Cortical bone trajectory screw versus pedicle screw fixation after posterior lumbar interbody fusion: a meta-analysis

doi:10.3969/j.issn.2095-4344.1089

Abstract

Abstract:

BACKGROUND: Traditional pedicle screw fixation technique has been widely used in posterior lumbar interbody fusion. Because of its complications such as extensive soft tissue dissection and invasion of intervertebral joints, since 2009, cortical bone trajectory screw fixation technique has been gradually used in posterior lumbar interbody fusion surgery in order to reduce these complications. There is a lack of meta-analysis exploring the clinical efficacy of cortical bone trajectory screw fixation versus traditional pedicle screw fixation after posterior lumbar interbody fusion.

OBJECTIVE: To evaluate the clinical efficacy of cortical bone trajectory screw fixation versus traditional pedicle screw fixation after posterior lumbar interbody fusion by meta-analysis.

METHODS: A computer-based search in databases of PubMed, The Cochrane Library, Embase, Scopus, Web of Science, CNKI, CBM, and WanFang was conducted for the articles published before July 2018. “CBT, cortical bone trajectory, cortical screw, PS, pedicle screw” were used as keywords in English and Chinese, respectively. Two researchers independently screened the retrieved literature, evaluated the quality of the included literature and extracted the data. Meta-analysis was performed using Rev Man 5.2 software.

RESULTS AND CONCLUSION: (1) A total of eight literatures were included, including seven in English and one in Chinese, two randomized controlled trials, and six cohort studies. 656 cases were included, 319 in cortical trajectory screw group and 337 in pedicle screw group. (2) The results of meta-analysis showed that there were significant differences in operation time, intraoperative blood loss and postoperative hospitalization time between two groups, and the cortical trajectory screw group was superior to the pedicle screw group (P < 0.05). (3) There were significant differences in the perioperative complications, total complications during follow-up and secondary operation rate between two groups, and the cortical trajectory screw group was superior to the pedicle screw group (P < 0.05). (4) The long-term complications and intervertebral fusion rate did not differ significantly between two groups (P > 0.05). (5) These results indicate that the cortical bone trajectory screws are better than the traditional pedicle screws in the operation time, intraoperative blood loss, postoperative hospitalization time, perioperative complications, total complications and secondary operation rate. But there is no significant difference in the intervertebral fusion rate and long-term complications between two methods.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

Key words: Lumbar Vertebrae, Spinal Fusion, Bone Nails, Meta-Analysis, Tissue Engineering

CLC Number:

R459.9

Wang Liang, Li Lijun, Zhu Fuliang, Jiang Zhuyan, Wang Shuai, Ni Dongkui . Cortical bone trajectory screw versus pedicle screw fixation after posterior lumbar interbody fusion: a meta-analysis [J]. Chinese Journal of Tissue Engineering Research, 2019, 23(8): 1291-1298.

Figures/Tables 5

2.2 Meta分析结果 2.2.1 术中出血量 7篇文献比较了后路腰椎椎体间融合术中皮质骨通道螺钉固定跟椎弓根螺钉固定2种固定技术的出血量[6-12]；其中皮质骨通道螺钉固定组284例，椎弓根螺钉固定组300例。将此7篇文献数据进行Meta分析，异质性检验结果表明纳入文献间有中度异质性(I2=67%，P=0.006)，故采用随机效应模型。合并统计量显示在后路腰椎椎体间融合术中，2种固定方式的出血量差异有显著性意义[MD=-69.47，95%CI(-92.50，46.44)，P < 0.000 01]。结果表明，在后路腰椎椎体间融合术中皮质骨通道螺钉固定较椎弓根螺钉固定能明显减少术中出血量，差异有显著性意义，见图2。 2.2.2 手术时间纳入文献中7篇文献包含后路腰椎椎体间融合术中皮质骨通道螺钉固定与椎弓根螺钉固定2种固定技术的手术时间[6-12]，其中皮质骨通道螺钉固定组284例, 椎弓根螺钉固定组300例，进行Meta分析，异质性检验结果表明纳入文献间有明显异质性(I2=80%，P < 0.000 1)，故采用随机效应模型，由于纳入文献中手术时间的单位存在小时与分钟，故效应量选用SMD，合并统计量显示在后路腰椎椎体间融合术中，2种固定方式的手术时间差异有显著性意义[SMD=-0.80，95%CI(-1.21，0.39)，P=0.000 1]。结果表明，在后路腰椎椎体间融合术中皮质骨通道螺钉固定组的手术时间明显少于椎弓根螺钉固定组，差异有显著性意义，见图3。 2.2.3 住院时间纳入文献中4篇文献包含后路腰椎椎体间融合术中皮质骨通道螺钉固定与椎弓根螺钉固定2种固定技术的住院时间[8-10，12]，其中皮质骨通道螺钉固定组125例，椎弓根螺钉固定组121例，进行Meta分析，异质性检验结果表明纳入文献间有明显异质性(I2=77%，P=0.000 5)，故采用随机效应模型，合并统计量显示在后路腰椎椎体间融合术中，2种固定方式的住院时间差异有显著性意义[MD=-1.00，95%CI(-1.91，-0.09)，P=0.03]。结果表明，在后路腰椎椎体间融合术中皮质骨通道螺钉固定组的住院时间明显少于椎弓根螺钉固定组，2组间差异有显著性意义，见图4。 2.2.4 椎间融合率纳入文献中6篇文献包含后路腰椎椎体间融合术中皮质骨通道螺钉固定与椎弓根螺钉固定术后末次随访的椎间融合率[6-7，9-11，13]，其中皮质骨通道螺钉固定组265例，椎弓根螺钉固定组282例，进行Meta分析，异质性检验结果表明纳入文献间无异质性(I2=0%，P=0.74)，故采用固定效应模型，二分类变量效应指标选用OR，合并统计量显示在后路腰椎椎体间融合术中，2种固定方式的椎间融合率差异无显著性意义[OR=0.96，95%CI(0.91，1.02)，P=0.19]。结果表明，在后路腰椎椎体间融合术中皮质骨通道螺钉固定组与椎弓根螺钉固定组比较，2组间椎间融合率差异无显著性意义，见图5。"

2.2.5 再次手术率纳入文献中5篇文献包含后路腰椎椎体间融合术中皮质骨通道螺钉固定与椎弓根螺钉固定术后随访期间的再次手术率[6-9，11]，其中皮质骨通道螺钉固定组248例，椎弓根螺钉固定组264例，进行Meta分析，异质性检验结果表明纳入文献间无异质性(I2=0%，P=0.42)，故采用固定效应模型，二分类变量的效应指标选用OR，合并统计量显示在后路腰椎椎体间融合术中，2种固定方式的再次手术率差异有显著性意义[OR=-0.05，95%CI(-0.09，-0.01)，P=0.02]。结果表明，在后路腰椎椎体间融合术中皮质骨通道螺钉固定组的再次手术率明显低于椎弓根螺钉固定组，2组间椎间再次手术率的差异有显著性意义，见图6。 2.2.6 围术期并发症纳入文献中6篇文献包含后路腰椎椎体间融合术中皮质骨通道螺钉与椎弓根螺钉固定2种固定技术围术期的并发症[6-11]，其中皮质骨通道组268例，椎弓根螺钉固定组274例，进行Meta分析，异质性检验结果表明纳入文献间无异质性(I2=2%，P=0.40)，故采用固定效应模型，二分类变量效应指标选用OR，合并统计量显示在后路腰椎椎体间融合术中，2种固定方式的围术期并发症差异有显著性意义[OR=0.36，95%CI(0.20，0.68)，P=0.001]。结果表明，在后路腰椎椎体间融合术中皮质骨通道螺钉固定组的围术期并发症发生率明显低于椎弓根螺钉固定组，2组间差异有显著性意义，见图7。 2.2.7 远期并发症纳入文献中6篇文献包含后路腰椎椎体间融合术中皮质骨通道螺钉与椎弓根螺钉固定2种固定技术术的远期并发症[6-7，9-11，13]，其中皮质骨通道组265例，椎弓根螺钉固定组282例，进行Meta分析，异质性检验结果表明纳入文献间无异质性(I2=0%，P=0.95)，故采用固定效应模型，二分类变量效应指标选用OR，合并统计量显示在后路腰椎椎体间融合术中，2种固定方式的远期并发症差异无显著性意义[OR=0.85，95%CI(0.54，1.34)，P=0.48]。结果表明，在后路腰椎椎体间融合术中2组间远期并发症发生率差异无显著性意义，见图8。 2.2.8 总并发症纳入文献中6篇文献包含后路腰椎椎体间融合术中皮质骨通道螺钉与椎弓根螺钉固定2种固定技术的总并发症[6-11]，其中皮质骨通道组268例，椎弓根螺钉固定组274例，进行Meta分析，异质性检验结果表明纳入文献间存在中度异质性(I2=49%，P=0.08)，故采用随机效应模型，二分类变量效应指标选用OR，合并统计量显示在后路腰椎椎体间融合术中，2种固定方式的总并发症差异有显著性意义[OR=0.50，95%CI(0.27，0.94)，P=0.03]。结果表明，在后路腰椎椎体间融合术中皮质骨通道螺钉固定组的总并发症发生率明显低于椎弓根螺钉固定组，2组间差异有显著性意义，见图9。"

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