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. 2021 Dec 17;54(2):304–314. [Article in Chinese] doi: 10.19723/j.issn.1671-167X.2022.02.018

显微外科手术与血管内栓塞治疗硬脊膜动静脉瘘临床疗效比较的meta分析

Clinical outcomes following microsurgery and endovascular embolization in the management of spinal dural arteriovenous fistula: A meta-analysis study

Chang-wei YUAN 1, Ying-jin WANG 1, Shu-jie ZHANG 1, Sheng-li SHEN 1, Hong-zhou DUAN 1,*
PMCID: PMC9069028  PMID: 35435197

Abstract

Objective

To compare the clinical effect of microsurgery and endovascular embolization in the treatment of spinal dural arteriovenous fistula (SDAVF) by meta-analysis.

Methods

A systematic review was performed to retrieve all relevant literature about surgical treatment or endovascular embolization of SDAVF up to December 2019 through PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials Results, CNKI, Wanfang Data, and SinoMed. The Chinese and English key words included: "SDAVF", "spinal dural arteriovenous fistula", "spinal AVM", "spinal vascular malformation and treatment". The included studies were evaluated using the Newcastle-Ottawa scale. The early failure rate, long-term recurrence, neurological recovery, and complications were evaluated and the clinical effects of the two methods in the treatment of SDAVF were compared by using RevMan 5.3 software. And a further subgroup analysis of the therapeutic effect of endovascular embolization with different embolic agents was conducted.

Results

A total of 46 studies involving 1 958 cases of SDAVF were included, in which 935 cases were treated by microsurgery and 1 023 cases were treated by endovascular embolization. The funnel plot demonstrated that there was no publication bias. The results of meta-analysis showed that the incidence of early surgical failure was lower than that of endovascular embolization (OR=0.20, 95%CI: 0.13-0.30, P < 0.05), and the long-term recurrence was also lower than that of endovascular embolization (OR=0.36, 95%CI: 0.22-0.58, P < 0.05). The improvement of neurological function in the surgical patients is significantly higher than that in the patients treated with endovascular embolization (OR=2.86, 95%CI: 1.36-5.99, P < 0.05). There was no significant difference in the occurrence of complications in these two groups (OR=1.52, 95%CI: 0.88-2.64, P=0.14). In the cases of endovascular embolization, the risk of treatment failure or recurrence was higher with Onyx glue than with n-butyl 2-cyanoacrylate (NBCA), and the difference was statistically significant (OR=4.70, 95%CI: 1.55-14.28, P < 0.05).

Conclusion

Although the treatment of dural arteriovenous fistulas by intravascular embolization has been widely used, the clinical effect of microsurgery is still better than that of endovascular embolization. Large scale and high-quality randomized controlled trials are required to validate the efficacy and safety of endovascular treatment in SDAVF patients.

Keywords: Dura mater; Arteriovenous fistula; Microsurgery; Embolization, therapeutic; Meta-analysis

硬脊膜动静脉瘘(spinal dural arteriovenous fistula, SDAVF)是脊髓血管畸形的一种常见类型，占脊髓血管畸形的70%~80%[1]。病灶位置常位于椎间孔附近的硬膜外侧或下方相当于神经根袖套“腋窝”处[2]，其由于动静脉“短路”形成异常动脉分流，导致脊髓引流静脉内压力增高，髓内正常动静脉压力梯度紊乱，出现脊髓充血水肿、缺血坏死，最终产生功能障碍。SDAVF起病隐匿，病情进展逐步恶化，临床表现主要为自下而上缓慢进展的运动和感觉障碍，大小便功能及性功能障碍。MRI典型影像学表现为病变节段脊髓表面串珠样或虫噬样血管流空影，脊髓血管造影可确诊。由于该病的临床症状无特异性，在临床上常被漏诊及误诊[3]，确诊时已难以恢复脊髓功能，患者的整体预后差。显微外科手术是SDAVF的经典治疗方式，近年来，随着介入材料的不断发展以及介入技术的不断进步，血管内栓塞治疗SDAVF亦得到广泛开展，然而到目前为止，这两种治疗方式孰优孰劣尚无定论。本研究统计了国内及国外近年来中英文发表的所有相关文献，旨在系统性比较国内外显微外科手术和血管内栓塞治疗SDAVF的疗效和安全性。

1. 资料与方法

1.1. 检索策略

以“硬脊膜动静脉瘘”“硬脊膜动静脉畸形”“硬脊膜血管畸形”“治疗”为中文检索关键词，通过计算机检索中国知网、万方数据库、中国生物医学文献数据库(Chinese BioMedical Literature Database，CBM)；以“SDAVF”“spinal dural arteriovenous fistula”“spinal AVM”“treatment”为英文检索词，检索PubMed、Embase、Web of Science、Cochrane临床试验数据库。检索时间从数据库建库至2019年12月，文献检索由2名研究人员独立检索完成。

1.2. 纳入标准和排除标准

纳入标准:(1)已发表的显微外科手术和血管内栓塞治疗SDAVF的随机或非随机对照试验、前瞻性或回顾性观察研究；(2)研究结果中包括随访疗效、治疗失败、远期复发率、神经功能改善及相关并发症情况等主要指标；(3)文献所用语言为英语或中文。

排除标准:(1)会议报告、个案报道、综述以及数据无法收集的文献；(2)样本量小于5例的研究或没有随访结果的研究；(3)重复发表的文献或某项研究的阶段性报告。

1.3. 文献筛选和质量评价

文献的筛选和质量评价由2名研究人员独立进行，如有意见分歧，则由本研究团队充分讨论后决定。首先去除各数据库中的重复文献，根据文章标题和摘要初步排除与本研究无关的文献，然后阅读文章全文，根据纳入与排除标准进一步排除不符合要求的文献。所纳入文献的质量采用纽卡斯尔-渥太华量表(Newcastle-Ottawa scale，NOS)评价，包括研究的对象选择、组间的可比性、结果测量，以记录的总分来评估文献质量，评估结果≥5分提示纳入文献质量良好，评估结果 < 5分提示纳入文献质量差。从文献中提取的内容包括:第一作者姓名、发表年份、患者数量、治疗方式、血管内栓塞材料[包括Onyx胶(乙烯醇聚合物衍生物)和α-氰基丙烯酸正丁酯(n-butyl 2-cyanoacrylate，NBCA胶)]、随访时间、研究结果等。

1.4. 评价指标

评价指标包括:(1)早期治疗失败:手术或栓塞后即刻或术后早期(1个月内)影像学检查瘘口未闭塞；(2)远期复发:影像学随访(术后3个月或以上)发现瘘口存在或再通；(3)神经功能改善:采用Aminoff-Logue表(ALS评分)[4]判断脊髓神经功能情况(步态和大小便功能)；(4)显微外科手术或血管内栓塞治疗的并发症:与本次手术或者血管内操作相关的新发疾病或症状。

1.5. 统计学分析

使用Cochrane协作网提供的RevMan 5.3软件进行meta分析，首先对纳入研究结果间的异质性进行检验，对异质性的大小进行定量分析，若P>0.1，I2 < 50%，认为研究无明显异质性，则采用固定效应模型进行meta分析；如P≤0.1，I2≥50%，认为研究存在异质性，则采用随机效应模型分析。P < 0.05为差异有统计学意义，使用漏斗图分析发表偏倚。

2. 结果

2.1. 文献检索结果

初筛文献共3 355篇，其中中文1 002，英文2 353篇，排除重复文献后剩余2 397篇，根据纳入和排除标准，阅读摘要后剩余76篇，阅读76篇全文后剩余46篇文献[5-50](表 1)，文献筛选流程见图 1，其中中文文献11篇，英文文献35篇，发表时间为1999—2019年，其中1篇为前瞻性研究[38]，其余45篇为回顾性研究[5-37, 39-50]。

表 1.

纳入文献的一般情况

Study characteristics of included studies

No. Author Year Study type S E Follow-up/months Initial failure(S/E) Late recurrence(S/E) Complications: S Complications: E NOS score
RS, retrospective study; PS, prospective study; S, surgical; E, endovascular embolization; CSF, cerebrospinal fluid; DVT, deep venous thrombosis; NOS, Newcastle-Ottawa scale.
1 Ushikoshi et al[5] 1999 RS 6 6 6 0/2 1/Not reported 1 transient deterioration of paraparesis;
1 hemorrhage in the medulla oblongata		 2 transient deterioration of paraparesis;
1 transient L4 radiculopathy		 6
2 Song et al[6] 2001 RS 7 23 10.5 0/7 2/5 Not reported Not reported 6
3 Jellema et al[7] 2005 RS 12 24 1-120 0/0 0/8 Not reported Not reported 5
4 Andres et al[8] 2008 RS 4 17 12 0/4 Not reported/ Not reported 0 0 5
5 Narvid et al[9] 2008 RS 24 39 49 4/7 0/5 0 0 7
6 Park et al[10] 2008 RS 1 17 12-160 0/2 0/1 0 1 transient aortic intimal dissection 5
7 Sherif et al[11] 2008 RS 7 19 24 0/0 0/2 0 0 5
8 Hessler et al[12] 2010 RS 54 102 24 0/21 2/6 Not reported Not reported 5
9 Shinoyama et al[13] 2010 RS 17 3 57 0/0 0/2 Not reported Not reported 6
10 Kaufmann et al[14] 2011 RS 33 1 Not reported 3/0 Not reported/ Not reported Not reported Not reported 5
11 Ruiz-Juretschke et al[15] 2011 RS 10 9 36 1/2 1/2 1 CSF fistula;
1 septic shock secondary to colon perforation		 1 spinal cord infarction 6
12 Cenzato et al[16] 2012 RS 55 10 36 0/3 Not reported/ Not reported 0 0 5
13 Cho et al[17] 2013 RS 5 23 20 0/2 0/2 1 CSF leak 3 temporary thromboembolic symtoms;
1 temporary radiculomedullary artery spasm;
1 asymptomatic aortic arch dissection		 5
14 Clark et al[18] 2013 RS 8 15 32 0/2 1/6 Not reported 0 6
15 Gemmete et al[19] 2013 RS 4 29 Not reported 0/3 0/2 0 1 transient neurological worsening due to penetration of embolic material deep into venous system 6
16 Inagawa et al[20] 2013 RS 2 12 5-97 0/4 0/1 0 1 transient gait disturbance;
1 permanent gait disturbance		 5
17 Kirsch et al[21] 2013 RS 17 61 18 0/14 Not reported/ Not reported 1 transient radicular pain;
1 transient paraperesis;
1 CSF leak		 1 spinal cord infarction 5
18 Takai et al[22] 2013 RS 23 4 14 0/0 Not reported/ Not reported 1 CSF fistula;
1 wrong-level laminectomy,
1 idiopathic venous thrombosis		 0 4
19 Gokhale et al[23] 2014 RS 17 10 24 0/0 0/3 2 wound infections 1 spinal cord infarction 5
20 Qi et al[24] 2014 RS 40 12 Not reported 0/5 0/3 1 wound infection;
1 haematoma		 0 4
21 Rashad et al[25] 2014 RS 9 3 3-24 0/1 0/1 Not reported Not reported 6
22 Yen et al[26] 2014 RS 2 10 6 0/2 Not reported/ Not reported 0 1 spinal cord infarction; 1 brainstem and cerebellar infarction 4
23 Chibbaro et al[27] 2015 RS 30 120 Not reported 0/2 0/6 0 Not reported 5
24 Özkan et al[28] 2015 RS 25 5 34.8 2/2 0/0 1 epidural haematoma 0 5
25 Shin et al[29] 2015 RS 6 9 27 0/0 Not reported/ Not reported 0 1 temporary cord ischaemia 5
26 Sri et al[30] 2015 RS 2 36 10 0/18 0/1 Not reported Not reported 5
27 Zogopoulos et al[31] 2016 RS 3 11 25.5 0/3 0/1 1 CSF leak 1 transient lower extremity weakness 6
28 Lee et al[32] 2016 RS 5 32 >24 0/12 Not reported/ Not reported 1 pseudomeningocele 0 5
29 Sasamori et al[33] 2016 RS 19 31 81.2 1/6 0/3 1 wound infection;
1 epidural haematoma;
1 subdural haematoma		 1 spinal cord infarct;
1 aortic dissection; two extravascular dislocations of a guide wire		 6
30 Adrianto et al[34] 2017 RS 5 4 37 2/1 Not reported/ Not reported Not reported Not reported 6
31 Durnford et al[35] 2017 RS 11 22 63 0/10 0/2 1 wound infection;
1 pseudomeningocele		 2 intercostal artery rupture with retroperitoneal haematoma; 1 DVT 6
32 Gross et al[36] 2017 RS 43 28 16 0/14 Not reported/ Not reported 1 epidural haematoma;
2 wound infections;
3 CSF leaks		 2 radicular artery ruptures; 1 transient worsened numbness;
1 lower extremity weakness		 7
33 Koch et al[37] 2017 RS 14 20 9 0/7 0/0 1 symptomatic pseudomeningocele;
1 wound seroma		 2 microcatheter ruptures 6
34 Ma et al[38] 2018 PS 81 13 12 0/3 0/1 1 surgical site infection 0 8
35 Bretonnier et al[39] 2019 RS 23 40 S: 21.7; E: 34.3 1/12 6/3 2 epidural haematoma;
1 CSF leak;
1 wound infection		 1 spinal cord infarction 6
36 Huang et al[40] 2003 RS 8 7 2-24 0/0 0/2 Not reported Not reported 5
37 Li et al[41] 2003 RS 98 12 3-120 0/0 Not reported/3 Not reported Not reported 5
38 Pan et al[42] 2005 RS 11 38 12-48 0/0 Not reported/0 Not reported Not reported 6
39 Yu et al[43] 2008 RS 16 5 2-120 1/1 Not reported/ Not reported Not reported Not reported 4
40 Yu et al [44] 2012 RS 9 2 6-24 0/0 0/0 Not reported Not reported 5
41 Li et al[45] 2013 RS 14 9 6-30 0/2 0/2 Not reported Not reported 5
42 Qi XQ et al[46] 2014 RS 40 12 6-72 5/2 Not reported/2 1 wound infections;
1 epidural haematoma		 Not reported 5
43 Zhao[47] 2014 RS 29 21 6-12 0/0 0/0 Not reported Not reported 4
44 Cai et al[48] 2018 RS 11 2 6 0/0 Not reported/ Not reported Not reported Not reported 4
45 Zhang et al[49] 2018 RS 10 34 9 0/0 0/6 0 Not reported 5
46 Hu[50] 2019 RS 28 13 10-65 0/0 0/2 Not reported Not reported 5
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图 1.

图 1

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文献筛选流程图

Flow of study selection

2.2. 文献质量评价

纳入本研究的46篇文献中，NOS评分为4~8分，其中8分1篇，7分2篇，6分14篇，5分23篇，4分6篇，质量良好者约占87%(表 1)。

2.3. 治疗成功率

46篇文献[5-50]均报道了治疗成功率，显微外科手术的治疗成功率是血管内栓塞治疗的1.17倍(97.4% vs. 83.3%)。考虑到血管内栓塞治疗很大程度上依赖于介入材料的进步，本研究进一步比较了近5年来[27-39, 48-50]及5年之前[5-26, 40-47]的文献数据，结果显示，显微外科手术治疗的近5年与5年之前的治疗成功率分别是血管内栓塞治疗的1.20倍(97.2% vs. 81.25%)和1.15倍(97.6% vs. 84.6%)。

2.4. 早期治疗失败

46篇文献[5-50]均报道了早期治疗失败的情况。异质性检验结果显示各研究间无明显异质性(I2=1%，P=0.45)，故采用固定效应模型进行meta分析，结果显示显微外科手术早期治疗失败的发生率低于血管内栓塞，差异有统计学意义(OR=0.20, 95%CI: 0.13~0.30, P < 0.05，图 2)。敏感性分析显示，逐一去除每项研究，未见异质性显著变化。

图 2.

图 2

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显微外科手术与血管内栓塞治疗早期失败率的比较

The forest plots of meta-analysis for rates of initial failure of microsurgery and endovascular embolization

2.5. 远期复发

30篇文献[6-7, 9-13, 15, 17-20, 23-25, 27-28, 30-31, 33, 35, 37-40, 44-45, 47, 49-50]报道了两种治疗方式的远期复发情况。异质性检验结果显示各研究间无明显异质性(I2=9%，P=0.34)，故采用固定效应模型进行meta分析，结果显示显微外科手术治疗的远期复发率低于血管内栓塞，差异有统计学意义(OR=0.36, 95%CI: 0.22~0.58, P < 0.05，图 3)。敏感性分析显示，逐一去除每项研究，未见异质性显著变化。

图 3.

图 3

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显微外科手术与血管内栓塞治疗远期复发率的比较

The forest plots of meta-analysis for rates of late recurrence of microsurgery and endovascular embolization

2.6. 神经功能改善情况

共16篇文献[7, 11, 15, 18, 25-26, 29, 31, 33, 36-38, 44, 47, 49-50]报道了治疗后患者神经功能改善情况。异质性检验结果显示各研究间存在异质性(I2=45%，P=0.04)，故采用随机效应模型进行meta分析，结果显示显微外科手术治疗后患者神经功能的改善情况优于血管内栓塞治疗的患者，差异有统计学意义(OR=2.86, 95%CI: 1.36~5.99, P < 0.05，图 4)。敏感性分析显示，去除Sasamori等[33]的研究，异质性检验提示I2=0%，P=0.50。

图 4.

图 4

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显微外科手术与血管内栓塞治疗患者神经功能改善情况的比较

The forest plots of meta-analysis for rates of neurological improvement of microsurgery and endovascular embolization

2.7. 并发症情况

共23篇文献[5, 8, 10-11, 15-17, 19-24, 26, 28-29, 31-33, 35-38]报道了两种治疗方式患者的并发症情况。异质性检验结果显示各研究间无明显异质性(I2=0%，P=0.99)，故采用固定效应模型进行meta分析，结果显示显微外科手术与血管内栓塞治疗后并发症的发生率差异无统计学意义(OR=1.52, 95%CI: 0.88~2.64, P=0.14，图 5)。敏感性分析显示，逐一去除每项研究，未见异质性显著变化。

图 5.

图 5

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显微外科手术与血管内栓塞治疗并发症的比较

The forest plots of meta-analysis for rates of complications of microsurgery and endovascular embolization NBCA, n-butyl 2-cyanoacrylate.

2.8. 亚组分析Onyx胶与NBCA胶在血管内栓塞治疗中的优劣性

把血管内栓塞治疗时早期治疗失败及晚期复发情况作为综合评价指标，共有6篇文献[18-19, 23, 25, 37, 40]报道了血管内栓塞治疗时Onyx和NBCA的使用情况。异质性检验结果显示各研究间无明显异质性(I2=0%，P=0.99)，故采用固定效应模型进行meta分析，结果显示，与NBCA相比，Onyx治疗失败或复发的风险更高，差异有统计学意义(OR=4.70, 95%CI: 1.55~14.28, P < 0.05，图 6)。敏感性分析显示，逐一去除每项研究，未见异质性显著变化。

图 6.

Onyx胶与NBCA治疗失败的比较

The forest plots of meta-analysis for rates of treatment failure of Onyx and NBCA

NBCA, n-butyl 2-cyanoacrylate.

图 6

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2.9. 发表偏倚评价

使用漏斗图进行发表偏倚风险评估，漏斗图基本呈对称(图 7)，故可以认为发表偏倚存在的可能性较小，结论可靠，但纳入研究的随机因素及文献数量可能影响偏倚。

图 7.

早期失败(A)、远期复发(B)、神经功能改善(C)、并发症(D)的漏斗图分析

The funnel plots for initial failure (A), late recurrence (B), neurological improvement (C), and complications (D)

SE, standard error; OR, odds ratio.

图 7

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3. 讨论

SDAVF较为少见，年发病率为5/100万~10/100万人[51]，临床起病隐匿，无特征性临床表现及体征，临床诊断困难，延误治疗可严重影响患者预后。MRI的典型表现为脊髓背侧和腹侧有虫噬状异常血管流空影，可伴有脊髓水肿、缺血等。脊髓数字减影血管造影(digital subtraction angiography，DSA)是本病诊断的金标准，可清晰显示瘘口所在部位，并为治疗方法的选择提供重要依据。目前的治疗方式主要为显微外科手术和血管内栓塞治疗，其原理均是通过闭塞瘘口，阻断异常的动静脉分流，解除脊髓静脉高压，遏制脊髓的进一步损伤。在脊髓功能未完全丧失前早期治疗，能使脊髓功能得到缓解或恢复，一旦脊髓完全缺血坏死，无论哪种治疗方式均难以恢复脊髓功能。以往报道，显微外科手术和血管内栓塞皆可以达到SDAVF的解剖治愈[11-12, 52-53]，但两种治疗方式孰优孰劣尚未见明确报道。

本研究利用循证医学的基本原理与方法，分析比较了两种不同方式治疗SDAVF的相关临床效果。本研究发现，手术治疗SDAVF比血管内栓塞治疗更具有优越性。显微外科手术早期治疗失败的发生率(2.6% vs. 16.7%)和远期复发率(2.6% vs. 11.7%)均显著低于血管内栓塞。显微外科手术治疗总的成功率是血管内栓塞治疗的1.17倍(97.4% vs. 83.3%)。考虑到血管内栓塞治疗成功与否与介入材料的使用息息相关，近年来所能获得的介入材料要明显好于既往，因此我们比较了近5年来及5年之前的文献数据, 发现显微外科手术治疗的成功率分别是血管内栓塞治疗方式的1.20倍(97.2% vs. 81.25%)和1.15倍(97.6% vs. 84.6%)，提示对于SDAVF的治疗来说，手术成功的决定性因素并不是手术材料的选择，而是治疗方式本身。

SDAVF治疗的成功与否取决于瘘口的闭塞与否。血管内栓塞治疗过程中需要将微导管尽可能接近瘘口进行注胶，但常常由于供血血管的异常迂曲或供血血管同时供应脊髓血供，导致微导管无法准确到位或到位后因怕闭塞脊髓供血动脉而不能注胶。显微外科手术避开了迂曲的供血动脉，直达瘘口，因此其首次治疗的成功率要高于血管内栓塞治疗。此外，有些患者的SDAVF存在多个供血动脉供应同一个瘘口的情况，仅仅栓塞一个供血动脉可以暂时缓解症状，但在随访过程中，却可以观察到瘘口的再通或再现。显微外科手术可直接闭塞瘘口而忽略供血动脉，这也是显微外科手术的远期复发率低于血管内栓塞治疗的重要原因。

Steinmetz等[54]和Bakker等[55]的研究中，血管内栓塞治疗SDAVF的成功率分别为46%和72.2%。本研究综合分析了国内外文献，显示血管内栓塞治疗的成功率为83.3%，其成功率的逐年增高，可能与介入影像学和介入材料的迅速发展相关，也不除外因患者例数的增加，术者经验的积累而得到更高的治疗成功率。此外，本研究分别统计了中文文献与英文文献的血管内栓塞治疗成功率，分别为98.1%和80.4%，国内的治疗成功率明显高于国外，考虑可能与病例的选择有关，国内医生常根据术前造影情况评估血管内栓塞的把握和难度，确有把握者行栓塞治疗，如有困难即选择较为熟悉且安全的手术切除方法；国外医生常尝试性栓塞，如栓塞不全或操作困难再行外科手术。此外，也不排除国内医生因病例数多而致栓塞技术较精湛等原因。

本文还对血管内栓塞治疗中采用的不同栓塞剂的栓塞效果进行了亚组分析，NBCA是既往脑脊髓动静脉畸形栓塞的主要材料，近年来新型的Onyx栓塞剂也有较多应用[56]。本研究经比较分析发现，Onyx胶与NBCA相比在治疗SDAVF上无明显优势，却存在更高的治疗失败及复发率，Blackburn等[57]认为，Onyx胶难以到达引流静脉是此种情况的原因，这为我们进行血管内栓塞治疗选择栓塞材料时提供了参考，但因所涉及的研究较少，其结果有待进一步大规模临床研究证实。

我们的meta分析结果显示，经显微外科手术治疗的患者神经功能改善情况优于经血管内栓塞治疗的患者，但有关此方面的研究存在明显的异质性，绝大多数文献未提及患者术前的神经功能评分情况，神经功能的改善与瘘口的成功封堵有关，且外科手术的成功率高于血管内栓塞，因此显微外科手术组的神经功能改善较为明显。两种治疗方式的并发症方面比较未见统计学差异，显微外科手术后并发症的发生率略高，为8.14%，血管内栓塞并发症的发生率为7.56%。手术并发症主要为伤口相关的问题，如感染、积血或积液，其他还有硬膜外血肿、脑脊液漏、脑脊膜膨出等。血管内栓塞的并发症与操作技术关系密切，如血管夹层形成、微导管断裂、脊髓梗死及其他未能准确栓塞造成的并发症。两种治疗方式均未见危及生命的严重不良并发症。

考虑到SDAVF患者治疗后的神经功能状况在很大程度上取决于患者术前的神经状况[16, 32, 38]，是否在脊髓血管造影时进行初步栓塞以改善最终的神经功能，以及血管内栓塞对SDAVF治疗的确切定位仍然有待确定。显微外科手术的成功取决于术前对瘘口的精准定位，术前的脊髓血管造影时，在供血血管内放置定位弹簧圈有助于术中对瘘口的判断与辨别[58]。血管内栓塞治疗技术在近些年来得到极大进步，在SDAVF的综合治疗中亦将发挥日益重要的作用。

前瞻性随机对照研究能够在基线相同的情况下更好地比较两种治疗方式的优劣性，但目前为止关于SDAVF的治疗仅有1篇前瞻性研究[38]，其余均为回顾性研究，可能导致合并分析结果时存在偏倚。Ma等[38]报道的这项前瞻性研究纳入了94例患者，81例接受外科手术治疗，10例接受血管内栓塞治疗，3例栓塞后失败行手术治疗，结果显示外科手术成功率(100.0%)明显高于血管内栓塞治疗(76.9%)，此结果与本文的meta分析结果相一致。

本研究在以下方面仍存在一定局限性，首先，部分文献对治疗方式的选择有一定的倾向性，可能影响分析结果；其次，部分文献对神经恢复效果未给出明确的评价指标，难以统计分析；再次，SDAVF可以存在于不同的部位，部分文献未给出瘘口位置，本文未对不同位置的SDAVF进行分析比较。

综上所述，对于SDAVF患者而言，显微外科手术的有效性优于血管内栓塞治疗，且不易复发。血管内栓塞的治疗创伤小，但完全闭塞率及复发率稍高。随着介入技术及新材料的不断出现，血管内栓塞治疗的有效性有望得到提升。对于SDAVF治疗方法的规范，尚需进行进一步随机对照试验以明确。

Funding Statement

国家自然科学基金(81541119)、北京大学第一医院交叉临床研究专项资助项目、北京大学第一医院青年临床研究专项基金(2019CR02)

Supported by the National Natural Science Foundation of China (81541119), the Peking University First Hospital Cross Clinical Study Foundation, and the Youth Clinical Research Project of Peking University First Hospital (2019CR02)

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