单纯或附加后路内固定的侧方腰椎椎体间融合术治疗腰椎退行性疾病疗效的Meta分析

A Meta-analysis of stand-alone lateral lumbar interbody fusion and lateral lumbar interbody fusion with supplemental posterior instrumentation in the treatment of lumbar degenerative disease

中文关键词:  侧方腰椎椎间融合  腰椎退行性疾病  后路内固定  融合率  融合器下沉

英文关键词:Lateral lumbar interbody fusion  Lumbar degenerative disease  Posterior instrumentation  Fusion rate  Cage subsidence

中文摘要:

  【摘要】 目的：通过Meta分析评价单纯侧方腰椎椎体间融合术（lateral lumbar interbody fusion，LLIF）与附加后路内固定的LLIF治疗腰椎退行性疾病的疗效。方法：检索PubMed、EMBASE、Web of Science、Cochrane Library、CNKI、万方数据库自建库起至2021年7月关于对比单纯LLIF（单纯组）与附加后路内固定的LLIF（内固定组）治疗腰椎退行性疾病疗效的研究，采用纽卡斯尔-渥太华量表（Newcastle-Ottawa Scale，NOS）对纳入研究进行质量评价，提取纳入研究的结局指标数据，包括术后末次随访时的融合率、融合器下沉发生率；术后末次随访时较术前的椎间隙高度、节段前凸角及腰椎前凸角改善值；术后末次随访时较术前腿痛的视觉模拟评分（visual analogue scale，VAS）、Oswestry功能障碍指数（Oswestry disability index，ODI）改善值；术中出血量；术后住院时间；术后并发症发生率、神经系统并发症发生率、翻修率和邻椎病发生率。提取数据后通过Review Manager 5.3软件进行Meta分析。连续性变量采用加权均数差（weighted mean difference，WMD）分析，二分类变量采用风险比（risk ratio，RR）分析，各效应量均给出其95%置信区间（confidence interval，CI）。结果：共纳入13篇文献，均为高质量文献，包括9篇队列研究，4篇病例对照研究。总计有1090例腰椎退行性疾病患者接受了LLIF，其中单纯组429例，内固定组661例，随访时间分别为17.66±5.39个月和16.40±5.41个月。Meta分析结果显示，融合率（RR 0.92，95%CI 0.87~0.98，P=0.006）、融合器下沉发生率（RR 1.68，95%CI 1.36~2.07，P<0.00001）、术后末次随访时较术前的椎间隙高度改善值（WMD -0.68，95%CI -1.04~-0.32，P=0.0002）、节段前凸角改善值（WMD -1.28，95%CI -2.30~-0.27，P=0.01）、ODI改善值（WMD -1.39，95%CI -2.45~-0.32，P=0.01）以及翻修率（RR 2.12，95%CI 1.02~4.43，P=0.04）的两组间差异有统计学意义，内固定组优于单纯组。术中出血量（WMD -106.62，95%CI -163.54~-49.70，P=0.0002）的两组间差异有统计学意义，单纯组少于内固定组。而术后末次随访时较术前的腰椎前凸角改善值（WMD -1.63，95%CI -3.36~0.10，P=0.06）、VAS评分改善值（WMD 0.63，95%CI -0.22~1.48，P=0.15）、术后住院时间（WMD -2.37，95%CI -4.82~0.07，P=0.06）、并发症发生率（RR 1.29，95%CI 0.94~1.78，P=0.12）、神经系统并发症发生率（RR 1.07，95%CI 0.67~1.72，P=0.78）以及邻椎病发生率（RR 0.43，95%CI 0.06~3.21，P=0.41）的两组间差异无统计学意义。结论：单纯LLIF与附加后路内固定的LLIF均能有效改善腰椎退行性疾病患者的临床疗效指标。与附加后路内固定的LLIF相比，单纯LLIF更易发生融合器下沉，进而导致融合率较低、维持间接减压效果较差及翻修率较高。对于具有高度融合器下沉的危险因素的患者，附加后路内固定的LLIF可能是更好的选择。

英文摘要:

  【Abstract】 Objectives: To analyze and compare the outcomes of stand-alone lateral lumbar interbody fusion (LLIF) and LLIF with supplemental posterior instrumentation in the treatment of lumbar degenerative disease by a Meta-analysis. Methods: A comprehensive literature search was performed for comparative studies relevant to stand-alone LLIF(stand-alone group) and LLIF with supplemental posterior instrumentation(instrumented group) in the treatment of lumbar degenerative disease using PubMed, EMBASE, Web of Science, Cochrane Library, CNKI, and Wanfang databases from their establishment to July 2021. The Newcastle-Ottawa scale (NOS) was adopted to evaluate the quality of the included studies. Outcome data was extracted, including fusion rate and cage subsidence rate at the last follow-up; the restoration of disc height, segmental lordosis, and lumbar lordosis at the last follow-up from those before operation; the improvement of visual analogue scale(VAS) score for leg pain and Oswestry disability index(ODI) score at the last follow-up from preoperation; intraoperative blood loss; length of hospital stay; postoperative complication rate, neurologic deficit rate, reoperation rate, and adjacent segment disease development rate. Meta analysis was performed with Review Manager 5.3 software. Continuous outcomes were analyzed by weighted mean difference(WMD), and dichotomous outcomes were analyzed by risk ratio(RR). The 95% confidence interval (CI) of each effect size was provided. Results: A total of 13 high-quality articles comprised of nine cohort studies and four case-control studies were included, involving 1090 patients who underwent LLIF(429 in the stand-alone group and 661 in the instrumented group) for lumbar degenerative disease. The length of follow-up was 17.66±5.39 months and 16.40±5.41 months in the stand-alone group and the instrumented group, respectively. The instrumented group was better than stand-alone group with significant differences in fusion rate(RR 0.92, 95%CI 0.87 to 0.98, P=0.006), cage subsidence rate (RR 1.68, 95%CI 1.36 to 2.07, P<0.00001), the restoration of disc height(WMD -0.68, 95%CI -1.04 to -0.32, P=0.0002) and segmental lordosis(WMD -1.28, 95%CI -2.30 to -0.27, P=0.01), the improvement of ODI(WMD -1.39, 95%CI -2.45 to -0.32, P=0.01), and reoperation rate(RR 2.12, 95%CI 1.02 to 4.43, P=0.04). While, comparing with instrumented group, the stand-alone group had less intraoperative blood loss(WMD -106.62, 95%CI -163.54 to -49.70, P=0.0002). There were no significant differences in the restoration of lumbar lordosis(WMD -1.63, 95%CI -3.36 to 0.10, P=0.06), the improvement of VAS scores(WMD 0.63, 95%CI -0.22 to 1.48, P=0.15), length of hospital stay (WMD-2.37, 95%CI -4.82 to 0.07, P=0.06), complication rate(RR 1.29, 95%CI 0.94 to 1.78, P=0.12), neurologic deficit rate (RR 1.07, 95%CI 0.67 to 1.72, P=0.78), and adjacent segment disease development rate (RR 0.43, 95%CI 0.06 to 3.21, P=0.41). Conclusions: Both stand-alone and instrumented LLIF were effective in improving the clinical outcomes of patients with lumbar degenerative disease. However, the stand-alone LLIF was associated with lower fusion rate, inferior maintenance of indirect decompression, and higher reoperation rate due to high-grade cage subsidence. For patients with risk factors of high-grade cage subsidence, the LLIF with posterior instrumentation may be a better choice.