后路寰枢椎融合术后颈椎矢状面参数变化及相关因素分析
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摘要
目的:测量后路寰枢椎融合手术对颈椎矢状面参数的变化,并对其相关影响因素进行评估。方法:回顾性研究2015年1月～2017年12月收治的寰枢椎脱位病例18例,男8例,女10例,年龄25～72岁,平均49.6±13.7岁。所有寰枢椎脱位患者均行单纯后路复位C1～C2固定融合术,随访时间为5～17个月,平均7.4±3.7个月。测量患者术前和末次随访时的枕颈角(C0～C2角)、下颈椎前凸角(C2～C7角)、颈椎前凸角(C0～C7角)、颈椎矢状面轴向垂直距离(C2-C7 sagittal vertical axis,C2-C7 SVA)、C1～C2角、T1倾斜角(T1 slope,T1S)、颈部倾斜角(neck tilt,NT)和胸廓入口角(thoracic inlet angle,TIA)等颈椎矢状面参数。在末次随访时,术后C2～C7角比术前减小的病例归为下颈椎前凸曲度减小组(5例),而术后C2～C7角比术前增加或不变的病例纳入下颈椎前凸曲度增加组(13例)。采用卡方检验做下颈椎前凸曲度减小与性别、年龄(以60岁为界限)、术前T1S(以25°为界限)、术前C2-C7 SVA(以15mm为界限)、术前TIA(以70°为界限)、术前C2-C7角(以20°为界限)、术前C0-C2角(以20°为界限)、术前C0-C7角(以45°为界限)和术后C1-C2角(以20°为界限)等临床因素相关性的单因素分析。采用Logistic回归对术后下颈椎前凸曲度减小的相关因素进行多因素分析。结果:所有患者术前和末次随访时的C0～C2角分别为21.6°±16.4°和28.3°±8.6°、C2～C7角分别为15.3°±12.9°和16.4°±11.1°、C0～C7角分别为36.8°±19.7°和44.9°±13.2°、C1～C2角分别为12.4°±17.6°和17.5°±7.3°、C2～C7 SVA分别为13.4±14.7mm和15.1±11.7mm、T1S分别为22.8°±8.2°和23.5°±7.3°、NT分别为50.8°±9.5°和51.9°±8.9°、TIA分别为73.6°±11.1°和75.4°±10.0°,以上这些颈椎矢状面参数在术前与末次随访的比较均无显著性差异(P>0.05)。对两组患者术前和末次随访的颈椎矢状面参数进行比较,前凸减小组的术前C2～C7角明显大于前凸增加组(27.6°±10.5°vs 10.5°±10.5°,P<0.05),余参数比较无统计学差异。单因素卡方分析显示术后下颈椎前凸曲度减小与术前C2～C7角≥20°有关(χ~2=4.923,P=0.026),多因素Logistic回归分析显示术前C2～C7角≥20°并不是独立危险因素(OR=0.147,P=0.225)。结论:后路寰枢椎融合术后有可能发生下颈椎前凸曲度减小,而术前C2-C7角≥20°是术后下颈椎前凸曲度减小的危险因素。
Objectives: To measure the changes of cervical sagittal parameters and evaluate the related fac-tors after posterior atlantoaxial fusion. Methods: Eighteen patients(aged 25-72 years with mean age of49.6±13.7 years) with atlantoaxial dislocation in Fuzhou Second Hospital Affiliated to Xiamen University be-tween January 2015 and December 2017 were retrospectively analyzed. There were 8 males and 10 females patients. All patients with atlantoaxial dislocation underwent simple posterior reduction and C1-2 fixation.They were followed up for 5 to 17 months, with an average of 7.4±3.7 months. Cervical sagittal parameters including C0-C2 angle, C2-C7 angle, C0-C7 angle, C1-C2 angle, C2-C7 SVA, T1 S, NT and TIA were measured before surgery and at the last follow-up. Chi-square test was used to analyze the relationship of lower cervical curvature lordosis and gender, age(bounded by 60 years old), preoperative T1 S(bounded by 25°),preoperative C2-C7 SVA(bounded by 15 mm), preoperative TIA(bounded by 70°), preoperative C2-C7 angle(bounded by 20°), preoperative C0-C2 angle(bounded by 20°), preoperative C0-C7 angle(bounded by 45°)and postoperative C1-2 angle(bounded by 20°). At the last follow-up, the subaxial lordosis loss group(5 cases) included the patients whose postoperative C2-C7 angle was reduced, and the subaxial lordosis increase group(13 cases) included the patients whose postoperative C2-C7 angle was increase. Logistic regression analysis was applied to analyze the factors related to the postoperative loss of subaxial lordosis after posterior atlantoaxial fusion. Results: The cervical sagittal parameters of preoperation and last follow-up were as follows respectively: C0-C2 angle 21.6°±16.4° and 28.3°±8.6°, C2-C7 angle 15.3°±12.9° and 16.4°±11.1°, C0-C7 angle 36.8°±19.7° and 44.9°±13.2°, C1-C2 angle 12.4°±17.6° and 17.5°±7.3°, C2-C7 SVA 13.4±14.7 mm and15.1±11.7 mm, T1 S 22.8°±8.2° and 23.5°±7.3°, NT 50.8°±9.5° and 51.9°±8.9°, TIA 73.6°±11.1° and 75.4°±10.0°. There was no significant difference between the preoperative and last follow-up cervical sagittal parameters(P>0.05). The cervical sagittal parameters of preoperative and final follow-up between two groups were compared, the preoperative C2-C7 angle of the subaxial lordosis loss group was bigger than the subaxial lordosis increase group(27.6°±10.5° vs 10.5°±10.5°, P<0.05), but there was no statistical difference in other parameters. Univariate chi-square analysis showed that reduction of subaxial lordosis after posterior atlantoaxial fusion was associated with preoperative C2-C7 angle ≥20°(χ~2=4.923,P=0.026). However, Logistic regression analysis showed that the preoperative C2-C7 angle ≥20° was not an independent risk factor(OR=0.147,P=0.225). Conclusions: Loss of subaxial lordosis can occur after posterior atlantoaxial fusion, and preoperative C2-C7 angle ≥20° is a risk factor of postoperative loss of subaxial lordosis.
Objectives: To measure the changes of cervical sagittal parameters and evaluate the related fac-tors after posterior atlantoaxial fusion. Methods: Eighteen patients(aged 25-72 years with mean age of49.6±13.7 years) with atlantoaxial dislocation in Fuzhou Second Hospital Affiliated to Xiamen University be-tween January 2015 and December 2017 were retrospectively analyzed. There were 8 males and 10 females patients. All patients with atlantoaxial dislocation underwent simple posterior reduction and C1-2 fixation.They were followed up for 5 to 17 months, with an average of 7.4±3.7 months. Cervical sagittal parameters including C0-C2 angle, C2-C7 angle, C0-C7 angle, C1-C2 angle, C2-C7 SVA, T1 S, NT and TIA were measured before surgery and at the last follow-up. Chi-square test was used to analyze the relationship of lower cervical curvature lordosis and gender, age(bounded by 60 years old), preoperative T1 S(bounded by 25°),preoperative C2-C7 SVA(bounded by 15 mm), preoperative TIA(bounded by 70°), preoperative C2-C7 angle(bounded by 20°), preoperative C0-C2 angle(bounded by 20°), preoperative C0-C7 angle(bounded by 45°)and postoperative C1-2 angle(bounded by 20°). At the last follow-up, the subaxial lordosis loss group(5 cases) included the patients whose postoperative C2-C7 angle was reduced, and the subaxial lordosis increase group(13 cases) included the patients whose postoperative C2-C7 angle was increase. Logistic regression analysis was applied to analyze the factors related to the postoperative loss of subaxial lordosis after posterior atlantoaxial fusion. Results: The cervical sagittal parameters of preoperation and last follow-up were as follows respectively: C0-C2 angle 21.6°±16.4° and 28.3°±8.6°, C2-C7 angle 15.3°±12.9° and 16.4°±11.1°, C0-C7 angle 36.8°±19.7° and 44.9°±13.2°, C1-C2 angle 12.4°±17.6° and 17.5°±7.3°, C2-C7 SVA 13.4±14.7 mm and15.1±11.7 mm, T1 S 22.8°±8.2° and 23.5°±7.3°, NT 50.8°±9.5° and 51.9°±8.9°, TIA 73.6°±11.1° and 75.4°±10.0°. There was no significant difference between the preoperative and last follow-up cervical sagittal parameters(P>0.05). The cervical sagittal parameters of preoperative and final follow-up between two groups were compared, the preoperative C2-C7 angle of the subaxial lordosis loss group was bigger than the subaxial lordosis increase group(27.6°±10.5° vs 10.5°±10.5°, P<0.05), but there was no statistical difference in other parameters. Univariate chi-square analysis showed that reduction of subaxial lordosis after posterior atlantoaxial fusion was associated with preoperative C2-C7 angle ≥20°(χ~2=4.923,P=0.026). However, Logistic regression analysis showed that the preoperative C2-C7 angle ≥20° was not an independent risk factor(OR=0.147,P=0.225). Conclusions: Loss of subaxial lordosis can occur after posterior atlantoaxial fusion, and preoperative C2-C7 angle ≥20° is a risk factor of postoperative loss of subaxial lordosis.
引文
1. Yoshida G, Kamiya M, Yoshihara H, et al. Subaxial sagittal alignment and adjacent-segment degeneration after atlantoaxial fixation performed using C-1 lateral mass and C-2 pedicle screws or transarticular screws[J]. J Neurosurg Spine, 2010,13(4):443-450.
2 . Toyama Y, Matsumoto M, Chiba K, et al. Realignment of postoperative cervical kyphosis in children by vertebral remodeling[J]. Spine(Phila Pa 1976), 1994, 19(22):2565-2570.
3 . Mukai Y, Hosono N, Sakaura H, et al. Sagittal alignment of the subaxial cervical spine after C1-C2 transarticular screw fixation in rheumatoid arthritis[J]. J Spinal Disord Tech, 2007,20(6):436-441.
4 . Kang D, Lehman R, Wagner S, et al. Subaxial cervical sagittal alignment following C1-C2 fusion for atlanto-axial osteoarthritis[J]. Global Spine J, 2015, 05(S01):S-0035-1554386.
5 . Lippa L, Cacciola F. Loss of cervical lordosis:What is the prognosis?[J]. J Craniovertebr Junction Spine, 2017, 8(1):9-14.
6 . Kaptain GJ, Simmons NE, Replogle RE, et al. Incidence and outcome of kyphotic deformity following laminectomy for cervical spondylotic myelopathy[J]. J Neurosurg, 2000, 93(2Suppl):199-204.
7 . Scheer JK, Tang JA, Smith JS, et al. Cervical spine alignment, sagittal deformity, and clinical implications:a review[J]. J Neurosurg Spine, 2013, 19(2):141-159.
8 . Tang JA, Scheer JK, Smith JS, et al. The impact of standing regional cervical sagittal alignment on outcomes in posterior cervical fusion surgery[J]. Neurosurgery, 2012, 71(3):662-669.
9 . Passias PG, Wang S, Kozanek M, et al. Relationship between the alignment of the occipitoaxial and subaxial cervical spine in patients with congenital atlantoxial dislocations[J]. J Spinal Disord Tech, 2013, 26(1):15-21.
10 . Clarke MJ, Cohen-Gadol AA, Ebersold MJ, et al. Long-term incidence of subaxial cervical spine instability following cervical arthrodesis surgery in patients with rheumatoid arthritis[J]. Surg Neurol, 2006, 66(2):136-140.
11 . Abumi K, Takada T, Shono Y, et al. Posterior occipitocervical reconstruction using cervical pedicle screws and platerod systems[J]. Spine(Phila Pa 1976), 1999, 24(14):1425-1434.
12 . Wang S, Wang C, Yan M, et al. Novel surgical classification and treatment strategy for atlantoaxial dislocations[J]. Spine(Phila Pa 1976), 2013, 38(21):E1348-1356.
13 . Nojiri K, Matsumoto M, Chiba K, et al. Relationship between alignment of upper and lower cervical spine in asymptomatic individuals[J]. J Neurosurg, 2003, 99(1 Suppl):80-83.
14 . Guo Q, Ni B, Yang J, et al. Relation between alignments of upper and subaxial cervical spine:a radiological study[J].Arch Orthop Trauma Surg, 2011, 131(6):857-862.
15 . Sherekar SK, Yadav YR, Basoor AS, et al. Clinical implications of alignment of upper and lower cervical spine[J]. Neurol India, 2006, 54(3):264-267.
16 .王圣林,王超, wood KB,等.寰枢关节不稳或脱位患者上颈椎曲度改变对下颈椎的影响[J].中国脊柱脊髓杂志, 2009,19(7):502-505.
17 . Oshima S, Sudo H, Ito M, et al. Subaxial sagittal alignment after atlantoaxial fixation techniques[J]. J Spinal Disord Tech,2015, 28(1):E49-55.
18 . Lee SH, Kim KT, Seo EM, et al. The influence of thoracic inlet alignment on the craniocervical sagittal balance in asymptomatic adults[J]. J Spinal Disord Tech, 2012, 25(2):E41-47.
19 . Iyer S, Lenke LG, Nemani VM, et al. Variations in occipitocervical and cervicothoracic alignment parameters based on age:a prospective study of asymptomatic volunteers using full-body radiographs[J]. Spine(Phila Pa 1976), 2016, 41(23):1837-1844.
20 .张奎渤,詹鸿锐,于兵,等. X线与CT影像学测量成人颈椎矢状面参数的差异[J].第三军医大学学报, 2015, 37(19):1997-2000.
21 .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[J].中国脊柱脊髓杂志,2015, 25(3):231-238.
22 . Hardacker JW, Shuford RF, Capicotto PN, et al. Radiographic standing cervical segmental alignment in adult volunteers without neck symptoms[J]. Spine(Phila Pa 1976), 1997, 22(13):1472-1480.
23 . Harrison DE, Harrison DD, Cailliet R, et al. Cobb method or Harrison posterior tangent method:which to choose for lateral cervical radiographic analysis[J]. Spine(Phila Pa 1976),2000, 25(16):2072-2078.
24 .黄季晨,钱邦平,邱勇.寰枢椎后路融合术后下颈椎曲度及退变影响因素的研究进展[J].中国脊柱脊髓杂志, 2016, 26(6):545-548.
25 .王健,倪斌,陶春生,等.寰枢椎后路融合角度与下位颈椎曲度的相关性研究[J].中华创伤骨科杂志, 2008, 10(11):1036-1039.
26 . Passias PG, Wang S, Zhao D, et al. The reversibility of swan neck deformity in chronic atlantoaxial dislocations[J].Spine(Phila Pa 1976), 2013, 38(7):E379-385.
27 . Kato Y, Itoh T, Kanaya K, et al. Relation between atlantoaxial(C1/2)and cervical alignment(C2-C7)angles with magerl and brooks techniques for atlantoaxial subluxation in rheumatoid arthritis[J]. J Orthop Sci, 2006, 11(4):347-352.
2 . Toyama Y, Matsumoto M, Chiba K, et al. Realignment of postoperative cervical kyphosis in children by vertebral remodeling[J]. Spine(Phila Pa 1976), 1994, 19(22):2565-2570.
3 . Mukai Y, Hosono N, Sakaura H, et al. Sagittal alignment of the subaxial cervical spine after C1-C2 transarticular screw fixation in rheumatoid arthritis[J]. J Spinal Disord Tech, 2007,20(6):436-441.
4 . Kang D, Lehman R, Wagner S, et al. Subaxial cervical sagittal alignment following C1-C2 fusion for atlanto-axial osteoarthritis[J]. Global Spine J, 2015, 05(S01):S-0035-1554386.
5 . Lippa L, Cacciola F. Loss of cervical lordosis:What is the prognosis?[J]. J Craniovertebr Junction Spine, 2017, 8(1):9-14.
6 . Kaptain GJ, Simmons NE, Replogle RE, et al. Incidence and outcome of kyphotic deformity following laminectomy for cervical spondylotic myelopathy[J]. J Neurosurg, 2000, 93(2Suppl):199-204.
7 . Scheer JK, Tang JA, Smith JS, et al. Cervical spine alignment, sagittal deformity, and clinical implications:a review[J]. J Neurosurg Spine, 2013, 19(2):141-159.
8 . Tang JA, Scheer JK, Smith JS, et al. The impact of standing regional cervical sagittal alignment on outcomes in posterior cervical fusion surgery[J]. Neurosurgery, 2012, 71(3):662-669.
9 . Passias PG, Wang S, Kozanek M, et al. Relationship between the alignment of the occipitoaxial and subaxial cervical spine in patients with congenital atlantoxial dislocations[J]. J Spinal Disord Tech, 2013, 26(1):15-21.
10 . Clarke MJ, Cohen-Gadol AA, Ebersold MJ, et al. Long-term incidence of subaxial cervical spine instability following cervical arthrodesis surgery in patients with rheumatoid arthritis[J]. Surg Neurol, 2006, 66(2):136-140.
11 . Abumi K, Takada T, Shono Y, et al. Posterior occipitocervical reconstruction using cervical pedicle screws and platerod systems[J]. Spine(Phila Pa 1976), 1999, 24(14):1425-1434.
12 . Wang S, Wang C, Yan M, et al. Novel surgical classification and treatment strategy for atlantoaxial dislocations[J]. Spine(Phila Pa 1976), 2013, 38(21):E1348-1356.
13 . Nojiri K, Matsumoto M, Chiba K, et al. Relationship between alignment of upper and lower cervical spine in asymptomatic individuals[J]. J Neurosurg, 2003, 99(1 Suppl):80-83.
14 . Guo Q, Ni B, Yang J, et al. Relation between alignments of upper and subaxial cervical spine:a radiological study[J].Arch Orthop Trauma Surg, 2011, 131(6):857-862.
15 . Sherekar SK, Yadav YR, Basoor AS, et al. Clinical implications of alignment of upper and lower cervical spine[J]. Neurol India, 2006, 54(3):264-267.
16 .王圣林,王超, wood KB,等.寰枢关节不稳或脱位患者上颈椎曲度改变对下颈椎的影响[J].中国脊柱脊髓杂志, 2009,19(7):502-505.
17 . Oshima S, Sudo H, Ito M, et al. Subaxial sagittal alignment after atlantoaxial fixation techniques[J]. J Spinal Disord Tech,2015, 28(1):E49-55.
18 . Lee SH, Kim KT, Seo EM, et al. The influence of thoracic inlet alignment on the craniocervical sagittal balance in asymptomatic adults[J]. J Spinal Disord Tech, 2012, 25(2):E41-47.
19 . Iyer S, Lenke LG, Nemani VM, et al. Variations in occipitocervical and cervicothoracic alignment parameters based on age:a prospective study of asymptomatic volunteers using full-body radiographs[J]. Spine(Phila Pa 1976), 2016, 41(23):1837-1844.
20 .张奎渤,詹鸿锐,于兵,等. X线与CT影像学测量成人颈椎矢状面参数的差异[J].第三军医大学学报, 2015, 37(19):1997-2000.
21 .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[J].中国脊柱脊髓杂志,2015, 25(3):231-238.
22 . Hardacker JW, Shuford RF, Capicotto PN, et al. Radiographic standing cervical segmental alignment in adult volunteers without neck symptoms[J]. Spine(Phila Pa 1976), 1997, 22(13):1472-1480.
23 . Harrison DE, Harrison DD, Cailliet R, et al. Cobb method or Harrison posterior tangent method:which to choose for lateral cervical radiographic analysis[J]. Spine(Phila Pa 1976),2000, 25(16):2072-2078.
24 .黄季晨,钱邦平,邱勇.寰枢椎后路融合术后下颈椎曲度及退变影响因素的研究进展[J].中国脊柱脊髓杂志, 2016, 26(6):545-548.
25 .王健,倪斌,陶春生,等.寰枢椎后路融合角度与下位颈椎曲度的相关性研究[J].中华创伤骨科杂志, 2008, 10(11):1036-1039.
26 . Passias PG, Wang S, Zhao D, et al. The reversibility of swan neck deformity in chronic atlantoaxial dislocations[J].Spine(Phila Pa 1976), 2013, 38(7):E379-385.
27 . Kato Y, Itoh T, Kanaya K, et al. Relation between atlantoaxial(C1/2)and cervical alignment(C2-C7)angles with magerl and brooks techniques for atlantoaxial subluxation in rheumatoid arthritis[J]. J Orthop Sci, 2006, 11(4):347-352.
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