单开门对前方严重压迫的多节段脊髓型颈椎病的疗效及影响因素分析
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摘要
目的：研究后路单开门椎管扩大椎板成形术对前方严重压迫的多节段脊髓型颈椎病的疗效，并采用多元回归分析影响术后疗效的相关因素，以期为临床工作提供参考。
研究方法：2005年1月～2010年12月在我院行单开门椎管扩大椎板成形术的脊髓型颈椎病患者105例。依据术前MRI显示为脊髓前后方受压，存在椎间盘突出或后纵韧带骨化致椎管狭窄的病变节段在3个以上，同时至少有一个节段或以上椎管侵占率≥50％的多节段脊髓型颈椎病患者(multilevel cervical myelopathy, MCM)，定义为合并前方严重压迫的MCM。符合入选标准的患者55例，男45例，女10例，年龄40～84岁，平均59.3岁，其中因颈椎间盘突出导致椎管狭窄的患者41例，伴有后纵韧带骨化者14例，进行回顾性研究。所有患者均获得随访。随访时间18～84个月（平均37.1个月）。
（1）将患者分为两组，A组：19例术后存在前方残留压迫；B组：36例术后不存在前方残留压迫。比较和分析两组术后疗效及影像学资料。
（2）应用相关分析观察术后改善率与患者年龄、病程、术前JOA评分、脊髓后移距离、术前颈椎曲度、脊髓受压比率、椎管侵占率和随访时间等8项指标的相关性。
（3）应用多元回归分析得出术后改善率与上述因素中最有价值的参数间的回归模型。
结果：A、B两组间平均年龄、随访时间、术前JOA评分及术前术后颈椎曲度比较均无统计学差异（P>0.05）。两组间病程比较有统计学差异（P<0.05）。两组平均术后JOA评分均优于术前（P<0.05）。B组改善率（60.6±13.7）%优于A组改善率（33.9±33.5）%，两组间比较有统计学差异（P<0.05）。A组椎管侵占率及脊髓受压比率分别为(67.0±10.3)%和(20.6±10.8)%，B组分别为(59.7±8.1)%和(25.4±6.3)%。两组间椎管侵占率、脊髓受压比率比较均有统计学差异（P<0.05）。
获得随访的所有患者平均术前JOA评分为（10.7±1.7）分，术后JOA评分为（14.0±1.4）分，两者比较有显著差异（P<0.01）。术后JOA改善率为(51.4±25.7)%。相关分析结果显示术后改善率与患者病程、椎管侵占率、脊髓受压比率、脊髓后移距离之间的相关系数有显著性意义，而与年龄、术前JOA评分、术前颈椎曲度和随访时间的相关系数无显著性意义。多元回归分析显示与术后改善率最有价值的因素为患者的脊髓后移距离（=0.417,P=0.001）和脊髓受压比率（=0.387，P=0.003），回归模型的R2值为0.256。
结论：
1、单开门手术可用于治疗前方严重压迫的脊髓型颈椎病，是一种相对安全的术式。
2、尽管单开门术后患者脊髓前方受到残留压迫时会阻碍神经功能的恢复，但对于脊髓前方减压充分的患者，仍可以获得满意的疗效。
3、多元回归分析提示，患者术前的脊髓受压比率和单开门术后脊髓后移距离与术后改善率密切相关，可以作为判断术后疗效的较好指标。
Objective: To investigate the therapeutic effects of laminoplasty for multilevelcervical myelopathy with anterior massive compressive mass, and the multivariate linearregression analysis was used to identify the influencing factors of the surgical outcome.
Methods: From January2005to December2010, there were105consecutive patientswho underwent expansive laminoplasty for the treatment of cervical spondyloticmyelopathy in the First Affiliated Hospital of Soochow University. According to thepreoperative MRI showing multilevel anterior and posterior compression with obviousanterior compression(occupying ratio≥50%), a total of55patients with multilevel cervicalmyelopathy and anterior massive compressive mass were reviewed in this study. Therewere45men and10women, ranging in age from40to84years(average,59.3years),41patients with cervical disc herniation and14with ossified posterior longitudinal ligament.All55patients were available for follow-up. The average follow-up period were37.1months(18-84months).
(1)Patients were divided into2groups: group A:19patients who had residual anteriorcord compression; group B:36patients who had no residual anterior cord compression.Clinical outcome and radiologic evaluation were compared between the two groups.
(2)Univariate analysis was used to analyze whether age at the time of surgery,duration of symptoms, preoperative JOA score, posterior movement of the spinal cord,preoperative cervical curvature angle, spinal cord compression ratio, occupying rate andfollow-up period may affect the recovery rate of JOA score.
(3)The most effective combination of parameters for predicting prognosis wasdetermined using a multivariate linear regression analysis.
Results: There were no significant differences with regard to mean age, follow-upperiod, preoperative JOA score, preoperative and postoperative curvature angle betweenthe two groups(P>0.05). The mean postoperative JOA score was superior than preoperative JOA score in both A and B groups. The recovery rate of JOA scores was(33.9±33.5)%in group A and（60.6±13.7）%in group B, which showed significantdifferences between two groups(P<0.05). The occupying rate and spinal cord ratio in groupA were67.0%and20.6%respectively, in group B were59.7%and25.4%. Significantdifferences were found in occupying rate and spinal cord ratio between the twogroups(P<0.05).
Statistical analysis of all the cases revealed that the mean JOA score was10.7±1.7andthe postoperative JOA score was14.0±1.4, which showed significant differences (P<0.01).The mean postoperative recovery rate was (51.4±25.7)%. Significant relations were notedbetween the recovery rate and the duration of symptoms, occupying rate, spinal cord ratioand posterior movement of the spinal cord, but there were no significant relations betweenthe recovery rate and age at the time of surgery, duration of symptoms, preoperative JOAscore, preoperative cervical curvature angle and follow-up period. The multivariate linearregression analysis showed that the best combination of surgical outcome predictorsincluded posterior movement of the spinal cord （=0.417,P=0.001）and spinal cord ratio（=0.387，P=0.003）.R-squared of the final multiple linear regression model was0.256.
Conclusion:
1. Laminoplasty, recognized as a comparatively safe procedure, should be consideredas an effective treatment for multilevel cervical myelopathy with anterior massivecompressive mass.
2. Although neurologic recovery is inhibited by residual anterior cord compressionafter laminoplasty, patients with sufficient indirect anterior decompression after LAMP canalso obtain a good satisfactory results.
3. The multivariate linear regression analysis showed that the best combination ofsurgical outcome predictors included posterior movement of the spinal cord and spinalcord ratio, which can be used as good indicators to judge the surgical outcome.
研究方法：2005年1月～2010年12月在我院行单开门椎管扩大椎板成形术的脊髓型颈椎病患者105例。依据术前MRI显示为脊髓前后方受压，存在椎间盘突出或后纵韧带骨化致椎管狭窄的病变节段在3个以上，同时至少有一个节段或以上椎管侵占率≥50％的多节段脊髓型颈椎病患者(multilevel cervical myelopathy, MCM)，定义为合并前方严重压迫的MCM。符合入选标准的患者55例，男45例，女10例，年龄40～84岁，平均59.3岁，其中因颈椎间盘突出导致椎管狭窄的患者41例，伴有后纵韧带骨化者14例，进行回顾性研究。所有患者均获得随访。随访时间18～84个月（平均37.1个月）。
（1）将患者分为两组，A组：19例术后存在前方残留压迫；B组：36例术后不存在前方残留压迫。比较和分析两组术后疗效及影像学资料。
（2）应用相关分析观察术后改善率与患者年龄、病程、术前JOA评分、脊髓后移距离、术前颈椎曲度、脊髓受压比率、椎管侵占率和随访时间等8项指标的相关性。
（3）应用多元回归分析得出术后改善率与上述因素中最有价值的参数间的回归模型。
结果：A、B两组间平均年龄、随访时间、术前JOA评分及术前术后颈椎曲度比较均无统计学差异（P>0.05）。两组间病程比较有统计学差异（P<0.05）。两组平均术后JOA评分均优于术前（P<0.05）。B组改善率（60.6±13.7）%优于A组改善率（33.9±33.5）%，两组间比较有统计学差异（P<0.05）。A组椎管侵占率及脊髓受压比率分别为(67.0±10.3)%和(20.6±10.8)%，B组分别为(59.7±8.1)%和(25.4±6.3)%。两组间椎管侵占率、脊髓受压比率比较均有统计学差异（P<0.05）。
获得随访的所有患者平均术前JOA评分为（10.7±1.7）分，术后JOA评分为（14.0±1.4）分，两者比较有显著差异（P<0.01）。术后JOA改善率为(51.4±25.7)%。相关分析结果显示术后改善率与患者病程、椎管侵占率、脊髓受压比率、脊髓后移距离之间的相关系数有显著性意义，而与年龄、术前JOA评分、术前颈椎曲度和随访时间的相关系数无显著性意义。多元回归分析显示与术后改善率最有价值的因素为患者的脊髓后移距离（=0.417,P=0.001）和脊髓受压比率（=0.387，P=0.003），回归模型的R2值为0.256。
结论：
1、单开门手术可用于治疗前方严重压迫的脊髓型颈椎病，是一种相对安全的术式。
2、尽管单开门术后患者脊髓前方受到残留压迫时会阻碍神经功能的恢复，但对于脊髓前方减压充分的患者，仍可以获得满意的疗效。
3、多元回归分析提示，患者术前的脊髓受压比率和单开门术后脊髓后移距离与术后改善率密切相关，可以作为判断术后疗效的较好指标。
Objective: To investigate the therapeutic effects of laminoplasty for multilevelcervical myelopathy with anterior massive compressive mass, and the multivariate linearregression analysis was used to identify the influencing factors of the surgical outcome.
Methods: From January2005to December2010, there were105consecutive patientswho underwent expansive laminoplasty for the treatment of cervical spondyloticmyelopathy in the First Affiliated Hospital of Soochow University. According to thepreoperative MRI showing multilevel anterior and posterior compression with obviousanterior compression(occupying ratio≥50%), a total of55patients with multilevel cervicalmyelopathy and anterior massive compressive mass were reviewed in this study. Therewere45men and10women, ranging in age from40to84years(average,59.3years),41patients with cervical disc herniation and14with ossified posterior longitudinal ligament.All55patients were available for follow-up. The average follow-up period were37.1months(18-84months).
(1)Patients were divided into2groups: group A:19patients who had residual anteriorcord compression; group B:36patients who had no residual anterior cord compression.Clinical outcome and radiologic evaluation were compared between the two groups.
(2)Univariate analysis was used to analyze whether age at the time of surgery,duration of symptoms, preoperative JOA score, posterior movement of the spinal cord,preoperative cervical curvature angle, spinal cord compression ratio, occupying rate andfollow-up period may affect the recovery rate of JOA score.
(3)The most effective combination of parameters for predicting prognosis wasdetermined using a multivariate linear regression analysis.
Results: There were no significant differences with regard to mean age, follow-upperiod, preoperative JOA score, preoperative and postoperative curvature angle betweenthe two groups(P>0.05). The mean postoperative JOA score was superior than preoperative JOA score in both A and B groups. The recovery rate of JOA scores was(33.9±33.5)%in group A and（60.6±13.7）%in group B, which showed significantdifferences between two groups(P<0.05). The occupying rate and spinal cord ratio in groupA were67.0%and20.6%respectively, in group B were59.7%and25.4%. Significantdifferences were found in occupying rate and spinal cord ratio between the twogroups(P<0.05).
Statistical analysis of all the cases revealed that the mean JOA score was10.7±1.7andthe postoperative JOA score was14.0±1.4, which showed significant differences (P<0.01).The mean postoperative recovery rate was (51.4±25.7)%. Significant relations were notedbetween the recovery rate and the duration of symptoms, occupying rate, spinal cord ratioand posterior movement of the spinal cord, but there were no significant relations betweenthe recovery rate and age at the time of surgery, duration of symptoms, preoperative JOAscore, preoperative cervical curvature angle and follow-up period. The multivariate linearregression analysis showed that the best combination of surgical outcome predictorsincluded posterior movement of the spinal cord （=0.417,P=0.001）and spinal cord ratio（=0.387，P=0.003）.R-squared of the final multiple linear regression model was0.256.
Conclusion:
1. Laminoplasty, recognized as a comparatively safe procedure, should be consideredas an effective treatment for multilevel cervical myelopathy with anterior massivecompressive mass.
2. Although neurologic recovery is inhibited by residual anterior cord compressionafter laminoplasty, patients with sufficient indirect anterior decompression after LAMP canalso obtain a good satisfactory results.
3. The multivariate linear regression analysis showed that the best combination ofsurgical outcome predictors included posterior movement of the spinal cord and spinalcord ratio, which can be used as good indicators to judge the surgical outcome.
引文
[1]贾连顺,史建刚,脊髓型颈椎病的早期诊断与外科干预的研究进展.中国脊柱脊髓杂志,2001.11(4): p.254-256.
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[7] Hukuda, S., T. Mochizuki, M. Ogata, et al., Operations for cervical spondyloticmyelopathy. A comparison of the results of anterior and posterior procedures. Journalof Bone&Joint Surgery, British Volume,1985.67(4): p.609-615.
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[1] Liu, H., Y. Li, Y. Chen, et al., Cervical curvature, spinal cord MRIT2signal, andoccupying ratio impact surgical approach selection in patients with ossification of theposterior longitudinal ligament. European Spine Journal,2013: p.1-9.
[2]孙宇,潘胜发,张凤山, et al.,椎管狭窄合并巨大椎间盘突出或骨赘的脊髓型颈椎病的手术治疗.中国脊柱脊髓杂志,2006.16(5): p.346-350.
[3] Chen, Y., Y. Guo, X. Lu, et al., Surgical strategy for multilevel severe ossification ofposterior longitudinal ligament in the cervical spine. J Spinal Disord Tech,2011.24(1): p.24.
[4] Tani, T., T. Ushida, K. Ishida, et al., Relative safety of anterior microsurgicaldecompression versus laminoplasty for cervical myelopathy with a massive ossifiedposterior longitudinal ligament. Spine (Phila Pa1976),2002.27(22): p.2491.
[5]吕振木,申勇,徐英进, et al.,后前路联合入路治疗重症脊髓型颈椎病.中国矫形外科杂志,2007.15(5): p.344-346.
[6] Bapat, M.R., K. Chaudhary, A. Sharma, et al., Surgical approach to cervicalspondylotic myelopathy on the basis of radiological patterns of compression:prospective analysis of129cases. European Spine Journal,2008.17(12): p.1651-1663.
[7] Hatta, Y., T. Shiraishi, H. Hase, et al., Is posterior spinal cord shifting by extensiveposterior decompression clinically significant for multisegmental cervical spondyloticmyelopathy? Spine (Phila Pa1976),2005.30(21): p.2414.
[8]林建聪,王少波,郑亚才, et al.,单开门颈椎管扩大术后脊髓后移的MRI测量及具临床意义.中华外科杂志,2009.46(3): p.224-225.
[9] Kong, Q., L. Zhang, L. Liu, et al., Effect of the decompressive extent on themagnitude of the spinal cord shift after expansive open-door laminoplasty. Spine(Phila Pa1976),2011.36(13): p.1030.
[10] Hirabayashi, K., J. Miyakawa, K. Satomi, et al., Operative results and postoperativeprogression of ossification among patients with ossification of cervical posteriorlongitudinal ligament. Spine (Phila Pa1976),1981.6(4): p.354.
[11]曾岩,党耕町,马庆军, et al.,颈椎前路融合术后颈部运动功能的评价.中华外科杂志,2005.42(24): p.1481-1484.
[12] Yonenobu, K., N. Hosono, M. Iwasaki, et al., Laminoplasty versus subtotalcorpectomy. A comparative study of results in multisegmental cervical spondyloticmyelopathy. Spine (Phila Pa1976),1992.17(11): p.1281.
[13] Hukuda, S., T. Mochizuki, M. Ogata, et al., Operations for cervical spondyloticmyelopathy. A comparison of the results of anterior and posterior procedures. Journalof Bone&Joint Surgery, British Volume,1985.67(4): p.609-615.
[14] Mizuno, J. and H. Nakagawa, Ossified posterior longitudinal ligament: managementstrategies and outcomes. The Spine Journal,2006.6(6): p. S282-S288.
[15] Mochizuki, M., A. Aiba, M. Hashimoto, et al., Cervical myelopathy in patients withossification of the posterior longitudinal ligament. Journal of Neurosurgery: Spine,2009.10(2): p.122-128.
[16] Matz, P.G., P.R. Pritchard, and M.N. Hadley, Anterior cervical approach for thetreatment of cervical myelopathy. Neurosurgery,2007.60(1): p. S1-64.
[17] Hee, H.T., M.E. Majd, R.T. Holt, et al., Complications of multilevel cervicalcorpectomies and reconstruction with titanium cages and anterior plating. J SpinalDisord Tech,2003.16(1): p.1-8.
[18] Sakai, K., A. Okawa, M. Takahashi, et al., Five-year follow-up evaluation of surgicaltreatment for cervical myelopathy caused by ossification of the posterior longitudinalligament: a prospective comparative study of anterior decompression and fusion withfloating method versus laminoplasty. Spine (Phila Pa1976),2012.37(5): p.367-376.
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