颈前路扩大纵向减压范围植骨融合及钢板内固定治疗脊髓型颈椎病
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摘要
背景:颈前路减压融合治疗脊髓型颈椎病因其疗效确切,术中创伤较小,减压明确,被脊柱外科医生奉为经典的手术方式。此次研究在遵循原有经典颈前路减压融合术式基础上扩大纵向减压范围,进而与经典术式的临床疗效相比较。目的:比较2种颈前路减压手术治疗脊髓型颈椎病的临床疗效。方法:将120例脊髓型颈椎病患者随机分为2组(n=60),其中A组接受经典颈前路减压融合治疗,B组接受颈椎前路扩大纵向减压范围手术。2组患者对治疗方案均知情同意,且得到哈尔滨医科大学附属第四医院伦理委员会批准。术后所有患者均随访1年,从术中及术后出血量、日本骨科协会评分(评估神经功能)、颈椎曲度、颈椎屈伸活动度、椎间植骨愈合时间及愈合率等方面对2种患者的临床疗效进行比较。结果与结论:①A组患者的术中及术后出血量显著低于B组,差异有显著性意义(P <0.05);②术后B组患者神经功能恢复情况(日本骨科协会评分)优于A组,差异有显著性意义(P<0.05);③2组患者术后颈椎曲度及颈椎活动度差异均无显著性意义(P> 0.05);④术后椎间植骨愈合时间B组短于A组(P <0.05),而在融合率方面2组差异无显著性意义(P> 0.05);⑤2种方案治疗脊髓型颈椎病均可获得较理想的临床疗效。经典的颈前路术式术中创伤较小,患者在术后离床活动方面存在一定优势;术后颈椎曲度恢复及椎间植骨融合率上2种术式无明显差异;但是在脊髓型颈椎病神经功能恢复及椎间植骨愈合时间方面,颈前路扩大纵向减压范围术式存在一定的优势。
BACKGROUND: Cervical anterior decompression and fusion for treating cervical spondylotic myelopathy is regarded as a classic surgical method because of its exact curative effect, small intraoperative trauma and the decompression. This study expands the longitudinal decompression range based on the original classical procedure and compares it with the clinical efficacy of the classic procedure.OBJECTIVE: To analyze the clinical efficacy of two different methods of anterior cervical decompression for treating cervical spondylotic myelopathy.METHODS: One hundred and twenty patients were randomly divided into two groups A(traditional anterior cervical decompression) and B(expansion of the longitudinal decompression range of the anterior cervical spine)(n=60/group). Informed consents were obtained from all patients, and the trial was approved by the Ethics Committee of the Fourth Affiliated Hospital of Harbin Medical University. All patients were followed up for 1 year. The intraoperative and postoperative blood loss, Japanese Orthopaedic Association score, cervical curvature index,cervical flexion and extension activity, intervertebral bone graft healing time and fusion rate were compared to assess the clinical efficacy.RESULTS AND CONCLUSION:(1) The intraoperative and postoperative blood loss in the group A was lower than that in group B(P < 0.05).(2) The recovery of neurological function(Japanese Orthopaedic Association score) in the group B was significantly better than that in the group A(P < 0.05).(3) There was no significant difference in the changes of cervical curvature index and range of motion between two groups(P > 0.05).(4) The postoperative healing time of intervertebral bone graft in the group B was significantly shorter than that in the group A(P <0.05). There was no significant difference in the fusion rate between two groups(P > 0.05).(5) In summary, both surgical procedures can achieve good clinical results in the treatment of different degrees of cervical spine. The classic cervical anterior approach has little trauma during operation, and patients have certain advantages in postoperative bed-lifting activities. There is no significant difference in the recovery of cervical curvature and the rate of interbody fusion between two methods. The expansion of the longitudinal decompression range of the anterior cervical spine holds certain advantages in the neurological function of cervical spondylotic myelopathy and the healing time of intervertebral bone grafting.
BACKGROUND: Cervical anterior decompression and fusion for treating cervical spondylotic myelopathy is regarded as a classic surgical method because of its exact curative effect, small intraoperative trauma and the decompression. This study expands the longitudinal decompression range based on the original classical procedure and compares it with the clinical efficacy of the classic procedure.OBJECTIVE: To analyze the clinical efficacy of two different methods of anterior cervical decompression for treating cervical spondylotic myelopathy.METHODS: One hundred and twenty patients were randomly divided into two groups A(traditional anterior cervical decompression) and B(expansion of the longitudinal decompression range of the anterior cervical spine)(n=60/group). Informed consents were obtained from all patients, and the trial was approved by the Ethics Committee of the Fourth Affiliated Hospital of Harbin Medical University. All patients were followed up for 1 year. The intraoperative and postoperative blood loss, Japanese Orthopaedic Association score, cervical curvature index,cervical flexion and extension activity, intervertebral bone graft healing time and fusion rate were compared to assess the clinical efficacy.RESULTS AND CONCLUSION:(1) The intraoperative and postoperative blood loss in the group A was lower than that in group B(P < 0.05).(2) The recovery of neurological function(Japanese Orthopaedic Association score) in the group B was significantly better than that in the group A(P < 0.05).(3) There was no significant difference in the changes of cervical curvature index and range of motion between two groups(P > 0.05).(4) The postoperative healing time of intervertebral bone graft in the group B was significantly shorter than that in the group A(P <0.05). There was no significant difference in the fusion rate between two groups(P > 0.05).(5) In summary, both surgical procedures can achieve good clinical results in the treatment of different degrees of cervical spine. The classic cervical anterior approach has little trauma during operation, and patients have certain advantages in postoperative bed-lifting activities. There is no significant difference in the recovery of cervical curvature and the rate of interbody fusion between two methods. The expansion of the longitudinal decompression range of the anterior cervical spine holds certain advantages in the neurological function of cervical spondylotic myelopathy and the healing time of intervertebral bone grafting.
引文
[1]Luo J,Cao K,Huang S,et al.Comparison of anterior approach versus posterior approach for the treatment of multilevel cervical spondylotic myelopathy.Eur Spine J.2015;24(8):1621-1630.
[2]Wang H,Ma L,Yang D,et al.Incidence and risk factors of postoperative adjacent segment degeneration following anterior decompression and instrumented fusion for degenerative disorders of the cervical spine.World Neurosurg.2017;105:78-85.
[3]Wang T,Wang H,Liu S,et al.Anterior cervical discectomy and fusion versus anterior cervical corPectomy and fusion in multilevel cervical spondylotic myelopathy:A meta-analysis.Medicine(Baltimore).2016;95(49):e5437.
[4]Park JH,Kim JH,Roh SW,et al.prognostic factor analysis after surgical decompression and stabilization for cervical spinal-cord injury.Br J Neurosurg.2017;31(2):194-198.
[5]周非非,孙宇,张凤山,等.颈椎前路椎间盘切除、植骨融合内固定术治疗脊髓型颈椎病术后轴性症状的前瞻性研究[J].中国脊柱脊髓杂志,2014,24(6):505-509.
[6]Kouyoumdjian P,Guerin P,Schanelderle C,et al.Fracture of the lower cervical spine in patients withankylosing spondylitis:retrosPective study of 19 cases.Orthop Traumatol Surg Res.2012;98(5):543-551.
[7]任志伟,杜恒,杨益民,等.颈椎前后路手术治疗多节段脊髓型颈椎病疗效对比观察[J].山东医药,2018,58(23):85-88.
[8]马原,高帅,阎朝辉,等.多节段颈椎病前路减压植骨内固定临床效果评价[J].中国矫形外科杂志,2012,20(17):1576-1579.
[9]石磊,陈德玉,史建刚,等.颈椎前路手术中硬膜损伤的预防与治疗[J].脊柱外科杂志,2017,15(3):156-160.
[10]Qi Q,Chen Y,Ling Z,et al.Modified laminoplasty Preserving the Posterior deep extensor insertion into C2 improves clinical and radiological results compared with conventional laminoplasty:Ameta-analysis.World Neurosurg.2018;111:157-165.
[11]Kimura A,Shiraishi Y,Inoue H,et al.Predictors of Persistent axial neck Pain after cervical laminoPlasty.Spine.2018;43(2):10-15.
[12]Lian XF,Xu JG,Zeng BF,et al.Noncontiguous anterior decompression and fusion for multilevel cervical spondylotic myelopathy:a prospective randomized control clinical study.Eur Spine J.2010;19(5):713-719.
[13]侯铁胜,严宁,虞舜志,等.前路手术治疗4节段脊髓型颈椎病的疗效分析[J].中华骨科杂志,2015,35(11):1129-1135.
[14]赖超博,刘斌.多节段脊髓型颈椎病前路手术治疗进展[J].生物骨科材料与临床研究,2017,14(6):64-68+72.
[15]张德生,董芳.椎间高度和颈椎曲度的变化对颈椎前路手术患者神经功能及轴性症状的影响[J].颈腰痛杂志,2017,38(6):602-603.
[16]何达,赵经纬,田伟.下颈椎前路间盘切除融合术与椎体次全切除融合术[J].骨科临床与研究杂志,2018,3(1):52-56.
[17]林栋,陈长青,林东,等.保留与切除钩椎关节在颈前路手术的临床效果比较[J].中国矫形外科杂志,2018,26(1):11-16.
[18]王荣生,石裕明,刘雄业,等.颈前路手术后出现早期并发症的相关因素分析[J].颈腰痛杂志,2018,39(3):269-272.
[19]Okamoto A,Shinomiya K,Furuya K,et al.Reduced neck movement after operation for cervical spondylotic myelopathy.Int Orthop.2015;19:295-297.
[20]张年春,任先军,张峡,等.保留与未保留终板的颈椎前路减压植骨融合术对融合节段高度的影响[J].脊柱外科杂志,2003,1(3):141-144
[21]Shou F,Li Z,Wang H,et al.Prevalence of C5 nerve root palsy after cervical decompressive surgery:a meta-analysis.Eur Spine J.2015;24(12):2724-2734.
[22]Alonso F,Voin V,Iwanaga J,et al.potential mechanism for some postoperative C5 Palsies:an anatomical study.Spine.2018;43(3):161-166.
[23]关立,汪文龙,海涌,等.颈椎前路非融合术与前路融合术治疗颈椎病的中期疗效比较[J].中华医学杂志,2016,96(25):1991-1996.
[24]Gu Y,Shi J,Cao P,et al.Clinical and imaging predictors of surgical outcome in multilevel cervical ossification of posterior longitudinal ligament:An analysis of 184 patients.PLoS One.2015;10(9):e0136042.
[25]甘立猛,鲁世保,孙文志,等.前路椎体次全切与椎间盘切除减压植骨融合内固定术治疗双节段颈椎病的临床疗效比较[J].北京医学,2016,38(7):631-637.
[26]Eicker SO,Steiger HJ,Elkathib M.Transtubular microsurgical approach to treat lateral cervical disc herniation.World Neurosurg.2016;88:503-509.
[27]Hartman J.Anatomy and clinical significance of the uncinate process and uncovertebral joint:a comprehensive review.Clin Anat.2014;27(3):431-440.
[28]刘长安,张卫平,王凌云,等.颈椎前路多节段椎体次全切减压植骨融合内固定术治疗多节段脊髓型颈椎病[J].解放军医药杂志,2015,27(4):24-27.
[29]姚高文,汪卫,周永强.前路不同手术方式治疗脊髓型颈椎病疗效分析[J].中国骨与关节损伤杂志,2015,30(6):1-2.
[30]Rieger A,Holz C,Marx T,Sanchin L,et al.Vertebral autograft used as bone transplant for anterior cervical corpectomy technical note.Neurosurgery.2003;52(2):449-453.
[31]Tetreault L,Ibrahim A,C?téP,et al.A systematic review of clinical and surgical predictors of complications following surgery for degenerative cervical myeloPathy.J Neurosurg SPine.2016;24(1):77-99.
[32]陈德玉,贾连顺,赵定麟,等.颈椎病前路减压术后再手术[J].中华骨科杂志,2002,22(3):134-137.
[33]Woods BI,Hohl J,Lee J,et al.Laminoplasty versus laminectomy and fusion for multilevel cervical spondylotic myelopathy.Clin Orthop Relat Res.2011;469(3):688-695.
[34]Liu JM,Peng HW,Liu ZL,et al.Hybrid decompression technique versus anterior cervical corpectomy and fusion for treating multilevel cervical spondylotic myelopathy:which one is better.World Neurosurg.2015;84(6):2022-2029.
[35]Shi JS,Lin B,Xue C,et al.Clinical and radiological outcomes following hybrid surgery in the treatment of multi level cervical spondylosis:over a 2 year follow Up.J Orthop Surg Res.2015;10:185.
[36]许良,孔鹏,徐展望.颈前路椎体次全切减压钛网植骨融合联合钛板固定治疗多节段脊髓型颈椎病[J].中国骨伤,2016,29(3):211-215.
[2]Wang H,Ma L,Yang D,et al.Incidence and risk factors of postoperative adjacent segment degeneration following anterior decompression and instrumented fusion for degenerative disorders of the cervical spine.World Neurosurg.2017;105:78-85.
[3]Wang T,Wang H,Liu S,et al.Anterior cervical discectomy and fusion versus anterior cervical corPectomy and fusion in multilevel cervical spondylotic myelopathy:A meta-analysis.Medicine(Baltimore).2016;95(49):e5437.
[4]Park JH,Kim JH,Roh SW,et al.prognostic factor analysis after surgical decompression and stabilization for cervical spinal-cord injury.Br J Neurosurg.2017;31(2):194-198.
[5]周非非,孙宇,张凤山,等.颈椎前路椎间盘切除、植骨融合内固定术治疗脊髓型颈椎病术后轴性症状的前瞻性研究[J].中国脊柱脊髓杂志,2014,24(6):505-509.
[6]Kouyoumdjian P,Guerin P,Schanelderle C,et al.Fracture of the lower cervical spine in patients withankylosing spondylitis:retrosPective study of 19 cases.Orthop Traumatol Surg Res.2012;98(5):543-551.
[7]任志伟,杜恒,杨益民,等.颈椎前后路手术治疗多节段脊髓型颈椎病疗效对比观察[J].山东医药,2018,58(23):85-88.
[8]马原,高帅,阎朝辉,等.多节段颈椎病前路减压植骨内固定临床效果评价[J].中国矫形外科杂志,2012,20(17):1576-1579.
[9]石磊,陈德玉,史建刚,等.颈椎前路手术中硬膜损伤的预防与治疗[J].脊柱外科杂志,2017,15(3):156-160.
[10]Qi Q,Chen Y,Ling Z,et al.Modified laminoplasty Preserving the Posterior deep extensor insertion into C2 improves clinical and radiological results compared with conventional laminoplasty:Ameta-analysis.World Neurosurg.2018;111:157-165.
[11]Kimura A,Shiraishi Y,Inoue H,et al.Predictors of Persistent axial neck Pain after cervical laminoPlasty.Spine.2018;43(2):10-15.
[12]Lian XF,Xu JG,Zeng BF,et al.Noncontiguous anterior decompression and fusion for multilevel cervical spondylotic myelopathy:a prospective randomized control clinical study.Eur Spine J.2010;19(5):713-719.
[13]侯铁胜,严宁,虞舜志,等.前路手术治疗4节段脊髓型颈椎病的疗效分析[J].中华骨科杂志,2015,35(11):1129-1135.
[14]赖超博,刘斌.多节段脊髓型颈椎病前路手术治疗进展[J].生物骨科材料与临床研究,2017,14(6):64-68+72.
[15]张德生,董芳.椎间高度和颈椎曲度的变化对颈椎前路手术患者神经功能及轴性症状的影响[J].颈腰痛杂志,2017,38(6):602-603.
[16]何达,赵经纬,田伟.下颈椎前路间盘切除融合术与椎体次全切除融合术[J].骨科临床与研究杂志,2018,3(1):52-56.
[17]林栋,陈长青,林东,等.保留与切除钩椎关节在颈前路手术的临床效果比较[J].中国矫形外科杂志,2018,26(1):11-16.
[18]王荣生,石裕明,刘雄业,等.颈前路手术后出现早期并发症的相关因素分析[J].颈腰痛杂志,2018,39(3):269-272.
[19]Okamoto A,Shinomiya K,Furuya K,et al.Reduced neck movement after operation for cervical spondylotic myelopathy.Int Orthop.2015;19:295-297.
[20]张年春,任先军,张峡,等.保留与未保留终板的颈椎前路减压植骨融合术对融合节段高度的影响[J].脊柱外科杂志,2003,1(3):141-144
[21]Shou F,Li Z,Wang H,et al.Prevalence of C5 nerve root palsy after cervical decompressive surgery:a meta-analysis.Eur Spine J.2015;24(12):2724-2734.
[22]Alonso F,Voin V,Iwanaga J,et al.potential mechanism for some postoperative C5 Palsies:an anatomical study.Spine.2018;43(3):161-166.
[23]关立,汪文龙,海涌,等.颈椎前路非融合术与前路融合术治疗颈椎病的中期疗效比较[J].中华医学杂志,2016,96(25):1991-1996.
[24]Gu Y,Shi J,Cao P,et al.Clinical and imaging predictors of surgical outcome in multilevel cervical ossification of posterior longitudinal ligament:An analysis of 184 patients.PLoS One.2015;10(9):e0136042.
[25]甘立猛,鲁世保,孙文志,等.前路椎体次全切与椎间盘切除减压植骨融合内固定术治疗双节段颈椎病的临床疗效比较[J].北京医学,2016,38(7):631-637.
[26]Eicker SO,Steiger HJ,Elkathib M.Transtubular microsurgical approach to treat lateral cervical disc herniation.World Neurosurg.2016;88:503-509.
[27]Hartman J.Anatomy and clinical significance of the uncinate process and uncovertebral joint:a comprehensive review.Clin Anat.2014;27(3):431-440.
[28]刘长安,张卫平,王凌云,等.颈椎前路多节段椎体次全切减压植骨融合内固定术治疗多节段脊髓型颈椎病[J].解放军医药杂志,2015,27(4):24-27.
[29]姚高文,汪卫,周永强.前路不同手术方式治疗脊髓型颈椎病疗效分析[J].中国骨与关节损伤杂志,2015,30(6):1-2.
[30]Rieger A,Holz C,Marx T,Sanchin L,et al.Vertebral autograft used as bone transplant for anterior cervical corpectomy technical note.Neurosurgery.2003;52(2):449-453.
[31]Tetreault L,Ibrahim A,C?téP,et al.A systematic review of clinical and surgical predictors of complications following surgery for degenerative cervical myeloPathy.J Neurosurg SPine.2016;24(1):77-99.
[32]陈德玉,贾连顺,赵定麟,等.颈椎病前路减压术后再手术[J].中华骨科杂志,2002,22(3):134-137.
[33]Woods BI,Hohl J,Lee J,et al.Laminoplasty versus laminectomy and fusion for multilevel cervical spondylotic myelopathy.Clin Orthop Relat Res.2011;469(3):688-695.
[34]Liu JM,Peng HW,Liu ZL,et al.Hybrid decompression technique versus anterior cervical corpectomy and fusion for treating multilevel cervical spondylotic myelopathy:which one is better.World Neurosurg.2015;84(6):2022-2029.
[35]Shi JS,Lin B,Xue C,et al.Clinical and radiological outcomes following hybrid surgery in the treatment of multi level cervical spondylosis:over a 2 year follow Up.J Orthop Surg Res.2015;10:185.
[36]许良,孔鹏,徐展望.颈前路椎体次全切减压钛网植骨融合联合钛板固定治疗多节段脊髓型颈椎病[J].中国骨伤,2016,29(3):211-215.