不同手术方式治疗多节段脊髓型颈椎病的手术效果及影响因素分析

Analysis of the effect and influencing factors of different surgical methods in the treatment of multi-level cervical spondylotic myelopathy

目的探究多节段脊髓型颈椎病(cervical spondylotic myelopathy,CSM)患者采用颈椎前路椎体切除融合术(anterior cervical corpectomy and fusion,ACCF)联合颈椎前路椎间盘切除融合术(anterior cervical discectomy and fusion,ACDF)与单纯后路单开门椎管扩大成形术的疗效及其影响因素。方法回顾性分析湖北省六七二中西医结合骨科医院脊柱外科2018年1月至2021年1月收治的83例多节段CSM患者的临床资料,依据采用的手术方式分为A、B组,A组44例患者采用颈前路ACCF联合ACDF治疗,B组39例患者采用后路单开门椎管扩大成形术治疗;收集两组患者手术时间、围手术期出血量、住院时间等临床指标,采用日本骨科协会(Japanese Orthopaedic Association,JOA)评分、颈椎功能障碍指数(neck disability index,NDI)量表评估患者术前及术后6个月神经功能与颈椎功能障碍改善效果,对比术前及术后6个月两组患者颈椎曲度,观察两组患者术后6个月并发症发生情况。依据患者手术效果分为改善组(72例)与未改善组(11例)。计数资料组间比较采用χ^(2)检验;符合正态分布的计量资料组间比较采用独立样本t检验,依据单因素分析的结果,将有意义的因素纳入到二元Logistic回归,分析患者手术疗效相关的影响因素。结果A组患者围手术期出血量[(153.36±10.68)mL]、住院时间[(10.11±2.30)d]均低于B组[(171.47±11.32)mL、(15.58±3.76)d],两组比较差异均有统计学意义(t值分别为7.50、8.10,均P<0.001)。术后6个月A、B组患者JOA评分[(13.70±1.49)、(12.94±1.63)分]、颈椎曲度(22.10±3.23、13.38±3.12)均高于术前[(9.40±1.32)、(9.36±1.51)分;11.16±2.60、11.23±2.71],且A组高于B组,差异均有统计学意义(手术前后JOA评分:t值分别为14.33、10.07,颈椎曲度:t值分别为17.50、3.25;两组间治疗后t值分别为2.22、12.47,P值分别为<0.001、<0.001、<0.001、0.002、0.029、<0.001)。术后6个月A、B组NDI指数[(11.38±4.76)、(14.79±4.85)]均低于术前[(39.56±9.43)、(39.74±9.51)],且A组低于B组,差异均有统计学意义(t值分别为17.70、14.60、3.23,均P<0.001)。二元Logistic回归表明,病程≥6个月(OR=59.045,95%CI:6.485~537.629)、存在颈髓MRI信号变化(OR=0.031,95%CI:0.002~0.587)、手术方式(后路单开门椎管扩大成形术)(OR=6.300,95%CI:1.269~31.273)是影响患者手术效果的独立性危险因素(P值分别为<0.001、0.021、0.024)。结论颈前路ACCF联合ACDF治疗多节段CSM患者手术疗效理想,能够显著改善患者颈椎脊髓神经功能及颈椎曲度,缩短手术时间并减少围手术期出血量;仍需关注患者病程、颈髓MRI信号变化及手术方式对其手术效果的影响。

Objective To explore the use of anterior cervical corpectomy and fusion(ACCF)combined with anterior cervical discectomy and fusion(ACDF)in patients with multilevel cervical spondylopathy myelopathy(CSM).Methods The clinical data of 83 patients with multi-segment CSM admitted to the Department of Spinal Surgery of Hubei Liuqi2 Orthopaedic Hospital of Integrated Traditional Chinese and Western Medicine from January 2018 to January 2021 were retrospectively analyzed.According to the different surgical methods used in their treatment,they were divided into group A and group B.In group A,44 patients were treated with anterior cervical ACCF combined with ACDF,and 39 patients in group B were treated with posterior single-door laminoplasty.The general clinical indexes such as operation time,perioperative bleeding volume and hospitalization time were collected.The neurological function and cervical dysfunction improvement effect of the patients before and 6 months after operation were evaluated by using the Japanese Orthopaedic Association(JOA)score and neck disability index(NDI)scale.The cervical curvature of the patients before and 6 months after operation was compared,The complications of the two groups were observed 6 months after operation.The patients were divided into improved group(72 cases)and non improved group(11 cases).Comparison between count data groups χ^(2) inspection.Independent sample t-test was used for comparison between measurement data groups conforming to normal distribution.According to the results of univariate analysis,the meaningful factors were included in the binary Logistic regression to analyze the influencing factors related to the surgical efficacy.Result The perioperative blood loss((153.36±10.68)mL)and hospital stay((10.11±2.30)d)in group A were lower than those in group B((171.47±11.32)mL,(15.58±3.76)d).There were significant differences between the two groups(t values were 7.50 and 8.10;both P<0.001).Six months after operation,the JOA score(13.70±1.49,12.94±1.63)and cervical curvature(22.10±3.23,13.38±3.12)of patients in groups A and B were all higher than those before operation(9.40±1.32,9.36±1.51;11.16±2.60,11.23±2.71),and group A was higher than group B,the difference was statistically significant(JOA scores before and after operation:t values were 14.33 and 10.07,respectively;cervical curvature:t values were 17.50 and 3.25,respectively;t values between groups were 2.22 and 12.47,respectively,and the P values were<0.001,<0.001,<0.001,0.002,0.029 and<0.001,respectively).Six months after the operation,the NDI indexes of groups A and B(11.38±4.76,14.79±4.85)were lower than those before the operation(39.56±9.43,39.74±9.51),and those in group A were lower than in group B,and the difference was statistically significant(t values were 17.70,14.60,and 3.23;all P<0.001).Binary Logistic regression showed that the duration of disease≥6 months(OR=59.045,95%CI:6.485-537.629),the presence of cervical spinal cord MRI signal changes(OR=0.031,95%CI:0.002-0.587),the surgical approach(posterior approach single-door laminoplasty)(OR=6.300,95%CI:1.269-31.273)was an independent risk factor affecting the surgical outcome(P values were<0.001,0.021,and 0.024,respectively).Conclusion Anterior cervical ACCF combined with ACDF has an ideal surgical effect in the treatment of patients with multi-segment CSM,which can significantly improve the cervical spinal nerve function and cervical curvature,shorten the operation time and reduce the perioperative blood loss.It isstill necessary to pay attention to the patient's disease course,MRI signals changes of cervical spinal cord and the effect of surgical methods on their surgical outcomes.