基于症状严重程度分层的脊髓型颈椎病患者颈前路椎间盘切除减压融合术后结局的研究

A study of postoperative outcomes of anterior cervical discectomy and fusion in CSM patients stratified by different symptom severity

目的探讨不同症状严重程度的脊髓型颈椎病(CSM)患者接受颈前路椎间盘切除减压融合术(ACDF)的临床结果和社会功能改善情况。方法前瞻性收集2017年1月至2023年1月郑州大学第一附属医院骨科因CSM行初次ACDF(单节段或双节段)手术的患者198例,根据患者术前日本骨科协会(JOA)量表评分将其分为轻度组(>13分,52例)、中度组(9~13分,87例)和重度组(<9分,59例)。采用颈部疼痛(NP)和手臂疼痛(AP)视觉模拟评分(VAS)评价疼痛程度;术后采用JOA量表、颈椎活动障碍指数(NDI)、物理成分得分(PCS)和心理成分得分(MCS)评价患者神经功能。采用最小临床重要差异(MCID)评价患者临床改善情况;采用社会功能满意度调查问卷了解患者术后社会功能恢复的满意程度,计算重返工作率(RTWR),采用方差分析或χ^(2)检验或Fisher确切概率法等对数据进行统计学分析。结果与术前比较,3组患者术后6个月和术后1年JOA评分升高[术前:(14.7±1.3)、(10.9±2.6)、(7.1±3.2),术后6个月:(15.9±1.4)、(13.8±1.6)、(12.3±2.9),术后1年:(16.1±1.2)、(14.4±1.9)、(12.9±2.7),F时间=76.724,P<0.05],NDI降低[术前:(23.1±16.3)、(28.1±16.9)、(46.3±18.5),术后6个月:(10.4±5.6)、(15.3±8.2)、(23.4±15.7),术后1年:(9.1±4.8)、(12.7±6.6)、(18.1±9.9),F时间=109.747,P<0.05],NP-VAS[术前:(3.5±1.6)、(3.7±1.4)、(3.6±1.5),术后6个月:(1.4±0.3)、(1.3±0.4)、(1.6±0.5),术后1年:(0.9±0.4)、(1.1±0.3)、(1.1±0.4),F时间=47.381,P<0.05]、AP-VAS[术前:(2.9±2.0)、(3.0±1.8)、(2.8±1.9),术后6个月:(0.9±0.7)、(1.3±0.6)、(1.4±0.6),术后1年:(0.8±0.6)、(0.9±0.6)、(1.1±0.5),F时间=43.774,P<0.05]评分降低,PCS升高[术前:(41.9±15.4)、(33.8±10.6)、(26.7±9.8),术后6个月:(49.3±17.2)、(44.6±15.8)、(37.9±12.6),术后1年:(49.9±19.1)、(47.4±17.1)、(41.3±16.0),F时间=96.219,P<0.05];除轻度组外,中度组和重度组术后6个月和术后1年MCS较术前升高[术前:(45.1±10.3)、(39.7±12.4),术后6个月:(49.9±10.7)、(51.2±10.8),术后1年:(51.1±10.8)、(51.4±11.2),F时间=27.921,P<0.05]。3组患者术后6个月、1年时NP-MCID(χ^(2)=0.163、0.209、0.000,P>0.05)和AP-MCID(χ^(2)=0.160、0.216、0.884,P>0.05)差异无统计学意义;重度组患者术后1年时JOA-MCID高于术后6个月(χ^(2)=3.997,P<0.05),轻度组、中度组术后1年与术后6个月差异无统计学意义(χ^(2)=0.000、0.473,P>0.05);3组术后1年时NDI-MCID(χ^(2)=3.994、4.266、4.470,P<0.05)和PCS-MCID(χ^(2)=3.994、5.217,P<0.05)均高于术后6个月(除外重度组PCS-MCID,χ^(2)=0.241,P>0.05);6个月和1年时轻度组、中度组和重度组PCS-MCID均依次升高(R=0.383、0.276,P<0.05),重度组的PCS-MCID的患者比例最高。术后6个月、1年,患者的满意率(R=-0.293、-0.202,P<0.05)和RTWR(R=-0.153、-0.202,P<0.05)随疾病严重程度加重而依次下降,重度组的满意率和RTWR最低,均明显低于其他两组。结论CSM患者行ACDF术后的临床结果和社会功能均可得到改善,重度组在满意率和RTWR方面明显低于轻度组和中度组。

Objective To explore clinical outcomes and improved social function on patients with different severity cervical spondylotic myelopathy(CSM)who underwent anterior cervical discectomy and fusion(ACDF).Methods A total of 198 patients undergoing initial ACDF(single or double level)for CSM in the Department of Orthopaedics in the First Affiliated Hospital of Zhengzhou University from January 2017 to January 2023 were prospectively collected.According to Japanese orthopaedic association(JOA)scores,the patients were stratified into three groups:mild(>13 points,52 cases),moderate(9-13 points,87 cases)and severe(<9 points,59 cases).Neck pain(NP)and arm pain(AP)were evaluated by visual analogue scale(VAS).Postoperative neurological function was evaluated by JOA scales,neck disability index(NDI),physical component score(PCS),and mental component score(MCS).Minimal clinically important difference(MCID)was used to evaluate the clinical improvement for patients.The social function satisfaction questionnaire was used to investigate the satisfaction degree of social function recovery after operation.Calculating the return to work rate(RTWR)was used to evaluate social function.The data were statistically analyzed by ANOVA orχ^(2) test or Fisher exact probability method.Results JOA scores[preoperative:(14.7±1.3),(10.9±2.6),(7.1±3.2),6 months after surgery:(15.9±1.4),(13.8±1.6),(12.3±2.9),1 year after surgery:(16.1±1.2),(14.4±1.9),(12.9±2.7),Ftime=76.724,P<0.05]and PCS[preoperative:(41.9±15.4),(33.8±10.6),(26.7±9.8),6 months after surgery:(49.3±17.2),(44.6±15.8),(37.9±12.6),1 year after surgery:(49.9±19.1),(47.4±17.1),(41.3±16.0),Ftime=96.219,P<0.05]were increased,NDI[preoperative:(23.1±16.3),(28.1±16.9),(46.3±18.5),6 months after surgery:(10.4±5.6),(15.3±8.2),(23.4±15.7),1 year after surgery:(9.1±4.8),(12.7±6.6),(18.1±9.9),Ftime=109.747,P<0.05],NP-VAS[preoperative:(3.5±1.6),(3.7±1.4),(3.6±1.5),6 months after surgery:(1.4±0.3),(1.3±0.4),(1.6±0.5),1 year after surgery:(0.9±0.4),(1.1±0.3),(1.1±0.4),Ftime=47.381,P<0.05]and AP-VAS[preoperative:(2.9±2.0),(3.0±1.8),(2.8±1.9),6 months after surgery:(0.9±0.7),(1.3±0.6),(1.4±0.6),1 year after surgery:(0.8±0.6),(0.9±0.6),(1.1±0.5),Ftime=43.774,P<0.05]scores were decreased in the three groups at 6 months and 1 year after surgery compared with those before surgery.In addition to the mild group,MCS in the moderate and severe groups were increased at 6 months and 1 year after surgery[before surgery:(45.1±10.3),(39.7±12.4),6 months after surgery:(49.9±10.7),(51.2±10.8),1 year after surgery:(51.1±10.8),(51.4±11.2),Ftime=27.921,P<0.05].There were no statistically significant differences in NP-MCID(χ^(2)=0.163,0.209,0.000,P>0.05)and AP-MCID(χ^(2)=0.160,0.216,0.884,P>0.05)among the three groups at 6 months and 1 year after surgery.Patients in the severe group had higher JOA-MCID at 1 year after surgery than 6 months after surgery(χ^(2)=3.997,P<0.05).There were no significant differences between 1 year after surgery and 6 months after surgery for JOA-MCID in both the mild group and the moderate group(χ^(2)=0.000,0.473,P>0.05).NDI-MCID(χ^(2)=3.994,4.266,4.470,P<0.05)and PCS-MCID(χ^(2)=3.994,5.217,P<0.05)of the 3 groups at 1 year after surgery were higher than those at 6 months after surgery(except for PCS-MCID in the severe group,χ^(2)=0.241,P>0.05).In the mild group,moderate group and severe group,PCS-MCID increased successively,then proportion of patients with PCS-MCID was highest in the severe group(R=0.383,0.276,P<0.05).At 6 months and 1 year after surgery,the satisfaction rates(R=-0.293,-0.202,P<0.05)and RTWR(R=-0.153,-0.202,P<0.05)of the patients were declined with the aggravation of disease.The satisfaction rates and RTWR of the severe group were the lowest,which were significantly lower than those of the mild group and the severe group.Conclusion Clinical outcomes and social function of CSM patients were improved after ACDF.The satisfaction rates and RTWR of the severe group were significantly lower than those of the mild group and the moderate group.