一期后前路联合手术治疗多节段脊髓型颈椎病

One-stage anterior-posterior approach for multilevel cervical spondylotic myelopathy

目的:探讨一期后前路联合手术治疗多节段脊髓型颈椎病的临床疗效。方法 :回顾性分析2009年9月～2010年7月我院收治的行一期后前路联合手术治疗的多节段脊髓型颈椎病患者28例,男16例,女12例,年龄32～63岁,平均51.3岁,病程平均5.6年。术前病变节段:3节段16例,4节段12例。其中累及C2/3节段5例次、C3/4 21例次、C4/5 26例次、C5/6 28例次、C6/7 16例次。合并高血压病4例,糖尿病5例。患者均采用一期后路改良颈椎椎管扩大椎板成形联合前路选择性减压植骨融合内固定术。术前、术后3、6及12个月随访时采用10秒握拳试验、双手握力、VAS评分、日本整形外科学会(JOA)评分及神经功能改善率评价临床疗效,并进行影像学检查观察颈椎曲度及植骨融合情况。结果:本组后前路联合手术时间平均6.5h,出血量平均375ml。患者均得到1年及以上有效随访。1年随访时JOA评分由术前的9.8±2.1分提高到15.9±1.2分(P<0.05),平均改善率(84.7±9.2)%。术前、术后10秒试验:左手由11.2±3.1次提高到18.2±2.6次,右手由10.8±1.0次提高到17.8±3.9次(P均<0.05)。平均握力:左手由18.7±7.1kg提高到33.2±6.3kg,右手由19.2±3.6kg提高到35.8±2.5kg(P均<0.05)。颈部轴性疼痛VAS评分为2.1±1.1分。颈椎前凸角由21.5°±5.7°减少到19.60°±4.10°(P>0.05)。影像学随访示颈椎管减压充分,椎间植骨融合满意,未见相邻节段不稳及内固定失败等并发症。结论:一期后前路联合手术创伤小、可有效改善颈椎后路术后轴性疼痛发生率及疼痛程度。在后路手术基础上,前路选择性减压植骨融合内固定术可有效解除脊髓压迫。

Objective：To evaluate the clinical results of one-stage anterior-posterior approach for multilevel cervical spondylotic myelopathy（CSM）.Method：A total of 28 patients（16 males and 12 females） suffering severe CSM underwent one-stage combined anterior-posterior approach,the average age was 51.3 years（range：32-63 years）.The affected level was C2/3 in 5 cases,C3/4 in 21 cases,C4/5 in 26 cases,C5/6 in 28 cases and C6/7 in 16 cases.The clinical results including JOA scores,the number of hand action in ten seconds,hand-grip strength,visual analog scale（VAS） of axial pain,and Cobb angle of sagittal alignment（C2-C7） were assessed retrospectively.Result：The average surgical time was 6.5h,the average blood loss was 375ml.All cases were followed up for one year.No neurological deterioration due to spinal cord injury,CSF leakage,or wound infection was noted.The JOA scores improved from preoperative 9.8±2.1 to 15.9±1.2 of 1 year later,with the average improve rate of（84.7±9.2）%.The number of hands action in ten seconds improved from preoperative 11.2±3.1 of left and 10.8±1 of right to postoperative 18.2±2.6 of left and 17.8±3.9 of right,and hand-grip strength improved from preoperative 18.7±7.1kg of left and 19.2±3.6kg of right to postoperative 33.2±6.3 of left and 35.8±2.5 of right（P0.05）.Cervical kyphosis decreased from 21.5°±5.7° to 19.60°±4.10°（P0.05）.All cases showed satisfactory decompression and good bony fusion on MRI or CT.No ASD and instrument failure were noted.Conclusion：Combined anterior-posterior approach is less invasive and can decrease postoperative axial pain;anterior approach can manage compression effectively.