前路手术治疗4节段脊髓型颈椎病的疗效分析

Anterior surgical treatment of 4-level cervical spondylotic myelopathy

目的 探讨前路手术治疗4节段脊髓型颈椎病的临床效果及其并发症分析。方法 回顾性分析2006年9月至2014年3月接受颈椎前路手术的所有病历资料, 其中接受前路手术治疗的4节段脊髓型颈椎病患者32例。采用疼痛视觉模拟评分（visual analogue scale, VAS）评估切口和颈肩肢体疼痛情况, 日本骨科协会（ Japanese Orthopaedic Association Scores, JOA）评分评估神经功能。应用颈椎侧位X线片测量颈椎的前凸角度和高度改变, 并评估植骨融合情况。对并发症进行统计和分析, 包括髂部疼痛、脑脊液漏、喉返神经损伤、C5神经根麻痹、轴性痛、一过性吞咽困难等。结果 32例患者手术均顺利完成, 手术时间平均为（136±18） min, 失血量平均为（67±16） ml。随访时间1~8年, 平均（3.6±1.7）年。颈肩肢体疼痛VAS评分术前平均（7.3±1.2）分, 术后12个月平均为（3.6±0.8）分, 差异有统计学意义。术前、术后1周、术后3、6及12个月的JOA评分分别平均为（9.2±1.6）分、（9.6±2.2）分、（12.5±3.3）分、（13.2±3.2）分和（13.7±3.4）分。随访期间所有患者的内植物均保持安全、有效, 无植入物松动、移位。自体髂骨植骨4例, 术后6个月均达到融合标准。应用钛网的28例, 24例在术后6个月、4例在术后1年达到融合标准。并发症包括取髂骨处疼痛、不适3例, 脑脊液漏2例, 喉返神经损伤1例, C5神经根麻痹1例、轴性痛5例、一过性吞咽困难1例。结论 以脊髓前方受压为主的4节段脊髓型颈椎病应用前路手术治疗, 根据压迫部位的不同采用不同的椎体次全切除方式, 最常用的是C4、C6椎体次全切除＋2个钛网植骨＋钢板内固定术。只要减压、重建、固定等环节做到精确到位, 可获得满意的临床疗效。

Objective To investigate the clinical results, neurological scores, radiographic changes and complications for patients with 4-level cervical spondylotic myelopathy （4-level CSM） who underwent anterior decompression and fusion surgery. Methods All the medical records of anterior cervical surgery in our hospital between September 2006 and March 2014 were collected. Among them, thirty-two consecutive patients with 4-level CSM underwent the anterior decompression and fusion procedures were retrospectively investigated. Neurological function was measured at different times using Japanese Orthopedic Association （JOA） scores. The visual analogue score （VAS） was recorded for neck-shoulder pain evaluation. X-rays were conducted before and after surgery for cervical lordosis and fusion rate. Complications such as iliac pain, dysphonia, C5 palsy, cerebral fluid leakage, axial neck pain and temporary dysphagia were recorded and analyzed as well. Results All the operations were performed uneventfully. The mean operative time was 136？18min and mean blood loss was 67？16ml. The overall follow-up period of the patients ranged from 1-8 years （average 3.6？1.7years）. The VAS score significantly decreased from 7.3？1.2 preoperatively to 3.6？0.8 at 12 months postoperatively. The JOA score was 9.2？1.6 preoperatively, and 9.6？2.2, 12.5？3.3, 13.2？3.2, 13.7？3.4 at 1 week, 3 months, 6 months and 12 months postoperatively. Autologous iliac bone grafts were used in 4 patients, whose fusion rate was 100% at 6 months postoperatively. Titanium meshes were used in 28 patients, whose fusion rate was 85.7% at 6 months postoperatively and 100% at 12 months postoperatively. No hardware-related complications such as screw pull-out or plate bending occurred during the short- or long-term follow-up. Complications included iliac pain （3 cases）, dysphonia （1 case）, C5 palsy （1 case）, cerebral fluid leakage （2 cases）, axial neck pain （5 cases） and temporary dysphagia （1 case）. Conclusion Anterior approach for 4-level CSM is a challenging surgical technique. The choice of corpectomy levels should depend on the characteristics of cord compression. C4 and C6 discontinuous corpectomy with titanium mesh graft fusion and plate fixation is recommended procedure. This technique will be safe and effective if proper decompression and steady fixation are guaranteed.