Minimally invasive versus open transforaminal lumbar interbody fusion for lumbar degenerative disease: a meta-analysis

doi:10.3969/j.issn.2095-4344.2014.22.018

Abstract

Abstract:

BACKGROUND: A large number of studies have confirmed that minimally invasive and open transforaminal lumbar interbody fusion approaches for single-segment and multi-segment lumbar degenerative diseases were effective, but their advantages and disadvantages remain inconclusive.

OBJECTIVE: To systematically evaluate the effectiveness and safety of minimally invasive versus open transforaminal lumbar interbody fusion for lumbar degenerative disease.

METHODS: Databases including The Cochrane Library (Issue 2, 2014), PubMed, EMbase, MEDLINE, SCI, CNKI, CBM, Wanfang Data were searched to collect the randomized controlled trails and non-randomized controlled trails about minimally invasive and open transforaminal lumbar interbody fusion for lumbar degenerative disease. The retrieval time was from foundation to February 2014. The studies were screened according to inclusion and exclusion criteria. The data were extracted and the quality was evaluated by two reviewers independently. Meta-analysis was conducted using RevMan 5.2 software.

RESULTS AND CONCLUSION: A total of 1 randomized controlled trail and 18 non-randomized controlled trails involving 1 400 patients were included. The results of meta-analysis showed that: compared with open transforaminal lumbar interbody fusion, minimally invasive transforaminal lumbar interbody fusion had many advantages, such as small paraspinal muscle injury, less blood loss, short hospital stay, good early effects and high long-period remission rate of lumbago. However, minimally invasive transforaminal lumbar interbody fusion was not superior to open transforaminal lumbar interbody fusion in improving long-period motor function, long-term remission rate of leg pain and in reducing complications. Moreover, the operation time of minimally invasive transforaminal lumbar interbody fusion was longer. Therefore, under the premise of strict indications, minimally invasive transforaminal lumbar interbody fusion could better solve the complaint of patients with lumbar degenerative disease. For the quantitative and qualitative limitation of the included studies, this conclusion still requires to be further proved by performing a larger scale and a higher quality of randomized controlled trails. It suggests that doctors should choose a best therapy for patients according to an integrative disease assessment.

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

全文链接：

Key words: cervical vertebrae, spinal fusion, surgical procedures, minimally invasive, treatment outcome, meta-analysis

CLC Number:

R318

Ran Bing, Yan Lei, Zhao Xiao-lei, Xie Yuan-long, Cai Lin. Minimally invasive versus open transforaminal lumbar interbody fusion for lumbar degenerative disease: a meta-analysis[J]. Chinese Journal of Tissue Engineering Research, 2014, 18(22): 3542-3550.

Figures/Tables 3

2.1 纳入研究的基本特征及质量评价初检出相关文献 1 563篇，其中中文文献862篇，英文文献701篇。排除动物实验、重复发表及明显不符合纳入标准的文献后，经阅读文题和摘要初筛纳入112篇文献。进一步查找和阅读全文，严格按照纳入与排除标准筛选最终纳入19篇文献[16-34]，共1 400例患者；其中英文文献14篇，中文文献5篇。微小切口经椎间孔腰椎椎间融合组621例，单节段融合529例，多节段融合73例，未说明融合节段19例；微小切口经椎间孔腰椎椎间融合组729例，单节段融合594例，多节段融合67例，未说明融合节段68例。采用NOS量表对纳入的19篇文献进行质量评价[35]，其中4篇文献8个评价条目均为优“★”属高质量研究；9篇文献8个评价条目中仅有1个条目评价为差“☆”属质量较高的研究；6篇文献8个条目中有2个条目质量评价为差“☆”属质量中等的研究。纳入研究的基本特征、文献质量评价见表1-3。 2.2 Meta分析结果 2.2.1 术中变量 19篇纳入研究中12篇报道了手术时间和术中出血量，故纳入12篇文献数据进行分析[20-21，23-27，29-31，33]。手术时间异质性检验结果显示各研究间异质性较大[MD= 12.19，95%CI(3.73，20.65)，P < 0.000 01，I2=85%]，故采用随机效应模型合并敏感性分析，结果显示，开放经椎间孔腰椎椎间融合组手术时间较微小切口经椎间孔腰椎椎间融合组短，两组差异有显著性意义(P=0.005，图1)。术中出血量异质性结果示，各研究间异质性较大[MD= -271.05，95%CI(-345.17，-196.93)，P < 0.000 01，I2=97%]，故采用随机效应模型分析，结果显示，微小切口经椎间孔腰椎椎间融合组术中出血量明显比开放经椎间孔腰椎椎间融合组少，两组差异有显著性意义(P < 0.000 01，图2)。 2.2.2 治疗后近期疗效 11个研究报道了平均住院时间[17，19-20，23-27，30-31，33]，故纳入11个研究的数据进行分析。异质性结果显示各研究异质性明显[MD=-3.32，95%CI (-4.16，-2.48)，P < 0.000 1，I2=93%]，故采用随机效应模型进行敏感性合并分析，结果显示，微小切口经椎间孔腰椎椎间融合组住院时间明显较开放经椎间孔腰椎椎间融合组短，二者差异有显著性意义(P < 0.000 01)，说明微小切口经椎间孔腰椎椎间融合组患者早期恢复更好(图3)。"

其他早期恢复指标较少被报道，有7个研究比较了两组治疗后镇痛药应用时间和剂量、引流量，及治疗后下床活动时间、开始工作时间[19，23，25-26，31-33]，结果显示微小切口经椎间孔腰椎椎间融合组优于开放经椎间孔腰椎椎间融合组。 2.2.3 治疗后远期疗效 17篇文献报道了末次随访(>10个月)的腰痛目测类比评分[17-31，33-34]，7篇文献报道了末次随访(>10个月)的腿痛目测类比评分[18-19，21，23，27-28，34]，13篇文献报道了末次随访(>10个月)ODI[17-21，23-24，25-29，31，34]，故纳入报道文献的数据进行分析。腰痛目测类比评分异质性检验结果显示各研究间异质性明显[MD=-0.54，95%CI(-0.79，-0.28)，P < 0.000 1，I2=86%]，故采用随机效应模型进行敏感性合并分析，结果示，微小切口经椎间孔腰椎椎间融合组腰背痛缓解率远期效果优于开放经椎间孔腰椎椎间融合组，两组差异有显著性意义(P < 0.0001，图4)。腿痛目测类比评分异质性检验结果显示各研究间异质性明显[MD=-0.00，95%CI(-0.38，-0.38)，P < 0.000 1，I2=81%]，故采用随机效应模型进行敏感性合并分析，结果示，微小切口经椎间孔腰椎椎间融合组与开放经椎间孔腰椎椎间融合组腿痛远期缓解率差异无显著性意义(P=1.0，图5)。ODI异质性检验结果显示各研究间异质性较明显[MD= -1.03，95%CI(-1.87，-0.18)，P=0.000 6，I2=65%]，故采用随机效应模型行敏感性合并分析，结果示，微小切口经椎间孔腰椎椎间融合组略优于开放经椎间孔腰椎椎间融合组，组间差异有显著性意义(P=0.02，图6)。 2.2.4 并发症 17篇文献报道了术后并发症[16-17，19-33]，报道的并发症包括伤口感染，术后神经损伤，硬膜粘连、破裂，内固定松动、断裂、Cage移位和骨不连等，故纳入17篇文献进行分析。并发症异质性结果显示各研究间异质性较小[MD=0.74，95%CI(0.51，1.08)，P=0.64，I2=0%]，故采用固定效应模型进行敏感性分析，结果示，两组治疗后并发症发生率差异无显著性意义(P=0.12，图7)。 2.3 发表性偏倚分析漏斗图分析结果显示，腰痛目测类比评分、手术时间、住院时间，并发症，ODI的漏斗图集中在图形上部，左右基本对称，表明存在发表偏倚的可能性较小。而术中出血量、3个指标的漏斗图不对称，表明其存在发表偏倚的可能性较大。"

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