DeLong W Bradford, Polissar Nayak, Neradilek Blazej
Department of Neurosurgery, University of California San Francisco, California, USA.
J Neurosurg Spine. 2008 Apr;8(4):305-20. doi: 10.3171/SPI/2008/8/4/305.
The authors performed exploratory meta-analyses of observational cohort studies, evidence level III, examining whether earlier surgery makes a difference in outcome in terms of urinary function once cauda equina syndrome (CES) from a herniated lumbar disc has progressed to urinary retention (CESR).
Literature search identified 27 studies of CESR patients with clear definition of surgical timing. Relative risk (RR) could not be calculated in 11 studies, leaving 16 for meta-analysis. Urinary retention related to surgical timing at 5 breakpoints: 12, 24, 36, 48, or 72 hours. Urinary outcome was classified as Normal, Fair, or Poor. Meta-analysis was performed for "Event = Fair/Poor" or "Event = Poor." Eight studies allowed separation into CESR and incomplete CES (CESI), and 5 of these had enough data for meta-analysis to compare CESR and CESI. A random effects meta-analysis model was used because of heterogeneity across the studies. A best-evidence synthesis was performed for the 4 largest studies that had 24- and 48-hour breakpoints.
For "Event = Fair/Poor," meta-analyses using the 5 breakpoints predicted a more likely Fair/Poor outcome for later surgery (RR range 1.77-2.19). The RR for later timing of surgery was statistically significant for 24-and 72-hour breakpoints and was elevated but not statistically significant for the other 3. For "Event = Poor," the RR range was 1.09-5.82, statistically significant for the 36 hour breakpoint only. Meta-analysis comparing CESR patients with CESI patients predicted a Fair/Poor result for CESR (RR 2.58, 95% confidence interval 0.59-11.31). The best-evidence synthesis did not disclose reasons for differences in the results of the 4 studies.
This study supports early surgery for CES and indicates that CESR and CESI cases should not be analyzed together.
作者对证据水平为III级的观察性队列研究进行了探索性荟萃分析，以检验一旦腰椎间盘突出症导致的马尾神经综合征（CES）进展为尿潴留（CESR），早期手术在尿功能方面是否会对预后产生影响。
文献检索确定了27项对手术时机有明确界定的CESR患者研究。11项研究无法计算相对风险（RR），剩余16项用于荟萃分析。在5个时间点分析尿潴留与手术时机的关系：12、24、36、48或72小时。将尿功能结果分为正常、尚可或较差。对“事件=尚可/较差”或“事件=较差”进行荟萃分析。8项研究可将CESR和不完全性CES（CESI）分开，其中5项有足够数据进行荟萃分析以比较CESR和CESI。由于各研究存在异质性，采用随机效应荟萃分析模型。对有24小时和48小时时间点的4项最大研究进行了最佳证据综合分析。
对于“事件=尚可/较差”，使用5个时间点进行的荟萃分析预测，较晚手术更可能出现尚可/较差的结果（RR范围为1.77 - 2.19）。手术时机较晚时，RR在24小时和72小时时间点具有统计学意义，在其他3个时间点虽有所升高但无统计学意义。对于“事件=较差”，RR范围为1.09 - 5.82，仅在36小时时间点具有统计学意义。比较CESR患者与CESI患者的荟萃分析预测CESR的结果为尚可/较差（RR 2.58，95%置信区间0.59 - 11.31）。最佳证据综合分析未揭示4项研究结果存在差异的原因。
本研究支持对CES进行早期手术，并表明不应将CESR和CESI病例合并分析。
