單純減壓術與減壓融合術比較治療退行性腰椎疾病的系統評價_《中國循證醫學雜志》

作者：

黃衛民 ¹ , 白靖平 ² , 錫林寶勒日 ² , 李同相 ² , 何祖勝 ² ,  吳泰相 ³

1. 新疆建工醫院（烏魯木齊 830002） 2. 新疆醫科大學附屬腫瘤醫院（烏魯木齊 830054） 3. 四川大學華西醫院中國循證醫學中心/ 國際臨床流行病學網華西研究與培訓中心（成都 610041）;

關鍵詞：

退行性腰椎疾病單純減壓術植骨融合術系統評價 Meta分析隨機對照試驗

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目的　系統評價單純減壓術與減壓融合術兩種手術方式治療退行性腰椎疾病。
方法　① 計算機檢索MEDLINE（from OVID, 1966～2006.4）、EMBASE（1984～2006.4）、CBMdisc（1978～2005.12）、萬方數據庫（1981～2006.4）、Cochrane圖書館（2006年第1期）、中文科技期刊數據庫（VIP, 1989～2006.4）；② 手工檢索相關雜志。納入單純減壓和減壓融合兩種手術方式治療退行性腰椎疾病且隨訪大于2年的隨機和半隨機對照試驗，并進行質量評價。采用RevMan4.2.8軟件對可以合并分析的指標作Meta分析；對不能合并的指標用描述性方法分析結果。
結果　有7篇研究符合納入標準，共412例。Meta分析結果顯示：單純減壓和減壓融合兩種手術方式治療退行性腰椎疾病在總體療效 [OR 1.83, 95%CI (0.92,3.41)]、疼痛減輕程度 [術前WMD 0.12, 95%CI (-0.44,0.68); 術后WMD 0.08, 95%CI (-1.08,1.25)]、術后腿痛人數 [OR 1.04, 95%CI (0.48,2.25)]、術后隨訪期二次手術人數 [OR 0.68, 95%CI (0.30,1.56)] 和圍手術期并發癥 [OR1.15, 95%CI (0.51,2.60)] 等方面，其差異均無統計學意義；但兩組在術后腰痛的發生人數上，差異有統計學意義 [OR 0.25, 95%CI (0.14,0.46)]。有4個研究比較了手術時間、術中失血、術后腰部使用支具固定時間、住院總費用，結果表明，單純減壓手術組少于減壓融合組。有3個研究比較了術前、術后椎體過伸過屈位滑移程度、手術間隙終板成角，術前術后椎間隙高度變化與手術療效的關系，但不同研究的結果矛盾。
結論　單純減壓和減壓融合兩種手術方式治療退行性腰椎疾病在總體療效、疼痛減輕程度、術后腿痛人數、術后隨訪期二次手術人數和圍手術期并發癥等方面，差異無統計學意義；術后腰痛的發生人數單純減壓組多于減壓融合組。但在手術時間、出血量、術后臥床時間、術后腰部使用支具固定時間及住院總費用方面，單純減壓手術組則少于減壓融合組。目前尚無足夠的證據證明X線表現椎體活動度的指標對預后術后腰痛有指導作用。鑒于本系統評價納入樣本數較小，文獻總體質量也不高，因此，上述結論還需更多高質量、大樣本的隨機對照試驗加以驗證。

引用本文： 黃衛民,白靖平,錫林寶勒日,李同相,何祖勝,吳泰相. 單純減壓術與減壓融合術比較治療退行性腰椎疾病的系統評價. 中國循證醫學雜志, 2006, 06(7): 484-493. doi: 復制

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2.	The Cochrane Collaboration.cochrane reviewers’ Handbook 4.2.3. http://www.cochraneeye.Org/documents/Cochrane%- 20Reviewers’%20Handbook%204.2.3.pdf.
3.	The Cochrane Collaboration.RevMan 4.2 User Guide. http://www.cc-ims.net/down load/revman/Documentation- /User%20guide.pdf.
4.	Grob D, Humke T, Dvorak J. Degenerative lumbar spinal stenosis. Decompression with and without arthrodesis. J Bone Joint Surg Am, 1995; 77(7): 1036-1041.
5.	Rompe JD, Eysel P, Hopf CH, et al. Surgical management of central lumbar spinal stenosis-results with decompressive laminectomy only and with concomitant instrumented fusion with the Cotrel-Dubousset-Instrumentation. Neuro-Orthopedics, 1995; 19(1): 17-31.
6.	Vaughan PA, Malcolm BW, Maistrelli GL. Results of L4-L5 Disc Excision Alone Versus Disc Excision and Fusion. Spine, 1988; 13(6): 690-695.
7.	Matsudaira K, Yamazaki T, Seichi A, et al. Spinal Stenosis in Grade I Degenerative Lumbar Spondylolisthsis: a Comparative Study of Outcomes Following Laminoplasty and Laminectomy with Instrumented Spinal fusion. J Orthop Sci, 2005; 10(3): 270-276.
8.	Takeshima T, Kambara K, Miyata S, et al. Clinical and radiographic evaluation of disc excision for lumbar disc herniation with and without posterolateral fusion. Spine, 2000; 25(4): 450-456.
9.	White AH, von Rogov P, Zucherman J, et al. Lumbar Laminectomy for Herniated Disc: A Prospective Controlled Comparison with Internal Fixation Fusion. Spine, 1987; 12(3): 305-307.
10.	Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am, 1991; 73(6): 802-808.
11.	Harris RI, Macnab I. Structural changes in the lumbar intervertebral discs; their relationship to low back pain and sciatica. J Bone Joint Surg Br, 1954; 36-B(2): 304-322.
12.	Kirkaldy-Willis WH, Farfan HF. Instability of the lumbar spine. Clin Orthop Relat Res, 1982; (165): 110-123.
13.	Spratt KF, Weinstein JN, Lehmann TR, et al. Efficacy of flexion and extension treatments incorporating braces for low-back pain patients with retrodisplacement, spondylolisthesis, or normal sagittal translation. Spine, 1993; 18(13): 1839-1849.
14.	Hanley EN, Matteri RE, Frymoyer JM. Accurate roentgenographic determination of lumbar flexion-extension. Clin Orthop Relat Res, 1976; (115): 145-148.
15.	Bjarke Christensen F, Stender Hansen E, Laursen M, et al. Long-Term Functional Outcome of Pedicle Screw Instrumentation as a Support for Posterolateral Spinal Fusion: Randomized Clinical Study With a 5-Year Follow-up. Spine, 2002; 27(12): 1269-1277.

1. Katz JN, Lipson SJ, Lew RA, et al. Lumbar laminectomy alone or with instrumented or noninstrumented arthrodesis in degenerative lumbar spinal stenosis. Patient selection, costs, and surgical outcomes. Spine, 1997; 22(10): 1123-1131.
2. The Cochrane Collaboration.cochrane reviewers’ Handbook 4.2.3. http://www.cochraneeye.Org/documents/Cochrane%- 20Reviewers’%20Handbook%204.2.3.pdf.
3. The Cochrane Collaboration.RevMan 4.2 User Guide. http://www.cc-ims.net/down load/revman/Documentation- /User%20guide.pdf.
4. Grob D, Humke T, Dvorak J. Degenerative lumbar spinal stenosis. Decompression with and without arthrodesis. J Bone Joint Surg Am, 1995; 77(7): 1036-1041.
5. Rompe JD, Eysel P, Hopf CH, et al. Surgical management of central lumbar spinal stenosis-results with decompressive laminectomy only and with concomitant instrumented fusion with the Cotrel-Dubousset-Instrumentation. Neuro-Orthopedics, 1995; 19(1): 17-31.
6. Vaughan PA, Malcolm BW, Maistrelli GL. Results of L4-L5 Disc Excision Alone Versus Disc Excision and Fusion. Spine, 1988; 13(6): 690-695.
7. Matsudaira K, Yamazaki T, Seichi A, et al. Spinal Stenosis in Grade I Degenerative Lumbar Spondylolisthsis: a Comparative Study of Outcomes Following Laminoplasty and Laminectomy with Instrumented Spinal fusion. J Orthop Sci, 2005; 10(3): 270-276.
8. Takeshima T, Kambara K, Miyata S, et al. Clinical and radiographic evaluation of disc excision for lumbar disc herniation with and without posterolateral fusion. Spine, 2000; 25(4): 450-456.
9. White AH, von Rogov P, Zucherman J, et al. Lumbar Laminectomy for Herniated Disc: A Prospective Controlled Comparison with Internal Fixation Fusion. Spine, 1987; 12(3): 305-307.
10. Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am, 1991; 73(6): 802-808.
11. Harris RI, Macnab I. Structural changes in the lumbar intervertebral discs; their relationship to low back pain and sciatica. J Bone Joint Surg Br, 1954; 36-B(2): 304-322.
12. Kirkaldy-Willis WH, Farfan HF. Instability of the lumbar spine. Clin Orthop Relat Res, 1982; (165): 110-123.
13. Spratt KF, Weinstein JN, Lehmann TR, et al. Efficacy of flexion and extension treatments incorporating braces for low-back pain patients with retrodisplacement, spondylolisthesis, or normal sagittal translation. Spine, 1993; 18(13): 1839-1849.
14. Hanley EN, Matteri RE, Frymoyer JM. Accurate roentgenographic determination of lumbar flexion-extension. Clin Orthop Relat Res, 1976; (115): 145-148.
15. Bjarke Christensen F, Stender Hansen E, Laursen M, et al. Long-Term Functional Outcome of Pedicle Screw Instrumentation as a Support for Posterolateral Spinal Fusion: Randomized Clinical Study With a 5-Year Follow-up. Spine, 2002; 27(12): 1269-1277.

《中國循證醫學雜志》

單純減壓術與減壓融合術比較治療退行性腰椎疾病的系統評價

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《中國循證醫學雜志》

單純減壓術與減壓融合術比較治療退行性腰椎疾病的系統評價

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