颈椎前路减压植骨融合内固定术及颈椎后路两种不同手术方法治疗多节段受累脊髓型颈椎病功能及影像学预后比较
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摘要
目的：多节段受累的脊髓型颈椎病是指颈椎病变超过3个节段以上脊髓型颈椎病。目前国内外针对采用何种术式治疗多节段受累脊髓型颈椎病仍无最终定论。前路手术包括使用结构性支撑植骨的前路椎间盘切除减压融合内固定术或椎体切除植骨融合术,后路手术则以椎板减压或椎管成形术为代表。每种不同的术式均具有不同的优缺点加之多节段受累脊髓型颈椎病致病因素复杂,因此为手术方案制定带来困难。目前国内外研究较多的前路椎体次全切除植骨融合内固定术和后路单开门椎管成形术大多属于来自单中心的回顾性病例对照研究,同时研究的关注点多集中于功能性对比,影像学研究较少,因此本课题第一部分拟针对目前研究中的不足之处纳入了来自2个不同脊柱中心的罹患多节段脊髓型颈椎病的患者资料,并对其功能性及影像学预后进行对比,以期找到两种不同术式在预后方面存在的不同。课题第二部分对比了两种不同的后路手术方法治疗多节段受累脊髓型颈椎病功能性及影像学预后,通过比较旨在明确后路扩大半椎板切除术治疗该病的有效性。
方法：分别搜集来自北京军区总医院及德国乌尔姆军医院脊柱外科的罹患多节段脊髓型颈椎病患者随访资料并分为两组：AG组和LPG组,从功能性指标(JOA评分、疼痛及麻木VAS评分)及影像学指标(Pavlov比值、颈椎活动度、颈椎曲度指数)两个方面分别对两组术前、术后各项指标变化进行对比分析,同时记录并分析两组术中手术时间、出血量及术后并发症发生率。在此基础上进一步设计了一项小样本的随机对照临床试验,依旧从上述几个方面对后路扩大半椎板切除单开门椎管成形术进行了对比,同时使用软件测量两种术式术前术后椎管开大率并进行比较。
结果：术前术后两组组内比较JOA评分均显著升高。两组患者术后优良率比较无统计学意义；AG组术后颈椎CCI较术前显著增加。颈椎活动度两组术前术后无显著差异；两组并发症发生率无显著差异；LPG组手术时间较AG组短,但术中出血量与AG组对比有统计学意义。术前髓内高信号对患者术后神经功能恢复无显著影响。两种不同后路手术方式对比：两组组内术前术后JOA评分具有显著差异,组间比较无统计学差异；两组术前术后颈椎CCI及颈椎活动度对比无统计学差异；LP组椎管开大率与LN组对比存在统计学差异,前者更大。两组对比术中出血量及手术时间具有统计学差异,LN组手术时间更短,出血更少；术后轴性症状发生率及住院花费比较具有统计学意义,LN组更低。
结论：前路减压植骨融合术与后路单开门椎管成形术治疗MCSM患者术后均可获得满意神经功能改善。合并先天性椎管狭窄患者后路单开门椎管成形术具有满意疗效；前路手术虽然术中出血相对少,但处理多节段病变手术时间明显延长,对高龄合并慢性疾病患者适合选择后路手术。前路手术可以有效的恢复术后颈椎生理曲度,更加适合不具备后路手术条件、椎间隙明显狭窄及术前有神经根症状的患者。颈椎后路扩大半椎板切除术及后路单开门椎管成形术均可以有效改善患者术后神经功能。术后6月随访均未出现颈椎生理曲度及活动度的明显丢失。扩大半椎板切除术相对于单开门椎管成形术具有对颈后部肌肉干扰少、手术时间短、术中出血少及更低的住院花费的特点,同时其术后发生轴性疼痛的几率也相应降低。但单开门椎管成形术较之扩大半椎板切除术可以更有效地释放椎管容积,对椎管的减压效果优于扩大半椎板切除术。因此对于合并后纵韧带骨化症和(或)黄韧带骨化症的椎管侵占率大于50%的患者,单开门椎管成形术较之扩大半椎板切除术占有明显优势。
Objective： Multilevel cervical spondylotic myelopathy (MCSM) refers to thecomplex pathologic changes, with more than3levels involved, resulting inmultilevel spinal cord and sac compression with corresponding clinical symptoms.Anterior approaches include ACDF and ACCF, while main posterior approaches arelaminoplasty and laminectomy. Each of the different surgical approaches hasdifferent advantages and disadvantages. Controversy exists concerning the choice ofsurgical approach in the treatment of multilevel CSM. Most of the current studiesfocus on the comparison of clinical outcomes of different methods instead ofradiological images, furthermore the comparative studies come from more than1spine center remain rare. Therefore, the first part of this study intends to comparethe functional and radiological outcomes based on the recurrent materials come from2different spine centers in Beijing and in Germany, respectively. The purpose of thesecond part in this study is to identify the effectiveness of posterior extensivesemi-laminectomy compared with classic posterior laminoplasty in treatment ofMCSM.
Methods：All the clinical data collected from2different spine centers in Beijing andin Germany, respectively. All the patients were suffered with MCSM and treatedwith anterior decompression and fusion (Germany) and posterior laminoplasty(Beijing). Retrospective comparative study was made to find out the differences infunctional and radiological outcomes between two different approaches, such as painor numbness JOA score, Pavlov ratio, range of motion and cervical curvature index. Besides these, intraoperative blood loss and duration of operation time were alsobeen recorded. In the second part of the study, we carried out a small sample ofrandomized controlled clinical trials. All the data of the patients were collected fromour spine center and the effectiveness of posterior semi-laminectomy was made bythe way of comparison with laminoplasty from different aspects in both functionaland radiological outcomes.
Results： Both anterior decompression fusion and posterior laminoplasty cansignificantly improve the neurological function of the patients. The patients withcongenital spinal stenosis could reach satisfying outcomes after accepting theposterior laminoplasty. The intraoperative blood loss in AG was significantly lessthan LPG, but the duration of operation was significantly longer than LPG due to thedecompression of long levels. Postoperative CCI was significantly improvedcompared with preoperative CCI in AG. Range of motion didn’t show significantlydifferent either in two groups or pre-and postoperatively. The incidence ofcomplications between2groups was not significant. Duration of operation time inLPG was shorter than AG, meanwhile, blood loss was much more than AG. Thepreoperative intramedullary hyperintense in MRI showed no effect to neurologicaloutcomes. Two different posterior decompression methods had the similarimprovement in JOA score postoperatively. CCI and range of motion were nosignificant changes either pre-and postoperatively or between two groups. Withrespect to the ability in spinal canal extension, there was significantly differentbetween2groups, LP was better than LN. LN had the much shorter duration ofoperation time, less intraoperative blood loss, lower incidence of axial symptom andhospital stay cost.
Conclusions：Both anterior decompression fusion and laminoplasty could reachsatisfying neurological improvement in treatment of MCSM. Anterior approach hadabetter ability to restore the height of anterior column and postoperative cervicalcurvature, but longer duration of operation time is one of the shortages due tocomplex direct decompression of long levels. Therefore, for aged people with different comorbidities, posterior laminoplasty is a good choice, while anteriorapproache are much more suitable for the patient with preoperative loss of cervicalcurvature and with radiculopathy. The neurological improvement after laminoplastyand extensive semi-laminectomy are similar in treatment of MCSM. Laminoplastyhas more advantage in the ability of spinal canal extension, for this reason, it is betterto be used in the circumstance of severe spinal canal stenosis, such as CSMcombined with OPLL, OYL or congenital spinal canal stenosis.
方法：分别搜集来自北京军区总医院及德国乌尔姆军医院脊柱外科的罹患多节段脊髓型颈椎病患者随访资料并分为两组：AG组和LPG组,从功能性指标(JOA评分、疼痛及麻木VAS评分)及影像学指标(Pavlov比值、颈椎活动度、颈椎曲度指数)两个方面分别对两组术前、术后各项指标变化进行对比分析,同时记录并分析两组术中手术时间、出血量及术后并发症发生率。在此基础上进一步设计了一项小样本的随机对照临床试验,依旧从上述几个方面对后路扩大半椎板切除单开门椎管成形术进行了对比,同时使用软件测量两种术式术前术后椎管开大率并进行比较。
结果：术前术后两组组内比较JOA评分均显著升高。两组患者术后优良率比较无统计学意义；AG组术后颈椎CCI较术前显著增加。颈椎活动度两组术前术后无显著差异；两组并发症发生率无显著差异；LPG组手术时间较AG组短,但术中出血量与AG组对比有统计学意义。术前髓内高信号对患者术后神经功能恢复无显著影响。两种不同后路手术方式对比：两组组内术前术后JOA评分具有显著差异,组间比较无统计学差异；两组术前术后颈椎CCI及颈椎活动度对比无统计学差异；LP组椎管开大率与LN组对比存在统计学差异,前者更大。两组对比术中出血量及手术时间具有统计学差异,LN组手术时间更短,出血更少；术后轴性症状发生率及住院花费比较具有统计学意义,LN组更低。
结论：前路减压植骨融合术与后路单开门椎管成形术治疗MCSM患者术后均可获得满意神经功能改善。合并先天性椎管狭窄患者后路单开门椎管成形术具有满意疗效；前路手术虽然术中出血相对少,但处理多节段病变手术时间明显延长,对高龄合并慢性疾病患者适合选择后路手术。前路手术可以有效的恢复术后颈椎生理曲度,更加适合不具备后路手术条件、椎间隙明显狭窄及术前有神经根症状的患者。颈椎后路扩大半椎板切除术及后路单开门椎管成形术均可以有效改善患者术后神经功能。术后6月随访均未出现颈椎生理曲度及活动度的明显丢失。扩大半椎板切除术相对于单开门椎管成形术具有对颈后部肌肉干扰少、手术时间短、术中出血少及更低的住院花费的特点,同时其术后发生轴性疼痛的几率也相应降低。但单开门椎管成形术较之扩大半椎板切除术可以更有效地释放椎管容积,对椎管的减压效果优于扩大半椎板切除术。因此对于合并后纵韧带骨化症和(或)黄韧带骨化症的椎管侵占率大于50%的患者,单开门椎管成形术较之扩大半椎板切除术占有明显优势。
Objective： Multilevel cervical spondylotic myelopathy (MCSM) refers to thecomplex pathologic changes, with more than3levels involved, resulting inmultilevel spinal cord and sac compression with corresponding clinical symptoms.Anterior approaches include ACDF and ACCF, while main posterior approaches arelaminoplasty and laminectomy. Each of the different surgical approaches hasdifferent advantages and disadvantages. Controversy exists concerning the choice ofsurgical approach in the treatment of multilevel CSM. Most of the current studiesfocus on the comparison of clinical outcomes of different methods instead ofradiological images, furthermore the comparative studies come from more than1spine center remain rare. Therefore, the first part of this study intends to comparethe functional and radiological outcomes based on the recurrent materials come from2different spine centers in Beijing and in Germany, respectively. The purpose of thesecond part in this study is to identify the effectiveness of posterior extensivesemi-laminectomy compared with classic posterior laminoplasty in treatment ofMCSM.
Methods：All the clinical data collected from2different spine centers in Beijing andin Germany, respectively. All the patients were suffered with MCSM and treatedwith anterior decompression and fusion (Germany) and posterior laminoplasty(Beijing). Retrospective comparative study was made to find out the differences infunctional and radiological outcomes between two different approaches, such as painor numbness JOA score, Pavlov ratio, range of motion and cervical curvature index. Besides these, intraoperative blood loss and duration of operation time were alsobeen recorded. In the second part of the study, we carried out a small sample ofrandomized controlled clinical trials. All the data of the patients were collected fromour spine center and the effectiveness of posterior semi-laminectomy was made bythe way of comparison with laminoplasty from different aspects in both functionaland radiological outcomes.
Results： Both anterior decompression fusion and posterior laminoplasty cansignificantly improve the neurological function of the patients. The patients withcongenital spinal stenosis could reach satisfying outcomes after accepting theposterior laminoplasty. The intraoperative blood loss in AG was significantly lessthan LPG, but the duration of operation was significantly longer than LPG due to thedecompression of long levels. Postoperative CCI was significantly improvedcompared with preoperative CCI in AG. Range of motion didn’t show significantlydifferent either in two groups or pre-and postoperatively. The incidence ofcomplications between2groups was not significant. Duration of operation time inLPG was shorter than AG, meanwhile, blood loss was much more than AG. Thepreoperative intramedullary hyperintense in MRI showed no effect to neurologicaloutcomes. Two different posterior decompression methods had the similarimprovement in JOA score postoperatively. CCI and range of motion were nosignificant changes either pre-and postoperatively or between two groups. Withrespect to the ability in spinal canal extension, there was significantly differentbetween2groups, LP was better than LN. LN had the much shorter duration ofoperation time, less intraoperative blood loss, lower incidence of axial symptom andhospital stay cost.
Conclusions：Both anterior decompression fusion and laminoplasty could reachsatisfying neurological improvement in treatment of MCSM. Anterior approach hadabetter ability to restore the height of anterior column and postoperative cervicalcurvature, but longer duration of operation time is one of the shortages due tocomplex direct decompression of long levels. Therefore, for aged people with different comorbidities, posterior laminoplasty is a good choice, while anteriorapproache are much more suitable for the patient with preoperative loss of cervicalcurvature and with radiculopathy. The neurological improvement after laminoplastyand extensive semi-laminectomy are similar in treatment of MCSM. Laminoplastyhas more advantage in the ability of spinal canal extension, for this reason, it is betterto be used in the circumstance of severe spinal canal stenosis, such as CSMcombined with OPLL, OYL or congenital spinal canal stenosis.
引文
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