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既往腰椎手术后腰椎相邻节段病变的治疗:系统评价。

The treatment of lumbar adjacent segment pathology after a previous lumbar surgery: a systematic review.

机构信息

Department of Neurosurgery, University of California San Francisco, San Francisco, CA 94143, USA.

出版信息

Spine (Phila Pa 1976). 2012 Oct 15;37(22 Suppl):S180-8. doi: 10.1097/BRS.0b013e31826d613d.

Abstract

STUDY DESIGN

Systematic review.

OBJECTIVE

To perform a systematic review, evaluating the best available evidence regarding the treatment of lumbar adjacent segment pathology (ASP) to facilitate clinical recommendations for treatment.

SUMMARY OF BACKGROUND DATA

It is unclear how nonoperative treatment of lumbar clinical ASP (CASP) compares with operative treatment, and it is also unclear if 1 type of operative treatment is superior to another in the treatment of lumbar CASP. Given that ASP occurs with a known frequency after fusion, it is important to understand outcomes for treatment based on the best available evidence.

METHODS

We conducted a systematic search in PubMed and the Cochrane Library for literature published through February 2012 for lumbar ASP. Our first goal was to identify studies comparing operative with nonoperative management of lumbar ASP. Our second goal was to identify studies comparing operative with operative management of lumbar CASP. Our third goal was to identify case series evaluating outcomes after the treatment of lumbar CASP. The overall body of evidence with respect to each clinical question was determined on the basis of precepts outlined by the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) working group and recommendations made by the Agency for Healthcare Research and Quality.

RESULTS

No studies comparing operative with nonoperative management or comparing operative with operative management of CASP were identified in the literature. Eight case series were identified for the treatment of CASP with decompression alone, decompression and fusion, or decompression and disc arthroplasty.

CONCLUSION

The strength of evidence supporting these clinical questions was insufficient based on GRADE criteria; therefore, conclusions are based on the best available evidence and clinical experience. Operative management for lumbar CASP should be considered after failure of nonoperative management. When considering the type of operative treatment for lumbar CASP, clinical judgment, radiographical appearance, and patient preference should guide operative intervention. If a patient's disability secondary to lumbar CASP is high enough, consideration should be given to operative treatment. All these recommendations are weak based on GRADE.

CONSENSUS STATEMENT

  1. Operative management for lumbar ASP should be considered after failure of nonoperative management of ASP. Strength of Statement: Weak. 2. When considering the type of operative treatment for the treatment of lumbar ASP, clinical judgment, radiographical appearance, and patient preference should guide operative intervention. Strength of Statement: Weak. 3. Although the level of evidence for the outcomes of the treatment of lumbar ASP is weak, there does seem to be some benefit from the surgical treatment of lumbar ASP. Thus, if the patient's disability secondary to lumbar ASP is high enough, consideration should be given to operative treatment. Strength of Statement: Weak.
摘要

研究设计

系统评价。

目的

进行系统评价,评估治疗腰椎相邻节段病变(ASP)的最佳现有证据,以便为治疗提供临床建议。

背景资料总结

腰椎临床 ASP(CASP)的非手术治疗与手术治疗相比如何尚不清楚,而且在治疗腰椎 CASP 时,一种手术治疗是否优于另一种也不清楚。鉴于 ASP 在融合后以已知的频率发生,了解基于最佳现有证据的治疗结果非常重要。

方法

我们在 PubMed 和 Cochrane 图书馆中进行了系统检索,以查找截至 2012 年 2 月发表的有关腰椎 ASP 的文献。我们的第一个目标是确定比较手术与非手术治疗腰椎 ASP 的研究。我们的第二个目标是确定比较手术与手术治疗腰椎 CASP 的研究。我们的第三个目标是确定评估腰椎 CASP 治疗后结果的病例系列研究。根据 Grades of Recommendation Assessment, Development, and Evaluation(GRADE)工作组概述的原则和医疗保健研究与质量局(Agency for Healthcare Research and Quality)提出的建议,确定了每个临床问题的整体证据。

结果

文献中未发现比较手术与非手术治疗或比较手术与手术治疗 CASP 的研究。确定了 8 项关于单独减压、减压和融合或减压和椎间盘关节成形术治疗 CASP 的病例系列研究。

结论

根据 GRADE 标准,支持这些临床问题的证据强度不足;因此,结论基于最佳现有证据和临床经验。腰椎 CASP 的手术治疗应在非手术治疗失败后考虑。当考虑腰椎 CASP 的手术治疗类型时,临床判断、影像学表现和患者偏好应指导手术干预。如果腰椎 CASP 引起的患者残疾程度足够高,应考虑手术治疗。所有这些建议基于 GRADE 均较弱。

共识声明

  1. 腰椎 ASP 的非手术治疗失败后,应考虑手术治疗。声明强度:弱。2. 在考虑治疗腰椎 ASP 的手术治疗类型时,临床判断、影像学表现和患者偏好应指导手术干预。声明强度:弱。3. 尽管腰椎 ASP 治疗结果的证据水平较弱,但手术治疗腰椎 ASP 似乎确实有一定的益处。因此,如果腰椎 ASP 引起的患者残疾程度足够高,应考虑手术治疗。声明强度:弱。

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