经皮与经肌间隙入路椎弓根螺钉内固定术治疗单节段胸腰椎骨折疗效的Meta分析

Percutaneous pedicle screw fixation versus mini-open Wiltse approach pedicle screw fixation in single level thoracolumbar fracture:a Meta-analysis

目的:系统评价经皮椎弓根螺钉内固定术(percutaneous pedicle screw fixation,PPSF)与经肌间隙入路椎弓根螺钉内固定术(mini-open Wiltse approach with pedicle screw fixation,MWPSF)治疗单节段胸腰椎骨折的疗效,为临床决策提供参考依据。方法:计算机检索Pubmed、Web of Science、Cochrane Library、万方数据库(Wangfang Database)、中国期刊全文数据库(CNKI)中关于PPSF与MWPSF治疗单节段胸腰椎骨折的临床对照研究,检索时限为自建库起至2020年3月。纳入文献包含下列参考指标中的两项以上:手术时间、术中出血量、术中透视次数、术后腰痛视觉模拟评分(visual analogue scale,VAS)、椎体后凸角(Cobb角)、伤椎椎体前缘高度比值(VBH)、Oswestry功能障碍指数(ODI)、手术并发症例数。Meta分析采用Cochrane Library提供的Rev-Man 5.3软件进行。结果:共纳入17篇文献[3篇随机对照研究(randomized controlled trial,RCT)、14篇队列研究]、1057例患者,其中PPSF组519例,MWPSF组538例。MWPSF组手术时间较短[SMD=17.87,95%CI(11.60,24.15),P<0.05],术中透视次数较少[SMD=4.96,95%CI(4.29,5.63),P<0.05];末次随访时,MWPSF组Cobb角矫正较多[SMD=-7.56,95%CI(-10.61,-4.52),P<0.01],矫正丢失较少[SMD=1.76,95%CI(0.41,3.11),P=0.01],VBH矫正丢失较少[SMD=0.90,95%CI(0.30,1.51),P<0.05];PPSF组术中出血较少[SMD=-62.01,95%CI(-78.84,-45.18),P<0.05],术后1周VAS评分较低[SMD=-0.49,95%CI(-0.87,-0.11),P=0.01]。在末次随访时两组的VAS评分、Cobb角、VBH、ODI、手术并发症无显著性差异(P>0.05)。结论:PPSF和MWPSF治疗单节段胸腰椎骨折安全可靠,疗效一致。相较于MWPSF,PPSF具有创伤小、出血少及术后恢复快的优点,但增加手术时间和医源性辐射,且后凸矫形能力不足。

Objectives:To evaluate the efficacy of percutaneous pedicle screw fixation(PPSF)and mini-open Wiltse approach pedicle screw fixation(MWPSF)in the treatment of single level thoracolumbar fractures,and to provide evidence for clinical procedure.Methods:Databases including PubMed,Web of Science,Cochrane Library,CNKI,and Wanfang Database were searched from their establishment to March 2020.Clinical controlled trials that compared PPSF and MWPSF for thoracolumbar fracture were identified.Studies included contained at least two of the following indicators:operation time,intraoperative blood loss,intraoperative radiation exposure,postoperative visual analog score(VAS),postoperative Cobb angle,postoperative VBH,postoperative ODI,and surgical complications.Meta-analyses were performed by using the RevMan 5.2 software.Results:There were 17 studies(3 randomized controlled trial,14 cohort studies)involving 1057 patients.Among them,519 patients underwent PPSF and 538 patients underwent MWPSF.The results of meta-analyses showed that:MWPSF had less operative time[SMD=17.87,95%CI(11.60,24.15),P<0.05],much less intraoperative radiation exposure time[SMD=4.96,95%CI(4.29,5.63),P<0.05].At final follow-up,MWPSF had higher 991 Cobb angle correction[SMD=-7.56,95%CI(-10.61,-4.52),P<0.01],lower Cobb angle correction loss[SMD=1.76,95%CI(0.41,3.11),P=0.01]and VBH correction loss[SMD=0.90,95%CI(0.30,1.51),P<0.05];PPSF had much less intraoperative blood loss[SMD=-62.01,95%CI(-78.84,-45.18),P<0.05],and lower VAS at one week follow-up[SMD=-0.49,95%CI(-0.87,-0.11),P=0.01].There was no statistical difference of postoperative VAS,VBH,ODI,operative complication at final follow-up between two groups(P>0.05).Conclusions:Both PPSF and MWPSF achieve satisfactory and safe clinical outcomes for single level thoracolumbar fracture.Compared to MWPSF,PPSF has less intraoperative blood loss and iatrogenic trauma,and can reduce early postoperative pain.However,PPSF has longer operative time,more iatrogenic radiation and less orthotic ability of kyphosis.