Nayak Nikhil R, Bauman Joel A, Stein Sherman C, Thawani Jayesh P, Malhotra Neil R
*Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA †Hartford Healthcare Medical Group-Neurosurgery, Hartford, CT.
Clin Spine Surg. 2017 Aug;30(7):E901-E908. doi: 10.1097/BSD.0000000000000375.
A decision analysis.
To perform a decision analysis utilizing postoperative complication data, in conjunction with health-related quality of life (HRQoL) utility scores, to rank order the average health utility associated with various surgical approaches used to treat symptomatic thoracic disk herniation (TDH).
Symptomatic TDH is an uncommon entity accounting for <1% of all symptomatic herniated disks. A variety of surgical approaches have been developed for its treatment, which may be classified into 4 major categories: open anterolateral transthoracic, minimally invasive anterolateral thoracoscopic, posterior, and lateral. These treatments have varying risk/benefit profiles, but there is still no set algorithm for choosing an approach in cases with multiple surgical options.
We searched Medline, EMBASE, and the Cochrane Library for relevant articles on surgical approaches for TDHs published between 1990 and August 2014. Pooled complication data and HRQoL utility scores associated with each complication were evaluated using standard meta-analytic techniques to determine which surgical approach resulted in the highest average HRQoL.
Posterior surgical approaches resulted in the highest average HRQoL, followed by thoracoscopic, lateral, and finally open anterolateral transthoracic procedures. The higher average HRQoL associated with posterior approaches over all others was highly significant (P<0.001); conversely, the open anterolateral approach resulted in a lower average postoperative utility compared with all other approaches (P<0.001).
The results of this decision analysis favor posterior over lateral approaches, and thoracoscopic over open anterolateral approaches for the treatment of symptomatic TDHs, which may guide surgeons in cases where multiple surgical options are feasible. Future studies, such as randomized clinical trials, are necessary to ascertain whether novel surgical strategies have risk/benefit profiles that ultimately supersede those of traditional approaches, and whether enough cases are encountered by the average surgeon to justify their adoption.
决策分析。
利用术后并发症数据以及与健康相关的生活质量（HRQoL）效用评分进行决策分析，对用于治疗症状性胸椎间盘突出症（TDH）的各种手术方法相关的平均健康效用进行排序。
症状性TDH是一种罕见疾病，占所有有症状椎间盘突出症的不到1%。已开发出多种手术方法用于治疗，可分为4大类：开放前外侧经胸、微创前外侧胸腔镜、后路和外侧入路。这些治疗方法具有不同的风险/获益特征，但在有多种手术选择的情况下，仍没有确定的选择方法。
我们检索了Medline、EMBASE和Cochrane图书馆，查找1990年至2014年8月间发表的关于TDH手术方法的相关文章。使用标准的荟萃分析技术评估汇总的并发症数据以及与每种并发症相关的HRQoL效用评分，以确定哪种手术方法导致最高的平均HRQoL。
后路手术方法导致最高的平均HRQoL，其次是胸腔镜、外侧入路，最后是开放前外侧经胸手术。与所有其他方法相比，后路手术较高的平均HRQoL具有高度显著性（P<0.001）；相反，开放前外侧入路与所有其他方法相比导致较低的术后平均效用（P<0.001）。
该决策分析结果支持在治疗症状性TDH时，后路手术优于外侧入路，胸腔镜手术优于开放前外侧入路，这可能在有多种手术选择可行的情况下为外科医生提供指导。未来的研究，如随机临床试验，对于确定新的手术策略是否具有最终超越传统方法的风险/获益特征，以及普通外科医生遇到的病例是否足以证明采用这些方法的合理性是必要的。
