超声骨刀不同切骨方式在颈椎后路单开门椎管扩大成形术中的应用

Application of different ultrasonic osteotomy methods in cervical expansive open-door laminoplasty

目的 :探讨超声骨刀不同的切骨入点和切骨角度在颈椎后路单开门椎管扩大成形术(cervical expansive open-door laminoplasty,CEOL)中应用的对比。方法:收集在我院骨科自2016年1月~2020年6月行CEOL术256例。根据术中开门侧的切骨方式将所有患者分为超声骨刀片状刀头竖直切骨组(A组)64例,改良片状刀头垂直椎板切骨组(B组)69例,改良钩状刀头切骨组(C组)46例及传统工具组(D组)77例。记录4组患者的开门时间、术中出血量,术中异体输血和截骨相关并发症;记录术前及术后3天JOA评分,JOA评分改善率等。结果:所有患者均行C3-C7节段CEOL。A、B、C三组开门时间均显著少于D组(10.3±2.7min、10.9±2.8min、10.1±2.7min vs 13.3±2.8min)(P<0.05)。术中出血量B、C两组显著少于D组(205.9±127.1ml、226.5±104.9ml vs 273.5±164.3ml)(P<0.05),A组与其余三组均无显著差异(P>0.05)。A组异体输血率显著高于B、C、D三组(12.5%vs 2.9%、2.2%、2.6%)(P<0.05)。A组C5神经麻痹发生率显著高于B、C、D组(P<0.05),其余组间无显著差异(P>0.05)。四组患者术后JOA评分均显著优于术前(P<0.05);四组患者间术前JOA评分、术后3天JOA评分及JOA改善率相比较,均无显著统计学差异(P>0.05)。结论:在CEOL中使用超声骨刀可显著减少开门时间及手术出血量,术后神经功能改善显著。在开门侧传统切骨入点竖直切骨会增加异体输血率,切骨入点内移1~2mm后垂直椎板切骨或选择钩状刀头可降低异体输血率。

Objectives: To investigate the different entry point and angle of bone cutting with ultrasonic bone cutter in patients underwent cervical expansive open-door laminoplasty(CEOL). Methods: 256 patients who were administrated in the Orthopedic Department of Peking University International Hospital from January 2016 to June 2020 were reviewed retrospectively. All the patients underwent CEOL and were divided into four groups according to different osteotomy access as followed. Group A, ultrasonic flake cutter withupright access in 64 cases;group B, improved ultrasonic flake cutter with vertical to lamina access in 69 cases;group C, improved ultrasonic hooked cutter with vertical to lamina access in 46 cases;group D, traditional osteotome in 77 cases. Open-door time, intraoperative blood loss, allogeneic blood transfusion, surgical complications related to osteotomy such as spinal cord injury, dura tear, and C5 paralysis. Japanese Orthopedic Association(JOA) scores before and 3 days after surgery, and the rates of improved JOA score were recorded.Results: All patients underwent C3-C7 CEOL. The open-door time of group A, B and C were significantly lower than that of group D(10.3 ±2.7 min, 10.9 ±2.8 min, 10.1 ±2.7 min vs 13.3 ±2.8 min)(P <0.05). Intraoperative blood loss in group B and C was significantly lower than that in group D(205.9±127.1 ml, 226.5±104.9 ml vs273.5±164.3 ml)(P<0.05), and there was no significant difference between group A and the other three groups(P>0.05). The rate of allogeneic blood transfusion in group A was significantly higher than that in group B, C and D(12.5% vs 2.9%, 2.2%, 2.6%)(P<0.05). The incidence of C5 paralysis in group A was significantly higher than that in group B, C and D(P<0.05), while there was no significant difference between the other 3 groups(P>0.05). The postoperative JOA score of all groups improved compared with preoperative JOA score(P<0.05), and there was no significant difference of the rates of improved JOA score, as well as of JOA score between preoperative and 3 days after surgery(P>0.05). Conclusions: The use of ultrasonic bone cutter in CEOL can significantly reduce the open-door time and intraoperative blood loss, and significantly improve the postoperative nerve function. Upright access at the traditional bone cutting point on the open side can increase the rate of allogeneic blood transfusion. Vertical to lamina access at the bone cutting point moved inwards by 1-2 mm can reduce the rate of allogeneic blood transfusion, so can the hooked cutter.