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微创外侧椎间融合术的并发症:一项比较腰大肌前入路和经腰大肌入路的系统评价与Meta分析

Complications for minimally invasive lateral interbody arthrodesis: a systematic review and meta-analysis comparing prepsoas and transpsoas approaches.

作者信息

Walker Corey T, Farber S Harrison, Cole Tyler S, Xu David S, Godzik Jakub, Whiting Alexander C, Hartman Cory, Porter Randall W, Turner Jay D, Uribe Juan

出版信息

J Neurosurg Spine. 2019 Jan 25;30(4):446-460. doi: 10.3171/2018.9.SPINE18800. Print 2019 Apr 1.

Abstract

OBJECTIVE

Minimally invasive anterolateral retroperitoneal approaches for lumbar interbody arthrodesis have distinct advantages attractive to spine surgeons. Prepsoas or transpsoas trajectories can be employed with differing complication profiles because of the inherent anatomical differences encountered in each approach. The evidence comparing them remains limited because of poor quality data. Here, the authors sought to systematically review the available literature and perform a meta-analysis comparing the two techniques.

METHODS

A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A database search was used to identify eligible studies. Prepsoas and transpsoas studies were compiled, and each study was assessed for inclusion criteria. Complication rates were recorded and compared between approach groups. Studies incorporating an analysis of postoperative subsidence and pseudarthrosis rates were also assessed and compared.

RESULTS

For the prepsoas studies, 20 studies for the complications analysis and 8 studies for the pseudarthrosis outcomes analysis were included. For the transpsoas studies, 39 studies for the complications analysis and 19 studies for the pseudarthrosis outcomes analysis were included. For the complications analysis, 1874 patients treated via the prepsoas approach and 4607 treated with the transpsoas approach were included. In the transpsoas group, there was a higher rate of transient sensory symptoms (21.7% vs 8.7%, p = 0.002), transient hip flexor weakness (19.7% vs 5.7%, p < 0.001), and permanent neurological weakness (2.8% vs 1.0%, p = 0.005). A higher rate of sympathetic nerve injury was seen in the prepsoas group (5.4% vs 0.0%, p = 0.03). Of the nonneurological complications, major vascular injury was significantly higher in the prepsoas approach (1.8% vs 0.4%, p = 0.01). There was no difference in urological or peritoneal/bowel injury, postoperative ileus, or hematomas (all p > 0.05). A higher infection rate was noted for the transpsoas group (3.1% vs 1.1%, p = 0.01). With regard to postoperative fusion outcomes, similar rates of subsidence (12.2% prepsoas vs 13.8% transpsoas, p = 0.78) and pseudarthrosis (9.9% vs 7.5%, respectively, p = 0.57) were seen between the groups at the last follow-up.

CONCLUSIONS

Complication rates vary for the prepsoas and transpsoas approaches owing to the variable retroperitoneal anatomy encountered during surgical dissection. While the risks of a lasting motor deficit and transient sensory disturbances are higher for the transpsoas approach, there is a reciprocal reduction in the risks of major vascular injury and sympathetic nerve injury. These results can facilitate informed decision-making and tailored surgical planning regarding the choice of minimally invasive anterolateral access to the spine.

摘要

目的

腰椎椎间融合术的微创前外侧腹膜后入路具有独特优势,吸引着脊柱外科医生。由于每种入路所遇到的固有解剖差异,腰大肌前或经腰大肌入路轨迹可导致不同的并发症情况。由于数据质量较差,比较二者的证据仍然有限。在此,作者试图系统回顾现有文献并进行荟萃分析以比较这两种技术。

方法

根据系统评价和荟萃分析的首选报告项目(PRISMA)指南进行系统评价和荟萃分析。使用数据库搜索来识别符合条件的研究。汇总腰大肌前和经腰大肌的研究,并对每项研究进行纳入标准评估。记录并发症发生率并在入路组之间进行比较。还对纳入术后沉降和假关节发生率分析的研究进行评估和比较。

结果

对于腰大肌前研究,纳入20项用于并发症分析的研究和8项用于假关节结果分析的研究。对于经腰大肌研究,纳入39项用于并发症分析的研究和19项用于假关节结果分析的研究。对于并发症分析,纳入1874例经腰大肌前入路治疗的患者和4607例经腰大肌入路治疗的患者。在经腰大肌组中,短暂性感觉症状发生率较高(21.7%对8.7%,p = 0.002),短暂性髋屈肌无力发生率较高(19.7%对5.7%,p < 0.001),永久性神经功能障碍发生率较高(2.8%对1.0%,p = 0.005)。腰大肌前组交感神经损伤发生率较高(5.4%对0.0%,p = 0.03)。在非神经并发症中,腰大肌前入路的主要血管损伤明显更高(1.8%对0.4%,p = 0.01)。泌尿系统或腹膜/肠道损伤、术后肠梗阻或血肿方面无差异(所有p > 0.05)。经腰大肌组感染率较高(3.1%对1.1%,p = 0.01)。关于术后融合结果,在最后随访时两组之间沉降率相似(腰大肌前组为12.2%,经腰大肌组为13.8%,p = 0.78),假关节发生率相似(分别为9.9%和7.5%,p = 0.57)。

结论

由于手术解剖过程中遇到的腹膜后解剖结构不同,腰大肌前和经腰大肌入路的并发症发生率有所不同。虽然经腰大肌入路导致持久运动功能障碍和短暂感觉障碍的风险较高,但主要血管损伤和交感神经损伤的风险相应降低。这些结果有助于在选择脊柱微创前外侧入路时做出明智的决策并制定个性化的手术计划。

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