脊髓型颈椎病患者术后神经功能与生活质量的变化及其之间的相关性分析

Correlation and change of quality of life and neurological function outcome for cervical spondylotic myelopathy after surgery

目的：分析脊髓型颈椎病（cervical spondylotic myelopathy，CSM）患者术后生活质量的康复规律及其与神经功能康复的相关性。方法：收集北京大学第三医院骨科2008年2月～2013年5月收治的280例诊断为CSM并接受手术治疗患者的资料。术前使用改良JOA评分（mJOA评分）评价患者的神经功能，使用SF-36评价患者的生活质量．在术后3个月、1年和末次随访时使用上述两项评价方法对患者进行连续性随访。采用Wilcoxonranksum检验探讨患者神经功能及生活质量的变化规律，采用Spearman相关检验探讨生活质量与神经功能康复的相关性，采用受试者工作特征（receiveroperatingcharacteristic，ROC）曲线评价mJOA评分的变化值、mJOA评分的改善率、SF-36的生理维度（PCS）及心理维度（MCS）四项指标对于患者主观评价健康变化（healthtransitionitem，HTI）的判断价值，使用ROC曲线下面积（areaunderthecurve，AUC）评价ROC曲线的准确性，同时用Spearman相关检验进一步探讨四个指标对于HTI的敏感性及可靠性。结果：随访50．5-10．3个月（24．84个月）。术后3个月、1年和末次随访时的神经功能改善率分别为（45．0±42．4）％、（64．4±31．6）％和（66．8±36．9）％。在SF-36的各个维度上，患者手术前的评分均较正常人群有不同程度的下降（P〈0．05）；术后3个月时，除了总体健康（GH）和社会功能（SF）两项外，其他各维度均有显著改善（P〈0．05）；术后1年以及末次随访时，SF一36的8个维度均有显著改善（P〈0．05）。术后3个月时，只有PCS有显著改善（P=0．000），而MCS则较术前无明显变化（P=0．103）；术后1年及末次随访时PCS及MCS均有显著改善（P〈0.05）。术后3个月、1年和末次随访时的HT1分别为2．27±1．06、1．84±0．90和1．84±0．88。在术后3个月时，只有PCS改善与神经功能改善显著相关（P〈0．05）；术后1年与末次随访时，PCS及MCS的改善均与神经功能改善相关（P〈0．05）。术后3个月时SF-36的PCS对于HTI的判别价值最高（AUC=0．97，相关系数=-0．81）；术后1年时为mJOA评分改善率（AUC=0．93，相关系数=-0．82）；末次随访时SF-36的MCS与HTI的相关性最高（相关系数-0．67），而mJOA评分改善率与HTI的AUC最大（AUC=0．95）。结论：CSM患者术后神经功能和生活质量显著改善；神经功能改善早期只与PCS相关，中期则与PCS和MCS两个方面相关；随着CSM患者术后随访时间的变化，判别患者主观评价最有效的指标是不同的。

Objectives： To investigate the profile of quality of life（QOL） outcome after surgery for cervical spondylotic myelopathy（CSM） and its consistency with neurological function by using a cohort study. Methods： The sample comprised 280 patients who underwent surgical treatment for cervical spondylotic myelopathy in our hospital between February 2008 and May 2013. The mJOA score and SF-36 were used to evaluate the neurologic function, QOL was recorded before surgery, 3 months after surgery, 1 year after surgery and at fi- nal follow-up. The profile of health status measures（HSMs） and changes in clinical effects in each group after surgeries were analyzed by the Wilcoxon rank-sum test. For investigating the correlation between the two HSMs, the Spearman rank correlation analysis was performed. To assess the ability to discriminate heahh tran- sition item（HTI） of the change of mJOA, recovery rate of mJOA, mental component score（MCS） and physical component score（PCS） of SF-36, receiver operating characteristic（ROC） curve was performed to distinguish the Somewhat Better from the About the Same patients. The accuracy of the ROC curve was evaluated by using the calculated area under the curve （AUC）. To evaluate the most valid and responsive measure of the thera- peutic effectiveness of CSM, AUC of the ROC curve and the correlations between responses to the anchor were calculated by Spearman rank correlation analysis. Results： The mean follow-up time was 50.5±10.3（2± 84） months. The recovery rate of neurological function at 3 months, 1 year postoperatively and final follow-up was （45.0±42.4）%, （64.4±31.6）% and （66.8±36.9）% respectively. The scores of all sections of the SF-36 scale revealed that patients with CSM had significant impairment compared to the healthy adult （P〈0.05）. After surgery, with the exception of general-health and social-function at three months after surgery, all the other items at every follow-up time showed significant improvement. PCS had a significant improvement（P=O.O00） at 3 months after surgery except of MCS until 1 year after surgery （P value was 0.103 for MCS at 3 months af- ter surgery compared with preoperation）. PCS and MCS showed significant improvement at 1 year after surgery and final follow-up（P〈0.05）. In terms of health transition item, the scores were 2.27±1.06, 1.84±0.90, 1.84± 0.88 at 3 months, 1 year and final follow-up after surgery respectively. The improvement of mJOA was cor- related with PCS at every follow-up and MCS at 1 year after surgery and final follow-up. At 3 months after surgery, the AUC（0.97） and correlation coefficient（-0.81） of PCS had the highest value of four indexes. While the recovery rate of mJOA was AUC=0.93, correlation coefficient =-0.82 at 1 year after surgery. As for the final follow-up, the results were not consistent, and the recovery rate of mJOA had the highest AUC （0.95） and the highest correlation coefficient（-0.67） was for MCS. Conclusions： The preoperative QOL of patients with CSM is severely impaired compared to the normal population and each domain of the SF-36 improves in varied degrees. At the early stage of recovery, the improvements in mJOA scores are essentially correlated with domains from the physical components of the SF-36, while at later stages associated with both domains. The most responsive indicator varies depending on the follow-up time.