不同内固定物联合植骨对颈椎管成形后轴性痛并发症的影响

An influence on postoperative axial pain by laminoplasty combined with different fixations and bone grafting

背景:临床为预防颈椎管后路单开门扩大成形后轴性痛的发生,多选择门轴侧开槽处诱导植骨联合不同内固定装置,以恢复术后持续颈椎序列动态稳定。目的:探讨颈椎管后路单开门扩大成形辅助两种不同内固定治疗中,门轴侧骨槽植骨对术后轴性痛发作的影响。方法:选择行颈椎管后路单开门扩大成形治疗的多节段颈椎后纵韧带骨化症患者106例,其中52例进行椎弓根钉棒内固定,54例进行微型板钉内固定,两种内固定中均有行门轴侧骨槽植骨患者,治疗后通过影像学判定门轴侧骨槽融合率及轴性痛发生情况和临床疗效。结果与结论:(1)106例患者均获得随访,随访时间3.2-5.9年,未发生内固定断裂或松动、门轴侧骨槽处内层骨皮质折断等并发症;(2)52例椎弓根钉棒内固定患者中,植骨24例,未植骨28例;54例微型板钉内固定患者中,植骨37例,未植骨17例;(3)106例患者中19例出现轴性痛,包括椎弓根钉棒内固定组9例(植骨4例、未植骨5例)、微型板钉内固定组10例(植骨3例、未植骨7例);(4)在椎弓根钉棒内固定治疗后,植骨组与未植骨组治疗后3个月门轴侧骨槽融合率和末次随访JOA评分改善率比较差异均无显著性意义;在微型板钉内固定治疗后,植骨组治疗后3个月门轴侧骨槽融合率高于未植骨组(P<0.05),两组末次随访JOA评分改善率比较差异无显著性意义;(5)在椎弓根钉棒内固定治疗后,植骨组与未植骨组轴性痛发生率、首发时间、首发疼痛程度、持续时间及疼痛改善程度比较差异均无显著性意义;(6)在微型板钉内固定治疗后,植骨组轴性痛持续时间、疼痛改善程度优于未植骨组(P<0.05),其余指标比较差异无显著性意义;(7)结果表明,椎弓根钉棒内固定联合门轴侧骨槽植骨,不影响轴性痛发作特点;微型板钉内固定联合门轴侧骨槽植骨,有助于缩短轴性痛病程,提高其预后效果,促进植骨融合,尽快重建序列平衡和生物力学稳定性。

BACKGROUND:In clinical practice,inducible grafting from trimmed spinous process of hinge groove combined with different internal fixators is primarily applied to prevent postoperative axial pain after unilateral open-door cervical expansive laminoplasty.OBJECTIVE:To investigate the influence of autologous grafting of hinge groove combined with two internal fixators on postoperative axial pain after unilateral open-door cervical expansive laminoplasty.METHODS:We retrospectively reviewed 106 patients with multilevel ossification of cervical posterior longitudinal ligament who had underwent unilateral open-door cervical expansive laminoplasty with pedicle screw fixation(n=52,including grafting in 24 cases and non-grafting in 28 cases)or with mini-plate fixation(n=54,including grafting in 37 cases and non-grafting in 17 cases).Fusion rate of hinge groove,characteristics of postoperative axial pain and postoperative efficacy were evaluated by means of imaging methods.RESULTS AND CONCLUSION:All the 106 patients were followed up for 3.2-5.9 years,with no appearance of breaking or loosening of fixed appliances,disruption of the interior cortex of hinge groove.The 19 of 106 cases appeared to have postoperative axial pain,including 9 cases in the pedicle screw group(grafting:4 cases,non-grafting:5 cases)and 10 cases in the mini-plate group(grafting:3 cases,non-grafting:7 cases).Under the condition of pedicle screw fixation,there were no significant differences in the fusion rate at 3 months postoperatively and improvement rate of Japanese Orthopaedic Association Scale(JOA)score at final follow-up between the grating and non-grafting groups.After the implementation of mini-plate fixation,there was also no difference in JOA improvement rate at final follow-up between the grafting and non-grafting groups,but the fusion rate in the grafting group was significantly higher than that in the non-grafting group at 3 months postoperatively(P<0.05).After pedicle screw fixation,there was no significant difference in incidence,onset time and severity of initial onset,duration,pain improvement between grafting and non-grafting groups.When fixed by mini-plates,pain duration and pain improvement were better in the grafting group than the non-grafting group(P<0.05),and there were still no significant differences in the other indices between the two groups.To conclude,hinge grafting combined with pedicle screw fixation cannot affect onset characteristics of postoperative axial pain,while hinge grafting combined with mini-plate fixation can reduce duration of postoperative axial pain,improve prognosis,promote definite fusion of hinge groove,thereby remodeling alignment balance and biomechanical stability as soon as possible.