Lubelski Daniel, Mihalovich Kathryn E, Skelly Andrea C, Fehlings Michael G, Harrop James S, Mummaneni Praveen V, Wang Michael Y, Steinmetz Michael P
*Cleveland Clinic Lerner College of Medicine and Cleveland Clinic Center for Spine Health, Cleveland, OH †Spectrum Research, Inc., Tacoma, WA ‡Krembil Neuroscience Center, University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada §Institutes of Medical Science, University of Toronto, University Health Network Toronto, Ontario, Canada ¶Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA ∥Department of Neurological Surgery, University of California, San Francisco **Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL; and ††Department of Neurological Surgery, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH.
Spine (Phila Pa 1976). 2014 Oct 15;39(22 Suppl 1):S65-74. doi: 10.1097/BRS.0000000000000571.
Systematic review.
To summarize and critically review the economic literature evaluating the cost-effectiveness of minimal access surgery (MAS) compared with conventional open procedures for the cervical and lumbar spine.
MAS techniques may improve perioperative parameters (length of hospital stay and extent of blood loss) compared with conventional open approaches. However, some have questioned the clinical efficacy of these differences and the associated cost-effectiveness implications. When considering the long-term outcomes, there seem to be no significant differences between MAS and open surgery.
PubMed, EMBASE, the Cochrane Collaboration database, University of York, Centre for Reviews and Dissemination (NHS-EED and HTA), and the Tufts CEA Registry were reviewed to identify full economic studies comparing MAS with open techniques prior to December 24, 2013, based on the key questions established a priori. Only economic studies that evaluated and synthesized the costs and consequences of MAS compared with conventional open procedures (i.e., cost-minimization, cost-benefit, cost-effectiveness, or cost-utility) were considered for inclusion. Full text of the articles meeting inclusion criteria were reviewed by 2 independent investigators to obtain the final collection of included studies. The Quality of Health Economic Studies instrument was scored by 2 independent reviewers to provide an initial basis for critical appraisal of included economic studies.
The search strategy yielded 198 potentially relevant citations, and 6 studies met the inclusion criteria, evaluating the costs and consequences of MAS versus conventional open procedures performed for the lumbar spine; no studies for the cervical spine met the inclusion criteria. Studies compared MAS tubular discectomy with conventional microdiscectomy, minimal access transforaminal lumbar interbody fusion versus open transforaminal lumbar interbody fusion, and multilevel hemilaminectomy via MAS versus open approach.
Overall, the included cost-effectiveness studies generally supported no significant differences between open surgery and MAS lumbar approaches. However, these conclusions are preliminary because there was a paucity of high-quality evidence. Much of the evidence lacked details on methodology for modeling, related assumptions, justification of economic model chosen, and sources and types of included costs and consequences. The follow-up periods were highly variable, indirect costs were not frequently analyzed or reported, and many of the studies were conducted by a single group, thereby limiting generalizability. Prospective studies are needed to define differences and optimal treatment algorithms.
系统评价。
总结并批判性地回顾评估微创手术（MAS）与传统开放手术治疗颈椎和腰椎疾病的成本效益的经济学文献。
与传统开放手术相比，MAS技术可能改善围手术期参数（住院时间和失血量）。然而，一些人质疑这些差异的临床疗效以及相关的成本效益影响。考虑到长期结果，MAS与开放手术之间似乎没有显著差异。
检索了PubMed、EMBASE、Cochrane协作数据库、约克大学、综述与传播中心（NHS-EED和HTA）以及塔夫茨成本效益分析注册库，以确定在2013年12月24日之前比较MAS与开放技术的完整经济学研究，这些研究基于事先确定的关键问题。仅纳入评估并综合了MAS与传统开放手术的成本和结果的经济学研究（即成本最小化、成本效益、成本效果或成本效用）。由2名独立研究人员对符合纳入标准的文章全文进行评审，以获得最终纳入研究的集合。由2名独立评审员对健康经济学研究质量工具进行评分，为对纳入的经济学研究进行批判性评价提供初步依据。
检索策略产生了198条潜在相关引文，6项研究符合纳入标准，评估了MAS与传统开放手术治疗腰椎疾病的成本和结果；没有关于颈椎疾病的研究符合纳入标准。这些研究比较了MAS管状椎间盘切除术与传统显微椎间盘切除术、微创经椎间孔腰椎椎间融合术与开放经椎间孔腰椎椎间融合术，以及MAS与开放手术的多节段半椎板切除术。
总体而言，纳入的成本效益研究普遍支持开放手术与MAS腰椎手术方法之间没有显著差异。然而，这些结论是初步的，因为高质量证据匮乏。许多证据缺乏建模方法、相关假设、所选经济模型的合理性以及纳入成本和结果的来源和类型的详细信息。随访期差异很大，间接成本未经常分析或报告，许多研究由单一团队进行，从而限制了研究结果的普遍性。需要进行前瞻性研究来确定差异和最佳治疗算法。
3级。
