多节段颈前路间盘切除融合手术与杂合手术的临床对比研究

A comparison of anterior cervical discectomy and fusion versus fusion combined with cervical disc replacement for treating multi- level cervical spondylotic disease

目的评价多节段颈椎病颈前路间盘切除融合（ACDF）联合颈椎间盘置换（CDR）的杂合手术与单纯ACDF治疗多节段颈椎病的临床效果。方法回顾性分析2015年1月—2017年3月清华大学附属垂杨柳医院骨科收治的53例多节段颈椎病患者的临床资料。根据手术方式不同，将患者分为ACDF组（n=29）和杂合手术组（n=24），分析两组患者的手术时间和术中出血量，术后1、3、6个月门诊复查随访评价视觉模拟评分（VAS）、颈椎功能障碍指数（NDI）评分、日本骨科协会评估治疗（JOA）评分、Odom分级和术后并发症，通过x线平片评价颈椎活动度（ROM）和邻近节段退变（ASD）情况。正态分布的计量资料以均数±标准差（x±s）表示，组间比较采用独立样本t检验，重复测量的计量资料采用方差分析。计数资料以百分比（％）表示，组间比较采用，检验或者Fisher精确检验；等级分组资料组问比较采用Kruskal—WallisH（K）秩和检验。结果杂合手术组患者手术时间[（81．0±15．4）min]和术中出血量[（69．0±38．4）ml]较少，差异无统计学意义（t=1．487，1．065；P=0．154，0．301）。术后并发症相比，ACDF组出现吞咽困难19例（65．5％）明显高于杂合手术组5例（20．8％），但是两组患者总体并发症相比差异无明显统计学意义（χ^2=9．759，P=0．082）。两组患者VAS、NDI评分及JOA评分术后均有明显改善，但两组比较差异无统计学意义（F组内：31．225，70．358，32．412，P=0．000，0．000，0．000；F自目=1．258，2．451，0．914，P=0．277，0．135，0．352）。两组患者手术效果Odom分级差异无明显统计学意义（x^2=260．500，P=0．077）。ACDF组C3-C7的ROM显著下降，而杂合手术组C3-C7的ROM下降不明显（t=2．514，1．776；P=0．022，0．093）。两组ROM相比，术后6个月C3-C7的ROM明显不同（t=2．353，P=0．030）。尽管杂合手术组随访期间没有发现放射学ASD改变，但是两组比较差异无统计学意义（χ^2=2．632，P=0．105）。结论多节段颈椎病杂合手术方案与以往的ACDF手术相比，能够有效保留颈椎ROM，减少邻近节段退变及术后吞咽不适感的发生。

Objective To evaluate the clinical efficacy of hybrid surgery, which combines fusion with cervical disc replacement （CDR）, compared to anterior cervical discectomy and fusion （ACDF） in patients with multi-level cervical spondylosis. Methods From January 2015 to March 2017, the clinical data of 53 patients with muhi-level cervical spondylosis admitted to Department of Orthopedics, Chui Yang Liu Hospital Affiliated to Tsinghua University, were retrospectively analyzed. They were divided into anterior cervical discectomy and fusion group （ACDF） （n = 29） and hybrid surgery group （n = 24） according to different operative methods. The operation time and intraoperative bleeding were analysised. Visual analogue scale （VAS） score, neck disability index （NDI）, Japanese orthopaedic association （JOA） scores, Odom criteria and surgical complications were evaluated when outpatient reviewed for 1, 3 and 6 months postoperative. The cervical range of motion （ ROM ） , and adjacent segments degeneration （ASD） were assessed with radiographs. The measurement data of normal distribution were expressed as （- ＋- s）, the comparison between groups was conducted by independent sample t test, and the repeated measurement data were analyzed by variance analysis. Counting data were expressed as percentage （%） and inter- group comparisons were performed by X2 test or Fisher exact test, and inter-group comparisons of classified data were performed by Kruskal-Wallis H （K） rank test. Results The operation time [ （81.0 ± 15.4 ） rain ] and the amount of bleeding [ （69.0 ± 38.4 ） ml ] in the hybrid surgery group were less, but there was no statistical difference （ t = 1. 487, 1. 065, P = 0. 154, 0. 301 ）. Compared with postoperative complications, dysphagia occurred in 19 patients （65.5%） in group ACDF, which was significantly higher than 5 in group hybrid surgery （20.8%）, but there was no significant difference in overall complications （X2 = 9. 759, P = 0. 082）. Significant improvements in VAS score, NDI score and JOA score were observed postoperation in ACDF and hybrid surgery group, but there was no significant difference between the two groups （Fintra-group =31. 225, 70. 358, 32. 412, P = 0.000, 0.000, 0.000; Finter-group =1.258, 2.451, 0.914, P=0.277, 0. 135, 0.352）. There was no significant difference in Odom criteria between the two groups （χ^2 = 260. 500, P = 0.077 ）. The ROM of C3-C7 in group ACDF decreased significantly, while that in group hybrid surgery was not significantly decreased （t = 2. 514, 1. 776, P = 0. 022,0. 093）. The ROM of C3-C7 was significantly different at 6 months postoperation （t =2. 353, P =0.030）. Although no ASD changes were found in the hybrid surgery group during the follow-up period, there was no significant statistical significance in the two groups （χ^2 = 2. 632, P = 0. 105 ）. Conclusion Compared with the previous ACDF operation, there is no significant difference in the clinical results of hybrid surgery operation for multilevel cervical spondylosis, but it can effectively preserve cervical ROM, reduce adjacent segment degeneration and postoperative dysphagia.