondylolisthesis published up to April 2016 was performed in PubMed, Cochrane Library, Embase, Sinomed, China Knowledge Resource Integrated Database （ CNKI ）, Wanfang Data and Vip Datebase. For the RCTs, we used the Jarad scale to assess the methodological quality, and for the cohort studies, the Newcastle-Ottawa scale （ NOS ） seemed more suitable. Two of the authors （ CHEN Jia-hai, BAI Xue-dong ） independently extracted the articles and predefined data. Statistical analyses were performed using Review Manager 5.3 software. Results Two RCTs and 2 cohort studies were included in this meta-analysis after systematic retrieval and screening. The patients who underwent reduction did achieve better slippage correction when compared with arthrodesis in situ [ SMD = -1.58, 95% CI （ -2.09 - -1.06 ）, P 〈 0.00001 ] and the slippage correction was preserved after more than 2 years＇ follow-up [ MD = 20.05, 95% CI（ 17.71 - 22.38 ）, P 〈 0.00001 ]. However, there was no significant difference in the Oswestry disability index （ ODI ） [ MD = 1.136, 95% CI（ -1.34 - 3.60 ）, P = 0.37 ], visual analogue scale （ VAS ） [ MD = 0.06, 95% CI（ -0.21 - 0.32 ）, P = 0.67 ], excellent and good rate [ RR = 1.01, 95% CI （ 0.92 - 1.10 ）, P = 0.87 ], fusion rate [ RR = 0.99, 95% CI （ 0.93 - 1.06 ）, P = 0.81 ] and complication rate [ RR = 0.78, 95% CI（ 0.36 - 1.72 ）, P = 0.54 ] between the arthrodesis in situ group and the reduction group. Conclusions Arthrodesis after reduction for low-grade lumbar isthmic spondylolisthesis reduces vertebral slippage well and preserves the reduction effectively, but it makes no difference in the clinical outcomes of the 2 surgical treatment methods. Both methods can relieve low back pain, achieve a good fusion rate and improve patients＇ satisfaction. How to choose the surgical method depends on the patient＇s condition and the orthopedist＇s surgical experience. A further study is needed on the long-term clinical outcomes and spinal sagittal balance.