手术与保守治疗无神经损伤A型胸腰椎爆裂骨折疗效差异的Meta分析
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摘要
目的通过Meta分析的方法比较手术与保守治疗无神经损伤的A型胸腰椎爆裂骨折的疗效差异。方法检索国内外已发表的病例对照研究,检索数据库包括Embase、Pubmed、Web of Science、Cochrane Library、知网、万方、百度学术、谷歌学术等。根据Cochrane偏倚风险评估标准对符合纳入标准的文献进行质量评价,采用Review manager 5.3软件对提取的数据进行统计学分析。结果共18篇病例对照研究纳入分析,共1 652例患者,其中保守组983例,手术组669例。相对于保守治疗,手术治疗A型胸腰椎爆裂骨折末次随访脊柱后凸角更小(P<0.0001)、椎管狭窄率更低(P<0.0001)、恢复工作用时更短(P<0.0001)。而住院时间(P=0.06)、VAS评分(P=0.72)、ODI评分(P=0.74)、恢复重体力劳动率(P=0.64)和恢复轻体力劳动率(P=0.11)、恢复工作情况(P=0.84)和并发症发生率(P=0.61)等结局指标,差异均无统计学意义。结论手术治疗无神经损伤的A型胸腰椎爆裂骨折相较于保守治疗具有脊柱后凸角小、椎管狭窄率低、恢复工作用时短等优点。
Objective To systematically compare the clinical efficacy of surgery with conservative treatment for type A thoracolumbar burst fractures without neurologic deficit. Methods The studies using case controlled trials to compare surgery with conservative treatment for type A thoracolumbar burst fractures without neurologic deficit were retrieved from Embase、Pubmed、Web of Science、Cochrane Library etc.The Cochrane risk assessment criteria were used to evaluate the quality of the articles that met the inclusion criteria.Data were analyzed with Review Manager 5.3 software. Results Eighteen case controlled studies(involving 1652 cases) were included in meta-analysis.Conservative treatment group consisted of 983 cases,and surgery group consisted of 669 cases.Through comparison,we found last follow-up kyphosis angle(P<0.0001)for surgery was smaller,spinal canal stenosis rate was less(P<0.0001)and time before return to work was shorter(P<0.0001)for surgery group than conservative treatment group.However,there is no statistical difference between two groups on the time in hospital(P=0.06),VAS score(P=0.72),ODI score(P=0.74),heavy physical labor recovery(P=0.64),Light physical labor recovery(P=0.11),return to work ratio(P=0.84)and incidence of complications(P=0.61).Conclusion Surgical treatment of thoracolumbar burst fractures without neurologic deficit has the advantages of less kyphosis angle,lower spinal stenosis rate,and shorter recovery time than conservative treatment.In summary,we believe that the surgical treatment of thoracolumbar burst fractures without neurologic Deficit is better than conservative treatment.
Objective To systematically compare the clinical efficacy of surgery with conservative treatment for type A thoracolumbar burst fractures without neurologic deficit. Methods The studies using case controlled trials to compare surgery with conservative treatment for type A thoracolumbar burst fractures without neurologic deficit were retrieved from Embase、Pubmed、Web of Science、Cochrane Library etc.The Cochrane risk assessment criteria were used to evaluate the quality of the articles that met the inclusion criteria.Data were analyzed with Review Manager 5.3 software. Results Eighteen case controlled studies(involving 1652 cases) were included in meta-analysis.Conservative treatment group consisted of 983 cases,and surgery group consisted of 669 cases.Through comparison,we found last follow-up kyphosis angle(P<0.0001)for surgery was smaller,spinal canal stenosis rate was less(P<0.0001)and time before return to work was shorter(P<0.0001)for surgery group than conservative treatment group.However,there is no statistical difference between two groups on the time in hospital(P=0.06),VAS score(P=0.72),ODI score(P=0.74),heavy physical labor recovery(P=0.64),Light physical labor recovery(P=0.11),return to work ratio(P=0.84)and incidence of complications(P=0.61).Conclusion Surgical treatment of thoracolumbar burst fractures without neurologic deficit has the advantages of less kyphosis angle,lower spinal stenosis rate,and shorter recovery time than conservative treatment.In summary,we believe that the surgical treatment of thoracolumbar burst fractures without neurologic Deficit is better than conservative treatment.
引文
[1]KRAEMER W J,SCHEMITSCH E H,LEVER J,et al.Functional outcome of thoracolumbar burst fractures without neurological deficit[J].J Orthop Trauma,1996,10(8):541-544.
[2]DENIS F.The three column spine and its significance in the classification of acute thoracolumbar spinal injuries[J].Spine(Phila Pa1976),1983,8(8):817-831.
[3]ESSES S I,BOTSFORD D J,KOSTUIK J P.Evaluation of surgical treatment for burst fractures[J].Spine(Phila Pa 1976),1990,15(7):667-673.
[4]MULLER U,BERLEMANN U,SLEDGE J,et al.Treatment of thoracolumbar burst fractures without neurologic deficit by indirect reduction and posterior instrumentation:bisegmental stabilization with monosegmental fusion[J].Eur Spine J,1999,8(4):284-289.
[5]HONGO M,ABE E,SHIMADA Y,et al.Surface strain distribution on thoracic and lumbar vertebrae under axial compression.The role in burst fractures[J].Spine(Phila Pa 1976),1999,24(12):1197-1202.
[6]BENSCH F V,KOIVIKKO M P,KIURU M J,et al.The incidence and distribution of burst fractures[J].Emerg Radiol,2006,12(3):124-129.
[7]GERTZBEIN S D,KHOURY D,BULLINGTON A,et al.Thoracic and lumbar fractures associated with skiing and snowboarding injuries according to the AO Comprehensive Classification[J].Am J Sports Med,2012,40(8):1750-1754.
[8]MAGERL F,AEBI M,GERTZBEIN S D,et al.A comprehensive classification of thoracic and lumbar injuries[J].Eur Spine J,1994,3(4):184-201.
[9]VERHEYDEN A P,HOLZL A,EKKERLEIN H,et al.Recommendations for the treatment of thoracolumbar and lumbar spine injuries[J].Unfallchirurg,2011,114(1):9-16.
[10]KANDZIORA F,SCHLEICHER P,SCHNAKE K J,et al.The AOSpine Classification of Thoraco-Lumbar Spine Injuries[J].Z Orthop Unfall,2016,154(1):35-42.
[11]JADAD A,MOORE R,CARROLL D,et al.Assessing the quality of reports of randomized clinical trials:is blinding necessary[J].Control Clin Trials,1996,17(1):1-12.
[12]AZHARI S,AZIMI P,SHAHZADI S,et al.Decision-Making Process in Patients with Thoracolumbar and Lumbar Burst Fractures with Thoracolumbar InjurySeverityand Classification Score Less than Four[J].AsianSpine J,2016,10(1):136-142.
[13]BUTLER J S,WALSH A,O'BYRNE J.Functional outcome of burst fractures of the first lumbar vertebra managed surgically and conservatively[J].Int Orthop,2005,29(1):51-54.
[14]DENIS F,ARMSTRONG G W,SEARLS K,et al.Acute thoracolumbar burst fractures in the absence of neurologic deficit.A comparison between operative and nonoperative treatment[J].Clin Orthop Relat Res,1984,(189):142-149.
[15]HITCHON P,HE W,VILJOEN S,et al.Predictors of outcome in the non-operative management of thoracolumbar and lumbar burst fractures[J].Br J Neurosurg,2014,28(5):653-657.
[16]KUMAR A,AUJLA R,LEE C.The management of thoracolumbar burst fractures:a prospective study between conservative management,traditional open spinal surgery and minimally interventional spinal surgery[J].Springerplus,2015(4):204.
[17]LEVIN J M,ANDERSON J T,HAAS A R,et al.Vertebroplasty and Return to Work for Thoracolumbar Fractures Within the Workers'Compensation Population[J].Spine(Phila Pa 1976),2017,42(13):1024-1030.
[18]SHEN W J,LIU T J,SHEN Y S.Nonoperative treatment versus posterior fixation for thoracolumbar junction burst fractures without neurologic deficit[J].Spine(Phila Pa 1976),2001,26(9):1038-1045.
[19]SIEBENGA J,LEFERINK V J,SEGERS M J,et al.Treatment of traumatic thoracolumbar spine fractures:a multicenter prospective randomized study of operative versus nonsurgical treatment[J].Spine(Phila Pa 1976),2006,31(25):2881-2890.
[20]WOOD K,BUTTERMANN G,MEHBOD A,et al.Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit.A prospective,randomized study[J].J Bone Joint Surg Am,2003,85-A(5):773-781.
[21]余晓杰,蒙思锋,唐光伟.保守疗法与手术治疗脊柱爆裂骨折胸腰椎损伤56例疗效对比[J].陕西医学杂志,2017,46(5):579-580.
[22]刘世伟,谭伦,王清.保守治疗与后路手术治疗胸腰椎A型骨折的疗效观察[J].颈腰痛杂志,2011,32(3):181-186.
[23]刘军.保守与手术治疗TLICS 4分胸腰段椎体骨折的前瞻性随机对照研究[D].苏州大学,2014.
[24]艾尼瓦尔·库尔班.无神经损伤胸腰椎爆裂骨折采用手术治疗与保守治疗的疗效比较[J/CD].临床医药文献电子杂志,2017,4(34):6603.
[25]张志宏,陈定法,刘菲.无神经症状的胸腰椎爆裂性骨折手术和非手术疗效的比较[J].吉林医学,2010,31(35):6431-6433.
[26]杨静波,邢秀峰.不同治疗方式对稳定型胸腰椎爆裂性骨折的疗效分析[J].西南国防医药,2017,27(10):1104-1106.
[27]王宇飞.无神经损伤的脊柱胸腰段爆裂型骨折治疗的临床观察[D].黑龙江中医药大学,2007:201-203.
[28]王敏.无神经损伤胸腰椎爆裂骨折手术治疗与保守治疗的疗效比较[D].陕西中医药大学,2015.
[29]鲁驷原,熊福军,周劲松,等.老年退行性腰椎管狭窄症应用全椎板切除脊柱内固定治疗的疗效观察[J].河北医学,2017,23(9):1429-1433.
[30]MCLAIN R F.Functional outcomes after surgery for spinal fractures:return to work and activity[J].Spine(Phila Pa 1976),2004,29(4):470-477;discussion Z476.
[31]KIM B G,DAN J M,SHIN D E.Treatment of thoracolumbar fracture[J].Asian Spine J,2015,9(1):133-146.
[32]P P O,TUINEBREIJER W E,PATKA P,et al.Combined anterior-posterior surgery versus posterior surgery for thoracolumbar burst fractures:a systematic review of the literature[J].Open Orthop J,2010,(4):93-100.
[33]WOOD K B,BOHN D,MEHBOD A.Anterior versus posterior treatment of stable thoracolumbar burst fractures without neurologic deficit:a prospective,randomized study[J].J Spinal Disord Tech,2005,18 Suppl:S15-23.
[34]CANTOR J B,LEBWOHL N H,GARVEY T,et al.Nonoperative managementofstablethoracolumbarburstfractureswithearlyambulation andbracing[J].Spine(Phila Pa1976),1993,18(8):971-976.
[35]CHOW G H,NELSON B J,GEBHARD J S,et al.Functional outcome of thoracolumbar burst fractures managed with hyperextension casting or bracingand earlymobilization[J].Spine(Phila Pa1976),1996,21(18):2170-2175.
[36]MUMFORD J,WEINSTEIN J N,SPRATT K F,et al.Thoracolumbar burst fractures.The clinical efficacy and outcome of nonoperative management[J].Spine(Phila Pa 1976),1993,18(8):955-970.
[37]THOMAS K C,BAILEY C S,DVORAK M F,et al.Comparison of operative and nonoperative treatment for thoracolumbar burst fractures in patients without neurological deficit:a systematic review[J].JNeurosurg Spine,2006,4(5):351-358.
[38]ABUDOU M,CHEN X,KONG X,et al.Surgical versus non-surgical treatmentforthoracolumbarburstfractureswithoutneurologicaldeficit[J].Cochrane Database Syst Rev,2013,(6):CD005079.
[39]GNANENTHIRAN S R,ADIE S,HARRIS I A.Nonoperative versus operative treatment for thoracolumbar burst fractures without neurologic deficit:a meta-analysis[J].Clin Orthop Relat Res,2012,470(2):567-577.
[40]JAFFRAY D C,EISENSTEIN S M,BALAIN B,et al.Early mobilisation of thoracolumbar burst fractures without neurology:a natural history observation[J].Bone Joint J,2016,98-B(1):97-101.
[41]SHEN W J,SHEN Y S.Nonsurgical treatment of three-column thoracolumbar junction burst fractures without neurologic deficit[J].Spine(Phila Pa 1976),1999,24(4):412-415.
[42]ARAS E L,BUNGER C,HANSEN E S,et al.Cost-Effectiveness of Surgical Versus Conservative Treatment for Thoracolumbar Burst Fractures[J].Spine(Phila Pa 1976),2016,41(4):337-343.
[43]AKBARNIA B A,CRANDALL D G,BURKUS K,et al.Use of long rods and a short arthrodesis for burst fractures of the thoracolumbar spine.Along-term follow-up study[J].J Bone Joint Surg Am,1994,76(11):1629-1635.
[44]ANDRESS H J,BRAUN H,HELMBERGER T,et al.Long-term results after posterior fixation of thoraco-lumbar burst fractures[J].Injury,2002,33(4):357-365.
[45]SCHEER J K,BAKHSHESHIAN J,FAKURNEJAD S,et al.Evidence-Based Medicineof TraumaticThoracolumbar Burst Fractures:A Systematic Review of Operative Management across 20 Years[J].Global Spine J,2015,5(1):73-82.
[46]ROMETSCH E,SPRUIT M,HARTL R,et al.Does Operative or Nonoperative Treatment Achieve Better Results in A3 and A4 Spinal Fractures Without Neurological Deficit?:Systematic Literature Review With Meta-Analysis[J].Global Spine J,2017,7(4):350-372.
[47]YI L,JINGPING B,GELE J,et al.Operative versus non-operative treatmentforthoracolumbarburstfractureswithoutneurologicaldeficit[J].Cochrane Database Syst Rev,2006,(4):CD005079.
[48]汪磊,沈建雄.手术与非手术治疗无神经损伤胸腰椎爆裂骨折的Meta分析[J].中华创伤杂志,2015,31(1):31-36.
[2]DENIS F.The three column spine and its significance in the classification of acute thoracolumbar spinal injuries[J].Spine(Phila Pa1976),1983,8(8):817-831.
[3]ESSES S I,BOTSFORD D J,KOSTUIK J P.Evaluation of surgical treatment for burst fractures[J].Spine(Phila Pa 1976),1990,15(7):667-673.
[4]MULLER U,BERLEMANN U,SLEDGE J,et al.Treatment of thoracolumbar burst fractures without neurologic deficit by indirect reduction and posterior instrumentation:bisegmental stabilization with monosegmental fusion[J].Eur Spine J,1999,8(4):284-289.
[5]HONGO M,ABE E,SHIMADA Y,et al.Surface strain distribution on thoracic and lumbar vertebrae under axial compression.The role in burst fractures[J].Spine(Phila Pa 1976),1999,24(12):1197-1202.
[6]BENSCH F V,KOIVIKKO M P,KIURU M J,et al.The incidence and distribution of burst fractures[J].Emerg Radiol,2006,12(3):124-129.
[7]GERTZBEIN S D,KHOURY D,BULLINGTON A,et al.Thoracic and lumbar fractures associated with skiing and snowboarding injuries according to the AO Comprehensive Classification[J].Am J Sports Med,2012,40(8):1750-1754.
[8]MAGERL F,AEBI M,GERTZBEIN S D,et al.A comprehensive classification of thoracic and lumbar injuries[J].Eur Spine J,1994,3(4):184-201.
[9]VERHEYDEN A P,HOLZL A,EKKERLEIN H,et al.Recommendations for the treatment of thoracolumbar and lumbar spine injuries[J].Unfallchirurg,2011,114(1):9-16.
[10]KANDZIORA F,SCHLEICHER P,SCHNAKE K J,et al.The AOSpine Classification of Thoraco-Lumbar Spine Injuries[J].Z Orthop Unfall,2016,154(1):35-42.
[11]JADAD A,MOORE R,CARROLL D,et al.Assessing the quality of reports of randomized clinical trials:is blinding necessary[J].Control Clin Trials,1996,17(1):1-12.
[12]AZHARI S,AZIMI P,SHAHZADI S,et al.Decision-Making Process in Patients with Thoracolumbar and Lumbar Burst Fractures with Thoracolumbar InjurySeverityand Classification Score Less than Four[J].AsianSpine J,2016,10(1):136-142.
[13]BUTLER J S,WALSH A,O'BYRNE J.Functional outcome of burst fractures of the first lumbar vertebra managed surgically and conservatively[J].Int Orthop,2005,29(1):51-54.
[14]DENIS F,ARMSTRONG G W,SEARLS K,et al.Acute thoracolumbar burst fractures in the absence of neurologic deficit.A comparison between operative and nonoperative treatment[J].Clin Orthop Relat Res,1984,(189):142-149.
[15]HITCHON P,HE W,VILJOEN S,et al.Predictors of outcome in the non-operative management of thoracolumbar and lumbar burst fractures[J].Br J Neurosurg,2014,28(5):653-657.
[16]KUMAR A,AUJLA R,LEE C.The management of thoracolumbar burst fractures:a prospective study between conservative management,traditional open spinal surgery and minimally interventional spinal surgery[J].Springerplus,2015(4):204.
[17]LEVIN J M,ANDERSON J T,HAAS A R,et al.Vertebroplasty and Return to Work for Thoracolumbar Fractures Within the Workers'Compensation Population[J].Spine(Phila Pa 1976),2017,42(13):1024-1030.
[18]SHEN W J,LIU T J,SHEN Y S.Nonoperative treatment versus posterior fixation for thoracolumbar junction burst fractures without neurologic deficit[J].Spine(Phila Pa 1976),2001,26(9):1038-1045.
[19]SIEBENGA J,LEFERINK V J,SEGERS M J,et al.Treatment of traumatic thoracolumbar spine fractures:a multicenter prospective randomized study of operative versus nonsurgical treatment[J].Spine(Phila Pa 1976),2006,31(25):2881-2890.
[20]WOOD K,BUTTERMANN G,MEHBOD A,et al.Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit.A prospective,randomized study[J].J Bone Joint Surg Am,2003,85-A(5):773-781.
[21]余晓杰,蒙思锋,唐光伟.保守疗法与手术治疗脊柱爆裂骨折胸腰椎损伤56例疗效对比[J].陕西医学杂志,2017,46(5):579-580.
[22]刘世伟,谭伦,王清.保守治疗与后路手术治疗胸腰椎A型骨折的疗效观察[J].颈腰痛杂志,2011,32(3):181-186.
[23]刘军.保守与手术治疗TLICS 4分胸腰段椎体骨折的前瞻性随机对照研究[D].苏州大学,2014.
[24]艾尼瓦尔·库尔班.无神经损伤胸腰椎爆裂骨折采用手术治疗与保守治疗的疗效比较[J/CD].临床医药文献电子杂志,2017,4(34):6603.
[25]张志宏,陈定法,刘菲.无神经症状的胸腰椎爆裂性骨折手术和非手术疗效的比较[J].吉林医学,2010,31(35):6431-6433.
[26]杨静波,邢秀峰.不同治疗方式对稳定型胸腰椎爆裂性骨折的疗效分析[J].西南国防医药,2017,27(10):1104-1106.
[27]王宇飞.无神经损伤的脊柱胸腰段爆裂型骨折治疗的临床观察[D].黑龙江中医药大学,2007:201-203.
[28]王敏.无神经损伤胸腰椎爆裂骨折手术治疗与保守治疗的疗效比较[D].陕西中医药大学,2015.
[29]鲁驷原,熊福军,周劲松,等.老年退行性腰椎管狭窄症应用全椎板切除脊柱内固定治疗的疗效观察[J].河北医学,2017,23(9):1429-1433.
[30]MCLAIN R F.Functional outcomes after surgery for spinal fractures:return to work and activity[J].Spine(Phila Pa 1976),2004,29(4):470-477;discussion Z476.
[31]KIM B G,DAN J M,SHIN D E.Treatment of thoracolumbar fracture[J].Asian Spine J,2015,9(1):133-146.
[32]P P O,TUINEBREIJER W E,PATKA P,et al.Combined anterior-posterior surgery versus posterior surgery for thoracolumbar burst fractures:a systematic review of the literature[J].Open Orthop J,2010,(4):93-100.
[33]WOOD K B,BOHN D,MEHBOD A.Anterior versus posterior treatment of stable thoracolumbar burst fractures without neurologic deficit:a prospective,randomized study[J].J Spinal Disord Tech,2005,18 Suppl:S15-23.
[34]CANTOR J B,LEBWOHL N H,GARVEY T,et al.Nonoperative managementofstablethoracolumbarburstfractureswithearlyambulation andbracing[J].Spine(Phila Pa1976),1993,18(8):971-976.
[35]CHOW G H,NELSON B J,GEBHARD J S,et al.Functional outcome of thoracolumbar burst fractures managed with hyperextension casting or bracingand earlymobilization[J].Spine(Phila Pa1976),1996,21(18):2170-2175.
[36]MUMFORD J,WEINSTEIN J N,SPRATT K F,et al.Thoracolumbar burst fractures.The clinical efficacy and outcome of nonoperative management[J].Spine(Phila Pa 1976),1993,18(8):955-970.
[37]THOMAS K C,BAILEY C S,DVORAK M F,et al.Comparison of operative and nonoperative treatment for thoracolumbar burst fractures in patients without neurological deficit:a systematic review[J].JNeurosurg Spine,2006,4(5):351-358.
[38]ABUDOU M,CHEN X,KONG X,et al.Surgical versus non-surgical treatmentforthoracolumbarburstfractureswithoutneurologicaldeficit[J].Cochrane Database Syst Rev,2013,(6):CD005079.
[39]GNANENTHIRAN S R,ADIE S,HARRIS I A.Nonoperative versus operative treatment for thoracolumbar burst fractures without neurologic deficit:a meta-analysis[J].Clin Orthop Relat Res,2012,470(2):567-577.
[40]JAFFRAY D C,EISENSTEIN S M,BALAIN B,et al.Early mobilisation of thoracolumbar burst fractures without neurology:a natural history observation[J].Bone Joint J,2016,98-B(1):97-101.
[41]SHEN W J,SHEN Y S.Nonsurgical treatment of three-column thoracolumbar junction burst fractures without neurologic deficit[J].Spine(Phila Pa 1976),1999,24(4):412-415.
[42]ARAS E L,BUNGER C,HANSEN E S,et al.Cost-Effectiveness of Surgical Versus Conservative Treatment for Thoracolumbar Burst Fractures[J].Spine(Phila Pa 1976),2016,41(4):337-343.
[43]AKBARNIA B A,CRANDALL D G,BURKUS K,et al.Use of long rods and a short arthrodesis for burst fractures of the thoracolumbar spine.Along-term follow-up study[J].J Bone Joint Surg Am,1994,76(11):1629-1635.
[44]ANDRESS H J,BRAUN H,HELMBERGER T,et al.Long-term results after posterior fixation of thoraco-lumbar burst fractures[J].Injury,2002,33(4):357-365.
[45]SCHEER J K,BAKHSHESHIAN J,FAKURNEJAD S,et al.Evidence-Based Medicineof TraumaticThoracolumbar Burst Fractures:A Systematic Review of Operative Management across 20 Years[J].Global Spine J,2015,5(1):73-82.
[46]ROMETSCH E,SPRUIT M,HARTL R,et al.Does Operative or Nonoperative Treatment Achieve Better Results in A3 and A4 Spinal Fractures Without Neurological Deficit?:Systematic Literature Review With Meta-Analysis[J].Global Spine J,2017,7(4):350-372.
[47]YI L,JINGPING B,GELE J,et al.Operative versus non-operative treatmentforthoracolumbarburstfractureswithoutneurologicaldeficit[J].Cochrane Database Syst Rev,2006,(4):CD005079.
[48]汪磊,沈建雄.手术与非手术治疗无神经损伤胸腰椎爆裂骨折的Meta分析[J].中华创伤杂志,2015,31(1):31-36.