控制性阶梯式减压术对比快速标准大骨瓣减压术治疗重度颅脑损伤疗效的meta分析

Meta-analysis of the efficacy of controlled stepwise decompression versus rapid standard large bone-flap decompression on the treatment of severe craniocerebral injury

目的比较控制性阶梯式减压术与快速标准大骨瓣减压术治疗重度颅脑损伤的疗效。方法计算机检索PubMed、Embase、The Cochrane Library、Web of Science、万方医学网、CNKI、CBM和VIP数据库,查找自建库至2022年11月能查到的有关控制性阶梯式减压术和快速标准大骨瓣减压术治疗重度颅脑损伤疗效对比的相关文献,采用RevMan 5.4软件对符合条件的文献进行meta分析。结果共纳入23篇文献,其中17篇是回顾性临床对照研究,6篇是随机对照试验,共计2141例患者,其中控制性阶梯式减压术患者1080例,快速标准大骨瓣减压术患者1061例。Meta分析结果显示,与快速标准大骨瓣减压术相比,控制性阶梯式减压术开始减压时间更早[MD=-25.39,95%CI(-30.96,-19.81),P<0.01]、手术时间[MD=-21.49,95%CI(-34.22,-8.76),P<0.01]、住院时间[MD=-3.02,95%CI(-3.70,-2.34),P<0.01]更短、术中出血量[MD=-23.82,95%CI(-32.42,-15.22),P<0.01]更少、减压术后第1天颅内压(ICP)[MD=-4.58,95%CI(-6.03,-3.13),P<0.01]更低,术中术后总并发症发生率[OR=0.18,95%CI(0.15,0.23),P<0.01]更低、术后2周GCS评分[MD=1.94,95%CI(1.31,2.56),P<0.01]及预后恢复良好率(GOS≥4)[OR=3.08,95%CI(2.15,4.43),P<0.01]优于快速标准大骨瓣减压。结论相比于快速标准大骨瓣减压术,控制性阶梯式减压术在开始减压时间、手术时间、术中出血量、术后住院时间、术中术后总并发症发生率以及后期恢复方面有着一定的优势,表明控制性阶梯式减压术可以在大多数情况下作为降低ICP的首选手术方式,可以在临床上进行推广及应用。

Objective To compare the efficacy of controlled stepwise decompression versus rapid standard large bone-flap decompression on the treatment of severe craniocerebral injury.Methods Relevant articles reporting the efficacy of controlled stepwise decompression versus rapid standard large bone-flap decompression on the treatment of severe craniocerebral injury published from the establishment of the database to November 2022 were searched in the PubMed,Embase,The Cochrane Library,Web of Science,Wanfang Medical Network,China National Knowledge Infrastructure(CNKI),Chinese Biomedicine Database(CBM)and VIP databases.Data were extracted from the eligible literatures for performing a meta-analysis using RevMan 5.4 software.Results A total of 23 eligible articles were included,involving 17 retrospective clinical controlled studies and 6 randomized controlled trials.Finally,2141 patients with severe craniocerebral injury were included,involving 1080 patients managed by controlled stepwise decompression and 1061 managed by rapid standard large bone-flap decompression.Meta-analysis results showed that compared to those treated with rapid standard large bone flap decompression,controlled stepwise decompression provided an earlier time of decompression(MD=-25.39,95%CI:-30.96,-19.81;P<0.01),less operation time(MD=-21.49,95%CI:-34.22,-8.76;P<0.01),shorter length of stay(MD=-3.02,95%CI:-3.70,-2.34;P<0.01),less intraoperative bleeding(MD=-23.82,95%CI:-32.42,-15.22;P<0.01),lower intracranial pressure(ICP)on the first day after decompression(MD=-4.58,95%CI:-6.03,-3.13;P<0.01),lower total incidence of intraoperative and postoperative complications(OR=0.18,95%CI:0.15,0.23;P<0.01),lower Glasgow Coma Scale(GCS)score at 2 weeks postoperatively(MD=1.94,95%CI:1.31,2.56;P<0.01)and higher rate of good prognosis with the Glasgow Outcome Scale(GOS)score≥4(OR=3.08,95%CI:2.15,4.43;P<0.01).Conclusion Compared to those of rapid standard large bone-flap decompression,controlled stepwise decompression has certain advantages in the time of decompression,operation time,intraoperative bleeding,postoperative length of stay,total incidence of intraoperative and postoperative complications,and postoperative recovery.The controlled stepwise decompression is preferred to lower ICP in most cases of craniocerebral injury,which can be promoted and applied in clinical practice.