不同脊髓前方致压因素对后路手术治疗脊髓型颈椎病疗效的影响

EFFECT OF ANTERIOR CERVICAL SPINAL CORD COMPRESSION FACTOR IN TREATMENT OF CERVICAL SPONDYLOTIC MYELOPATHY

目的比较多节段脊髓型颈椎病（cervical spondylotic myelopathy,CSM）采用颈后路椎管扩大成形术后软性或骨性致压物、轻型或重型患者的疗效差异,以明确脊髓前方致压物分型的意义。方法回顾分析1998年2月-2013年2月采用颈后路扩大单开门减压术治疗的1 216例多节段CSM患者临床资料。将患者分为4组：A组为脊髓前方致压物为软性、椎管侵占率为轻型（MRI示致压物椎管侵占率〈50%）者,569例（46.8%）;B组为脊髓前方致压物为软性、椎管侵占率为重型（MRI示致压物椎管侵占率≥50%）者,365例（30.0%）;C组为脊髓前方致压物为骨性、椎管侵占率为轻型者,210例（17.3%）;D组为脊髓前方致压物为骨性、椎管侵占率为重型者,72例（5.9%）。4组患者性别、年龄、病程、病变节段、合并基础疾病等一般资料比较,差异均无统计学意义（P〉0.05）;因脊髓受压程度不同,术前4组患者日本骨科协会（JOA）评分及疼痛视觉模拟评分（VAS）比较,差异均有统计学意义（P〈0.05）。结果术后共发生脑脊液漏9例,其中A组2例、B组1例、C组3例、D组3例,经对症处理后均治愈。术后4组患者均未发生切口感染、椎板再关门及C5神经根麻痹等并发症。患者均获随访,随访时间24～74个月,平均35个月。D组17例（23.6%）于术后6～12个月出现症状再恶化,其他3组患者脊髓神经功能恢复良好。末次随访时,各组JOA评分及VAS评分均较术前显著改善（P〈0.05）;D组JOA评分、改善率及VAS评分均显著低于A、B、C组（P〈0.05）,A、B、C组间比较差异无统计学意义（P〉0.05）。结论将脊髓前方致压物分为软性、骨性及轻型、重型,对判断多节段CSM手术预后、确定术式具有指导意义。

Objective To observe the effectiveness of posterior cervical laminoplasty, and to determine the significance of the classification of spinal cord compression of multi-level cervical spondylotic myelopathy （CSM）. Methods The clinical data were analyzed from 1 216 cases of multi-level CSM undergoing posterior cervical laminoplasty between February 1998 and February 2013. The patients were divided into 4 groups： soft anterior spinal cord compression and light canal occupation （〈50%） in 569 cases （46.8%, group A）, soft anterior spinal cord compression and heavy canal occupation （≥ 50%） in 365 cases （30.0%, group B）, bony anterior spinal cord compression and light canal occupation in 210 cases （17.3%, group C）, and bony anterior spinal cord compression and heavy canal occupation in 72 cases （5.9%, group D）. There was no significant difference in gender, age, disease duration, lesion level, and complications among 4 groups （P〉0.05）. Because of different levels of spinal cord compression, there were significant differences in visual analogue scale （VAS） and Japanese Orthopaedic Association （JOA） score among 4 groups （P〈0.05）. Results Cerebrospinal fluid leakage occurred in 9 cases （2 cases in group A, 1 case in group B, 3 cases in group C, and 3 cases in group D）, and was cured after symptomatical treatment. There was no postoperative complication of wound infection, lamina re-closing, or C5 nerve root paralysis in 4 groups. The follow-up time ranged from 24 to 74 months （mean, 35 months）. In group D, 17 patients （23.6%） had deteriorated symptom at 6-12 months after operation, and good recovery was achieved in the patients of the Other 3 groups. At last follow-up, the JOA score and VAS score were significantly improved when compared with the preoperative scores in 4 groups （P〈0.05）; the JOA score, improvement rate, and VAS score of group D were significantly lower than those of groups A, B, and C （P〈0.05）, but there was no significant difference among groups A, B, and C （P〉0.05）. Conclusion In the multi-level CSM, the anterior compression of the spinal cord should be classified, this has a guiding significance for the prognosis of CSM and the choice of surgical method.