不同年龄C_(3,4)脊髓型颈椎病患者的临床特征与影像学对照研究

Comparative clinical and imaging study of C_(3,4) spondylotic myelopathy in different age groups

目的探讨老年、中老年和青年C_(3,4)单节段脊髓型颈椎病患者临床特点及影像学征象的差异。方法回顾性分析2017年1月至2021年12月于郑州大学第一附属医院因单节段C_(3,4)脊髓型颈椎病行手术治疗51例患者的临床及影像学资料。青年组10例,男8例、女2例,年龄(35.8±7.62)岁(范围23~44岁);中老年组14例,男9例、女5例,年龄(53.21±4.14)岁(范围48~60岁);老年组27例,男24例、女3例,年龄(68.04±5.97)岁(范围61~84岁)。分析三组患者临床表现[首发症状、症状、病理体征及日本骨科协会(Japanese Orthopaedic Association,JOA)评分]的差异;通过影像学资料分析静态因素(骨赘增生、滑移程度、黄韧带厚度)、动态因素(颈椎整体活动度、颈椎单节段活动度、颈椎不稳、颈椎项韧带钙化)、解剖因素(C_(2)~C_(7) Cobb角、C_(3)~C_(7) Cobb角、C_(4)~C_(7) Cobb角、C_(3)椎管径、C_(4)椎管径、C_(3) Pavlov比值、C_(4) Pavlov比值)、脊髓压迫(脊髓信号、压迫位置、压迫性质)的差异。结果三组患者在性别分布及身高差异无统计学意义(P>0.05)。老年组多以上肢无力为首发症状、下肢无力感及步态异常为主诉,中老年多以上肢麻木为首发症状、上肢麻木无力为主诉,青年组多以上肢疼痛为首发症状、以上肢麻木为主诉,三组的差异有统计学意义(P<0.05)。三组Hoffmann征和Babinski征的差异有统计学意义,其中老年组较青年组有更高的阳性率(P<0.05)。JOA总评分、运动及下肢运动JOA评分的差异有统计学意义,老年组JOA总评分较青年组低,尤其是运动JOA评分,特别是下肢运动JOA评分更低(P<0.05)。首发症状分布、症状分布、肱二头肌反射、肱三头肌反射、桡骨膜反射及膝腱反射的差异均无统计学意义(P>0.05)。静态因素方面,三组患者滑移和黄韧带厚度的差异有统计学意义(P<0.05),老年组较青年组和中老年组易发生滑移(P<0.05);老年组黄韧带厚度为(2.18±0.68)mm,较青年组的(1.60±0.30)mm及中老年组的(1.60±0.62)mm增厚(P<0.05);骨赘增生的差异无统计学意义(P>0.05)。动态因素方面,三组患者在C_(3)~C_(7)活动度、C_(4)~C_(7)活动度、C_(3,4)活动度及项韧带钙化的差异有统计学意义(P<0.05),老年组C_(3)~C_(7)活动度为22.18°较青年组(9.52°)更大(P<0.05),而老年组C_(4)~C_(7)活动度为9.60°较青年组(18.97°)更小(P<0.05),老年组C_(3,4)活动度为15.30°较青年组(9.97°)更大(P<0.05),老年组较青年组和中老年组更易发生项韧带钙化(P<0.05)。C_(4,5)活动度、C_(5,6)活动度、C_(6,7)活动度和颈椎不稳的差异无统计学意义(P>0.05)。脊髓压迫方面,三组患者在脊髓压迫性质、压迫位置及MRI T2WI脊髓信号的差异有统计学意义(P<0.05),老年组更倾向于前后的骨性压迫;老年组MRI T2WI脊髓信号较青年组更易出现高信号改变(P<0.05)。解剖因素方面,三组患者在C_(2)~C_(7) Cobb角、C_(3)椎管径及C_(3) Pavolv比值的差异有统计学意义(P<0.05),老年组C_(2)~C_(7) Cobb角为21.06°较青年组(16.45°)更大(P<0.05),老年组C_(3)椎管径为(9.61±0.33)mm,较青年组的(10.38±1.19)mm更小(P<0.05),老年组C_(3) Pavolv比值为0.52±0.03,较青年组的0.59±0.11减小(P<0.05),其中前凸存在时老年组C_(4)~C_(7) Cobb角为4.96°±4.05°,较青年组的12.42°±4.83°及中老年组的10.07°±6.14°减小(P<0.05),后凸存在时老年组C_(4)~C_(7) Cobb角为4.02°±1.19°,较青年组的0.06°±0.01°及中老年组的1.83°±0.93°增大(P<0.05)。C_(3)~C_(7) Cobb角、C_(4)椎管径及C_(4) Pavolv比值的差异无统计学意义(P>0.05)。结论青年患者C_(3,4)单节段脊髓型颈椎病多由前方椎间盘突出软性压迫所致,多以颈部和上肢疼痛为主诉,脊髓压迫及临床表现相对较轻;而老年患者多为C_(3,4)后滑移,脊髓钳夹型骨性压迫为主,多以上肢麻木为主诉,多伴有步态异常等严重脊髓压迫的临床表现;中老年患者以前方钙化椎间盘突出硬性压迫为主,以上肢麻木为主诉。

Objective To compare the clinical features,X-ray,CT,MRI imaging findings of C_(3,4) single segment cervical spondylotic myelopathy among the elderly group,the middle-aged group and the young group.Methods The medical records and imaging data of 51 cases of single segment C_(3,4) cervical spondylotic myelopathy treated from January 2017 to December 2021 were retrospectively reviewed.There were 10 cases in the young group,including 8 males and 2 females,23-44 years,with an average age of 35.8±7.62 years;14 cases in the middle-aged group,including 9 males and 5 females,48-60 years,with an average age of 53.21±4.14 years;27 cases in the elderly group,including 24 males and 3 females,61-84 years,with an average age of 68.04±5.97 years.Based on the medical record data,the differences in clinical manifestations among the three groups(initial symptoms,symptom distribution,pathological sign distribution and JOA score)were analyzed.Based on the imaging data,the static factors(cervical osteophyte,alignment and thickness of cervical ligamentum flavum)and dynamic factors[overall cervical range of motion(ROM),individual segment cervical ROM,cervical instability and cervical nuchal ligament calcification]were analyzed.Anatomical factors(C_(2)-C_(7) Cobb angle,C_(4)-C_(7) Cobb angle,C_(3) vertebral canal diameter,C_(4) vertebral diameter,C_(3) Pavlov ratio,C_(4) Pavlov ratio)and spinal cord compression(spinal cord signal,compression position and compression nature)were also analyzed.Results There were no statistically significant difference in gender distribution and height in three groups of patients(P>0.05).In terms of clinical manifestations,there were statistically significant differences among the three groups in initial symptoms and chief symptoms(P<0.05).The elderly group had upper limb weakness as the first symptom,lower limb weakness and abnormal gait as the chief complaint;the middle-aged group had upper limb numbness as the first symptom,upper limb numbness and weakness as the chief complaint;the young group had upper limb pain as the first symptom,upper limb numbness as the chief complaint.There were statistically significant differences in Hoffmann sign and Babinski sign among the three groups(P<0.05).Hoffmann sign and Babinski sign were more common in the elderly group than in the young group(P<0.05).There were significant differences among the three groups in total JOA score,JOA score of motor and lower limb motor JOA(P<0.05).The total JOA score in the elderly group was lower than that in the young group(P<0.05),especially for motor JOA score(P<0.05),and lower limb motor JOA score(P<0.05).There were no significant differences in first symptoms distribution,symptoms distribution,biceps reflex,triceps reflex,radial reflex or knee tendon reflex among the three groups(P>0.05).In terms of static factors,there was significant difference in alignment and thickness of cervical ligamentum flavum among the three groups(P<0.05).The elderly group was more prone to slip than the young and middle aged groups(P<0.05).The thickness of ligamentum flavum in the elderly group(2.18±0.68 mm)was thicker than that in the young group(1.60±0.30 mm)and the middle-elderly group(1.60±0.62 mm)(P<0.05).There was no significant difference in cervical osteophyte among the three groups(P>0.05).In terms of dynamic factors,there were statistically significant difference in C_(3)-C_(7) ROM,C_(4)-C_(7) ROM,C_(3,4) ROM and ossification of nuchal ligament among the three groups(P<0.05).In the elderly group,C_(3)-C_(7) ROM(22.18°)was larger than that in the young group(21.27°)(P<0.05),while in the elderly group C_(4)-C_(7) ROM(9.60°)was smaller than that in the young group(14.19°)(P<0.05).In the elderly group,C_(3,4) ROM(15.30°)was larger than that in the young group(9.97°)(P<0.05),and the elderly group was more prone to nuchal ligament calcification than the young and the middle-elderly group(P<0.05).There were no significant difference among the three groups in C_(4,5) ROM,C_(5,6) ROM,C_(6,7) ROM or cervical instability(P>0.05).For spinal cord compression,there were statistically significant differences among the three groups in the compression nature,compression location and MRI T2WI spinal cord signal(P<0.05).The elderly group was more prone to anterior and posterior bony compression.The elderly group was more likely to show high signal intensity on spinal cord MRI T2WI than the young group(P<0.05).For anatomical factors,there were statistically significant differences in C_(2)-C_(7) Cobb,C_(3) vertebral diameter and C_(3) Pavolv among the three groups(P<0.05).The C_(2)-C_(7) Cobb of the elderly group(21.06°)was larger than that of the young group(16.45°)(P<0.05),and the C_(3) diameter of the elderly group(9.61±0.33 mm)was smaller than that of the young group(10.38±1.19 mm)(P<0.05).The C_(3) Pavolv of the elderly group(0.52±0.03)was lower than that of the young group(0.59±0.11)(P<0.05).In the presence of lordosis,C_(4)-C_(7) Cobb in the elderly group(4.96°±4.05°)was smaller than that in the young group(12.42°±4.83°)and the middle-aged group(10.07°±6.14°)(P<0.05).In the presence of kyphosis,C_(4)-C_(7) Cobb in the elderly group(4.02°±1.19°)was larger than that in the young group(0.06°±0.01°)and the middle-aged group(1.83°±0.93°)(P<0.05).There were no significant differences in C_(3)-C_(7) Cobb,C_(4) vertebral diameter or C_(4) Pavolv among the three groups(P>0.05).Conclusion Young patients mostly have anteriorly soft compression of disc herniation,and most of them complain of neck and upper limb pain,while spinal cord compression and clinical manifestations are relatively mild.For the elderly patients,most of them have C_(3) retrolisthesis,with the pinching type bony compression of spinal cord from both anteriorly and posteriorly,and their complaints are usually upper limb numbness,mostly accompanied by radiographically severe spinal cord compression and clinically gait abnormalities.In the middle-aged patients,the rigid compression of anterior calcified disc herniation is the main reason,and the numbness of upper limb is the chief complain.