腰椎间盘镜手术和显微手术治疗腰椎间盘突出症的系统评价

目的 系统评价腰椎间盘镜手术和显微手术治疗腰椎间盘突出症的疗效和安全性.方法 分别以椎间盘镜、显微镜、腰椎间盘突出等相关中英文关键词作为检索词,计算机检索PubMed、EMbase、Cochrane图书馆临床对照试验资料库、中国知网中国期刊全文数据库和万方数据知识服务平台学术期刊库,并对部分杂志进行手工检索,收集椎间盘镜手术和显微手术治疗腰椎间盘突出症的随机对照临床试验.采用Jadad 量表进行文献质量评价,数据提取和文献质量评价由两名评价员独立进行,RevMan 5.0.24 统计软件行Meta分析.结果 共纳入4 项临床研究计1069 例患者.Meta分析结果显示,术后Oswestry 功能障碍指数比较,两种术式间差异无统计学意义(MD = - 0.170,95%CI:- 3.590 ~ 3.260;P = 0.920).椎间盘镜手术患者术中硬脊膜撕裂(RR = 3.040,95%CI:1.170 ~ 7.890;P = 0.020)、神经根损伤(RR = 5.130,95%CI:0.890 ~ 29.420;P = 0.070)等并发症发生率和术后复发率(RR = 2.320,95%CI:0.970 ~ 5.520;P = 0.060)均高于显微手术;两种手术所用时间(MD = 10.780,95%CI:7.180 ~ 14.370;P =0.000)、手术切口长度(MD = - 0.950,95%CI:- 1.840 ~ 0.070;P = 0.030)和术后住院时间(MD = 0.210,95%CI:- 0.080 ~ 0.340;P = 0.002)具有统计学差异,但术中出血量比较差异无统计学意义(MD = 27.420,95%CI:- 8.840 ~ 63.680;P = 0.140).结论 椎间盘镜手术和显微手术治疗腰椎间盘突出症疗效相当,但椎间盘镜手术术后复发率和手术并发症发生率均高于显微手术.鉴于所纳入临床研究的整体质量较低且数量较少,应谨慎引用本研究结果,上述结论尚需更多高质量的随机对照临床试验加以验证.

Microendoscopic discectomy versus microscopic discectomy for treatment of lumbar disc herniations: a systematic review of randomized controlled trials

Objective To compare the effectiveness and safety of microendoscopic discectomy (MED) versus microscopic discectomy (MD) for treatment of lumbar disc herniations. Methods Key words were defined as microendoscopic discectomy, microscopic discectomy, lumbar disc herniation, etc. The electronic databases (PubMed, EMbase, Cochrane Central Register of Controlled Trials, CNKI, and Wanfang) were searched in order to retrieve randomized controlled trials (RCTs) about comparing MED and MD for the treatment of lumbar disc herniations. We also applied manual searching to screen out relevant journals. Data were extracted and evaluated by two reviewers independently. The quality of the included trails was evaluated by Jadad scales. Cochrane collaboration’s RevMan 5.0.24 were used for data analysis. Results Four RCTs involving 1069 patients were included in the Meta analysis. Results of Meta analysis showed that: the Oswestry dysfunctional index (ODI) after operation in MED group was not significantly different from that in the MD group ( MD = 0.170, 95% CI: 3.590-3.260; P = 0.920); dural tears in MED group were higher than those of MD group ( RR = 3.040, 95% CI: 1.170-7.890; P = 0.020); there were no significant difference between MED group and MD group in terms of root injury ( RR = 5.130, 95% CI: 0.890-29.420; P = 0.070) and recurrent herniation ( RR = 2.320, 95%CI: 0.970-5.520; P = 0.060); there weresignificant difference between MED group and MD group in terms of surgical time ( MD = 10.780, 95% CI: 7.180-14.370; P = 0.000), size of incision ( MD = 0.950, 95% CI: 1.840-0.070; P = 0.030) and length of hospital stay ( MD = 0.210, 95% CI: 0.080-0.340; P = 0.002). There was no significant difference between MED group and MD group in terms of blood loss ( MD = 27.420, 95% CI: 8.840-63.680; P = 0.140). Conclusion According to present knowledge, the two techniques were found to be effective for the treatment of lumbar disc herniations, but recurrent herniations were significantly more common in MED group. As for the safety of the two techniques, dural tears and root injuries were significantly more common in MED group. Because of the limitation of the quality and amount for the RCTs included, the results of this systematic review should be prudently cited, and more high quality RCTs are needed to be performed.