不同时期颈椎减压手术治疗不完全性颈脊髓损伤的疗效比较

Comparison of the efficacy of cervical decompression performed at different times in the treatment of incomplete cervical spinal cord injury

目的比较不同时期颈椎减压手术治疗不完全性颈脊髓损伤的疗效。方法采用多中心回顾性队列研究分析2018年5月至2021年5月西安交通大学附属红会医院等6家医院收治的96例不完全性颈脊髓损伤患者的临床资料,其中男60例,女36例;年龄28~42岁[(35.2±6.7)岁]。损伤节段:C37例,C415例,C520例,C623例,C731例。美国脊髓损伤协会(ASIA)分级:B级59例,C级27例,D级10例。36例伤后24 h内行颈椎减压手术(早期组),33例伤后24~72 h行颈椎减压手术(晚期组),27例伤后4~14 d内行颈椎减压手术(延迟组)。比较三组手术时间、术中出血量、术后引流量、住院时间;术前及术后3 d Cobb角、椎间隙高度、椎管占位;术前,术后3个月、1年及末次随访时ASIA分级、ASIA运动评分、ASIA轻触觉评分、ASIA针刺觉评分、视觉模拟评分(VAS)、日本骨科学会(JOA)评分、颈部功能障碍指数(NDI);并发症发生率。结果患者均获随访12~21个月[(16.4±4.2)个月]。三组手术时间差异无统计学意义(P均>0.05)。早期组术中出血量和术后引流量分别为(312.5±5.2)ml、(165.3±45.8)ml,多于晚期组的(253.5±40.0)ml、(120.4±60.6)ml和延迟组的(267.3±36.8)ml、(130.4±38.6)ml(P均<0.01);晚期组和延迟组差异无统计学意义(P均>0.05)。早期组住院时间为(5.2±1.6)d,短于晚期组的(7.6±2.3)d和延迟组的(8.0±1.3)d(P均<0.05);晚期组和延迟组差异无统计学意义(P>0.05)。三组术前及术后3 d Cobb角、椎间隙高度、椎管占位差异无统计学意义(P均>0.05)。三组术前ASIA分级,ASIA运动评分、轻触觉评分、针刺觉评分,VAS、JOA评分、NDI差异无统计学意义(P均>0.05)。早期组术后3个月、1年及末次随访时ASIA分级优于晚期组和延迟组(P<0.05或0.01),晚期组和延迟组差异无统计学意义(P均>0.05)。早期组术后3个月、1年及末次随访时ASIA运动评分分别为(56.4±4.5)分、(76.3±3.6)分、(85.4±6.5)分,高于晚期组的(52.3±2.4)分、(60.3±8.6)分、(72.3±2.4)分和延迟组的(51.9±2.3)分、(62.8±4.6)分、(71.9±1.3)分;轻触觉评分分别为(70.2±2.9)分、(72.6±4.3)分、(78.3±2.3)分,高于晚期组的(66.2±3.7)分、(68.3±1.6)分、(73.3±1.6)分和延迟组的(65.2±2.1)分、(67.8±1.9)分、(72.3±2.5)分;针刺觉评分分别为(71.9±3.1)分、(80.1±3.8)分、(89.1±7.6)分,高于晚期组的(67.4±2.7)分、(72.6±3.7)分、(77.9±1.8)分和延迟组的(68.3±2.2)分、(72.6±3.1)分、(77.2±1.9)分(P均<0.05)。早期组术后3个月、1年及末次随访时VAS分别为(4.3±0.6)分、(2.4±0.3)分、(1.6±0.2)分,低于晚期组的(5.1±1.3)分、(4.1±0.6)分、(3.0±0.6)分和延迟组的(5.0±1.7)分、(4.0±0.8)分、(3.1±0.2)分;JOA评分分别为(12.8±1.6)分、(14.4±2.6)分、(17.9±3.3)分,高于晚期组的(11.9±1.9)分、(13.3±1.6)分、(8.9±1.3)分和延迟组的(11.6±1.8)分、(13.2±1.4)分、(9.3±2.1)分;NDI分别为12.1±3.3、10.1±2.1、7.3±1.4,低于晚期组的14.4±3.1、12.3±1.6、8.9±1.3和延迟组的14.1±2.3、12.9±1.9、9.5±2.1(P均<0.05)。术后3个月、1年及末次随访时晚期组和延迟组各评分差异无统计学意义(P均>0.05)。早期组并发症发生率为25.0%(9/36),晚期组为27.3%(9/33),延迟组为37.0%(10/27)(P均>0.05)。结论与伤后24~72 h和4~14 d内相比,伤后24 h内行颈椎减压手术治疗不完全性颈脊髓损伤,可缩短住院时间、改善脊髓神经功能、减轻疼痛且不增加并发症发生率。

Objective To compare the efficacy of cervical decompression performed at different times in the treatment of incomplete cervical spinal cord injury.Methods A multicenter retrospective cohort study was conducted to analyze the clinical data of 96 patients with incomplete cervical spinal cord injury admitted to six hospitals including Honghui Hospital affiliated to Xi'an Jiaotong University,etc,from May 2018 to May 2021.There were 36 females and 60 males,aged 28-42 years[(35.2±6.7)years].The injured segments were at C3 in 7 patients,C4 in 15,C5 in 20,C6 in 23 and C7 in 31.According to the American Spinal Injury Association(ASIA)scale,there were 59 patients with grade B,27 grade C,and 10 grade D.A total of 36 patients underwent cervical decompression within 24 hours after injury(early group),33 patients within 24-72 hours after injury(late group),and 27 patients within 4-14 days after injury(delayed group).The operation time,intraoperative blood loss,postoperative drainage,length of hospital stay,Cobb angle,height of intervertebral space and space occupation of the spinal canal before surgery and at postoperative 3 days,and ASIA score,ASIA motor score,ASIA light tactile score,ASIA acupuncture sensation score,visual analog scale(VAS)score,Japanese Orthopedic Association(JOA)score,neck dysfunction index(NDI)before surgery and at postoperative 3 months,1 year and at the last follow-up and incidence of complications were compared among the three groups.Results All the patients were followed up for 12-21 months[(16.4±4.2)months].There was no significant difference in the operation time among the three groups(all P>0.05).The intraoperative blood loss and postoperative drainage volume in the early group were(312.5±5.2)ml and(165.3±45.8)ml,which were higher than those in the late group[(253.5±40.0)ml,(120.4±60.6)ml]and the delayed group[(267.3±36.8)ml and(130.4±38.6)ml](all P<0.01).There was no significant difference between the late group and the delayed group(all P>0.05).The length of hospital stay in the early group was(5.2±1.6)days,which was shorter than that in the late group[(7.6±2.3)days]and the delayed group[(8.0±1.3)days](all P<0.05),but there was no significant difference between the late group and the delayed group(P>0.05).There was no significant difference in the Cobb angle,height of intervertebral space and space occupation of the spinal canal among the three groups before and at postoperative 3 days(all P>0.05).There was no significant difference in the ASIA score,ASIA motor score,ASIA light tactile score,ASIA acupuncture sensation score,VAS score,JOA score and NDI among the three groups before surgery(all P>0.05).At postoperative 3 months,1 year and at the last follow-up,the ASIA grading of the early group was better than that of the late group and the delayed group(P<0.05 or 0.01),but there was no statistically significant difference between the late group and the delayed group(all P>0.05).The ASIA motor scores of the early group were(56.4±4.5)points,(76.3±3.6)points and(85.4±6.5)points at postoperative 3 months,postoperative 1 year and the last follow-up,respectively,which were higher than those in the late group[(52.3±2.4)points,(60.3±8.6)points and(72.3±2.4)points]and the delayed group[(51.9±2.3)points,(62.8±4.6)points and(71.9±1.3)points];the ASIA light tactile scores of the early group were(70.2±2.9)points,(72.6±4.3)points and(78.3±2.3)points,which were higher than those in the late group[(66.2±3.7)points,(68.3±1.6)points and(73.3±1.6)points]and the delayed group[(65.2±2.1)points,(67.8±1.9)points and(72.3±2.5)points];acupuncture sensation scores of the early group were(71.9±3.1)points,(80.1±3.8)points and(89.1±7.6)points,which were higher than those in the late group[(67.4±2.7)points,(72.6±3.7)points and(77.9±1.8)points]and the delayed group[(68.3±2.2)points,(72.6±3.1)points and(77.2±1.9)points](all P<0.05).VAS scores of the early group at postoperative 3 months,1 year and at the last follow-up were(4.3±0.6)points,(2.4±0.3)points and(1.6±0.2)points,which were lower than those in the late group[(5.1±1.3)points,(4.1±0.6)points and(3.0±0.6)points]and the delayed group[(5.0±1.7)points,(4.0±0.8)points and(3.1±0.2)points];JOA scores of the early group were(12.8±1.6)points,(14.4±2.6)points and(17.9±3.3)points,which were higher than those in the late group[(11.9±1.9)points,(13.3±1.6)points and(8.9±1.3)points]and the delayed group[(11.6±1.8)points,(13.2±1.4)points and(9.3±2.1)points];NDI scores of the early group were 12.1±3.3,10.1±2.1 and 7.3±1.4,which were lower than those in the late group(14.4±3.1,12.3±1.6 and 8.9±1.3)and the delayed group(14.1±2.3,12.9±1.9 and 9.5±2.1)(all P<0.05).There was no significant difference in all the above-mentioned scores at postoperative 3 months,1 year and at the last follow-up between the late group and the delayed group(all P>0.05).The incidence of complications was 25.0%(9/36)in the early group,27.3%(9/33)in the late group and 37.0%(10/27)in the delayed group(all P>0.05).Conclusion Compared with within 24-72 hours and 4-14 days after injury,cervical decompression performed within 24 hours after injury for patients with incomplete cervical spinal cord injury can shorten the length of hospital stay,improve the function of the spinal cord nerves and relieve pain,with no increase of the incidence of complications.