节段型严重颈椎后纵韧带骨化症前路、后路手术的疗效比较与选择策略

Anterior or posterior approach for segmental severe ossification of posterior longitudinal ligament of the cervical spine： the efficacy and selection strategy

目的探讨前路和后路手术治疗节段型严重颈椎后纵韧带骨化症的疗效与选择策略。方法2007年1月至2011年5月，手术治疗59例节段型严重颈椎后纵韧带骨化症患者，男41例，女18例；年龄43-73岁，平均55．7岁。24例行前路椎体次全切减压植骨融合内固定术，35例行后路全椎板减压侧块螺钉内固定术。比较两组患者的手术时间、出血量、整体和节段曲度变化、并发症等情况；采用日本骨科协会评分（JapaneseOrthopaedicAssociationScores，JOA）评估手术前后的神经功能并计算改善率。结果所有患者随访12-18个月，平均15．4个月。前路手术组患者JOA评分术前平均为（7．33±1．09）分，末次随访时平均为（13．63±0．82）分，改善率为65．16％±7．50％；后路手术组患者JOA评分术前平均为（7．20±1．05）分，末次随访时平均为（12．23±1．11）分，改善率为51．46％±9．64％，两组间差异有统计学意义。手术部位的节段曲度术后即刻均较术前明显增加，前路手术组为5.38°±1．14°，后路手术组为3．89°±1．65°，差异有统计学意义。末次随访时颈部轴性症状发生率前路手术组为20．83％，后路手术组为51．43％，差异有统计学意义。结论对于骨化范围在3个节段以内的严重后纵韧带骨化症患者，前路手术能直接去除压迫，神经功能恢复良好，并有效地恢复颈椎曲度，术后轴性症状发生率低；后路手术在减压同时应用侧块螺钉内固定，能较好地维持减压节段的曲度。

Objective To investigate the efficacy and selection of anterior and posterior approaches for segmental severe ossification of posterior longitudinal ligament （OPLL）of the cervical spine. Method From January 2007 to May 2011, 59 patients with segmental severe OPLL underwent surgical treatment, including 41 males and 18 females, with an average age of 55.7 years. Among them, 24 patients underwent anterior corpectomy and fusion, and 35 patients underwent laminectomy and lateral mass screw fixation. In two groups, the operation time, intraoperative blood loss, change of cervical curvature, neck axial symptoms, and JOA （Japanese Orthopaedic Association） score were recorded and compared. Result All patients were fol- lowed up for 12 to 18 months （average, 15.4 months）. The average JOA score in anterior approach group in- creased from preoperative 7.33 ± 1.09 to 13.63 ± 0.82 at final follow-up, with an average improvement rate of 65.16% ±7.50%; the average JOA score in posterior approach group increased from preoperative 7.20 ± 1.05 to 12.23 ± 1.11 at final follow-up, with an improvement rate of 51.46%±9.64%; and the difference be- tween two groups was statistically significant. Immediately after the operation, the segmental curvature of the operative site was 5.38°±1.14° in anterior approach group and 3.89°±1.65° in posterior approach group, and the difference was statistically significant. At final follow-up, the rate of neck axial symptoms was 20.83% in anterior approach group and 51.43% in posterior approach group, and the difference was also statistically significant. Conclusion For severe OPLL with not more than 3 segments of ossification, the anterior ap- proach can remove the ossified mass directly, get a better neurological recovery, provide a good biomechani- cal alignment, and decrease the postoperative axial symptoms. However, posterior laminectomy and lateral mass screw fixation also can obtain enough decompression and maintain the segmental curvature.