对称、非对称减压与保守治疗后脊髓型颈椎病突出椎间盘体积变化的中长期对比观察

A medium- and long-term comparative observation on volumetric changes of cervical disc herniation after symmetrically or asymmetrically decompression and conservative treatment for cervical spondylotic myelopathy

目的比较脊髓型颈椎病行内镜下微创颈椎管成形术(CMEL)、单开门颈椎管成形术(EOLP)或保守治疗后突出颈椎间盘的体积变化。方法回顾性收集2012年4月至2021年4月郑州大学第一附属医院骨科收治的101例脊髓型颈椎病患者的临床及影像学资料。男性52例,女性49例,年龄(54.7±11.8)岁(范围:25~86岁)。其中35例患者接受CMEL治疗,33例接受EOLP治疗,33例接受保守治疗。使用三维体积法测量患者治疗前和末次随访时的突出颈椎间盘体积,计算突出颈椎间盘的吸收率和再突出率等,当吸收率或再突出率>5%时分别定义为发生了吸收或再突出变化。采用日本骨科协会(JOA)评分和颈椎功能障碍指数(NDI)分别评估临床疗效及生活质量。组间比较采用单因素方差分析、Kruskal-Wallis秩和检验或χ^(2)检验,两两比较采用多重比较的LSD-t检验。结果CMEL组、EOLP组及保守治疗组的随访时间分别为(27.9±18.2)个月、(21.6±6.9)个月和(24.9±16.3)个月,差异无统计学意义(P>0.05)。突出颈椎间盘体积变化:(1)CMEL组35例患者共存在96个突出颈椎间盘,末次随访时78个吸收,占81.3%(78/96),吸收率为5.9%~90.9%;9个出现再突出,占9.4%(9/96),再突出率为5.9%~13.3%;(2)EOLP组33例患者共存在94个突出颈椎间盘,末次随访时45个吸收,占47.9%(45/94),吸收率为5.0%~26.7%;20个出现再突出,占21.3%(20/94),再突出率为5.8%~28.3%;(3)保守治疗组33例患者共存在102个突出颈椎间盘,末次随访时5个吸收,占4.9%(5/102),吸收率为7.2%~14.3%;58个出现再突出,占56.9%(58/102),再突出率为5.4%~174.1%。CMEL组的吸收、再突出占比与EOLP组、保守治疗组均有差异(P值均<0.01);EOLP组吸收、再突出占比与保守治疗组均有差异(P值均<0.01)。临床症状方面,末次随访时CMEL组和EOLP组的JOA评分优良率、NDI均与保守治疗组有差异(P值均<0.01),CMEL组和EOLP组间无差异(P值均>0.05)。结论CMEL是治疗脊髓型颈椎病的有效方法,与EOLP和保守治疗相比,CMEL术后突出椎间盘更易发生自然吸收,有利于提高神经减压效果,为临床治疗脊髓型颈椎病提供新的策略。

Objective To compare the volumetric changes of cervical disc herniation(CDH)after cervical microendoscopic laminoplasty(CMEL),expansive open-door laminoplasty(EOLP)and conservative treatment.Methods A retrospective study was conducted involving 101 patients with cervical spondylotic myelopathy(CSM),at the Department of Orthopaedic Surgery,the First Affiliated Hospital of Zhengzhou University from April 2012 to April 2021.The patients included 52 males and 49 females with an age of(54.7±11.8)years(range:25 to 86 years).Among them,35 patients accepted CMEL treatment,33 patients accepted EOLP treatment,while 33 patients accepted conservative treatment.Volume data of CDH were measured by three-dimensional analysis of the initial and follow-up MRI images.The absorption rate and reprotrusion rate of CDH were calculated.The happening of resorption or reprotrusion was defined when the ratio was greater than 5%.The clinical outcomes and quality of life were evaluated by the Japanese Orthopaedic Association(JOA)score and the neck disability index(NDI).Quantitative data was analyzed by one-way ANOVA with post LSD-t test(multiple comparison)or Kruskal-Wallis test.Categorical data was analyzed byχ^(2) test.Results The follow-up time of the CMEL group,EOLP group and the conservative treatment group were(27.6±18.8)months,(21.6±6.9)months and(24.9±16.3)months respectively with no significant difference(P>0.05).Changes of CDH volume in patients:(1)There were 96 CDH of 35 patients in the CMEL group,among which 78 showed absorption.The absorption frequency was 81.3%(78/96)and the absorption rate was ranged 5.9%to 90.9%;9 CDH showed reprotrusion,the reprotrusion frequency was 9.4%(9/96)and the reprotrusion rate was 5.9%to 13.3%;(2)There were 94 CDH of 33 patients in the EOLP group,of which 45 showed absorption.The absorption prevalence was 47.9%(45/94)and the absorption rate was 5.0%to 26.7%;20 CDH showed reprotruded,with the reprotrusion frequency of 21.3%(20/94)and the reprotrusion rate was 5.8%to 28.3%;(3)There were 102 CDH in 33 patients of the conservative group.Among them,5 showed absorption.The absorption frequency was 4.9%(5/102),and the absorption rate was 7.2%to 14.3%;58 CDH showed reprotruded with the re-protrusion ratio of 56.9%(58/102)and the re-protrusion rate was 5.4%to 174.1%.The absorption ratio and reprotrusion ratio of the CMEL group were statistically different from EOLP group or the conservative group(P<0.01).The absorption ratio and reprotrusion ratio of the EOLP group was different from conservative group(all P<0.01).In terms of clinical outcomes,the excellent/good rate of the JOA score and NDI scores in the CMEL group were different from that of conservative group(all P<0.01)but not from that of the EOLP group(P>0.05).Conclusions CMEL is an effective method for the treatment of CSM,making CDH easier to resorption compared to the EOLP or conservative treatment,thus making a better decompression effect on the nerves.This study enlightened on a new strategy for the clinical treatment of CSM.