脊髓线标准下Ⅱ型多节段脊髓型颈椎病手术选择及疗效研究

Surgery Plan and Curative Effect of TypeⅡMultilevel Cervical Spondylotic Myelopathy According to Spinal Cord Line

目的通过脊髓线(spinal cord line,SC线)这一指标和分类方法来对前路减压融合(anterior decompression with fusion,ADF)与后路单开门椎板成形术(posterior open-door laminoplasty,LAMP)治疗Ⅱ型多节段脊髓型颈椎病(multilevel cervical spondylotic myelopathy,MCSM)的临床疗效及影像学结果进行比较,为术式的选择提供参考。方法回顾性研究2014年1月至2018年6月在我院接受手术治疗的65例Ⅱ型MCSM患者。将纳入的研究对象分为ADF组及LAMP组。ADF组30例,男21例,女9例;年龄37~79岁,平均(62.5±10.7)岁;LAMP组35例,男22例,女13例;年龄34~81岁,平均(61.1±10.1)岁。根据LAMP术后颈椎MRI是否存在脊髓前方残余压迫,分为前方残余压迫亚组LAMP(+)12例,前方无残余压迫亚组LAMP(-)23例。比较患者日本骨科协会评分(Japanese orthopaedic association,JOA)、改善率及手术前后疼痛视觉模拟评分(visual analogue scale,VAS)、颈椎曲度及颈椎活动度(range of motion,ROM)。结果末次随访时,ADF组和LAMP组的JOA改善率分别为(64.0±8.1)%、(48.7±14.9)%,VAS分别为(1.1±0.4)分、(1.4±0.6)分,两组JOA改善率及VAS比较差异均有统计学意义(P<0.05)。末次随访时,ADF组平均颈椎曲度从术前(12.9±7.7)°增加为(15.7±6.8)°,LAMP组从术前(17.1±6.1)°下降至(14.1±5.4)°,组内比较差异有统计学意义(P<0.05)。ADF组术前ROM为(24.5±6.3)°,末次随访为(19.2±5.5)°;LAMP组术前颈椎ROM为(23.9±6.6)°,末次随访为(18.9±5.4)°,两组术后颈椎ROM较术前均明显下降(P<0.05)。末次随访时,LAMP(+)与LAMP(-)亚组JOA改善率分别为(32.7±9.2)%、(57.0±9.4)%,VAS分别为(1.8±0.5)分、(1.3±0.5)分,曲度角改变分别为(4.0±1.0)°、(2.3±1.5)°,两亚组间JOA改善率、VAS及曲度角改变比较差异均有统计学意义(P<0.05)。ADF组术后并发症发生率16.7%,LAMP组发生率25.7%,差异无统计学意义(χ^(2)=0.782,P=0.376)。结论对于Ⅱ型MCSM患者前路手术恢复效果更好;术前脊髓前方致压物接触或超过SC线、术后颈椎曲度丢失是造成LAMP术后出现脊髓前方残余压迫的危险因素;LAMP术后脊髓前方残余压迫阻碍神经功能恢复。

Objective To compare the clinical efficacy and imaging results of anterior decompression with fusion(ADF)and of posterior open-door laminoplasty(LAMP)in the treatment of typeⅡmultilevel cervical spondylotic myelopathy(MCSM)according to spinal cord line(SC line)and to provide a reference for the selection of surgical procedures.Methods 65 patients with typeⅡMCSM who underwent surgical treatment in our hospital from January 2014 to June 2018wereretrospectively analyzed.The research objects were divided into ADF group and LAMP group.There were 30 cases in the ADF group,including 21 males and 9 femaleswith an average of(62.5±10.7)(range:37~79 year).The LAMP group involves 35 cases,including 22 males and 13 femaleswith an average of(61.1±10.7)(range:34~81 year).According to whether there was residual compression of the anterior spinal cord during the follow-up after LAMP operation,the patients were divided into the subgroup LAMP(+)andLAMP(-)subgroup.There were12 cases of residual anterior compressionin LAMP(+)groupand 23 cases of without residual anterior compressionin LAMP(-)group.The the Japanese Orthopaedic Association Scores(JOA),improvement rate and pain visual analogue scale(VAS),cervical curvature and range of motion before and after operation were studied.Results The JOA improvement rate at the last follow-up in the ADF group and the LAMP group were(64.0±8.1)%and(48.7±14.7)%respectively.The VAS score was(1.1±0.4)and(1.4±0.6)points respectively.There were statistically significant differences in the VAS scores and the JOA of the two groups(P<0.05).At the last follow-up,the average cervical curvature in the ADF group increased from(12.9±7.7)°to(15.7±6.8)°,and the LAMP group decreased from(17.1±6.1)°to(14.1±5.4).There were statistical differences(P<0.05).The range of motion(ROM)of the cervical spine before operation in the ADF group was(24.5±6.3)°,and the last follow-up was(19.2±5.5)°.The preoperative cervical ROM of the LAMP group was(23.9±6.6)°,and the last follow-up was(18.9±5.4)°,and the ROM of the cervical spine in both groups was significantly lower than that before operation(P<0.05).The improvement rates of JOA at the last follow-up of LAMP(+)and LAMP(-)subgroups were(32.7±9.2)%and(57.0±9.4)%respectively.The VAS scores were(1.8±0.5)points and(1.3±0.5)points,respectively.The changes in the angle of curvature were(4.0±1.0)°and(2.3±1.5)°,respectively.There were statistically significant differences in the JOA improvement rate,VAS score and changes in the angle of curvature between the two subgroups(P<0.05).The postoperative complication rate was 16.7%in the ADF group and 25.7%in the LAMP group,and the difference was not statistically significant(χ^(2)=0.782,P=0.376).Conclusion The recoveryis better for patients with typeⅡMCSMunderwentanterior surgery.The contact with or exceed the SC line in the front of the spinal cord before surgery,and loss of postoperative cervical spine curvature are risk factors for residual compression of the anterior spinal cord after LAMP surgery.Residual compression in front of the spinal cord after LAMP surgery impedes recovery of neurological function.