前路与后路减压融合术治疗颈椎后纵韧带骨化症的效果比较及术后1年预后的影响因素分析

Effects of anterior and posterior decompression with fusion on ossification of posterior longitudinal ligament of cervical spine and influence factors of 1-year outcome

目的比较前路减压融合术(ADF)与后路减压融合术(PDF)治疗颈椎后纵韧带骨化症(OPLL)的效果并分析术后1年预后的影响因素。方法选取2015年6月至2017年6月空军军医大学第一附属医院收治的OPLL患者77例,根据手术治疗路径的不同分为ADF组(42例)及PDF组(35例)。比较2组患者的一般资料、手术时间、术中出血量以及手术前后的日本骨科学会(JOA)评分、C2~7角和C2~7矢状面垂直距离和术后1年内并发症发生率,应用单因素分析及多因素Logistic回归方法分析OPLL患者术后1年预后的影响因素。结果术前PDF组椎管狭窄率、术前磁共振成像T2高密度影率及骨化融合范围均高于ADF组[(61±22)%比(41±15)%、54.3%(19/35)比28.6%(12/42)、(3.9±0.4)节段比(1.9±0.6)节段],差异均有统计学意义(均P<0.05)。ADF组的手术时间长于PDF组、术中出血量大于PDF组[(5.6±1.6)h比(4.7±1.4)h、(782±45)ml比(308±68)ml],差异均有统计学意义(均P<0.05)。术后1年ADF组JOA评分改善率高于PDF组[(71±24)%比(49±19)%],差异有统计学意义(P<0.05)。ADF组与PDF组术后1年内并发症发生率比较差异无统计学意义(P=0.942)。单因素分析结果显示,预后良好组症状持续时间≥24个月、术前JOA评分<9分、截骨平面数≥3比例均低于预后不良组(均P<0.05)。Logistic回归分析结果显示,术前JOA评分≥9分是OPLL患者术后1年预后的保护因素(比值比=0.473,95%置信区间:0.302~0.741,P=0.001),截骨平面数≥3为危险因素(比值比=3.816,95%置信区间:1.727~8.432,P=0.002)。结论 ADF适用于骨化范围较小的OPLL,其疗效显著,但术中伤害较大;PDF适用于骨化范围较大的OPLL,操作相对简单;术前低JOA评分与多截骨平面(≥3)是预后不良的预测指标。

Objective To compare the effects of anterior decompression with fusion(ADF) and posterior decompression with fusion(PDF) on cervical ossification of posterior longitudinal ligament(OPLL) and to analyze the influence factors of 1-year prognosis after operation. Methods A total of 77 patients with OPLL admitted to the First Affiliated Hospital of Army Air Force Military Medical University from June 2015 to June 2017 were divided into ADF group(42 cases) and PDF group(35 cases) depended on the surgical approach. General information, operation time, intraoperative blood loss, score of Japanese Orthopedic Society(JOA), C2-7 angle, C2-7vertical distance at sagittal plane and incidence of complications within 1-year after surgery were analyzed. Univariate analysis and multivariate logistic regression were used to analyze the factors affecting 1-year prognosis. Results Rates of spinal canal stenosis and T2-weighted magnetic resonance imaging, range of ossification in PDF group were significantly higher than those in ADF group[(61±22)% vs (41±15)%, 54.3%(19/35) vs 28.6%(12/42),(3.9±0.4)cervical segments vs (1.9±0.6)cervical segments](all P<0.05). Operation time and intraoperative blood loss in ADF group were significantly longer/more than those in PDF group[(5.6±1.6)h vs (4.7±1.4)h,(782±45)ml vs (308±68)ml](both P<0.05). The 1-year improvement rate of JOA score in ADF group was significantly higher than that in PDF group[(71±24)% vs (49±19)%](P<0.05). There was no significant difference of the 1-year incidence of complications between groups(P=0.942). Univariate analysis results showed that patients with good prognosis had higher proportions of duration of symptoms≥24 months, preoperative JOA score<9, segments of spinal osteotomy≥3 than patients with poor prognosis(all P<0.05). Logistic regression analysis showed that preoperative JOA score≥9 was an independent protective factor(odds ratio=0.473, 95% confidence interval: 0.302-0.741, P=0.001) and segments of spinal osteotomy≥3 was an independent risk factor(odds ratio=3.816, 95% confidence interval: 1.727-8.432, P=0.002) of the prognosis of OPLL surgery. Conclusions ADF is available for mild OPLL;it has significant therapeutic effect but large surgical damage. PDF is suitable for extensive OPLL and the operation is simple. Low JOA score and multi-level corpectomies(≥3) are predictors of poor prognosis.