颈椎全椎间盘置换术后相邻节段退变或疾病：一项随机对照试验的荟萃分析

Adjacent segment degeneration or disease after cervical total disc replacement: a meta-analysis of randomized controlled trials.

作者信息

Xu Shuai, Liang Yan, Zhu Zhenqi, Qian Yalong, Liu Haiying

机构信息

Department of Spinal Surgery, Peking University People's Hospital, Peking University, No. 11 Xizhimen South Street, Xicheng District, Beijing, People's Republic of China.

出版信息

J Orthop Surg Res. 2018 Oct 3;13(1):244. doi: 10.1186/s13018-018-0940-9.

BACKGROUND

Anterior cervical discectomy and fusion (ACDF) has been widely used in cervical spondylosis, but adjacent segment degeneration/disease (ASD) was inevitable. Cervical total disc replacement (TDR) could reduce the stress of adjacent segments and retard ASD in theory, but the superiority has not been determined yet. This analysis aimed that whether TDR was superior to ACDF for decreasing adjacent segment degeneration (ASDeg) and adjacent segment disease (ASDis).

METHODS

A meta-analysis was performed according to the guidelines of the Cochrane Collaboration with PubMed, EMBASE, Cochrane Library and CBM (China Biological Medicine) databases. It included randomized controlled trials (RCTs) that reported ASDeg, ASDis, and reoperation on adjacent segments after TDR and ACDF. Two investigators independently selected trials, assessed methodological quality, and evaluated the quality of this meta-analysis using the grades of recommendation, assessment, development, and evaluation (GRADE) approach.

RESULTS

Eleven studies with 2632 patients were included in the meta-analysis. The overall rate of ASD in TDR group was lower than ACDF group (OR = 0.6; 95% CI [0.38, 0.73]; P < 0.00001). Both the incidence of ASDeg and the reoperation rate were statistically lower in the TDR group than in the ACDF group (OR = 0.58, P < 0.00001; OR = 0.52, P = 0.01, respectively). Subgroup analysis was performed according to the follow-up time and trial site; the rate of ASDeg was lower in patients underwent TDR no matter the follow-up time, and TDR tended to increase the superiority across time. The rate of ASDeg was also lower with TDR both in the USA and China (P < 0.0001, P = 0.03, respectively). But the cost-effectiveness result might be prone to neither of the two surgery approaches. According to GRADE, the overall quality of this meta-analysis was moderate.

CONCLUSIONS

TDR decreased the rates of ASDeg and reoperation compared with that of ACDF, and the superiority may become more apparent over time. We cautiously and slightly suggest adopting TDR according to the GRADE but may not believe it excessively.

背景

颈椎前路椎间盘切除融合术（ACDF）已广泛应用于颈椎病治疗，但相邻节段退变/疾病（ASD）难以避免。理论上，颈椎全椎间盘置换术（TDR）可减轻相邻节段应力并延缓ASD，但该优势尚未确定。本分析旨在探讨TDR在减少相邻节段退变（ASDeg）和相邻节段疾病（ASDis）方面是否优于ACDF。

方法

按照Cochrane协作网指南，检索PubMed、EMBASE、Cochrane图书馆及中国生物医学文献数据库（CBM）进行荟萃分析。纳入报告TDR和ACDF术后ASDeg、ASDis及相邻节段再次手术情况的随机对照试验（RCT）。两名研究者独立筛选试验、评估方法学质量，并采用推荐分级、评估、制定与评价（GRADE）方法评估本荟萃分析的质量。

结果

荟萃分析纳入11项研究共2632例患者。TDR组ASD总体发生率低于ACDF组（OR = 0.6；95%CI[0.38, 0.73]；P < 0.00001）。TDR组ASDeg发生率及再次手术率均低于ACDF组，差异有统计学意义（OR分别为0.58，P < 0.00001；OR为0.52，P = 0.01）。根据随访时间和试验地点进行亚组分析；无论随访时间长短，接受TDR的患者ASDeg发生率较低，且TDR的优势随时间推移有增加趋势。在美国和中国，TDR组的ASDeg发生率也较低（分别为P < 0.0001，P = 0.03）。但成本效益结果可能对两种手术方式均无倾向。根据GRADE，本荟萃分析的总体质量为中等。