Orthopaedic Surgery, Harvard Medical School, and Spine Service, Massachusetts General Hospital, Boston, MA 02114, USA
Spine (Phila Pa 1976). 2011 Oct 1;36(21 Suppl):S110-9. doi: 10.1097/BRS.0b013e31822ef8c5.
Systematic review.
To determine if the presence of isthmic spondylolisthesis modifies the effect of treatment (fusion vs. multidimensional supervised rehabilitation) in patients with chronic low back pain (CLBP).
Results of spinal surgery for CLBP are variable. It is unclear whether patients with CLBP and isthmic spondylolisthesis have more success with surgery versus a multidimensional supervised rehabilitation program when compared with those with CLBP but without spondylolisthesis.
A systematic search was conducted in MEDLINE and the Cochrane Collaboration Library for articles published through January 2011. Randomized controlled trials (RCTs) were included that compared spine fusion versus multidimensional supervised rehabilitation in patients with and without isthmic spondylolisthesis. Standardized mean differences (SMDs) and risk differences were calculated for common outcomes, and then compared to determine potential heterogeneity of treatment effect. The final strength of the body of literature was expressed as "high," "moderate," or "low" confidence that the evidence reflects the true effect.
No studies were found that directly compared the two subgroups. Three RCTs compared fusion with supervised nonoperative care in patients with CLBP without isthmic spondylolisthesis; one RCT evaluated these treatments in patients with isthmic spondylolisthesis. There were study differences in patient characteristics, type of fusion, the nature of the rehabilitation, outcomes assessed, and length of follow-up. The SMDs for pain in favor of fusion were modest at 2 years for those without isthmic spondylolisthesis, but large in favor of fusion for those with isthmic spondylolisthesis compared with rehabilitation. Similarly, the SMDs for function in patients without isthmic spondylolisthesis compared with rehabilitation was small at 2 years, but appreciably higher in favor of fusion in patients with isthmic spondylolisthesis.
The overall strength of evidence evaluating whether the presence of isthmic spondylolisthesis modifies the effect of fusion compared with rehabilitation patients with CLBP is "low." Fusion should be considered for patients with low back pain and isthmic spondylolisthesis who have failed nonoperative treatment.
We recommend considering fusion for patients with isthmic spondylolisthesis and lower back pain who have failed nonoperative treatment.
Weak.
系统评价。
确定是否存在峡部裂性脊椎滑脱会改变慢性下腰痛（CLBP）患者的治疗效果（融合与多维监督康复）。
脊柱手术治疗 CLBP 的结果是可变的。目前尚不清楚 CLBP 伴峡部裂性脊椎滑脱患者在手术治疗与多维监督康复计划方面是否比无脊椎滑脱的 CLBP 患者更成功。
在 MEDLINE 和 Cochrane 协作图书馆中进行了系统搜索，以查找截至 2011 年 1 月发表的文章。纳入了比较融合与多维监督康复治疗伴或不伴峡部裂性脊椎滑脱的患者的随机对照试验（RCT）。对于常见结局，计算标准化均数差（SMD）和风险差异，然后进行比较以确定治疗效果的潜在异质性。文献的最终证据强度表示为“高”、“中”或“低”，置信度表示证据反映真实效果。
未发现直接比较这两个亚组的研究。三项 RCT 比较了融合与无峡部裂性脊椎滑脱的 CLBP 患者的监督非手术治疗；一项 RCT 评估了这些治疗方法在峡部裂性脊椎滑脱患者中的应用。研究中患者特征、融合类型、康复性质、评估结局和随访时间存在差异。对于无峡部裂性脊椎滑脱的患者，融合治疗在 2 年时的疼痛 SMD 适中，但对于有峡部裂性脊椎滑脱的患者，融合治疗的 SMD 较大，优于康复治疗。同样，在 2 年时，无峡部裂性脊椎滑脱患者的功能 SMD 与康复治疗相比较小，但在有峡部裂性脊椎滑脱的患者中，融合治疗的 SMD 明显更高。
评估峡部裂性脊椎滑脱是否会改变 CLBP 患者融合治疗与康复治疗效果的证据总体强度为“低”。对于非手术治疗失败的峡部裂性脊椎滑脱和慢性下腰痛患者，应考虑融合治疗。
我们建议对非手术治疗失败的伴有峡部裂性脊椎滑脱和慢性下腰痛的患者考虑融合治疗。
弱。
