改良式颈前路椎间盘切除减压融合术治疗退变性颈椎后凸患者的疗效分析

Effect analysis of modified anterior cervical discectomy and fusion in patients with degenerative cervical kyphosis

目的:探讨颈前路经椎间隙扩大减压融合术(anterior trans-intervertebral space decompression and fusion,ATIDF)治疗退变性颈椎后凸患者的临床疗效。方法:回顾性分析2017年6月~2019年6月在我科接受ATIDF手术治疗的65例退变性颈椎后凸患者的临床资料。其中男性37例,女性28例;年龄63.4±11.2岁(35~85岁),病程18.2±8.4个月(4~28个月)。接受两节段ATIDF患者16例(C3~C57例、C4~C69例),三节段ATIDF患者38例(C3~C618例、C4~C720例),四节段ATIDF(C3~C7)患者11例。纳入患者中僵硬型后凸患者35例(53.85%),柔韧性后凸患者30例(46.15%);僵硬型后凸患者在减压时均采用了部分钩椎关节切除。分别于术前、术后第2天及末次随访时采用日本骨科学会(Japanese Orthopedic Association,JOA)评分、颈椎功能障碍指数(neck disability index,NDI)及疼痛视觉模拟评分(visual analogue scale,VAS)对患者的神经功能和疼痛情况进行评估;拍摄颈椎正侧位及动力位X线片评价颈椎曲度(C2~C7 Cobb角)、手术节段Cobb角、手术节段椎间隙高度、C2~C7矢状位轴向垂直距离(sagittal vertical axis,SVA),并计算后凸的矫正率。采用颈椎MRI平扫和CT评估患者神经减压情况和植骨融合情况。记录纳入患者随访期间相关并发症出现情况。结果:纳入患者随访时间为33.5±5.4个月(24~50个月)。手术时间为158.2±31.4min(105~215min),术中出血量为117.6±36.3ml(65~200ml)。纳入患者均取得了满意的神经功能改善,术后和末次随访时JOA评分、NDI和VAS评分均较术前明显改善(P<0.05)。所有纳入患者术后颈椎后凸角度均取得一定程度的改善,后凸矫正率为147.43%。术后第2天和末次随访时C2~C7 Cobb角、手术节段局部Cobb角较术前明显增加(P<0.05),SVA较术前明显改善(P<0.05)。手术节段的平均椎间隙高度从术前的2.14±1.53mm增加至术后第2天的5.94±3.11m(P=0.001),末次随访时为5.36±2.47mm(P=0.001)。随访期间有8例(12.31%)患者出现颈部轴性症状,术后第2天有33例(50.77%)患者主诉吞咽困难,3例(4.62%)患者出现C5神经根麻痹,经对症处理后均改善。结论:ATIDF治疗退变性颈椎后凸可取得满意的临床疗效和后凸矫正,对于存在严重椎间隙狭窄、钩椎关节增生的僵硬型颈椎后凸具有良好的矫形和减压作用。

Objectives:To investigate the clinical efficacy of anterior trans-intervertebral space decompression and fusion(ATIDF)in the treatment of degenerative cervical kyphosis.Methods:The clinical data of 65 patients with degenerative cervical kyphosis who received ATIDF surgery in our department from June 2017 to June 2019 were retrospectively analyzed.There were 37 males and 28 females.The mean age was 63.4±11.2 years(35-85 years),and the mean course of disease was 18.2±8.4 months(4-28 months).16 patients(7 patients C3-C5,9 patients C4-C6)received two-segment ATIDF,38 patients(18 patients C3-C6,20 patients C4-C7)received three-segment ATIDF,and 11 patients received four-segment ATIDF(C3-C7).Among the included patients,35(53.85%)had rigid kyphosis and 30(46.15%)had flexible kyphosis.All the patients with rigid kyphosis underwent partial uncovertebral joint excision during decompression.Japanese Orthopaedic Association(JOA)score,neck disability index(NDI)and visual analogue scale(VAS)score were used to evaluate the symptoms and neurological function of the patients before surgery,on day 2 after surgery and at final follow-up.Cervical curvature(C2-C7 Cobb angle),surgical level Cobb angle,and surgical level intervertebral height were measured on anteroposterior and lateral and dynamic cervical radiographs,and the correction rate of kyphosis was calculated.Nerve decompression and bone graft fusion were evaluated by plain MRI and CT of cervical spine.The occurrence of related complications during the follow-up period was recorded.Results:The mean follow-up time of included patients was 33.5±5.4 months(24-50 months).The average operation time was 158.2±31.4min(105-215min),and the average intraoperative blood loss was 117.6±36.3ml(65-200ml).All included patients achieved satisfactory neurological function improvement,and JOA score,NDI score and VAS score were significantly improved after surgery and at final follow-up.The postoperative kyphosis angle of cervical spine in all patients improved to some extent,and the kyphosis correction rate was 147.43%.The C2-C7 Cobb angle and the local Cobb angle of the operative segment were significantly increased on day 2 after surgery and at final follow-up,and the sagittal vertical axis(SVA)was significantly improved than before operation.The mean intervertebral height at the operative level increased from 2.14±1.53mm before surgery to 5.36±2.47mm at the final follow-up(P=0.001).During the follow-up period,8 patients(12.31%)developed cervical axial symptoms,33 patients(50.77%)complained of dysphagia on the second day after surgery,and 3 patients(4.62%)developed C5 nerve root paralysis,all of which were improved after symptomatic management.Conclusions:ATIDF can achieve satisfactory clinical efficacy and correction of kyphosis in treating degenerative cervical kyphosis,which also has good orthopedic and decompression effects for stiff cervical kyphosis with severe intervertebral stenosis and uncovertebral joint hyperplasia.