颈椎后路单开门椎管扩大成形术中应用不同数量钛板内固定的临床疗效分析
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摘要
目的:比较多节段脊髓型颈椎病行颈椎后路单开门椎管扩大成形术中,应用2枚钛板与4枚钛板手术疗效的差异。方法:对2010年7月～2017年12月因多节段脊髓型颈椎病在我院行颈椎后路C3～C6单开门钛板固定椎管扩大成形术治疗的65例患者进行回顾性研究。其中男47例、女18例,平均年龄58.3±10.2岁,病程3d～20年,术前JOA评分平均11.3±2.9分。根据术中钛板使用数量的不同,分为2枚钛板组(A组,n=49)和4枚钛板组(B组,n=16)。记录两组患者手术时间、术中出血量、术后住院天数、耗材费用、JOA评分;记录手术相关并发症(轴性症状、C5神经根麻痹、螺钉松动、再关门、颈椎后凸);应用影像学评估颈椎曲度(Giovanni D值法)、C2～C7 Cobb角、C3～C6椎管矢状径以及Pavlov比值变化情况。结果:术后平均随访29.7±22.9个月。两组患者基线资料的差异无统计学意义(P>0.05)。组间比较两组患者手术时间、术中出血量、术后住院天数、JOA改善率及并发症发生率差异均无统计学意义(P>0.05)。耗材费用A组为48850±2783元,B组为82474±26121元,两组间比较差异有统计学意义(P<0.001)。术后6个月与术前差值比较C4椎管矢状径、C4 Pavlov比值两组间差异有统计学意义(P<0.01)。组内比较末次随访时两组JOA评分,术后6个月C3～C6椎管矢状径、C3～C6Pavlov比值较术前均有明显改善,差异有统计学意义(P<0.05);颈椎曲度、C2～C7 Cobb角术后6个月随访时较术前均有减小的趋势,A组差异有统计学意义(P<0.05),B组差异无统计学意义(P>0.05)。结论:颈椎后路单开门椎管扩大成形术中应用2枚或4枚钛板固定均可达到有效支撑防止再关门,术后均可出现颈椎生理曲度变直或后凸的趋势。应用4枚钛板固定在维持颈椎曲度及减少术后并发症方面无明显优势。
Objectives: To compare the clinical effect of fixation with two plates versus four plates in expansive open-door cervical laminoplasty. Methods: A retrospective study was performed on 65 patients with multi-segmental cervical spondylotic myelopathy who underwent C3-C6 single-door titanium plate fixation for spinal canal enlargement from July 2010 to December 2017. According to the number of titanium plates used in the operation, the patients were placed into either a two-titanium-plate group(n=49) or a four-titaniumplate group(n=16). There were 47 males and 18 females with an average age of 58.3±10.2 years. The course of disease ranged from 3 days to 20 years. The preoperative JOA score was 11.3 ±2.9 points. The average follow-up time was 29.7±22.9 months. The operation time, intraoperative blood loss, postoperative hospital stay, consumables cost and JOA score were recorded in both groups. Surgical complications were recorded, including the development of axial symptoms, C5 nerve root paralysis, postoperative screw loosening, re-closing and cervical kyphosis. Imaging evaluation programs included cervical curvature(Giovanni D value), C2-C7 Cobb angle, C3-C6 spinal sagittal diameter and Pavlov ratio. Results: There were no significant differences in baseline data between the two groups(P>0.05). There were no significant differences between the two groups in terms of operation time, intraoperative blood loss, postoperative hospital stay, JOA improvement rate and the rate of surgical complications(P>0.05). The cost of consumables was significantly different(P<0.001). There was statistically significant difference in the ratio of C4 spinal sagittal diameter and C4 Pavlov between before surgery and 6 months after surgery(P <0.01). The JOA scores at the final follow-up, the anteroposterior diameter of C3-C6 and the C3-C6 Pavlov ratio were significantly improved at 6 months after surgery, and the difference was statistically significant(P <0.05). Cervical curvature and the C2-C7 Cobb angle had a decreasing trend at the 6-month follow-up compared with preoperative values. There was significant difference when two titanium plates were used(P<0.05), but no difference when four titanium plates were used(P>0.05).Conclusions: Both groups can achieve effective support to prevent re-closure, and the improvement rate at the final follow-up is greatly improved. The tendency for the cervical curvature to straighten or become kyphotic appeared in both groups. There is insufficient evidence to suggest that four titanium plates are superior in maintaining cervical curvature and reducing postoperative complications.
Objectives: To compare the clinical effect of fixation with two plates versus four plates in expansive open-door cervical laminoplasty. Methods: A retrospective study was performed on 65 patients with multi-segmental cervical spondylotic myelopathy who underwent C3-C6 single-door titanium plate fixation for spinal canal enlargement from July 2010 to December 2017. According to the number of titanium plates used in the operation, the patients were placed into either a two-titanium-plate group(n=49) or a four-titaniumplate group(n=16). There were 47 males and 18 females with an average age of 58.3±10.2 years. The course of disease ranged from 3 days to 20 years. The preoperative JOA score was 11.3 ±2.9 points. The average follow-up time was 29.7±22.9 months. The operation time, intraoperative blood loss, postoperative hospital stay, consumables cost and JOA score were recorded in both groups. Surgical complications were recorded, including the development of axial symptoms, C5 nerve root paralysis, postoperative screw loosening, re-closing and cervical kyphosis. Imaging evaluation programs included cervical curvature(Giovanni D value), C2-C7 Cobb angle, C3-C6 spinal sagittal diameter and Pavlov ratio. Results: There were no significant differences in baseline data between the two groups(P>0.05). There were no significant differences between the two groups in terms of operation time, intraoperative blood loss, postoperative hospital stay, JOA improvement rate and the rate of surgical complications(P>0.05). The cost of consumables was significantly different(P<0.001). There was statistically significant difference in the ratio of C4 spinal sagittal diameter and C4 Pavlov between before surgery and 6 months after surgery(P <0.01). The JOA scores at the final follow-up, the anteroposterior diameter of C3-C6 and the C3-C6 Pavlov ratio were significantly improved at 6 months after surgery, and the difference was statistically significant(P <0.05). Cervical curvature and the C2-C7 Cobb angle had a decreasing trend at the 6-month follow-up compared with preoperative values. There was significant difference when two titanium plates were used(P<0.05), but no difference when four titanium plates were used(P>0.05).Conclusions: Both groups can achieve effective support to prevent re-closure, and the improvement rate at the final follow-up is greatly improved. The tendency for the cervical curvature to straighten or become kyphotic appeared in both groups. There is insufficient evidence to suggest that four titanium plates are superior in maintaining cervical curvature and reducing postoperative complications.
引文
1.Hirabayashi K,Watanabe K,Wakano K,et al.Expansive open-door laminoplasty for cervical spinal stenotic myelopathy[J].Spine,1983,8(7):693-699.
2.Park AE,Heller JG.Cervical laminoplasty:use of a novel titanium plate to maintain canal expansion-surgical technique[J].J Spinal Disord Tech,2004,17(4):265-271.
3.Cheung JPY,Cheung PWH,Cheung AYL,et al.Comparable clinical and radiological outcomes between skipped-level and all-level plating for open-door laminoplasty[J].Eur Spine J,2018,27(6):1365-1374.
4.Wang ZF,Chen GD,Xue F,et al.All levels versus alternate levels plate fixation in expansive open door cervical laminoplasty[J].Indian J Orthop,2014,48(6):582-586.
5.Yang HL,Chen GD,Zhang HT,et al.Open-door laminoplasty with plate fixation at alternating levels for treatment of multilevel degenerative cervical disease[J].J Spinal Disord Tech,2013,26(1):E13-18.
6.赵定麟,张文明,徐印坎,等.对颈椎椎管矢状径的研究:附200例X线片对比观察[J].解放军医学杂志,1982,7(6):324-327.
7.Pavlov H,Torg JS,Robie B,et al.Cervical spinal stenosis:determination with vertebral body ratio method[J].Radiology,1987,164(3):771-775.
8.Hirabayashi K,Miyakawa J,Satomi K,et al.Operative results and postoperative progression of ossification among patients with ossification of cervical posterior longitudinal ligament[J].Spine,1981,6(4):354-364.
9.Sakaura H,Hosono N,Mukai Y,et al.C5 palsy after decompression surgery for cervical myelopathy:review of the literature[J].Spine,2003,28(21):2447-2451.
10.Matsumoto M,Watanabe K,Tsuji T,et al.Risk factors for closure of lamina after open-door laminoplasty[J].J Neurosurg Spine,2008,9(6):530-537.
11.Suda K,Abumi K,Ito M,et al.Local kyphosis reduces surgical outcomes of expansive open-door laminoplasty for cervical spondylotic myelopathy[J].Spine,2003,28(12):1258-1262.
12.Tamai K,Suzuki A,Terai H,et al.Laminar closure after expansive open-door laminoplasty:fixation methods and cervical alignments impact on the laminar closure and surgical outcomes[J].Spine J,2016,16(9):1062-1069.
13.McLaughlin MR,Wahlig JB,Pollack IF.Incidence of postlaminectomy kyphosis after Chiari decompression[J].Spine,1997,22(6):613-617.
14.Hukuda S,Ogata M,Mochizuki T,et al.Laminectomy versus laminoplasty for cervical myelopathy:brief report[J].J Bone Joint Surg Br,1988,70(2):325-326.
15.Matsunaga S,Sakou T,Nakanisi K.Analysis of the cervical spine alignment following laminoplasty and laminectomy[J].Spinal Cord,1999,37(1):20-24.
16.Yonenobu K,Hosono N,Iwasaki M,et al.Laminoplasty versus subtotal corpectomy:a comparative study of results in multisegmental cervical spondylotic myelopathy[J].Spine,1992,17(11):1281-1284.
17.Liu J,Ebraheim NA,Sanford CG Jr,et al.Preservation of the spinous process-ligament-muscle complex to prevent kyphotic deformity following laminoplasty[J].Spine J,2007,7(2):159-164.
18.Lin S,Zhou F,Sun Y,et al.The severity of operative invasion to the posterior muscular-ligament complex influences cervical sagittal balance after open-door laminoplasty[J].Eur Spine J,2015,24(1):127-135.
19.Kawaguchi Y,Matsui H,Ishihara H,et al.Axial symptoms after en bloc cervical laminoplasty[J].J Spinal Disord,1999,12(5):392-395.
20.Wang M,Luo XJ,Deng QX,et al.Prevalence of axial symptoms after posterior cervical decompression:a metaanalysis[J].Eur Spine J,2016,25(7):2302-2310.
21.Wang SJ,Jiang SD,Jiang LS,et al.Axial pain after posterior cervical spine surgery:a systematic review[J].Eur Spine J,2011,20(2):185-194.
22.Wang T,Wang H,Liu S,et al.Incidence of C5 nerve root palsy after cervical surgery:A meta-analysis for last decade[J].Medicine(Baltimore),2017,96(45):e8560.doi:10.1097/MD.0000000000008560.
23.Uematsu Y,Tokuhashi Y,Matsuzaki H.Radiculopathy after laminoplasty of the cervical spine[J].Spine,1998,23(19):2057-2062.
2.Park AE,Heller JG.Cervical laminoplasty:use of a novel titanium plate to maintain canal expansion-surgical technique[J].J Spinal Disord Tech,2004,17(4):265-271.
3.Cheung JPY,Cheung PWH,Cheung AYL,et al.Comparable clinical and radiological outcomes between skipped-level and all-level plating for open-door laminoplasty[J].Eur Spine J,2018,27(6):1365-1374.
4.Wang ZF,Chen GD,Xue F,et al.All levels versus alternate levels plate fixation in expansive open door cervical laminoplasty[J].Indian J Orthop,2014,48(6):582-586.
5.Yang HL,Chen GD,Zhang HT,et al.Open-door laminoplasty with plate fixation at alternating levels for treatment of multilevel degenerative cervical disease[J].J Spinal Disord Tech,2013,26(1):E13-18.
6.赵定麟,张文明,徐印坎,等.对颈椎椎管矢状径的研究:附200例X线片对比观察[J].解放军医学杂志,1982,7(6):324-327.
7.Pavlov H,Torg JS,Robie B,et al.Cervical spinal stenosis:determination with vertebral body ratio method[J].Radiology,1987,164(3):771-775.
8.Hirabayashi K,Miyakawa J,Satomi K,et al.Operative results and postoperative progression of ossification among patients with ossification of cervical posterior longitudinal ligament[J].Spine,1981,6(4):354-364.
9.Sakaura H,Hosono N,Mukai Y,et al.C5 palsy after decompression surgery for cervical myelopathy:review of the literature[J].Spine,2003,28(21):2447-2451.
10.Matsumoto M,Watanabe K,Tsuji T,et al.Risk factors for closure of lamina after open-door laminoplasty[J].J Neurosurg Spine,2008,9(6):530-537.
11.Suda K,Abumi K,Ito M,et al.Local kyphosis reduces surgical outcomes of expansive open-door laminoplasty for cervical spondylotic myelopathy[J].Spine,2003,28(12):1258-1262.
12.Tamai K,Suzuki A,Terai H,et al.Laminar closure after expansive open-door laminoplasty:fixation methods and cervical alignments impact on the laminar closure and surgical outcomes[J].Spine J,2016,16(9):1062-1069.
13.McLaughlin MR,Wahlig JB,Pollack IF.Incidence of postlaminectomy kyphosis after Chiari decompression[J].Spine,1997,22(6):613-617.
14.Hukuda S,Ogata M,Mochizuki T,et al.Laminectomy versus laminoplasty for cervical myelopathy:brief report[J].J Bone Joint Surg Br,1988,70(2):325-326.
15.Matsunaga S,Sakou T,Nakanisi K.Analysis of the cervical spine alignment following laminoplasty and laminectomy[J].Spinal Cord,1999,37(1):20-24.
16.Yonenobu K,Hosono N,Iwasaki M,et al.Laminoplasty versus subtotal corpectomy:a comparative study of results in multisegmental cervical spondylotic myelopathy[J].Spine,1992,17(11):1281-1284.
17.Liu J,Ebraheim NA,Sanford CG Jr,et al.Preservation of the spinous process-ligament-muscle complex to prevent kyphotic deformity following laminoplasty[J].Spine J,2007,7(2):159-164.
18.Lin S,Zhou F,Sun Y,et al.The severity of operative invasion to the posterior muscular-ligament complex influences cervical sagittal balance after open-door laminoplasty[J].Eur Spine J,2015,24(1):127-135.
19.Kawaguchi Y,Matsui H,Ishihara H,et al.Axial symptoms after en bloc cervical laminoplasty[J].J Spinal Disord,1999,12(5):392-395.
20.Wang M,Luo XJ,Deng QX,et al.Prevalence of axial symptoms after posterior cervical decompression:a metaanalysis[J].Eur Spine J,2016,25(7):2302-2310.
21.Wang SJ,Jiang SD,Jiang LS,et al.Axial pain after posterior cervical spine surgery:a systematic review[J].Eur Spine J,2011,20(2):185-194.
22.Wang T,Wang H,Liu S,et al.Incidence of C5 nerve root palsy after cervical surgery:A meta-analysis for last decade[J].Medicine(Baltimore),2017,96(45):e8560.doi:10.1097/MD.0000000000008560.
23.Uematsu Y,Tokuhashi Y,Matsuzaki H.Radiculopathy after laminoplasty of the cervical spine[J].Spine,1998,23(19):2057-2062.