颈前路分节段减压植骨融合术治疗多节段颈椎病:3种方法移植骨融合率的比较(英文)

Segmental anterior cervical decompression with fusion for treating multilevel cervical myelopathy:Comparison of fusion rates among three methods

背景: 多节段颈椎病的传统治疗方法前路长节段减压存在着手术创伤大、难度高、植骨融合率低等的不足, 影响术后疗效。目的: 比较 3 种不同方式的前路手术治疗多节段颈椎病的临床效果。设计: 对比观察。单位: 解放军第二军医大学长征医院骨科。对象: 选择 1999- 06/2003- 06 解放军第二军医大学长征医院骨科手术治疗的三间隙连续节段病变的多节段颈椎病患者 36 例, 男 25 例, 女 11例; 年龄 35～62 岁; 病程 3～26 个月。根据临床表现及影像学检查结果诊断为多节段颈椎病; 均不伴有连续型后纵韧带骨化及黄韧带骨化; 患者及家属均对手术方案知情同意。方法: 所有病例植骨均采用自体骨植骨。取自体髂骨或将咬除椎体的松质骨填充入钛网或 Cage 内, 所用钛网或 Cage 为钛材质, 具有强度高,耐腐蚀、生物相容性好等特点。按照手术方式分为 3 组: ①长节段减压组11 例, 其中 4 例为长钛网植骨, 7 例为自体髂骨植骨。行两椎体次全切除长节段植骨融合内固定术。②分节段减压组 16 例, 其中 12 例为钛网 +Cage 植骨, 4 例为自体骨 +Cage 植骨。行单间隙减压 + 单椎体次全切除植骨融合内固定术。③三间隙减压组 9 例。不作椎体的次全切除,仅行多个椎间盘切除减压, 减压后, 应用 3 个 cage 内填充人工骨或自体骨植入。主要观察指标: 所有病例于术后 1 周内及 3, 6, 12 个月复查颈椎正侧位、伸屈侧位片。以日本骨科协会(JOA) 评分法评价术前、术后 3 个月神经功能, 该评分总分 17 分, 分数越高表明神经功能越好。分别记录 3 组患者的手术时间、术中出血量、住院时间、住院费用、术后 3 个月时植骨融合情况、术后 3 个月 JOA 评分较术前提高分数。术后采用复诊的方式进行术后并发症发生情况的观察。结果: 多节段颈椎病患者 36 例均进入结果分析。分节段减压组和三间隙减压组患者平均手术时间、术中平均出血量、平均住院时间均明显少于 /短于长节段减压组(P < 0.05), 平均住院费用明显高于长节段减压组(P < 0.05)。分节段减压组、三间隙减压组和长节段减压组术后 JOA 评分提高分数和植骨融合率相近(P > 0.05) 。结论: 综合植骨融合率、神经功能恢复情况、手术时间、术中出血量、住院时间多种因素, 3 种术式中以颈前路分节段减压植骨融合术为治疗多节段颈椎病的手术方式较佳方案。

BACKGROUND： As a traditional treatment for multilevel cervical myelopathy, anterior long-segmental decompression has the shortcomings of great operative trauma, high difficulty, low fusion rate, etc., which can affect the postoperative efficacy. OBJECTIVE ： To evaluate the clinical effects of three different anterior surgeries on multilevel cervical myelopathy. DESIGN： A comparative observation. SETTING ： Department of Orthopaedics, Changzheng Hospital, the Second Military Medical University of Chinese PLA. PARTICIPANTS： Thirty-six patients with multilevel cervical myelopathy of 3 consecutive segments, who were surgically treated, were selected from the Department of Orthopaedics, Changzheng Hospital, the Second Military Medical University of Chinese PLA from June 1999 to June 2003, including 25 males and 11 females, 35-62 years of age, the disease course ranged from 3 to 26 months. According to the clinical manifestations and imaging results, they were diagnosed as multilevel cervical myelopathy, and they were not suffering from consecutive ossification of posterior longitudinal ligament and ossification of ligamenta flava. Informed contents were obtained from all the patients and their relatives. METHODS： All the patients ware grafted with autologous bone. Autologous ilium or cancellous bone excluding vertebral body was filled into titan net or Cage, which were made of titan and characterized by high intensity, tolerance to decay, good biocompatibility, etc. According to the operative manner, the patients were divided into 3 groups： ① two-level corpectomy with fusion group （long-segmental decompression group, n =11）; There were 4 cases grafted with long-titan net, and 7 cases grafted with autologous lilac bone. Sub-total two-level corpectomy with fusion was performed. ② segmental decompression group （n =16）： including 12 cases of titan net＋cage graft, 4 cases of autologous bone＋cage graft. One-level decompression and sub-total single corpectomy with fusion were performed. ③ three-level decompression group （n =9）： Only discectomy without corpectomy was performed. After complete decompression, 3 cages were used to fill artificial bone or grafted with autologous bone. MAIN OUTCOME MEASURES： Cervical anteroposterior and lateral radiographies, flexion and extension radiograph were reexamined within 1 week and at 3, 6 and 12 months postoperatively. The neurological function was assessed using the Japanese Orthopaedic Association （JOA） scoring method preoperatively and 3 months postoperatively. The total score was 17 points, the higher the score, the better the neurological function. The duration of operation, perioperative bleeding amount, length of stay, cost of hospitalization, graft fusion at 3 months postoperatively, improved JOA score at 3 months postoperatively were recorded in the three groups. The occurrence of postoperative complications was observed by means of return visit. RESULTS： All the 36 patients with multilevel cervical myelopathy were involved in the analysis of results. The mean duration of operation, mean perioperative bleeding amount and mean length of stay in the segmental-decompression group and three-level decompression group were obviously fewer or shorter than those in the long-segmental decompression group （P 〈 0.05）, and the average cost of hospitalization was obviously higher than that in the long-segmental decompression group （P 〈 0.05）, The postoperative improved JOA score and graft fusion rate were close among the groups （P 〉 0.05）. CONCLUSION： Segmental anterior cervical decompression is a recommendable technique for multilevel cervical myelopathy by comprehensively considering the fusion rate, recovery of neurological function, duration of operation, perioperative bleeding and length of stay.