小切口前路零切迹自锁融合器治疗四节段颈椎病的临床疗效分析

Clinical outcomes of anterior cervical discectomy and fusion by self-locking cages for four-level cervical spondylosis with minimal incision

目的探讨小切口前路零切迹自锁融合器治疗四节段颈椎病临床疗效。方法回顾性分析2012年3月至2016年3月,在我院因颈椎病行四节段前路椎间隙减压零切迹自锁融合器固定融合的患者24例,记录所有患者的手术时间、术中出血量及并发症发生情况。比较术前及术后随访时颈部疼痛视觉模拟评分(visual analogue scale,VAS),颈椎日本骨科协会(Japanese orthopaedic association,JOA)评分及颈椎功能障碍指数(neck disabilitv index,NDI),采用Odom标准评价末次随访时患者临床疗效的主观满意度;同时采用X线及CT进行影像学评价,比较术前,术后随访时颈椎曲度,活动度,融合节段高度,C2~7矢状位力线(C2~7 sagittal vertical axis,SVA),T1倾斜角(T1 slope)等参数,并计算末次随访时的融合率。结果 24例均获完整随访,随访21~68个月,平均(40.6±5.3)个月,手术时间110~230 min,平均(133±24.2) min。术中出血65~300 ml,平均(85.5±33.6) ml,术后1个月随访时VAS、JOA、NDI评分分别为(1.7±1.75)分,(10.5±1.58)分及(13.4±6.02)分;末次随访时分别为(1.9±2.23)分,(12.8±1.61)分及(14.7±5.91)分;术后1个月及末次随访时的评分与术前VAS评分(4.1±2.53)分,JOA评分(8.3±1.05)分及NDI评分(30.1±7.25)分比较差异均有统计学意义(P<0.05);根据Odom标准,末次随访时优良率为87.5%。术后1个月及末次随访时颈椎整体曲度分别为(17.8±5.76)°、(15.3±5.87)°较术前颈椎曲度(8.9±7.85)°有明显改善,差异有统计学意义(P<0.05);术后1个月及末次随访时融合节段高度分别为(80.5±6.55) mm、(78.8±5.83) mm,均高于术前的(72.4±8.46) mm,差异有统计学意义(P<0.05);术后1个月及末次随访时C2~7SVA及T1 slope分别为(24.5±8.67) mm、(28.1±7.32)°;(23.9±7.17) mm、(27.9±8.11)°均较术前(21.4±9.63) mm、(23.6±6.56)°改善,差异有统计学意义(P<0.05)。随访期间所有患者无内固定相关并发症。末次随访时融合率达89.7%。并发症包括吞咽困难7例,C5神经根麻痹4例,轴性痛6例。结论零切迹自锁融合器行四节段颈椎前路椎间隙减压融合内固定术(anterior cervical discectomy and fusion,ACDF)能取得良好的临床疗效,能够获得坚强的融合,并改善颈椎曲度及矢状位力线。但是四节段ACDF,其手术适应证选择较窄,对手术技巧要求较高,仍然具备一定的难度及风险。

Objective To investigate clinical results of the treatment of 4-level cervical spondylosis in patients by anterior decompression and fusion approach with self-locking and zero-profile cages.Methods From March 2012 to March 2016,a total of 24 patients with 4-level cervical spondylosis who received anterior cervical decompression,internal fixation were included in our study.Operation time,intraoperative blood loss and postoperational complications were recorded.Recording the neck pain VAS score,the Japanese Orthopedic Association(JOA)score and Neck disability Index(NDI)score to investigate the clinical outcomes pre-operation and postoperation.Surgical results according to Odom’s criteria were evaluated at the final follow-up.Meanwhile,X-ray and CT were used to evaluate the whole cervical Cobb’s angle,range motion of cervical spine,height of fusion segment(FSH),C<sub>2-7 sagittal vertical axis(SVA)and T1 slope pre-and post-operation.Fusion rates were evaluated at the final follow-up.Results The mean follow-up was(40.6±5.3)months(range:21-68 months).The average operation time was(133±24.2)min(range:110-230 min).The average bleeding volume was(85.5±33.6)ml(range:65-300 ml).Neurological function was significantly improved after operation.VAS scores were significantly lower at 1 month(1.7±1.75)and the last follow-up(1.9±2.23)post-operatively comparing with those preoperatively(4.1±2.53)(P<0.05).JOA scores at 1 month(10.5±1.58)and the last follow-up(12.8±1.61)were significantly higher post-operatively comparing with those pre-operatively(8.3±1.05)(P<0.05).NDI scores 1 month after operation and at the last follow-up were(13.4±6.02)and(14.7±5.91)respectively,which were significantly lower comparing with those pre-operatively(30.1±7.25).According to the Odom criteria,the share of patients with excellent and good clinical outcomes was 87.5%.The C<sub>2-7 Cobb’s angle(cervical lordosis)was(8.9±7.85)°before surgery,(17.8±5.76)°1 month after surgery,(15.3±5.87)°at the final follow-up examination,which were improved significantly after surgery compared with that before surgery(P<0.05).FSH increased from(72.4±8.46)mm pre-operatively to(80.5±6.55)mm postoperatively at 1 month after surgery and(78.8±5.83)mm at the last follow-up.Pre-operative FSH improved significantly after surgery at 1 month and last follow-up postoperatively(P<0.05).Pre-operative C<sub>2-7 SVA(21.4±9.63 mm)improved significantly at 1 month(24.5±8.67 mm)and last follow-up(23.9±7.17 mm)post-operatively(P<0.05).The pre-operative T1-slope(23.6±6.56)°also improved significantly at 1 month after surgery(28.1±7.32)°and the last follow-up(27.9±8.11)°(P<0.05).No instrument-related complications happened during the follow-up.At the final follow-up,the fusion rate was 89.7%.Complications included dysphagia(7 cases),C5 palsy(4 cases),axial neck pain(6 cases).Conclusions Anterior cervical discectomy and fusion with self-locking cages is effective and safe for 4-level cervical spondylotic myeloradiculopathy.It allows to restore cervical lordosis and normal cervical alignment with good fusion rate and satisfactory clinical outcomes.However,surgical skills required are relatively high as narrow indications.Difficulties and risks still exist.