颈后路单开门椎管扩大成形跳跃式与连续式微型钛板内固定术治疗多节段脊髓型颈椎病的对比研究

Unilateral open-door laminoplasty through cervical posterior approach combined with intermittent internal fixation versus continuous internal fixation with miniature titanium plates for treatment of multiple-segment cervical spondylotic myelopathy:a compar

目的:比较颈后路单开门椎管扩大成形跳跃式与连续式微型钛板内固定术治疗多节段脊髓型颈椎病的临床疗效及安全性。方法:回顾性分析120例多节段脊髓型颈椎病患者的病例资料,其中采用颈后路单开门椎管扩大成形跳跃式微型钛板内固定治疗60例(跳跃式固定组),C_3、C_5、C_7开门侧予以Arch钛板固定,C_4、C_6开门侧予以传统缝线固定;采用颈后路单开门椎管扩大成形连续式微型钛板内固定60例(连续式固定组),C_3～C_7开门侧均予以Arch钛板固定。同时按照内固定方式不同将600节椎板固定节段分为钛板固定节段和缝线固定节段。比较2组患者的手术时间、术中出血量、住院费用、住院时间、日本骨科协会(Japanese orthopaedic association,JOA)脊髓型颈椎病评分(17分法)、颈椎功能障碍指数(the neck disability index,NDI)评分、JOA改善率、颈椎曲度指数、颈椎活动度、脊髓后移距离以及并发症发生情况。比较钛板固定节段和缝线固定节段的椎管矢状径、Pavlov比值、椎板开门角度。结果:①一般指标。跳跃式固定组住院费用少于连续式固定组[(5.56±0.29)万元,(7.76±0.37)万元,t=-36.383,P=0.000];2组患者术中出血量、手术时间及住院时间比较,差异均无统计学意义[(305.50±59.99)mL,(292.50±52.35)mL,t=1.265,P=0.208;(132.33±16.79)min,(132.67±18.88)min,t=-0.102,P=0.919;(10.38±2.34)d,(10.42±2.36)d,t=-0.078,P=0.938]。②JOA脊髓型颈椎病评分。术前和术后1年,2组患者JOA脊髓型颈椎病评分比较,组间差异均无统计学意义[(9.58±1.37)分,(9.55±1.53)分,t=0.126,P=0.900;(14.52±1.52)分,(14.42±1.64)分,t=0.400,P=0.690];术后1年,2组患者JOA脊髓型颈椎病评分均高于术前(t=49.103,P=0.000;t=48.991,P=0.000)。③NDI评分。术前和术后1年,2组患者NDI评分比较,组间差异均无统计学意义[(27.40±10.10)分,(27.70±9.91)分,t=-0.164,P=0.870;(14.17±6.08)分,(14.43±5.38)分,t=-0.255,P=0.799];术后1年,2组患者NDI评分均低于术前(t=-13.285,P=0.000;t=-10.365,P=0.000)。④JOA改善率。术后1年,2组患者JOA改善率比较,差异无统计学意义[(68.73±16.13)%,(67.88±16.36)%,t=0.355,P=0.723]。⑤颈椎曲度指数。术前和术后1年,2组患者颈椎曲度指数比较,差异均无统计学意义[(20.07±3.63)%,(19.76±3.15)%,t=0.495,P=0.622;(19.92±3.82)%,(19.53±3.20)%,t=0.614,P=0.540];术后1年2组患者颈椎曲度指数与术前相比,差异均无统计学意义(t=-0.794,P=0.430;t=-1.186,P=0.240)。⑥颈椎活动度。术前和术后1年,2组患者颈椎活动度比较,差异均无统计学意义(45.52°±5.76°,44.93°±3.75°,t=-0.672,P=0.503;32.78°±6.59°,32.81°±5.03°,t=-0.031,P=0.975);术后1年,2组患者颈椎活动度均小于术前(t=-42.051,P=0.000;t=-32.826,P=0.000)。⑦脊髓后移距离。术后1年,2组患者脊髓后移距离比较,差异无统计学意义[(2.97±0.43)mm,(3.09±0.61)mm,t=-1.243,P=0.216]。⑧椎管矢状径。时间因素与分组因素不存在交互效应(F=1.929,P=0.165);钛板固定节段和缝线固定节段椎管矢状径比较,差异无统计学意义,即不存在分组效应(F=0.001,P=0.972);手术前后不同时间点之间椎管矢状径的差异有统计学意义,即存在时间效应(F=14 533.825,P=0.000);钛板固定节段和缝线固定节段椎管矢状径随时间均呈先增加后小幅度下降趋势,且二者的变化趋势完全一致[(10.09±0.79)mm,(17.16±1.26)mm,(16.91±1.30)mm,F=5 954.60,P=0.000;(10.25±0.96)mm,(17.07±1.52)mm,(16.83±1.56)mm,F=953.260,P=0.000]。⑨Pavlov比值。时间因素与分组因素不存在交互效应(F=1.516,P=0.219);钛板固定节段和缝线固定节段Pavlov比值比较,组间差异无统计学意义,即不存在分组效应(F=0.004,P=0.950);手术前后不同时间点之间Pavlov比值的差异有统计学意义,即存在时间效应(F=2 499.316,P=0.000);钛板固定节段和缝线固定节段Pavlov比值随时间均呈先增加后小幅度下降趋势,且二者的变化趋势完全一致[(74.11±4.50)%,(93.52±5.98)%,(93.34±6.00)%,F=1 945.93,P=0.000;(74.54±4.78)%,(93.63±5.49)%,(92.72±5.55)%,F=497.54,P=0.000]。⑩椎板开门角度。术后3 d和术后1年,缝线固定节段的椎板开门角度均小于钛板固定节段(38.91°±4.86°,41.15°±3.88°,t=4.676,P=0.000;37.04°±4.71°,41.20°±4.02°,t=9.808,P=0.000);术后1年,钛板固定节段的椎板开门角度与术后3 d比较,差异无统计学意义(t=-1.260,P=0.208);缝线固定节段的椎板开门角度小于术后3 d(t=-29.709,P=0.000)。(11)安全性。2组患者均未出现心脑血管意外事件、颈部轴性症状和切口感染等并发症。跳跃式固定组4例出现C5神经根麻痹,连续式固定组3例出现C5神经根麻痹; 7例患者均予甘露醇脱水、甲泼尼龙琥珀酸钠抗炎和甲钴胺营养神经治疗后,C5神经根麻痹症状消失。2组患者并发症发生率比较,差异无统计学意义(χ~2=0. 000,P=1. 000)。结论:采用颈后路单开门椎管扩大成形跳跃式微型钛板内固定治疗多节段脊髓型颈椎病,虽然存在缝线固定节段开门角度丢失问题,但可取得与颈后路单开门椎管扩大成形连续式微型钛板内固定相当的临床疗效和安全性,且可明显降低住院费用。

Objective:To compare the clinical curative effects and safety of unilateral open-door laminoplasty through cervical posterior approach and intermittent internal fixation with miniature titanium plates versus unilateral open-door laminoplasty through cervical posterior approach and continuous internal fixation with miniature titanium plates for treatment of multiple-segment cervical spondylotic myelopathy(CSM).Methods:The medical records of 120 patients with multiple-segment CSM were analyzed retrospectively.Sixty patients were treated with unilateral open-door laminoplasty through cervical posterior approach and intermittent internal fixation with miniature titanium plates(intermittent fixation group),and the vertebral plate of C 3,C 5 and C 7 at door-opening side were fixed with Arch titanium plates,and the vertebral plates of C 4 and C 6 were fixed with traditional suture.The other sixty patients were treated with unilateral open-door laminoplasty through cervical posterior approach and continuous internal fixation with miniature titanium plates(continuous fixation group),and the vertebral plates of C 3-C 7 at door-opening side were fixed with Arch titanium plates.The 600 segments of fixed vertebral plates were divided into titanium plate fixation segments and suture fixation segments according to the internal fixation methods.The operative time,intraoperative blood loss,cost of hospitalization,hospital stay,Japanese Orthopedic Association(JOA)CSM scores,the neck disability index(NDI),JOA improvement rate,cervical curvature index(CCI),range of motion(ROM)of cervical vertebrae,post-displacement distance of the spinal cord and complications were compared between the 2 groups.The sagittal diameter of vertebral canal,Pavlov ratio and the opening angle of vertebral plate were compared between titanium plate fixation segments and suture fixation segments.Results:The total cost of hospitalization was less in intermittent fixation group compared to continuous fixation group(55.6+/-2.9 vs 77.6+/-3.7 thousands Yuan, t=-36.383 ,P =0.000).There was no statistical difference in intraoperative blood loss,operative time and hospital stays between the 2 groups(305.50+/-59.99 vs 292.50+/-52.35 mL, t=1.265,P =0.208;132.33+/-16.79 vs 132.67+/-18.88 min, t=-0.102,P =0.919;10.38+/-2.34 vs 10.42+/-2.36 days, t=-0.078,P =0.938).There was no statistical difference in JOA CSM scores between the 2 groups before the surgery and at 1 year after the surgery(9.58+/-1.37 vs 9.55+/-1.53 points, t=0.126,P =0.900;14.52+/- 1.52 vs 14.42+/-1.64 points, t=0.400,P =0.690).The JOA CSM scores increased in both of the 2 groups at 1 year after the surgery compared to pre-surgery( t=49.103,P=0.000;t=48.991,P =0.000).There was no statistical difference in NDI scores between the 2 groups before the surgery and at 1 year after the surgery(27.40+/-10.10 vs 27.70+/-9.91 points, t=-0.164,P =0.870;14.17+/-6.08 vs 14.43+/-5.38 points, t=-0.255,P =0.799).The NDI scores decreased in both of the 2 groups at 1 year after the surgery compared to pre-surgery( t=-13.285,P=0.000;t=-10.365,P =0.000).There was no statistical difference in JOA improvement rate between the 2 groups at 1 year after the surgery(68.73+/-16.13 vs 67.88+/-16.36%, t=0.355,P =0.723).There was no statistical difference in CCI between the 2 groups before the surgery and at 1 year after the surgery(20.07+/-3.63 vs 19.76+/-3.15%, t=0.495,P =0.622;19.92+/-3.82 vs 19.53+/-3.20%, t=0.614,P =0.540).There was no statistical difference in CCI between pre-surgery and postoperative year 1 in the 2 groups( t=-0.794,P=0.430;t=-1.186,P =0.240).There was no statistical difference in ROM of cervical vertebrae between the 2 groups before the surgery and at 1 year after the surgery(45.52+/-5.76 vs 44.93+/-3.75 degrees, t=-0.672 ,P =0.503;32.78+/-6.59 vs 32.81+/-5.03 degrees, t=-0.031,P =0.975).The ROM of cervical vertebrae decreased in both of the 2 groups at 1 year after the surgery compared to pre-surgery( t=-42.051,P=0.000;t=-32.826,P =0.000).There was no statistical difference in post-displacement distance of the spinal cord between the 2 groups at 1 year after the surgery(2.97+/-0.43 vs 3.09+/-0.61 mm, t=-1.243,P =0.216).There was no interaction between time factor and group factor in sagittal diameter of vertebral canal( F=1.929,P =0.165).There was no statistical difference in sagittal diameter of vertebral canal between titanium plate fixation segments and suture fixation segments,in other words,there was no group effect( F=0.001,P =0.972).There was statistical difference in sagittal diameter of vertebral canal between different timepoints before and after the surgery,in other words,there was time effect( F= 14 533.825 ,P =0.000).The sagittal diameter of vertebral canal presented a time-dependent trend of increasing firstly and decreasing slightly subsequently in titanium plate fixation segments and suture fixation segments,and the both were consistent with each other in the variation tendency of sagittal diameter of vertebral canal(10.09+/-0.79,17.16+/-1.26,16.91+/-1.30 mm, F=5 954.60,P= 0.000;10.25+/-0.96,17.07+/-1.52,16.83+/-1.56 mm, F=953.260,P =0.000).There was no interaction between time factor and group factor in Pavlov ratio( F=1.516,P =0.219).There was no statistical difference in Pavlov ratio between titanium plate fixation segments and suture fixation segments,in other words,there was no group effect( F=0.004,P =0.950).There was statistical difference in Pavlov ratio between different timepoints before and after the surgery,in other words,there was time effect( F=2 499.316,P =0.000).The Pavlov ratio presented a time-dependent trend of increasing firstly and decreasing slightly subsequently in titanium plate fixation segments and suture fixation segments,and the both were consistent with each other in the variation tendency of Pavlov ratio(74.11+/-4.50,93.52+/- 5.98 ,93.34+/-6.00%, F=1 945.93,P =0.000;74.54+/-4.78,93.63+/-5.49,92.72+/-5.55%, F=497.54,P= 0.000).The opening angles of vertebral plate were smaller in suture fixation segments compared to titanium plate fixation segments at 3 days and 1 year after the surgery(38.91+/-4.86 vs 41.15+/-3.88 degrees, t=4.676,P =0.000;37.04+/-4.71 vs 41.20+/-4.02 degrees, t= 9.808 ,P= 0.000).There was no statistical difference in opening angles of vertebral plate between postoperative day 3 and postoperative year 1 in titanium plate fixation segments( t=-1.260,P =0.208),and the opening angles of vertebral plate were smaller at postoperative year 1 compared to postoperative day 3 in suture fixation segments( t=-29.709,P =0.000).No complications such as cardiovascular and cerebrovascular accidents,cervical axial symptoms and incision infection were found in the 2 groups.The C 5 nerve-root paralysis were found in 4 patients in intermittent fixation group and 3 patients in continuous fixation group,and the symptoms disappeared after treatment by dehydration therapy,anti-inflammatory therapy and neurotrophic therapy using mannitol,methylprednisolone sodium succinate and mecobalamine respectively.There was no statistical difference in complication incidences between the two groups(χ^2=0.000,P =1.000).Conclusion:Intermittent internal fixation with miniature titanium plates is similar to continuous internal fixation with miniature titanium plates in clinical curative effect and safety in unilateral open-door laminoplasty through cervical posterior approach for treatment of multiple-segment CSM,and it can obviously reduce the total cost of hospitalization,although it may result in door-opening angle lose in suture fixation segments.