后颅窝减压及硬膜成形术与单纯后颅窝减压术比较治疗Ⅰ型Chiari畸形效果的Meta分析_《中国循证医学杂志》

作者：

张豆豆 , 陈海锋 ,  黄思庆 , 郝德 , 任海波 , 汤俊佳

四川大学华西医院神经外科（成都 610041）;

关键词：

Ⅰ型Chiari畸形硬膜成形术 Meta 分析系统评价队列研究

DOI：

10.7507/1672-2531.20120170

视频：

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摘要 全文 图表 视频 参考文献 施引文献 补充材料

目的　系统评价后颅窝减压及硬膜成形术（PFDD）与单纯后颅窝减压（PFD）两种术式比较治疗Ⅰ型Chiari 畸形的有效性和安全性。
方法　计算机检索CENTRAL、Science Citation Index Expanded、MEDLINE（Ovid）、PubMed、CBM、CNKI和WanFang Data，收集比较后颅窝减压及硬膜成形术（PFDD）与单纯后颅窝减压（PFD）治疗Ⅰ型Chiari 畸形有效性和安全性的文献，并辅以检索纳入研究的参考文献。检索时限均从1993年至2011年9月。由2位评价者按照纳入和排除标准独立选择文献，提取资料，采用 Newcastle-Ottawa量表对纳入研究进行方法学质量评价，然后采用 RevMan 5.1软件对数据进行 Meta 分析，并采用 GRADE 系统评价证据质量评价。
结果　共纳入10个队列研究，829例患者。Meta 分析结果显示：① PFDD组再手术率低于PFD组［RR=0.41，95%CI（0.23，0.74），P=0.003］，PFDD组术后脊髓空洞缩小率高于PFD组［RR=1.27，95%CI（1.03，1.56），P=0.02］，术后临床症状改善两组差异无统计学意义［RR=1.11，95%CI（0.95，1.28），P=0.18］。② PFDD组术后脑脊液相关并发症发生率显著高于PDF组［RR=6.3，95%CI（2.71，14.67），P lt;0.000 1］，而术后枕部疼痛及伤口感染发生率两组差异均无统计学意义（P gt;0.05）。基于上述系统评价结果，采用 GRADE 系统评价证据质量及推荐等级，证据总体质量评级为低质量，推荐强度为弱推荐。
结论　与PFD相比，PFDD可减少再次手术率，提高脊髓空洞缩小率，但会显著增加脑脊液相关并发症发生的风险。受纳入研究质量较低等因素影响，上述结论尚需更多高质量、大样本的RCT 进一步加以验证。我们建议临床上根据患者情况，个性化选择使用。

引用本文： 张豆豆,陈海锋,黄思庆,郝德,任海波,汤俊佳. 后颅窝减压及硬膜成形术与单纯后颅窝减压术比较治疗Ⅰ型Chiari畸形效果的Meta分析. 中国循证医学杂志, 2012, 12(9): 1090-1097. doi: 10.7507/1672-2531.20120170 复制

1.	Tubbs RS, Lyerly MJ, Loukas M, et al. The pediatric Chiari I malformation: a review. Childs Nerv Syst, 2007, 23(11): 1239-1250.
2.	Mortazavi MM, Tubbs RS, Hankinson TC, et al. The first posterior fossa decompression for Chiari malformation: the contributions of Cornelis Joachimus van Houweninge Graftdijk and a review of the infancy of “Chiari decompression”. Childs Nerv Syst, 2011, 27(11): 1851-1856.
3.	Wells G, Shea B, O’connell D, et al. The Newcastle-Ottawa Scale NOS for assessing the quality of nonrandomized studies in meta-analyses. Ottawa, Canada: Dept of Epidemiology and Community Medicine, University of Ottawa. http: // www.ohri.ca/programs /clinical_epidemiology /oxford.htm.
4.	Munshi I, Frim D, Stine-Reyes R, et al. Effects of posterior fossa decompression with and without duraplasty on Chiari malformation-associated hydromyelia. Neurosurgery, 2000, 46(6): 1384-1390.
5.	Limonadi FM, Selden NR. Dura-splitting decompression of the craniocervical junction: reduced operative time, hospital stay, and cost with equivalent early outcome. J Neurosurg, 2004, 101(2 Supp l): 184-188.
6.	Navarro R, Olavarria G, Seshadri R, et al. Surgical results of posterior fossa decompression for patients with Chiari I malformation. Childs Nerv Syst, 2004, 20(5): 349-356.
7.	Yeh DD, Koch B, Crone KR. Intraoperative ultrasonography used to determine the extent of surgery necessary during posterior fossa decompression in children with Chiari malformation type I. J Neurosurg, 2006, 105(1 Supp l): 26-32.
8.	McGirt MJ, Attenello FJ, Datoo G, et al. Intraoperative ultrasonography as a guide to patient selection for duraplasty after suboccipital decompression in children with Chiari malformation Type I. J Neurosurg Pediatr, 2008, 2(1): 52-57.
9.	张斌, 沈冰. 不同术式对Arnold-Chiari畸形并脊髓空洞的疗效分析. 宁夏医学杂志, 2009, 31(4): 333-334.
10.	Mutchnick IS, Janjua RM, Moeller K, et al. Decompression of Chiari malformation with and without duraplasty: morbidity versus recurrence. J Neurosurg Pediatr, 2010, 5(5): 474-478.
11.	Romero FR, Pereira CA. Suboccipital craniectomy with or without duraplasty: what is the best choice in patients with Chiari type 1 malformation? Arq Neuropsiquiatr, 2010, 68(4): 623-626.
12.	刘彬, 王振宇, 李振东, 等. 不同手术方式治疗 Chiari 畸形合并脊髓空洞的临床研究.中华神经医学杂志, 2005, 4 (11) : 1137-1139.
13.	Yilmaz A, Kanat A, Musluman AM, et al. When is duraplasty required in the surgical treatment of Chiari malformation type I based on tonsillar descending grading scale? World Neurosurg, 2011, 75(2): 307-313.
14.	Guyatt GH, Oxman AD, Akl E, et al. GRADE Guidelines: 1. Introduction to GRADE Evidence Proiles and Summary of Findings Tables. J Clin Epidemiol, 2011, 64(4): 383-943.
15.	Sackett DL, Straus SE, Ricbardson WS, et al. Evidence-based Medicine: how to practice and teach EBM. 2nd edition. Churchill Livingstone,London. 2000: 173-175.
16.	Weiner SJ. Contextualizing medical decisions to individualize care: lessons from the qualitative sciences. J Gen Intern Med, 2004, 19(3): 281-285.
17.	Schulz KF, Moher D, Altman DG. CONSORT 2010 comments. Lancet, 2010, 376(9748): 1222-1223.

1. Tubbs RS, Lyerly MJ, Loukas M, et al. The pediatric Chiari I malformation: a review. Childs Nerv Syst, 2007, 23(11): 1239-1250.
2. Mortazavi MM, Tubbs RS, Hankinson TC, et al. The first posterior fossa decompression for Chiari malformation: the contributions of Cornelis Joachimus van Houweninge Graftdijk and a review of the infancy of “Chiari decompression”. Childs Nerv Syst, 2011, 27(11): 1851-1856.
3. Wells G, Shea B, O’connell D, et al. The Newcastle-Ottawa Scale NOS for assessing the quality of nonrandomized studies in meta-analyses. Ottawa, Canada: Dept of Epidemiology and Community Medicine, University of Ottawa. http: // www.ohri.ca/programs /clinical_epidemiology /oxford.htm.
4. Munshi I, Frim D, Stine-Reyes R, et al. Effects of posterior fossa decompression with and without duraplasty on Chiari malformation-associated hydromyelia. Neurosurgery, 2000, 46(6): 1384-1390.
5. Limonadi FM, Selden NR. Dura-splitting decompression of the craniocervical junction: reduced operative time, hospital stay, and cost with equivalent early outcome. J Neurosurg, 2004, 101(2 Supp l): 184-188.
6. Navarro R, Olavarria G, Seshadri R, et al. Surgical results of posterior fossa decompression for patients with Chiari I malformation. Childs Nerv Syst, 2004, 20(5): 349-356.
7. Yeh DD, Koch B, Crone KR. Intraoperative ultrasonography used to determine the extent of surgery necessary during posterior fossa decompression in children with Chiari malformation type I. J Neurosurg, 2006, 105(1 Supp l): 26-32.
8. McGirt MJ, Attenello FJ, Datoo G, et al. Intraoperative ultrasonography as a guide to patient selection for duraplasty after suboccipital decompression in children with Chiari malformation Type I. J Neurosurg Pediatr, 2008, 2(1): 52-57.
9. 张斌, 沈冰. 不同术式对Arnold-Chiari畸形并脊髓空洞的疗效分析. 宁夏医学杂志, 2009, 31(4): 333-334.
10. Mutchnick IS, Janjua RM, Moeller K, et al. Decompression of Chiari malformation with and without duraplasty: morbidity versus recurrence. J Neurosurg Pediatr, 2010, 5(5): 474-478.
11. Romero FR, Pereira CA. Suboccipital craniectomy with or without duraplasty: what is the best choice in patients with Chiari type 1 malformation? Arq Neuropsiquiatr, 2010, 68(4): 623-626.
12. 刘彬, 王振宇, 李振东, 等. 不同手术方式治疗 Chiari 畸形合并脊髓空洞的临床研究.中华神经医学杂志, 2005, 4 (11) : 1137-1139.
13. Yilmaz A, Kanat A, Musluman AM, et al. When is duraplasty required in the surgical treatment of Chiari malformation type I based on tonsillar descending grading scale? World Neurosurg, 2011, 75(2): 307-313.
14. Guyatt GH, Oxman AD, Akl E, et al. GRADE Guidelines: 1. Introduction to GRADE Evidence Proiles and Summary of Findings Tables. J Clin Epidemiol, 2011, 64(4): 383-943.
15. Sackett DL, Straus SE, Ricbardson WS, et al. Evidence-based Medicine: how to practice and teach EBM. 2nd edition. Churchill Livingstone,London. 2000: 173-175.
16. Weiner SJ. Contextualizing medical decisions to individualize care: lessons from the qualitative sciences. J Gen Intern Med, 2004, 19(3): 281-285.
17. Schulz KF, Moher D, Altman DG. CONSORT 2010 comments. Lancet, 2010, 376(9748): 1222-1223.

《中国循证医学杂志》

后颅窝减压及硬膜成形术与单纯后颅窝减压术比较治疗Ⅰ型Chiari畸形效果的Meta分析

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《中国循证医学杂志》

后颅窝减压及硬膜成形术与单纯后颅窝减压术比较治疗Ⅰ型Chiari畸形效果的Meta分析

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