显微镜辅助下前路颈椎间盘切除融合术治疗骨性压迫致神经根型颈椎病的临床研究

A clinical study of microscope-assisted anterior cervical discectomy and fusion for treatmen to fcervical spondylotic radiculopathy caused by bone compression

目的:观察显微镜辅助下前路颈椎间盘切除融合术(anterior cervical discectomy and fusion,ACDF)治疗骨性压迫致神经根型颈椎病的临床疗效和安全性。方法:回顾性分析46例骨性压迫致神经根型颈椎病患者的病例资料,其中采用显微镜辅助下ACDF(术中行精细化减压)治疗22例(显微镜辅助下ACDF组),采用前路颈椎体次全切除融合术(anterior cervical corpectomy and fusion,ACCF)治疗24例(ACCF组)。比较2组患者的术中出血量、手术时间、颈椎疼痛视觉模拟量表(visual analogue scale,VAS)评分、日本骨科学会(Japanese Orthopaedic Association,JOA)脊髓型颈椎病评分、椎间融合率及并发症发生率。结果:①一般结果。显微镜辅助下ACDF组患者术中出血量少于ACCF组[(41.18±11.00)mL,(91.42±21.31)mL,t=-9.906,P=0.000],手术时间短于ACCF组[(59.59±8.71)min,(79.79±17.45)min,t=-4.896,P=0.000]。②颈椎疼痛VAS评分。时间因素和分组因素存在交互效应(F=3.689,P=0.036);2组患者的颈椎疼痛VAS评分总体比较,组间差异有统计学意义,即存在分组效应(F=4.564,P=0.038);手术前后不同时间点颈椎疼痛VAS评分的差异有统计学意义,即存在时间效应(F=278.765,P=0.000);2组患者颈椎疼痛VAS评分随时间变化均呈下降趋势,但2组的下降趋势不完全一致(F=165.747,P=0.000;F=210.692,P=0.000);术前、术后1个月,2组患者颈椎疼痛VAS评分比较,组间差异均无统计学意义[(3.95±0.79)分,(4.00±0.85)分,t=-0.208,P=0.836;(0.75±0.44)分,(0.80±0.40)分,t=-0.474,P=0.638];术后1周,显微镜辅助下ACDF组患者颈椎疼痛VAS评分低于ACCF组[(2.05±0.70)分,(2.75±0.75)分,t=-3.222,P=0.002]。③JOA脊髓型颈椎病评分。时间因素和分组因素存在交互效应(F=3.863,P=0.021);2组患者的JOA脊髓型颈椎病评分总体比较,组间差异有统计学意义,即存在分组效应(F=6.276,P=0.016);手术前后不同时间点JOA脊髓型颈椎病评分的差异有统计学意义,即存在时间效应(F=517.958,P=0.000);2组患者JOA脊髓型颈椎病评分随时间变化均呈上升趋势,但2组的上升趋势不完全一致(F=154.860,P=0.000;F=179.492,P=0.000);术前、术后6个月,2组患者JOA脊髓型颈椎病评分比较,组间差异均无统计学意义[(7.73±1.08)分,(8.04±1.08)分,t=-0.986,P=0.329;(14.55±1.10)分,(14.63±1.10)分,t=-0.245,P=0.807];术后1个月、术后3个月,显微镜辅助下ACDF组患者JOA脊髓型颈椎病评分均低于ACCF组[(9.86±1.04)分,(11.00±1.10)分,t=-3.590,P=0.001;(11.64±1.05)分,(12.50±1.14)分,t=-2.664,P=0.011]。④椎间融合率。术后3个月,显微镜辅助下ACDF组椎间未融合2例,ACCF组椎间未融合6例;术后6个月,显微镜辅助下ACDF组椎间全部融合,ACCF组椎间未融合3例;术后1年,2组患者椎间全部融合。术后3个月、术后6个月及术后1年,2组患者椎间融合率比较,组间差异均无统计学意义(χ^(2)=2.022,P=0.155;χ^(2)=2.942,P=0.086;P=1.000)。⑤并发症发生率。显微镜辅助下ACDF组术后出现声音嘶哑1例、C_(5)神经根麻痹1例,ACCF组术后出现硬脊膜外血肿1例、吞咽困难1例。硬脊膜外血肿患者经手术清创后血肿消除,无神经并发症发生;其余患者经口服药物、理疗等治疗后均好转。2组患者并发症发生率比较,差异无统计学意义(χ^(2)=0.008,P=0.927)。结论:采用显微镜辅助下ACDF治疗骨性压迫致神经根型颈椎病,与ACCF比较,术中出血量少、手术时间短、颈椎疼痛缓解快,但颈椎功能恢复慢,二者在椎间融合及安全性方面均相当。

Objective:To investigate the clinical efficacy and safety of microscope-assisted anterior cervical discectomy and fusion(ACDF)for treatment of cervical spondylotic radiculopathy(CSR)caused by bone compression.Methods:The medical records of 46 patients with CSR caused by bone compression were analyzed retrospectively.Twenty-two patients were treated with microscope-assisted ACDF(microscope-assisted ACDF group)and 24 ones with anterior cervical corpectomy and fusion(ACCF)(ACCF group).The intraoperative blood loss,operative time,cervical pain visual analogue scale(VAS)score,Japanese Orthopaedic Association(JOA)score for assessing cervical spondylotic myelopathy(CSM),intervertebral fusion rate and complications were compared between the 2 groups.Results:①The intraoperative blood loss was less and the operative time was shorter in microscope-assisted ACDF group compared to ACCF group(41.18±11.00 vs 91.42±21.31 mL,t=-9.906,P=0.000;59.59±8.71 vs 79.79±17.45 minutes,t=-4.896,P=0.000).②There was interaction between time factor and group factor in cervical pain VAS score(F=3.689,P=0.036).There was statistical difference in cervical pain VAS scores between the 2 groups in general,in other words,there was group effect(F=4.564,P=0.038).There was statistical difference in cervical pain VAS scores between different timepoints before and after the surgery,in other words,there was time effect(F=278.765,P=0.00).The cervical pain VAS scores presented a downward trend over time in the 2 groups,while the 2 groups were inconsistent with each other in the variation tendency(F=165.747,P=0.000;F=210.692,P=0.000).There was no statistical difference in cervical pain VAS scores between the 2 groups before the surgery and at postsurgical month 1(3.95±0.79 vs 4.00±0.85 points,t=-0.208,P=0.836;0.75±0.44 vs 0.80±0.40 points,t=-0.474,P=0.638),while the cervical pain VAS scores decreased in microscope-assisted ACDF group compared to ACCF group at postsurgical week 1(2.05±0.70 vs 2.75±0.75 points,t=-3.222,P=0.002).③There was interaction between time factor and group factor in JOA CSM score(F=3.863,P=0.021).The difference was statistically significant in JOA CSM scores between the 2 groups in general,in other words,there was group effect(F=6.276,P=0.016),furthermore,the difference was statistically significant between the different timepoints before and after the surgery,in other words,there was time effect(F=517.958,P=0.000).The JOA CSM scores presented a upward trend over time in the 2 groups,while the 2 groups were inconsistent with each other in the variation tendency(F=154.860,P=0.000;F=179.492,P=0.000).There was no statistical difference in JOA CSM scores between the 2 groups before the surgery and at postsurgical month 6(7.73±1.08 vs 8.04±1.08 points,t=-0.986,P=0.329;14.55±1.10 vs 14.63±1.10 points,t=-0.245,P=0.807),while the JOA CSM scores decreased in microscope-assisted ACDF group compared to ACCF group at postsurgical month 1 and 3(9.86±1.04 vs 11.00±1.10 points,t=-3.590,P=0.001;11.64±1.05 vs 12.50±1.14 points,t=-2.664,P=0.011).④At postsurgical month 3,failed interbody fusion was found in 2 patients in microscope-assisted ACDF group and 6 patients in ACCF group.At postsurgical month 6,interbody fusion was found in all patients in microscope-assisted ACDF group and failed interbody fusion was found in 3 patients in ACCF group.At postsurgical month 12,interbody fusion was found in all patients in the 2 groups.There was no statistical difference in intervertebral fusion rate between the 2 groups at postsurgical month 3,6 and 12(χ^(2)=2.022,P=0.155;χ^(2)=2.942,P=0.086;P=1.000).⑤After the surgery,the hoarse voice(1 case)and C_(5) nerve root palsy(1 case)were found in microscope-assisted ACDF group,while the spinal epidural hematoma(1 case)and dysphagia(1 case)were found in ACCF group.The spinal epidural hematoma was removed after surgical debridement,and no neurological complications occurred.The other complications,such as hoarse voice,C_(5) nerve root palsy and dysphagia,were improved after treatment with medication and physiotherapy.There was no statistical difference in complication incidence between the 2 groups(χ^(2)=0.008,P=0.927).Conclusion:The microscope-assisted ACDF displays the advantages of less intraoperative blood loss,shorter operative time and faster cervical pain relief,but the disadvantage of slower cervical function recovery compared to ACCF in treatment of CSR caused by bone compression,whereas the two therapies are similar to each other in intervertebral fusion and safety.