对不同形态退变性颈椎后凸寰枢椎影像学参数的比较

Impact of degenerative cervical focal and global kyphosis on the radiographic parameters of occipito- atlantoaxial complex

目的探讨不同形态退变性颈椎后凸对寰枢椎影像学参数的影响。方法对2018年12月至2020年12月首都医科大学附属北京天坛医院骨科行三节段颈前路减压融合术(ACDF)治疗的颈椎病患者96例(神经根型36例、脊髓型38例和混合型22例)的临床资料进行回顾性分析。其中男53例,女43例;年龄(56.7±8.5)(41~79)岁。根据颈椎形态将患者分为3组:退变性颈椎整体前凸组(简称整体前凸组)50例,退变性颈椎节段后凸组(简称为节段后凸组)24例,退变性颈椎整体后凸组(简称为整体后凸组)22例。于术前1周和术后1年对所有患者行颈椎标准侧位和过屈过伸位数字化X线检查。采用日本骨科学会评分(JOA)和颈椎功能障碍指数(NDI)对颈椎功能进行评价,采用疼痛视觉模拟评分(VAS)对患者疼痛程度进行评价。通过X线测量颈椎矢状位参数,包括C2-7、C0-1和C1-2的曲度和活动度以及C2倾斜角。对3组患者术前与术后各项参数进行组内和组间比较。结果3组患者性别、年龄、手术节段和内固定方式等基线资料及病史资料差异均无统计学意义(均P>0.05)。整体后凸组术前NDI评分较另两组更高(P<0.05),术前C2倾斜角(11.24°±4.39°)(3.60°~20.00°)及其术后变化值(5.89°±4.27°)(1.00°~16.00°)较另两组更大(均P<0.05)。术前整体后凸组C0-1活动度(16.07°±2.71°)(10.00°~19.00°)显著高于另两组(P<0.05),术后节段后凸组的C0-1活动度变化值(7.33°±5.03°)(2.00°~13.70°)大于整体后凸组(P<0.05)。节段后凸组C2倾斜角与C1-2曲度呈正相关(r=0.546,P<0.05);整体后凸组C2倾斜角与C0-1活动度呈负相关(r=-0.653,P<0.05)。结论退变性颈椎节段后凸和整体后凸患者特点不同。对颈椎节段后凸患者,应关注C2倾斜角对上颈椎曲度的提示意义和术后寰枕关节退变甚至发生病理改变的可能;对颈椎整体后凸患者,应关注C2倾斜角对上颈椎活动度的提示意义,同时手术会造成患者已增大的上颈椎活动度进一步增大。

Objective To explore the impact of degenerative cervical lordosis,focal kyphosis and global kyphosis on the sagittal parameters of upper cervical spine.Methods Clinical data of 96 patients with degenerative cervical spondylosis(36 in radicular type,38 in myolopathy and 22 in mixed type)underwent 3-level anterior cervical decompression and fusion(ACDF)between December 2018 and December 2020 were retrospectively analyzed.Fifty-three males and 43 females aged(56.7±8.5)(41-79)years were included.All patients were divided into 3 groups according to the status of cervical deformity:global loadosis group(50 patients),focal kyphosis group(24 patients)and global kyphosis group(22 patients).Standard radiographs of cervical spine and the flexion and extension cervical X-rays were obtained in all patients at one week before and 12 months after operation.The Japanese Orthopaedic Association(JOA)Scores,visual analogue scale(VAS)and neck disability index(NDI)were used to evaluate the clinical effectiveness.Cervical sagittal parameters such as the platform angle of axis(C2 slope),the Cobb's angle and the range of motion(ROM)of C2-7,C0-1 and C1-2 were assessed using the X-ray images.All the parameters were compared among the 3 groups.Results No statistically defference of the general clinical data such as age,sex distribution,operation segements and internal fixation were found among the 3 groups(all P>0.05).The pre-operative NDI was higher in the global kyphosis group(P<0.05).The pre-operative C2 slope and C0-1 ROM of the patients with global kyphosis were(11.24±4.39)°(ranged,3.60°-20.00°)and(16.07±2.71)°(ranged,10.00°-19.00°),which were the highest in the 3 groups(P<0.05).The compensatory change of the C0-1 ROM was higher in the patients with focal kyphosis(P<0.05).The C2 slope was significantly correlated with the Cobb's angle of the upper cervical spine in the focal kyphosis group(r=0.546,P<0.05)and the ROM of the atlantooccipital joint in the global kyphosis group(r=-0.653,P<0.05).Conclusion The characters between cervical focal and global kyphosis are distinctive.In the patients with focal kyphosis,the alignment of the upper cervical spine could be predicted by the C2 slope and the compensatory change in C0-1 ROM may aggravate the post-operation degeneration;the higher C0-1 ROM was explored in the global-kyphosis patients and the lower C2 slope may relate to the risk of the instability or dislocation in the atlanto-occipital joint.