老年多节段脊髓型颈椎病矢状面平衡特点及手术入路比较

Characteristics of sagittal balance and comparison of surgical approaches in elderly patients with multilevel cervical spondylotic myelopathy

目的分析老年多节段脊髓型颈椎病(MCMS)患者颈椎矢状面平衡特点,并比较不同手术入路对其预后的影响。方法回顾性分析2015年1月—2017年12月收治的102例MCMS患者临床资料,其中年龄>60岁患者(老年组)62例,年龄≤60岁且>40岁患者(中年组)40例。比较2组患者术前及末次随访时日本骨科学会(JOA)评分、JOA评分改善率、术前及末次随访时颈椎矢状面垂直轴(cSVA)、cSVA差值(ΔcSVA)、T1倾斜角(T1-slope),分析老年患者矢状面平衡变化的特点。将2组患者按术前T1-slope角度分为T1-slope<25°和T1-slope≥25°亚组。每个亚组内比较前路手术和后路手术ΔcSVA及JOA评分改善率差异。结果所有患者术前症状均得以改善。中年组术前T1-slope、末次随访cSVA、ΔcSVA及JOA评分改善率均优于老年组,差异均有统计学意义(P<0.05)。中年组T1-slope<25°亚组和T1-slope≥25°亚组,前后路手术ΔcSVA及JOA评分改善率差异均无统计学意义(P>0.05)。老年组T1-slope<25°亚组,前后路手术ΔcSVA及JOA评分改善率差异均无统计学意义(P>0.05);老年组T1-slope≥25°亚组,前路手术ΔcSVA及JOA评分改善率优于后路手术,差异均有统计学意义(P<0.05)。结论老年MCMS患者cSVA更易出现改变,术后cSVA也更易失代偿。T1-slope作为矢状面平衡变化的预测因素,对于老年患者手术入路选择具有一定的参考意义。当老年患者术前T1-slope较大(≥25°)时,后路手术可能增加颈椎矢状面失衡的风险,前路手术有利于颈椎矢状面平衡的维持与重建。

Objective To analyze the characteristics of cervical sagittal balance parameters in elderly patients with multilevel cervical spondylotic myelopathy(MCSM),and compare the impacts of various surgical approaches on surgical outcome.Methods The clinical data of 102 patients with MCMS from January 2015 to December 2017 were retrospectively analyzed,including 62 with age>60 years(elderly group)and 40 aged≤60 years and>40 years(middle-aged group).The Japanese Orthopaedic Association(JOA)score before operation and at the final follow-up,JOA score improvement rate,cervical sagittal vertical axis(cSVA)before operation and at the final follow-up,cSVA difference(ΔcSVA),T1-slope were compared between the 2 groups,and the characteristics of sagittal balance in elderly patients were analyzed.According to the preoperative T1-slope angle,the 2 groups were divided into T1-slope<25°and T1-slope≥25°subgroups.The difference ofΔcSVA and JOA score improvement rate between anterior and posterior surgery was compared in each subgroup.Results The symptoms were relieved in all the patients.The T1-slope,cSVA,ΔcSVA and JOA score improvement rate in middle-aged group were better than those in elderly group,all with a significant difference(P<0.05).In the T1-slope<25°subgroup and T1-slope≥25°subgroup of middle-aged group,there was no significant difference in theΔcSVA and JOA score improvement rate between anterior and posterior surgery(P>0.05).In the T1-slope<25°subgroup of elderly group,there was no significant difference in theΔcSVA and JOA score improvement rate between anterior and posterior surgery(P>0.05).In the T1-slope≥25°subgroup of elderly group,ΔcSVA and JOA score improvement rate of anterior surgery were better than those of posterior surgery,all with a significant difference(P<0.05).Conclusion Elderly patients with MCMS are more likely to have changes in cSVA and more likely to be decompensated after operation.T1-slope,as a predictor of sagittal balance changes,has certain reference significance for the selection of surgical approaches in elderly patients.When the preoperative T1-slope of elderly patients is high(≥25°),posterior surgery may increase the risk of sagittal balance decompensation,whereas anterior surgery can maintain and restore the sagittal balance.