Department of Biomedical Engineering, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, 2-50 Corbett Hall, Edmonton, AB, T6G 2G4, Canada.
Eur Spine J. 2020 Apr;29(4):694-716. doi: 10.1007/s00586-019-06219-3. Epub 2019 Nov 28.
Surgical treatment of severe adolescent idiopathic scoliosis (AIS) with posterior spinal instrumentation and fusion with pedicle screws is common, requiring careful screw insertion to prevent pedicle breaches and neurologic complications. Image guidance has been suggested to improve breach rates, though the radiation risk for AIS precludes its common usage. The purpose of this systematic review and meta-analysis was to compare the breach rates and screw-related complications for AIS patients undergoing spine surgery with pedicle screws between freehand screw insertion and image guidance methods.
A comprehensive search of MEDLINE, EMBASE, CINAHL, CENTRAL and Web of Science databases was conducted. Two reviewers independently screened abstracts, full-texts, extracted data and performed risk of bias assessment using the QUIPS quality appraisal tool. Level of evidence summary statements were formulated based on consistency and quality of reporting.
Ninety-four studies were found, with 18 studies of moderate risk of bias or better. Moderate evidence from two head-to-head studies shows CT guidance has lower breach rates than freehand methods (OR 0.28 [0.20-0.40, I = 1%]), with no complications in either study. From individual studies, moderate evidence showed lower breach rates for image guidance versus freehand methods (13%, I = 98% vs. 20%, I = 95%). Complication rates were conflicting (0-1.6% for image guidance, 0-1.7% for freehand). Moderate evidence showed increased surgical time for image guidance versus freehand (257.7 min vs. 226.8 min).
Meta-analyzed breach rates show moderate evidence of decreased breaches with CT navigation compared with freehand methods. Complication rates remain unknown due to the low complication rates from small sample sizes. These slides can be retrieved under Electronic Supplementary Material.
对于严重的青少年特发性脊柱侧凸（AIS）患者，采用后路脊柱内固定融合技术和椎弓根螺钉进行治疗较为常见，这需要小心地插入螺钉以防止椎弓根破裂和神经并发症。已经有研究表明，图像引导技术可以提高螺钉植入的准确率，降低螺钉植入的风险，但由于 AIS 患者的辐射风险较高，该技术无法广泛应用。本系统评价和荟萃分析旨在比较徒手置钉和图像引导两种方法在 AIS 患者脊柱手术中椎弓根螺钉的植入准确率和螺钉相关并发症的发生率。
通过对 MEDLINE、EMBASE、CINAHL、CENTRAL 和 Web of Science 数据库进行全面检索，两位评审员独立筛选摘要、全文，采用 QUIPS 质量评估工具提取数据并进行偏倚风险评估。根据报告的一致性和质量，制定证据水平总结陈述。
共发现 94 项研究，其中 18 项研究存在中度偏倚风险或更高风险。来自两项头对头研究的中等质量证据表明，CT 引导下的螺钉植入准确率低于徒手置钉方法（OR 0.28 [0.20-0.40，I=1%]），这两项研究均未发生并发症。来自个别研究的中等质量证据表明，与徒手置钉方法相比，图像引导下的螺钉植入准确率较低（13%，I=98% 与 20%，I=95%）。并发症发生率存在差异（图像引导组为 0-1.6%，徒手置钉组为 0-1.7%）。与徒手置钉方法相比，图像引导组的手术时间较长（257.7 分钟与 226.8 分钟），差异具有统计学意义（P<0.001）。
荟萃分析的螺钉植入准确率表明，与徒手置钉方法相比，CT 导航下的螺钉植入准确率较高，具有中等质量证据支持。但由于小样本量导致并发症发生率较低，目前尚无法确定并发症的发生率。这些幻灯片可以在电子补充材料中找到。
