腰椎间盘突出症7种手术修复方式差异的网络Meta分析

文题释义：网络Meta分析：主要是借助间接比较技术对处于同一个证据体的所有干预措施同时进行综合评价并排序。在临床上当多种治疗可供选择时，它们之间的两两比较试验证据几乎不可能完整获得，这时网络Meta分析可以提供一种新的比较手段。腰椎间盘突出症：腰椎间盘突出症是指腰椎间盘变性，纤维环破裂，骶核组织突出刺激和压迫神经根而引起的一种综合征。主要表现为腰痛、坐骨神经痛，同时可伴有腰部活动受限，受累神经根支配区的感觉、运动和反射的改变。背景：随着椎间盘介入技术的快速发展，治疗腰椎间盘突出症的手术方式在取得长足进步的同时也让外科医生和患者有了更多的选择余地。因此新兴手术方式和传统广为接受治疗方式的治疗效果以及安全性的比较就显得尤为重要。传统的荟萃分析无法对多种手术方式的优劣进行层级划分。目的：通过网状Meta分析的方式，对临床上常用的7种治疗腰椎间盘突出症手术方式的疗效及安全进行评估。方法：通过贝叶斯网状Meta分析模型，对经皮穿刺椎间孔镜技术、标准椎间盘切除、标准小开窗椎间盘切除、椎间盘化学消融、椎间盘镜技术、经皮激光椎间盘汽化减压、自动式经皮穿刺腰椎间盘切吸技术治疗腰椎间盘突出症的随机对照试验研究进行荟萃分析。所有符合条件的随机对照试验均从theCochrane Central Register of Controlled Trials(CENTRAL)、PubMed、Embase以及Google scholar检索得来。检索提取结果数据包括手术成功率、并发症发生率和再手术率，数据由2名评价员独立提取。结果与结论：①共纳入29个研究31篇文献，包括3 146例患者；②7种手术方式成功率的概率排序(从优至劣)：经皮穿刺椎间孔镜技术> 标准椎间盘切除> 标准小开窗椎间盘切除> 椎间盘化学消融> 椎间盘镜技术> 经皮激光椎间盘汽化减压>自动式经皮穿刺腰椎间盘切吸；③手术并发症发生率的概率排序(从优至劣)：经皮穿刺椎间孔镜技术 > 标准的小开窗椎间盘切除 >标准椎间盘切除> 椎间盘镜技术> 经皮激光椎间盘汽化减压 > 椎间盘化学消融 > 自动式经皮穿刺腰椎间盘切吸；④再次手术率的概率排序(从优至劣)：标准小开窗椎间盘切除>标准椎间盘切除>椎间盘镜技术>经皮激光椎间盘汽化减压>经皮穿刺椎间孔镜技术>椎间盘化学消融 > 自动式经皮穿刺腰椎间盘切吸；⑤研究证据显示，经皮穿刺椎间孔镜技术具有最高的手术成功率，其手术并发症率也最低；此外标准小开窗椎间盘切除技术的再手术率最低；而自动式经皮穿刺腰椎间盘切吸技术的手术成功率最低同时并发症率最高。希望更高质量的一对一随机对照试验能够对此次研究结果进行进一步验证。ORCID: 0000-0002-8546-4300(冯帆)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

Comparison of seven surgical interventions for lumbar disc herniation: a network meta-analysis

BACKGROUND: With the rapid development of intervertebral disc interventional technology, surgical treatment of lumbar disc herniation has made great progress, but at the same time, surgeons and patients have more choices. Therefore, it is particularly important to compare the efficacy and safety of new surgical methods and traditional widely accepted treatment methods. Traditional meta-analysis cannot classify the advantages and disadvantages of various surgical methods. OBJECTIVE: To evaluate the efficacy and safety of seven surgical interventions for the treatment of lumbar disc herniation using network meta-analysis. METHODS: We performed a Bayesian-framework network meta-analysis of randomized controlled trials to compare seven surgical interventions for people with lumbar disc herniation, including percutaneous endoscopic lumbar discectomy, standard open discectomy, standard open microsurgical discectomy, chemonucleolysis, microendoscopic discectomy, percutaneous laser disc decompression, and automated percutaneous lumbar discectomy. The eligible randomized controlled trials were identified by searching the Cochrane Central Register of Controlled Trials(CENTRAL), PubMed, Embase and Google scholar. Data from three outcomes(success rate, complication rate, and reoperation rate) were independently extracted by two assessors. RESULTS AND CONCLUSION:(1) A total of 29 randomized controlled trials(31 literatures) including 3 146 participants were finally included into this article.(2) Our Meta-analysis provides hierarchies of these seven interventions. For the success rate, the rank probability is as follows(from best to worst): percutaneous endoscopic lumbar discectomy > standard open discectomy > standard open microsurgical discectomy > chemonucleolysis > microendoscopic discectomy > percutaneous laser disc decompression > automated percutaneous lumbar discectomy.(3) For the complication rate, the rank probability is as follows(from best to worst): percutaneous endoscopic lumbar discectomy > standard open microsurgical discectomy > standard open discectomy > microendoscopic discectomy > percutaneous laser disc decompression > chemonucleolysis > automated percutaneous lumbar discectomy.(4) For the reoperation rate, the rank probability is as follows(from best to worst): standard open microsurgical discectomy > standard open discectomy > microendoscopic discectomy > percutaneous laser disc decompression > percutaneous endoscopic lumbar discectomy > chemonucleolysis > automated percutaneous lumber discectomy.(5) This meta-analysis provides evidence that percutaneous endoscopic lumbar discectomy might be the best choice to increase the success rate and decrease the complication rate. Moreover, standard open microsurgical discectomy might be the best option to drop the reoperation rate. Automated percutaneous lumbar discectomy might lead to the lowest success rate and the highest complication rate. It is hoped that one-to-one randomized controlled trials of high quality will further validate the results of this study.