Thursday, April 4, 2019
Multilevel Cervical Spondylotic Myelopathy Treatment
Multilevel Cervical Spondylotic Myelopathy discourseComparison mingled with precedent flackes and shadow approaches for the discourse of multilevel cervical spondylotic myelopathy a meta analysisAbstractObjective Both anterior and tush approaches atomic number 18 utilize in the word of multilevel cervical spondylotic myelopathy (MCSM) collectable to spinal anesthesia anesthesia anesthesia anesthesia anaesthesia stricture or accordance of asshole longitudinal ligament (OPLL). However, the optimum st rankgy remains controversial. To comp ar the clinical results surrounded by the cardinal approaches, a meta-analysis was conducted.Methods PubMed, Embase and the Cochrane library were searched up to July 2014 without language restriction. The reference lists of selected searches comparing anterior and piece of ass approaches were screened manu on the wholey. Sub multitude analysis was conducted according to the cause of MCSM. A fixed effect manakin was used for pool information, and a random effects model for complex data. Mean contrariety (MD) and odds ratio (OR) was used for continuous and dichotomous outcomes, respectively.Results Seventeen articles were selected in this study, every(prenominal) of which were non- randomised controlled trials. There were significant difference amid two approaches for post-Japanese Orthopedic Association (JOA) wee (MD=1.13, 95% CI=0.41, 1.86), operating theater time (MD=67.43, 95% CI=16.94, 117.91), post- black market of motion (ROM) (MD=1.86, 95% CI=0.61, 3.12), continuance of stay (MD=-1.54, 95% CI=-2.25, -0.5)and complicatedness rate (OR=2.28, 95% CI=1.52, 3.41). Mean speckle, on that point were no significant difference for pre-JOA, blood passage, neurological retrieval rate, pre-ROM, pre- and post-Nurick grade.Conclusions Based on this meta-analysis, post-JOA and length of stay are importantly repair in the anterior grouping, but elevated complication rate and no apparent difference for neur ological recuperation rate made it required to conclude more than trials with high quality to further confirm the conclusion.Keywords multilevel cervical spondylotic myelopathy clinical outcomes meta-analysisIntroductionCervical spondylotic myelopathy (CSM) is caused by compression of the spinal cord due to degeneration. Spinal stenosis and ossification of laughingstock longitudinal ligament (OPLL) sire been considered as the two common causes of CSM. CSM can be inured by a variety of anterior, cigaret, or combined anterior and posterior working(a) approaches. The decision to use an anterior or a posterior approach depends on many factors, such as the reason of spinal cord compression, the number of vertebral segments, cervical alignment, and the surgeons familiarity with the techniques1. preliminary approaches usu tout ensembley include anterior cervical corpectomy with coalescency (ACCF) and cervical discectomy with fusion (ACDF), whereas the typical posterior approache s involve laminectomy and laminoplasty2. Anterior decompressing and fusion has been successfully used for CSM involving hotshot or two levels3, 4. But failures will be observed when three or more levels are involved (multilevel cervical spondylotic myelopathy, MCSM) with anterior approaches5, 6. Compared with anterior approaches, posterior strategies hand over an indirect canal decompression by allowing the spinal cord to float away from ventral compression. The disadvantages of posterior approach were also noned, for example, neck pain, loss of lordotic curvature, segmental instability, and after-hours neurologic deterioration7.Although many studies comparing the two approaches have been done, the optimal approach providing satisfactory decompression remains to be determined. No systematic analysis of the two approaches in the treatment of MCSM has been produce yet. In order to provide a basis for selecting, a meta-analysis of clinical results of anterior approaches compared with posterior approaches for patients with MCSM was performed.Materials and methods literary productions searchThe authors searched multiple databases, includingPubMed, Embase and The Cochrane library up to June 11, 2014 without language restriction. Additionally, the reference lists of selected searches and colligate articles that not yet included in the electronic database were screened manually. The searching thread were (1) myelopathy or cervical spondylosis or cervical vertebrae or cervical stenosis (2) Corpectomy or anterior cervical discectomy or anterior decompression or ventral (3) laminoplasty or laminectomy or posterior decompression or dorsal, with the hustler AND.Literature screeningArticles were reviewed according to the following criteria (1) The researches were designed as randomize controlled trials, case-control studies or cohort studies (2) Patients with multilevel cervical spondylotic myelopathy (MCSM) due to spinal stenosis or ossification of posterior longi tudinal ligament (OPLL) (3) The anterior approaches group was treated by anterior cervical canal decompression (4) The posterior approaches group was treated by posterior cervical canal decompression (5) The outcomes was clinical endpoint, like neurological recovery rates, Japanese Orthopedic Association (JOA) score, range of motion (ROM), Nurick grade, complication rate, running(a) process time, blood loss, and length of stay in hospital.Also, there are five dollar bill exclusion criteria for literature screening. These were (1) The cases followed up little than one year (2) Patients with MSCM were caused by tumors, trauma, soft disk herniation, or front surgery (3) Patients without MSCM (4) Researches without control (5) non-nature literatures, such as reviews, letters and comments.Data line of descent and studies quality assessmentTwo investigators respectively assessed severally potentially legal study and then extracted data from the included studies. Disagreements wer e resolved through discussion. The tuition extracted including the author, publication year, area, ages, sex, number of patients, follow-up period, surgical methods and outcomes. Furthermore, We used the Cochrane8 for assessing the quality of randomized studies, and the Newcastle-Ottawa Scale (NOS)9 for nonrandomised sudies or cohort studies. respectively.Statistical analysisThe aim of this meta-analysis was to quantify the divergence of all outcomes, and all analyses were performed by RevMan5.2 software. Weighted mean difference (WMD) and 95% confidence interval (CI) were calculated for Continuous variables, while odds ratios (ORs) and 95% CI were calculated for dichotomous data. Statistic heterogeneity was identified exploitation chi-square test and I2 test. If P2 50%, which indicated heterogeneity exists among all results, random effects model was applied. If P0.05 or I2 50%, which indicated heterogeneity, the fixed effects model was selected10. The publication slash was tes ted by constructing a funnel plot.ResultsSearch resultsA run for diagram of the literature search and study selection was shown in fig.1. Basing on the aforementioned criteria, we searched 1216, 1710, and 13 articles from PubMed, Embase, and the Cochrane library respectively. A total of 2234 articles were remained after excluding recur publications. And a total of 2191 articles that mismatched the included criteria were excluded after screening titles and abstracts. Therefore, a total of 43 articles were identified. Of these, sixteen articles were excluded after reading the abstracts ten articles did not compare the effects between anterior approaches and posterior approaches and six articles were reviews. decade articles were excluded for the following reasons two articles were not about multilevel cervical spondylotic myelopathy, one was self-controlled study, four were about MCSM due to soft disc herniation, and three articles did not have statistic data. Manual search of refe rences did not find any additional articles. As a result, a total of 17 articles1, 6, 11-25 were identified for the Meta analysis. baseline characteristicsAs shown in Table 1, seventeen studies were included for our meta analysis. Patients with MSCM in 10 studies1, 11, 12, 15, 17, 19-21, 24, 25 were caused by spinal stenosis, and 5 studies6, 13, 14, 18, 23 were caused by ossification of posterior longitudinal ligament (OPLL), two studies16, 22 caused by twain types above. The articles were published from 1992 to 2013. The mean ages ranged from 51.8 to 66.8 years old. The sample size, gender ratio, follow-up period, and surgical methods of each study are listed in Table 1.All studies included were non-randomized controlled trails. The qualities of all studies were assessed using Newcastle-Ottawa Quality Assessment Scale (NOQAS).The scale for non-randomized controlled trails and cohort studies was used to allocate a maximum of 9 points for the quality of selection (4), comparabili ty (1), and exposure (3) or outcomes (3). As shown in supplement table 1, five studies scored 7 points and twelve scored 8 points. Hence, all studies were of a relatively high quality.Clinical outcomesThe main outcomes in this Meta analysis were operative JOA score, postoperative JOA score, operation time, blood loss, complication rate and neurological recovery rates. According to patients type, studies were separate into three subgroups subgroup spinal stenosis, subgroup OPLL, subgroup spinal stenosis and OPLL.The results of heterogeneity for preoperative JOA score was P=0.21, I2=22%, indicating no heterogeneity. So the fixed-effects model was selected and MD was 0.39 (95% CI =0.09, 0.69, P=0.01) (Fig. 2). However, except subgroup spinal stenosis and OPLL had significantly differences, the other two subgroups had no significantly differences in the preoperative JOA. By contrast, there has a statistically significance in the postoperative JOA score (MD=1.13, 95% CI =0.41, 1.86) am ong the three subgroups. But both subgroup spinal stenosis and subgroup OPLL showed apparent heterogeneity (Fig. 3).We also analyzed operation time, blood loss, complication rate for subgroup OPLL and subgroup spinal stenosis, respectively. Comparison of operation time and blood loss of the two subgroups showed that subgroup spinal stenosis had heterogeneity but not for subgroup OPLL. The operation time for both subgroups had statistically significance (MD=67.43 95% CI =16.94, 117.91), while blood loss did not (MD=52.43 95% CI =-79.8, 184.66) (Fig. 4, Fig. 5). Furthermore, when we compared the two subgroups we raise the following results. The complication rate of subgroup spinal stenosis was significantly higher in the anterior approaches than in posterior approaches (OR=2.60 95% CI =1.63, 4.15 P2=38%), while subgroup OPLL was not significant (Fig. 6). The neurological recovery rates compared among three subgroups showed no significantly difference (MD=11.85, 95% CI=0.86, 22.84) (F ig. 7).Since few studies was reported, secondary outcomes like pre- and postoperative range of motion (ROM) , pre- and postoperative Nurick grade and length of stay are listed in table 2. Only postoperative ROM (MD=1.86, 95% CI=0.61, 3.12) and length of stay (MD=-1.54, 95% CI= -2.59, -0.50) showed significant difference (P=0.04). there were no statistical difference in pre-ROM, pre- and postoperative Nurick grade between anterior and posterior approaches.Publication biasA variety of clinical outcomes had been calculated, funnel plots only for preoperative JOA score and postoperative JOA score were displayed. As shown in Fig. 8 and Fig. 9, all studies were within the confidential intervals and the shape of the funnel plots revealed symmetric distribution, which suggested there were no significant publication bias.DiscussionThe surgical treatment for cervical spondylotic myelopathy (CSM) has been studied for a long time. Anterior approaches have been widely accepted as an effective an d reliable method for the treatment of CSM. but which surgical strategy should be selected for the treatment of multilevel cervical spondylotic myelopathy (MCSM) remains controversial and challenge. Therefore, we had compared the clinical outcomes of anterior and posterior approaches in the treatment of MCSM due to spinal stenosis or OPLL. In this study, we searched the PubMed, Embase and the Cochrane library and rig 17 articles comparing anterior and posterior approaches for treatment of MCSM. According to NOQAS, all included studies had high quality. And a meta-analysis was performed to determine which surgical treatment is more effective.Based on the cause of MCSM, the studies were divided into three subgroups subgroup spinal stenosis, subgroup OPLL, subgroup spinal stenosis and OPLL. For the clinical results, there was significant difference in preoperative JOA scores in subgroup spinal stenosis and subgroup OPLL. Postoperative JOA scores was kick downstairs in the anterior gr oup compared with posterior group. This results show that the groups had standardised baseline neural function, and the postoperative neural function condition was relegate in anterior group.Authors selected operation time and blood loss for meta analysis to appraisal surgical trauma. In our study, the operation time was significant difference between the two groups, while blood loss had no statistically significance. This suggests that surgical trauma in anterior group was higher than that inposterior group in the treatment of MCSM. In addition, the post-ROM was better in posterior group while length of stay was shorter in anterior group. The preoperative ROM, pre- and post-Nurick grad did not differ significantly between the two groups.In the meta-analysis of neurological recovery rate, significant heterogeneity was found between the studies. Subsequent subgroup analysis was similar for the three subgroups. Complication rate was selected to evaluate complication-related outcome s by some authors. And they found a significantly higher incidence of complications in anterior group compared with the posterior group. Our analysis showed the same results. Subsequent subgroup analysis showed the complication rate of anterior group was higher in subgroup spinal stenosis. This suggests that the anterior approaches were associated with a higher incidence of complications for the treatment of MCSM.There are limitations in our study. First, all studies included in the meta-analysis were non-randomized controlled trails. Second, only few studies were included to evaluate pre- and post-ROM each in subgroup OPLL or subgroup spinal stenosis and OPLL. Therefore, it is necessary to include more prospective and randomized controlled trials with high quality to provide more data on the clinical results of both procedures. Hence, though anterior approaches seems have better clinical outcomes compared with posterior approaches in our study, we could not draw a well conclusion about which strategy is preferred to the treatment of MCSM due to spinal stenosis or OPLL.ConclusionsOn the basis of the meta-analysis of anterior approaches and posterior approaches for the treatment of MCSM, we can conclude that the clinical outcomes of anterior approaches are superior to posterior approaches for post-JOA, length of stay, the outcomes blood loss, neurological recovery rate are similar between two groups. Because of the existing limitations of the study, future studies with high quality are needed for update meta-analysis in order to evaluate the strategy for MCSM treatment.