颈椎前路椎间盘切除减压不同融合节段对脊柱-骨盆矢状位平衡的影响
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摘要
目的探讨颈椎前路椎间盘切除减压椎间融合术(anterior cervical discectomy and fusion,ACDF)术中融合节段数量对脊柱-骨盆矢状位平衡的影响。方法回顾分析2010年1月—2016年12月326例因脊髓型颈椎病接受ACDF治疗的患者临床资料。男175例,女151例;年龄34~81岁,平均56岁。融合节段:单节段69例,双节段85例,三节段90例,四节段82例。患者术前及术后12个月摄脊柱全长正侧位X线片,测量并比较脊柱-骨盆矢状位参数,包括:C_(0~2) Cobb角、C_(2~7) Cobb角、C_(2~7)矢状垂直距离(C_(2-7) sagittal vertical axis,C_(2-7) SVA)、T_1倾斜角(T_1 slope,T_1S)、胸廓入口角(thoracic inlet angle,TIA)、胸椎后凸角(thoracic kyphosis,TK)、腰椎前凸角(lumbar lordosis,LL)、骨盆入射角(pelvic incidence,PI)、骶骨倾斜角(sacral slope,SS)、C7矢状位平衡(C7sagittal vertical axis,C7 SVA)、T_1骨盆角(T_1 pelvic angle,TPA)。比较术前及术后12个月颈椎日本骨科协会(JOA)评分、颈椎及上肢疼痛视觉模拟评分(VAS)。对手术前后LL、PI、SS、C7 SVA及TPA进行Pearson相关性分析,评估ACDF术后下腰段脊柱-骨盆拟合关系变化。结果 326例患者术后均获随访,随访时间12~32个月,平均18.5个月。随访期间内固定物在位,无脊髓神经及周围软组织损伤。术后12个月JOA及颈椎VAS评分均较术前显著改善(P<0.05),双上肢VAS评分与术前比较差异无统计学意义(P>0.05)。4组间术前颈椎VAS评分及术后12个月JOA评分比较差异有统计学意义(P<0.05)。术后12个月,单节段融合组各脊柱-骨盆矢状位参数与术前比较,差异均无统计学意义(P>0.05)。双节段、三节段及四节段融合组C_(0~2) Cobb角、C_(2~7) Cobb角、C_(2-7)SVA、T_1S、TIA、C7 SVA及TPA均较术前显著增加(P<0.05)。4组间比较术前及术后12个月C_(0~2) Cobb角、C_(2~7)Cobb角、T_1S、C7 SVA及TPA差异有统计学意义(P<0.05)。术后12个月双节段、三节段、四节段融合组的C7 SVA及TPA改变量均显著大于单节段融合组(P<0.05);双节段、三节段、四节段融合组间比较差异无统计学意义(P>0.05)。手术前后各组PI与LL、SS均成正相关(P<0.05)。结论脊髓型颈椎病患者具有生理状态下腰椎与骨盆正常拟合关系,而且ACDF不能改变这一特定关系;单节段融合后脊柱-骨盆矢状位序列无变化,而双节段及多节段融合后脊柱-骨盆矢状位平衡改变。
Objective To explore the effect on sagittal spine-pelvis balance of different fusion segments in anterior cervical discectomy and fusion(ACDF). Methods The clinical data of 326 patients with cervical spondylotic myelopathy, treated by ACDF between January 2010 and December 2016, was retrospectively analysed. There were175 males and 151 females with an average age of 56 years(range, 34-81 years). Fusion segments included single segment in 69 cases, double segments in 85 cases, three segments in 90 cases, and four segments in 82 cases. Full spine anterolateral X-ray films were performed before operation and at 12 months after operation. The spine-pelvis parameters of fusion segments were measured and compared. The parameters included C_(0-2) Cobb angle, C_(2-7) Cobb angle, C_(2-7) sagittal vertical axis(C_(2-7) SVA), T_1 slope(T_1 S), thoracic inlet angle(TIA), thoracic kyphosis(TK), lumbar lordosis(LL), pelvic incidence(PI), sacral slope(SS), C_7 sagittal vertical axis(C_7 SVA), T_1 pelvic angle(TPA). The Japanese Orthopaedic Association(JOA) score of cervical spine and visual analogue scale(VAS) scores of pain of cervical spine and upper extremity were compared before operation and at 12 months after operation. Pearson correlation analysis was performed on LL, PI, SS, C_7 SVA, and TPA before and after operation to evaluate the changes of spine-pelvis fitting relationship after ACDF. Results All 326 patients were followed up 12-32 months(mean, 18.5 months). During the follow-up period,internal fixator was in place, and no spinal cord nerve or peripheral soft tissue injury was found. JOA scores and cervical VAS scores improved significantly at 12 months after operation(P<0.05), no significant difference was found in VAS scores of upper extremity when compared with preoperative scores(P>0.05). The preoperative cervical VAS scores and the postoperative JOA scores at 12 months had significant differences between groups(P<0.05). At 12 months after operation, there was no significant difference in sagittal spine-pelvis parameters in the single segment group compared with preoperative ones(P>0.05); but the C_(0-2)Cobb angle, C_(2-7) Cobb angle, C_(2-7) SVA, T_1 S, TIA, C_7 SVA, and TPA in the double segments, three segments, and four segments groups were significant larger than preoperative ones(P<0.05). The C_(0-2)Cobb angle, C_(2-7) Cobb angle, T_1 S, C_7 SVA, and TPA among 4 groups had significant differences before operation and at12 months after operation(P<0.05). At 12 months after operation, the changes of C_7 SVA and TPA in the double segments, three segments, and four segments groups were significantly larger than those in the single segment group(P<0.05). PI had positive correlations with LL and SS before and after operation in 4 groups(P<0.05). Conclusion Normal fitting relationship between lumbar spine and pelvis in physiological state also exists in patients with cervical spondylotic myelopathy, and ACDF can not change this specific relationship. In patients with cervical spondylotic myelopathy, the sagittal spine-pelvis sequence do not change after ACDF single-level fusion, while the sagittal spine-pelvis balance change after double-level and multi-level fusion.
Objective To explore the effect on sagittal spine-pelvis balance of different fusion segments in anterior cervical discectomy and fusion(ACDF). Methods The clinical data of 326 patients with cervical spondylotic myelopathy, treated by ACDF between January 2010 and December 2016, was retrospectively analysed. There were175 males and 151 females with an average age of 56 years(range, 34-81 years). Fusion segments included single segment in 69 cases, double segments in 85 cases, three segments in 90 cases, and four segments in 82 cases. Full spine anterolateral X-ray films were performed before operation and at 12 months after operation. The spine-pelvis parameters of fusion segments were measured and compared. The parameters included C_(0-2) Cobb angle, C_(2-7) Cobb angle, C_(2-7) sagittal vertical axis(C_(2-7) SVA), T_1 slope(T_1 S), thoracic inlet angle(TIA), thoracic kyphosis(TK), lumbar lordosis(LL), pelvic incidence(PI), sacral slope(SS), C_7 sagittal vertical axis(C_7 SVA), T_1 pelvic angle(TPA). The Japanese Orthopaedic Association(JOA) score of cervical spine and visual analogue scale(VAS) scores of pain of cervical spine and upper extremity were compared before operation and at 12 months after operation. Pearson correlation analysis was performed on LL, PI, SS, C_7 SVA, and TPA before and after operation to evaluate the changes of spine-pelvis fitting relationship after ACDF. Results All 326 patients were followed up 12-32 months(mean, 18.5 months). During the follow-up period,internal fixator was in place, and no spinal cord nerve or peripheral soft tissue injury was found. JOA scores and cervical VAS scores improved significantly at 12 months after operation(P<0.05), no significant difference was found in VAS scores of upper extremity when compared with preoperative scores(P>0.05). The preoperative cervical VAS scores and the postoperative JOA scores at 12 months had significant differences between groups(P<0.05). At 12 months after operation, there was no significant difference in sagittal spine-pelvis parameters in the single segment group compared with preoperative ones(P>0.05); but the C_(0-2)Cobb angle, C_(2-7) Cobb angle, C_(2-7) SVA, T_1 S, TIA, C_7 SVA, and TPA in the double segments, three segments, and four segments groups were significant larger than preoperative ones(P<0.05). The C_(0-2)Cobb angle, C_(2-7) Cobb angle, T_1 S, C_7 SVA, and TPA among 4 groups had significant differences before operation and at12 months after operation(P<0.05). At 12 months after operation, the changes of C_7 SVA and TPA in the double segments, three segments, and four segments groups were significantly larger than those in the single segment group(P<0.05). PI had positive correlations with LL and SS before and after operation in 4 groups(P<0.05). Conclusion Normal fitting relationship between lumbar spine and pelvis in physiological state also exists in patients with cervical spondylotic myelopathy, and ACDF can not change this specific relationship. In patients with cervical spondylotic myelopathy, the sagittal spine-pelvis sequence do not change after ACDF single-level fusion, while the sagittal spine-pelvis balance change after double-level and multi-level fusion.
引文
[1]刘涛,邱水强,黄宇峰,等.颈前路椎间融合术后矢状位参数变化与临床疗效的相关性研究.中华骨科杂志,2018, 38(2):79-85.
2宋卿鹏,田伟,何达,等.人工颈椎间盘角对人工颈椎间盘置换术后远期疗效的影响.中国修复重建外科杂志,2018, 32(5):526-530.
3 Gillis CC, Kaszuba MC, Traynelis VC. Cervical radiographic parameters in 1-and 2-level anterior cervical discectomy and fusion. J Neurosurg Spine, 2016, 25(4):421-429.
4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.中华骨科杂志,2015, 35(11):1129-1135.
5臧法智,陈华江,王建喜,等.T1倾斜角对颈椎后纵韧带骨化患者后路单开门椎板成形术后颈椎曲度的影响.脊柱外科杂志,2016, 14(1):26-29.
6杨洋,黎庆初,朱召银,等.双节段前路颈椎自锁式融合器融合术后矢状位影像学参数的变化.中国脊柱脊髓杂志,2016, 26(2):116-123.
7林圣荣,周非非,孙宇,等.颈后路单开门椎管扩大椎板成形术后颈椎矢状面平衡的变化.中华医学杂志,2014, 94(35):2726-2730.
8 Kim JH, Park JY, Yi S, et al. Anterior cervical discectomy and fusion alters whole-spine sagittal alignment. Yonsei Med J, 2015,56(4):1060-1070.
9赵文奎,于淼,韦峰,等.无症状成人颈椎矢状位曲度分析及其与全脊柱矢状位参数的关系.中脊柱脊髓杂志,2015, 25(3):231-238.
10刘涛,李浩曦,黄宇峰,等.下颈椎前路减压融合术后颈椎矢状位平衡的变化.中国脊柱脊髓杂志,2018, 28(6):496-502.
11李危石,孙卓然,陈仲强.正常脊柱-骨盆矢状位参数的影像学研究中华骨科杂志,2013, 33(5):447-453.
12王俊魁,刘宏建,寇宏伟,等.胸腰椎骨质疏松性椎体压缩性骨折患者脊柱-骨盆矢状位参数的研究.中国脊柱脊髓杂志,2016,26(5):408-414.
13孙卓然,李危石.骨盆矢状位形态参数在脊柱外科的应用.中华外科杂志,2012, 50(12):1147-1150.
14王智伟,刘臻,王渭君,等.正常汉族青少年骨盆矢状面形态的影像学研究.中国脊柱脊髓杂志,2012, 22(10):919-924.
15蔡思逸,花苏榕,袁青,等.骨盆参数及骨盆空间位置关系与腰椎稳定,性的相关性.中华医学杂志,2014, 94(17):1338-1341.
16乔军,邱勇,朱锋,等.T1骨盆角与退变性脊柱侧凸患者脊柱-骨盆矢状面平衡以及生活质量的相关性分析.中国脊柱脊髓杂志,2014, 24(8):686-690.
17徐宝山,马信龙.脊柱骨盆矢状面平衡的研究进展.中华医学杂志,2014, 94(39):3117-3120.
18 Barrey C, Roussouly P, Le Huec JC, et al. Compensatory mechanisms contributing to keep the sagittal balance of the spine.Eur Spine J, 2013, 22 Suppl 6:S834-841.
2宋卿鹏,田伟,何达,等.人工颈椎间盘角对人工颈椎间盘置换术后远期疗效的影响.中国修复重建外科杂志,2018, 32(5):526-530.
3 Gillis CC, Kaszuba MC, Traynelis VC. Cervical radiographic parameters in 1-and 2-level anterior cervical discectomy and fusion. J Neurosurg Spine, 2016, 25(4):421-429.
4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.中华骨科杂志,2015, 35(11):1129-1135.
5臧法智,陈华江,王建喜,等.T1倾斜角对颈椎后纵韧带骨化患者后路单开门椎板成形术后颈椎曲度的影响.脊柱外科杂志,2016, 14(1):26-29.
6杨洋,黎庆初,朱召银,等.双节段前路颈椎自锁式融合器融合术后矢状位影像学参数的变化.中国脊柱脊髓杂志,2016, 26(2):116-123.
7林圣荣,周非非,孙宇,等.颈后路单开门椎管扩大椎板成形术后颈椎矢状面平衡的变化.中华医学杂志,2014, 94(35):2726-2730.
8 Kim JH, Park JY, Yi S, et al. Anterior cervical discectomy and fusion alters whole-spine sagittal alignment. Yonsei Med J, 2015,56(4):1060-1070.
9赵文奎,于淼,韦峰,等.无症状成人颈椎矢状位曲度分析及其与全脊柱矢状位参数的关系.中脊柱脊髓杂志,2015, 25(3):231-238.
10刘涛,李浩曦,黄宇峰,等.下颈椎前路减压融合术后颈椎矢状位平衡的变化.中国脊柱脊髓杂志,2018, 28(6):496-502.
11李危石,孙卓然,陈仲强.正常脊柱-骨盆矢状位参数的影像学研究中华骨科杂志,2013, 33(5):447-453.
12王俊魁,刘宏建,寇宏伟,等.胸腰椎骨质疏松性椎体压缩性骨折患者脊柱-骨盆矢状位参数的研究.中国脊柱脊髓杂志,2016,26(5):408-414.
13孙卓然,李危石.骨盆矢状位形态参数在脊柱外科的应用.中华外科杂志,2012, 50(12):1147-1150.
14王智伟,刘臻,王渭君,等.正常汉族青少年骨盆矢状面形态的影像学研究.中国脊柱脊髓杂志,2012, 22(10):919-924.
15蔡思逸,花苏榕,袁青,等.骨盆参数及骨盆空间位置关系与腰椎稳定,性的相关性.中华医学杂志,2014, 94(17):1338-1341.
16乔军,邱勇,朱锋,等.T1骨盆角与退变性脊柱侧凸患者脊柱-骨盆矢状面平衡以及生活质量的相关性分析.中国脊柱脊髓杂志,2014, 24(8):686-690.
17徐宝山,马信龙.脊柱骨盆矢状面平衡的研究进展.中华医学杂志,2014, 94(39):3117-3120.
18 Barrey C, Roussouly P, Le Huec JC, et al. Compensatory mechanisms contributing to keep the sagittal balance of the spine.Eur Spine J, 2013, 22 Suppl 6:S834-841.