Meta-analysis of the efficacy of controlled stepwise decompression versus rapid standard large bone-flap decompression on the treatment of severe craniocerebral injury

doi:10.3969/j.issn.1004-583X.2023.09.003

Abstract

Abstract:

Objective To compare the efficacy of controlled stepwise decompression versus rapid standard large bone-flap decompression on the treatment of severe craniocerebral injury. Methods Relevant articles reporting the efficacy of controlled stepwise decompression versus rapid standard large bone-flap decompression on the treatment of severe craniocerebral injury published from the establishment of the database to November 2022 were searched in the PubMed, Embase, The Cochrane Library, Web of Science, Wanfang Medical Network, China National Knowledge Infrastructure (CNKI), Chinese Biomedicine Database (CBM) and VIP databases. Data were extracted from the eligible literatures for performing a meta-analysis using RevMan 5.4 software. Results A total of 23 eligible articles were included, involving 17 retrospective clinical controlled studies and 6 randomized controlled trials. Finally, 2141 patients with severe craniocerebral injury were included, involving 1080 patients managed by controlled stepwise decompression and 1061 managed by rapid standard large bone-flap decompression. Meta-analysis results showed that compared to those treated with rapid standard large bone flap decompression, controlled stepwise decompression provided an earlier time of decompression ( $M D$ =-25.39, 95% $C I$ : -30.96, -19.81; $P$ <0.01), less operation time ( $M D$ =-21.49, 95% $C I$ : -34.22, -8.76; $P$ <0.01), shorter length of stay ( $M D$ =-3.02, 95% $C I$ : -3.70, -2.34; $P$ <0.01), less intraoperative bleeding ( $M D$ =-23.82, 95% $C I$ : -32.42, -15.22; $P$ <0.01), lower intracranial pressure (ICP) on the first day after decompression ( $M D$ =-4.58, 95% $C I$ : -6.03, -3.13; $P$ <0.01), lower total incidence of intraoperative and postoperative complications ( $O R$ =0.18, 95% $C I$ : 0.15, 0.23; $P$ <0.01), lower Glasgow Coma Scale (GCS) score at 2 weeks postoperatively ( $M D$ =1.94, 95% $C I$ : 1.31, 2.56; $P$ <0.01) and higher rate of good prognosis with the Glasgow Outcome Scale (GOS) score ≥4 ( $O R$ =3.08, 95% $C I$ : 2.15, 4.43; $P$ <0.01). Conclusion Compared to those of rapid standard large bone-flap decompression, controlled stepwise decompression has certain advantages in the time of decompression, operation time, intraoperative bleeding, postoperative length of stay, total incidence of intraoperative and postoperative complications, and postoperative recovery. The controlled stepwise decompression is preferred to lower ICP in most cases of craniocerebral injury, which can be promoted and applied in clinical practice.

Key words: craniocerebral trauma, stepwise decompression surgery, standard large bone flap decompression surgery, efficacy, meta analysis

CLC Number:

R651

Li Hai, Liu Wenhu, Peng Shaopeng, Wang Fei. Meta-analysis of the efficacy of controlled stepwise decompression versus rapid standard large bone-flap decompression on the treatment of severe craniocerebral injury[J]. Clinical Focus, 2023, 38(9): 788-795.

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URL: https://huicui.hebmu.edu.cn/EN/10.3969/j.issn.1004-583X.2023.09.003

https://huicui.hebmu.edu.cn/EN/Y2023/V38/I9/788

Figures/Tables 9

Fig. 1 Flow chart of literature retrieval and screening

Tab.1 Basic information of patients included in the study

纳入研究	研究时间	研究类型	手术方式	例数	年龄(岁)	男/女(例)
李强2021^[5]	2018.10-2020.10	RCT	控制性阶梯减压术/快速标准骨瓣减压术	40/40	43.5±2.4/42.8±2.8	26 14/25 15
张敏2021^[6]	2018.01-2020.01	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	65/65	45.71±5.42/45.26±5.95	36 29/34 31
董陶2022^[7]	2018.02-2020.03	RCT	控制性阶梯减压术/快速标准骨瓣减压术	41/41	44.42±7.01/43.76±6.99	24 17/25 16
许银才2022^[8]	2014.02-2019.12	RCT	控制性阶梯减压术/快速标准骨瓣减压术	33/33	35.3±1.6/34.9±1.5	16 17/15 18
张清超2022^[9]	2020.01-2020.12	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	60/60	45.3±12.86/45.4±13.71	37 23/39 21
蓝一帆2019^[12]	2016.01-2018.10	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	43/43	44(28-60)/ 43(28-59)	29 14/28 15
王星2018^[13]	2010.01-2016.06	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	91/68	43.3±15.1/42.9±16.3	61 30/45 23
窦建胜2018^[14]	2015.05-2017.05	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	48/45	46.2±6.9/45.8±6.5	38 10/34 11
王文刚2017^[15]	2013.01-2016.10	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	40/40	45.10±5.21/46.12±5.41	25 15/26 14
谢树波2017^[16]	2012.06-2016.06	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	60/56	43.52±11.03/43.28±10.36	40 20/35 21
付涛2017^[17]	2013.08-2015.08	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	31/36	44.6±11.7/45.1±12.4	19 12/21 15
李军2015^[18]	2011.01-2014.09	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	30/29	41.8±9.4/40.2±10.1	16 14/17 12
张继洲2019^[19]	2016.08-2018.11	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	44/44	46.52±5.74/46.68±5.47	28 16/26 18
张永兵2019^[20]	2015.07-2017.07	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	49/48	43.45±8.27/43.86±7.94	28 21/29 19
姜海涛2019^[21]	2016.08-2017.08	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	32/32	51.04±3.41/51.08±3.45	16 16/17 15
赵永峰2019^[22]	2014.01-2015.12	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	43/43	34.2±5.6/34.2±5.6	—/—
张毓2020^[23]	2016.02-2019.02	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	58/64	39.5±10.4/37.8±12.5	42 16/47 17
靳腾龙2020^[24]	2016.03-2019.03	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	44/44	45.58±6.33/45.61±6.27	24 20/26 18
焦锟2020^[25]	2017.05-2018.10	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	49/51	42.34±5.01/43.15±4.67	32 17/30 21
周晓成2020^[26]	2018.01-2019.01	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	42/42	41.95±10.86/40.98±10.37	27 15/26 16
孙阳2018^[27]	2014.11-2015.12	RCT	控制性阶梯减压术/快速标准骨瓣减压术	34/34	33.04±3.58/35.21±3.17	25 9/23 11
王爱国2020^[28]	2016.01-2019.12	RCT	控制性阶梯减压术/快速标准骨瓣减压术	53/53	43.87±6.22/44.46±6.69	31 22/29 24
孙翔宇2020^[29]	2017.08-2019.08	RCT	控制性阶梯减压术/快速标准骨瓣减压术	50/50	42.53±2.05/42.25±1.88	25 25/21 29

Tab.1 Basic information of patients included in the study

纳入研究	研究时间	研究类型	手术方式	例数	年龄(岁)	男/女(例)
李强2021^[5]	2018.10-2020.10	RCT	控制性阶梯减压术/快速标准骨瓣减压术	40/40	43.5±2.4/42.8±2.8	26 14/25 15
张敏2021^[6]	2018.01-2020.01	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	65/65	45.71±5.42/45.26±5.95	36 29/34 31
董陶2022^[7]	2018.02-2020.03	RCT	控制性阶梯减压术/快速标准骨瓣减压术	41/41	44.42±7.01/43.76±6.99	24 17/25 16
许银才2022^[8]	2014.02-2019.12	RCT	控制性阶梯减压术/快速标准骨瓣减压术	33/33	35.3±1.6/34.9±1.5	16 17/15 18
张清超2022^[9]	2020.01-2020.12	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	60/60	45.3±12.86/45.4±13.71	37 23/39 21
蓝一帆2019^[12]	2016.01-2018.10	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	43/43	44(28-60)/ 43(28-59)	29 14/28 15
王星2018^[13]	2010.01-2016.06	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	91/68	43.3±15.1/42.9±16.3	61 30/45 23
窦建胜2018^[14]	2015.05-2017.05	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	48/45	46.2±6.9/45.8±6.5	38 10/34 11
王文刚2017^[15]	2013.01-2016.10	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	40/40	45.10±5.21/46.12±5.41	25 15/26 14
谢树波2017^[16]	2012.06-2016.06	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	60/56	43.52±11.03/43.28±10.36	40 20/35 21
付涛2017^[17]	2013.08-2015.08	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	31/36	44.6±11.7/45.1±12.4	19 12/21 15
李军2015^[18]	2011.01-2014.09	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	30/29	41.8±9.4/40.2±10.1	16 14/17 12
张继洲2019^[19]	2016.08-2018.11	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	44/44	46.52±5.74/46.68±5.47	28 16/26 18
张永兵2019^[20]	2015.07-2017.07	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	49/48	43.45±8.27/43.86±7.94	28 21/29 19
姜海涛2019^[21]	2016.08-2017.08	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	32/32	51.04±3.41/51.08±3.45	16 16/17 15
赵永峰2019^[22]	2014.01-2015.12	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	43/43	34.2±5.6/34.2±5.6	—/—
张毓2020^[23]	2016.02-2019.02	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	58/64	39.5±10.4/37.8±12.5	42 16/47 17
靳腾龙2020^[24]	2016.03-2019.03	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	44/44	45.58±6.33/45.61±6.27	24 20/26 18
焦锟2020^[25]	2017.05-2018.10	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	49/51	42.34±5.01/43.15±4.67	32 17/30 21
周晓成2020^[26]	2018.01-2019.01	回顾性	控制性阶梯减压术/快速标准骨瓣减压术	42/42	41.95±10.86/40.98±10.37	27 15/26 16
孙阳2018^[27]	2014.11-2015.12	RCT	控制性阶梯减压术/快速标准骨瓣减压术	34/34	33.04±3.58/35.21±3.17	25 9/23 11
王爱国2020^[28]	2016.01-2019.12	RCT	控制性阶梯减压术/快速标准骨瓣减压术	53/53	43.87±6.22/44.46±6.69	31 22/29 24
孙翔宇2020^[29]	2017.08-2019.08	RCT	控制性阶梯减压术/快速标准骨瓣减压术	50/50	42.53±2.05/42.25±1.88	25 25/21 29

Tab.2 NOS scores of included cohort studies (scores)

纳入研究	研究人群				组间可比性	结果测量			评分
纳入研究	暴露组代表性	非暴露组选择方法	暴露因素确定方法	结局指标	组间可比性	结果评价	随访是否够长	随访是否充分	评分
张敏2021^[6]	1	1	1	0	2	1	1	1	8
张清超2022^[9]	1	1	1	0	1	1	1	1	7
蓝一帆2019^[12]	1	1	1	0	2	1	1	1	8
王星2018^[13]	1	1	1	0	2	1	1	1	8
窦建胜2018^[14]	1	1	1	0	1	1	1	1	7
王文刚2017^[15]	1	1	1	0	2	1	1	1	8
谢树波2017^[16]	1	1	1	0	1	1	1	1	7
付涛2017^[17]	1	1	1	0	1	1	1	1	7
李军2015^[18]	1	1	1	0	1	1	1	1	7
张继洲2019^[19]	1	1	1	1	2	1	1	1	9
张永兵2019^[20]	1	1	1	0	2	1	1	1	8
姜海涛2019^[21]	1	1	1	0	1	1	1	1	7
赵永峰2019^[22]	1	1	1	0	1	1	1	1	7
张毓2020^[23]	1	1	1	0	2	1	1	1	8
靳腾龙2020^[24]	1	1	1	0	2	1	1	1	8
焦锟2020^[25]	1	1	1	0	1	1	1	1	7
周晓成2020^[26]	1	1	1	0	1	1	1	1	7

Fig.2 Bias risk map for RCT studies

Tab.3 Meta-analysis of some outcome indicators after controlled stepwise decompression and rapid standard large bone-flap decompression

结局指标	文献数量	样本量(例)		效应模型	异质性		$M D$ 值	95% $C I$	$P$ 值
结局指标	文献数量	控制性阶梯减压术	快速标准骨瓣减压术	效应模型	$I 2$ (%)	$P$ 值	$M D$ 值	95% $C I$	$P$ 值
开始减压时间比较	3	184	161	随机	96%	<0.1	-25.39	(-30.96,-19.81)	<0.01
手术时间比较	10	510	492	随机	99%	<0.1	-21.49	(-34.22,-8.76)	<0.01
住院时间比较	3	118	118	随机	62%	0.07	-3.02	(-3.70,-2.34)	<0.01
术中出血量比较	9	419	424	随机	98%	<0.1	-23.82	(-32.42,-15.22)	<0.01
减压术后第1天ICP	5	232	231	随机	94%	<0.1	-4.58	(-6.03,-3.13)	<0.01
术后2周GCS评分	3	175	152	固定	0%	0.91	1.94	(1.31,2.56)	<0.01

Tab.3 Meta-analysis of some outcome indicators after controlled stepwise decompression and rapid standard large bone-flap decompression

结局指标	文献数量	样本量(例)		效应模型	异质性		$M D$ 值	95% $C I$	$P$ 值
结局指标	文献数量	控制性阶梯减压术	快速标准骨瓣减压术	效应模型	$I 2$ (%)	$P$ 值	$M D$ 值	95% $C I$	$P$ 值
开始减压时间比较	3	184	161	随机	96%	<0.1	-25.39	(-30.96,-19.81)	<0.01
手术时间比较	10	510	492	随机	99%	<0.1	-21.49	(-34.22,-8.76)	<0.01
住院时间比较	3	118	118	随机	62%	0.07	-3.02	(-3.70,-2.34)	<0.01
术中出血量比较	9	419	424	随机	98%	<0.1	-23.82	(-32.42,-15.22)	<0.01
减压术后第1天ICP	5	232	231	随机	94%	<0.1	-4.58	(-6.03,-3.13)	<0.01
术后2周GCS评分	3	175	152	固定	0%	0.91	1.94	(1.31,2.56)	<0.01

Fig.3 Meta-analysis of total complications of controlled stepwise decompression versus rapid standard large bone-flap decompression

Tab.4 Meta-analysis of single complication between controlled stepwise decompression and rapid standard large bone-flap decompression

结局指标	文献数量	样本量(例)		效应模型	异质性		$M D$ 值	95% $C I$	$P$ 值
结局指标	文献数量	控制性阶梯减压术	快速标准骨瓣减压术	效应模型	$I 2$ (%)	$P$ 值	$M D$ 值	95% $C I$	$P$ 值
术中脑膨出	23	1080	1061	固定	0%	1	0.3	(0.22,0.40)	<0.01
术后脑梗死	23	1080	1061	固定	0%	0.93	0.34	(0.24,0.49)	<0.01
迟发性血肿	23	1080	1061	固定	0%	1	0.35	(0.26,0.47)	<0.01

Tab.4 Meta-analysis of single complication between controlled stepwise decompression and rapid standard large bone-flap decompression

结局指标	文献数量	样本量(例)		效应模型	异质性		$M D$ 值	95% $C I$	$P$ 值
结局指标	文献数量	控制性阶梯减压术	快速标准骨瓣减压术	效应模型	$I 2$ (%)	$P$ 值	$M D$ 值	95% $C I$	$P$ 值
术中脑膨出	23	1080	1061	固定	0%	1	0.3	(0.22,0.40)	<0.01
术后脑梗死	23	1080	1061	固定	0%	0.93	0.34	(0.24,0.49)	<0.01
迟发性血肿	23	1080	1061	固定	0%	1	0.35	(0.26,0.47)	<0.01

Fig.4 Meta-analysis of good recovery after controlled stepwise decompression and rapid standard large bone-flap decompression

Fig.5 Publication bias of total complications and good prognosis between controlled stepwise decompression and rapid standard large bone-flap decompression a. total complications; b.good prognosis

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