单节段与短节段椎弓根钉棒固定手术治疗单节段胸腰段椎体爆裂性骨折疗效的Meta分析

Mono-segment versus short-segment pedicle instrumentation for treatment of one-level thoracolumbar burst fracture: a Meta analysis

目的:对单节段与短节段椎弓根钉棒固定手术治疗单节段胸腰段椎体爆裂性骨折的疗效进行Meta分析。方法:计算机检索Pubmed、Embase、Web of Science、Cochrane Library、中国知网全文数据库等数据库,检索的主题词为“单节段(mono-segment pedicle instrumentation,MSPI或monosegmental pedicle instrumentation)”及“爆裂性骨折(burst fracture)”,检索自建库起至2018年10月30日时的对照研究文献,语言限定为英文或中文。纳入关于单节段与短节段椎弓根钉棒固定手术治疗单节段胸腰段椎体爆裂性骨折的相关对照研究,患者年龄>18岁,随访时间≥1年。对纳入文献进行质量评价,回顾性队列研究使用纽卡斯尔-渥太华量表(NOS),随机对照研究采用物理治疗证据数据库(Physiotherapy Evidence Database,PEDro)量表。利用Stata 12.0统计学软件进行数据分析,根据组间异质性以加权均数差(WMD)合并效应量,并计算其95%置信区间(95%CI),异质性较大者进行敏感性分析和亚组分析辨别其异质性来源。评价指标包括手术时间、术中出血量,术前、术后及末次随访时的视觉模拟评分(VAS)、椎体后凸角和椎体压缩率。结果:经过筛选共纳入6篇文献,其中2篇为随机对照研究,4篇为回顾性队列研究,共390例患者,单节段固定组190例,短节段固定组200例。质量评价提示纳入文献均属于高质量研究,其中4篇回顾性队列研究NOS评分为5~9分、2篇随机对照研究PEDro评分均为8分。单节段固定组的手术时间显著少于短节段固定组(WMD=-23.19,95%CI:-44.63,-1.75,P=0.034),术中出血量无显著性差异(P=0.10)。术前的椎体后凸角、椎体压缩率、VAS评分两组比较无显著性差异(P>0.05);术后1周和末次随访时的椎体压缩率两组间无显著性差异(P>0.05);椎体后凸角(WMD=0.67,95%CI:-0.48,1.83)和VAS评分(WMD=-0.39,95%CI:-0.60,-0.18)在术后1周时单节段固定组均优于短节段固定组(P=0.001,P<0.0001),但在末次随访时两组无显著性差异(P=0.875,P=0.523)。经伤椎置钉的亚组分析表明,相比于跨伤椎固定组(WMD=-0.44,95%CI:-1.02,0.15),经伤椎固定(WMD=0.11,95%CI:-0.28,0.50)可显著改善末次随访时的VAS评分(P=0.006)。纳入文献经漏斗图及Egger′s检验无发表偏倚(P=0.055)。结论:在治疗单节段胸腰段椎体爆裂性骨折时,与短节段椎弓根钉棒固定相比,单节段椎弓根钉棒固定治疗具有手术时间短、术后短期疼痛轻与椎体后凸角度恢复好的优势,在随访1年时两者的临床疗效相当。

Objectives: To compare the clinical effect between mono-segment pedicle instrumentation(MSPI) and short-segment pedicle instrumentation(SSPI) in the treatment of one-level thoracolumbar burst fracture. Methods: By searching PubMed, Embase, Web of Science, Cochrane Library and China National Knowlage Infrastructure(CNKI) etc, the studies of MSPI versus SSPI for treatment of thoracolumbar burst fracture were collected. The key words were "mono-segment pedicle instrumentation","MSPI" or "monosegmental pedicle instrumentation" and "burst fracture". Studies from the establishment of database to October 30, 2018 were retrieved, with a language restriction of Chinese or English. Comparative studies about the treatment of thoracolumbar burst fractures with mono-segment and short-segment internal fixation were included. The patients were older than 18 years old with more than one year follow-up. The risk of bias of the included studies was evaluated, Newcastle-Ottawa Scale(NOS) for retrospective cohort studies and Physiotherapy Evidence Database(PEDro) for randomized controlled studies were used. All data were analyzed by Stata 12.0 software. Weighted mean differnce(WMD) and its 95% confidence interval(95%CI) were calculated according to the heterogeneity between groups. Sensitivity analysis and subgroup analysis were performed to identify the heterogeneity sources. The outcomes included surgery related indexes(operation time, blood loss);visual analogue score(VAS), vertebral kyphosis angle and vertebral compression ratio at preoperation, postoperation and the end of follow-up. Results: Two randomized controlled trials and four cohort studies including 390 patients were included in the Meta analysis(190 patients for MSPI and 200 patients for SSPI). Quality evaluation indicated that all the included studies were high quality cohort studies(the NOS of 4 retrospective cohort studies ranged from 5 to 9, and the PEDro scores of 2 randomized controlled studies were 8). The operation time (WMD=-23.19, 95%CI:-44.63,-1.75) of the mono-segment fixation group was significantly lower than that of the short-segment fixation group(P=0.034), while the intraoperative blood loss was not significant(P=0.10). There was no significant difference between the two groups in the kyphosis angle, compression ratio or VAS score before operation (P>0.05), and there was no significant difference between the two groups in the compression ratio at postoperation and the end of follow-up(P>0.05). The vertebral kyphosis angle(WMD=0.67, 95%CI:-0.48, 1.83) and VAS (WMD=-0.39, 95%CI:-0.60,-0.18) were better in the mono-segment fixation group than in the short-segment fixation group at postoperation(P=0.001, P<0.0001). However, there was no significant difference between the two groups at the end of follow-up(P=0.875, P=0.523). The subgroup analysis of injured vertebral fixation method showed that compared with the trans-injured vertebra fixation group(WMD=-0.44, 95%CI:-1.02, 0.15), the across-injured vertebra fixation group(WMD=0.11, 95%CI:-0.28, 0.50) significantly improved the VAS at the end of follow-up(P=0.006). There was no published bias of included studies, evaluating by funnel graph and Egger′s test(P=0.055). Conclusions: In the treatment of one-level thoracolumbar burst fracture, MSPI has the advantages of less operation time, less postoperative pain in short-term and better recovery of kyphosis angle comparing with SSPI. The clinical efficacy of both is comparable at least for 1 year follow-up.