Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave, S-40, Cleveland, OH 44195, USA; Case Western Reserve University School of Medicine, 2109 Adelbert Rd, Cleveland, OH 44106, USA; Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Ave, S-40, Cleveland, OH 44195, USA; Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave, S-40, Cleveland, OH 44195, USA.
Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave, S-40, Cleveland, OH 44195, USA; Case Western Reserve University School of Medicine, 2109 Adelbert Rd, Cleveland, OH 44106, USA; Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Ave, S-40, Cleveland, OH 44195, USA; Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave, S-40, Cleveland, OH 44195, USA; Department of Population and Quantitative Health Science, Case Western Reserve University, 2109 Adelbert Rd, Cleveland, OH 44106, USA.
Spine J. 2018 Jun;18(6):1088-1098. doi: 10.1016/j.spinee.2018.01.028. Epub 2018 Feb 13.
Lumbar fusion is an effective and durable treatment for symptomatic lumbar spondylolisthesis; however, the current literature provides insufficient evidence to recommend an optimal surgical fusion strategy.
The present study aims to compare the clinical outcomes, fusion rates, blood loss, and operative times between open posterolateral lumbar fusion (PLF) alone and open transforaminal lumbar interbody fusion (TLIF) + posterolateral fusion for spondylolisthesis.
This is a systematic literature review and meta-analysis of English language studies for the treatment of spondylolisthesis with PLF versus PLF + TLIF.
Data were obtained from published randomized controlled trials (RCTs) and retrospective cohort studies.
Clinical outcomes included Oswestry Disability Index (ODI), back pain, leg pain, and health-related quality of life (HRQOL) scores. Fusion rate, operative time, blood loss, and infection rate were also assessed.
A literature search of three electronic databases was performed to identify investigations performed comparing PLF alone with PLF + TLIF for treatment of low-grade lumbar spondylolisthesis. The summary effect size was assessed from pooling observational studies for each of the outcome variables, with odds ratios (ORs) used for fusion and infection rate, mean difference used for improvement in ODI and leg pain as well as operative time and blood loss, and standardized mean difference used for improvement in back pain and HRQOL outcomes. Studies were weighed based on the inverse of the variance and heterogeneity. Heterogeneity was assessed using the I-an estimate of the error caused by between-study variation. Effect sizes from the meta-analysis were then compared with data from the RCTs to assess congruence in outcomes.
The initial literature search yielded 282 unique, English language studies. Seven were determined to meet our inclusion criteria and were included in our qualitative analysis. Five observational studies were included in our quantitative meta-analysis. The pooled fusion success rates were 84.7% (100/118) in the PLF group and 94.3% (116/123) in the TLIF group. Compared with TLIF patients, PLF patients had significantly lower odds of achieving solid arthrodesis (OR 0.33, 95% confidence interval [CI] 0.13-0.82, p=.02; I=0%). With regard to improvement in back pain, the point estimate for the effect size was -0.27 (95% CI -0.43 to -0.10, p=.002; I=0%), in favor of the TLIF group. For ODI, the pooled estimate for the effect size was -3.73 (95% CI -7.09 to -0.38, p=.03; I=35%), significantly in favor of the TLIF group. Operative times were significantly shorter in the PLF group, with a summary effect size of -25.55 (95% CI -43.64 to -7.45, p<.01; I=54%). No significant difference was observed in leg pain, HRQOL improvement, blood loss, or infection rate. Our meta-analysis results were consistent with RCTs, in favor of TLIF for achieving radiographic fusion and greater improvement in ODI and back pain.
Our results demonstrate that for patients undergoing fusion for spondylolisthesis, TLIF is superior to PLF with regard to achieving radiographic fusion. However, current data only provide weak support, if any, favoring TLIF over PLF for clinical improvement in disability and back pain.
腰椎融合术是治疗有症状的腰椎滑脱症的有效且持久的方法；然而，目前的文献提供的证据不足以推荐最佳的手术融合策略。
本研究旨在比较单纯后路腰椎融合术（PLF）与经椎间孔腰椎体间融合术（TLIF）+后路融合术治疗腰椎滑脱症的临床效果、融合率、出血量和手术时间。
这是一项针对 PLF 与 PLF+TLIF 治疗腰椎滑脱的英文文献的系统综述和荟萃分析。
数据来自已发表的随机对照试验（RCT）和回顾性队列研究。
临床结果包括 Oswestry 残疾指数（ODI）、腰背疼痛、下肢疼痛和健康相关生活质量（HRQOL）评分。还评估了融合率、手术时间、出血量和感染率。
通过对三个电子数据库进行文献检索，确定了比较单纯 PLF 与 PLF+TLIF 治疗低度腰椎滑脱的研究。对每个结局变量的观察性研究进行了汇总效应量评估，使用比值比（OR）表示融合和感染率，使用平均差值表示 ODI 和下肢疼痛的改善，以及手术时间和出血量，使用标准化平均差值表示腰背疼痛和 HRQOL 结局的改善。研究根据方差和异质性的倒数进行加权。使用 I-估计值来评估研究间差异引起的误差来评估异质性。然后将荟萃分析的效应量与 RCT 数据进行比较，以评估结果的一致性。
最初的文献检索产生了 282 篇独特的英文研究。确定有 7 篇符合我们的纳入标准，并纳入了我们的定性分析。5 项观察性研究纳入了我们的定量荟萃分析。PLF 组的融合成功率为 84.7%（100/118），TLIF 组为 94.3%（116/123）。与 TLIF 患者相比，PLF 患者实现稳定融合的可能性显著降低（OR 0.33，95%置信区间 [CI] 0.13-0.82，p=.02；I=0%）。关于腰背疼痛的改善，效应量的点估计值为-0.27（95% CI -0.43 至 -0.10，p=.002；I=0%），TLIF 组更优。对于 ODI，效应量的汇总估计值为-3.73（95% CI -7.09 至 -0.38，p=.03；I=35%），TLIF 组明显更优。PLF 组的手术时间明显更短，汇总效应量为-25.55（95% CI -43.64 至 -7.45，p<.01；I=54%）。下肢疼痛、HRQOL 改善、出血量或感染率无显著差异。我们的荟萃分析结果与 RCT 一致，TLIF 在实现影像学融合和改善 ODI 和腰背疼痛方面优于 PLF。
我们的结果表明，对于接受融合术治疗的腰椎滑脱症患者，TLIF 在实现影像学融合方面优于 PLF。然而，目前的数据仅提供了微弱的支持，如果有的话，也支持 TLIF 优于 PLF 改善残疾和腰背疼痛的临床效果。
