Minimally Invasive versus Open Spine Surgery: What Does the Best Evidence Tell Us?
Minimally Invasive versus Open Spine Surgery: What Does the Best Evidence Tell Us?
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DOI：
10.4103/jnrp.jnrp_472_16
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发表时间：
2017-04
影响因子：
1.4
通讯作者：
Goldstein JA
中科院分区：
文献类型：
--
作者：
McClelland S 3rd;Goldstein JA
随着微创手术的发展，脊柱外科已经发生了巨大的变化。作为一种创伤更小、切口更小、易于患者接受的手术，它通常被认为优于传统的脊柱开放手术。检验了与开放脊柱手术比较的最高质量的证据。使用PubMed数据库的Entrez网关对涉及管理信息系统和脊柱开放手术的随机对照试验(RCT)进行系统综述，检索截至2015年12月28日的英文文章。对颈椎间盘突出症、腰椎间盘突出症和腰椎后路融合术这三种特殊的实体进行了随机对照试验和随机对照试验与开放脊柱手术的系统评价。总共确定了17项随机对照试验，以及6项系统评价。对于颈椎间盘突出症，在整体功能、手臂疼痛缓解或长期颈部疼痛方面，MI组没有差别。在腰椎间盘突出症中，在腿部/下腰痛缓解、再住院率、生活质量改善方面，MISI较差，并且使外科医生受到10倍以上的辐射，以换取更短的住院时间和更少的手术部位感染。在后路腰椎融合术中，经孔腰椎间融合术(TLIF)显著降低了2年的社会成本，减少了医疗并发症，减少了重返工作的时间，并改善了短期OSwestry残疾指数评分，代价是翻修率、再住院率和术中透视的两倍以上。最高水平的证据不支持在颈椎或腰椎间盘突出症的开放手术中使用管理信息系统。然而，管理信息系统TLIF显示出更高的修订/再入院率的优势。无论患者的适应症如何，外科医生都会暴露在明显更多的辐射中；目前还不清楚这对患者有何影响。这些结果应该会优化关于管理信息系统和开放脊柱手术的明智决策，特别是在目前非常有利于管理信息系统的广告环境下。
Spine surgery has been transformed significantly by the growth of minimally invasive surgery (MIS) procedures. Easily marketable to patients as less invasive with smaller incisions, MIS is often perceived as superior to traditional open spine surgery. The highest quality evidence comparing MIS with open spine surgery was examined. A systematic review of randomized controlled trials (RCTs) involving MIS versus open spine surgery was performed using the Entrez gateway of the PubMed database for articles published in English up to December 28, 2015. RCTs and systematic reviews of RCTs of MIS versus open spine surgery were evaluated for three particular entities: Cervical disc herniation, lumbar disc herniation, and posterior lumbar fusion. A total of 17 RCTs were identified, along with six systematic reviews. For cervical disc herniation, MIS provided no difference in overall function, arm pain relief, or long-term neck pain. In lumbar disc herniation, MIS was inferior in providing leg/low back pain relief, rehospitalization rates, quality of life improvement, and exposed the surgeon to >10 times more radiation in return for shorter hospital stay and less surgical site infection. In posterior lumbar fusion, MIS transforaminal lumbar interbody fusion (TLIF) had significantly reduced 2-year societal cost, fewer medical complications, reduced time to return to work, and improved short-term Oswestry Disability Index scores at the cost of higher revision rates, higher readmission rates, and more than twice the amount of intraoperative fluoroscopy. The highest levels of evidence do not support MIS over open surgery for cervical or lumbar disc herniation. However, MIS TLIF demonstrates advantages along with higher revision/readmission rates. Regardless of patient indication, MIS exposes the surgeon to significantly more radiation; it is unclear how this impacts patients. These results should optimize informed decision-making regarding MIS versus open spine surgery, particularly in the current advertising climate greatly favoring MIS.