颈前路椎间盘切除植骨融合内固定术治疗颈椎管狭窄患者颈椎挥鞭样损伤的疗效评价

Evaluation of the curative effect of anterior cervical discectomy and fusion in treating cervical whiplash injury in patients with spinal canal stenosis

中文关键词:  颈脊髓损伤  颈前路颈椎间盘切除植骨融合内固定术  颈椎间盘突出  挥鞭样损伤  颈椎椎管狭窄

英文关键词:Cervical spinal cord injury  Anterior cervical discectomy and fusion  Cervical intervertebral disc herniation  Whiplash injury  Cervical spinal canal stenosis

中文摘要:

  【摘要】 目的: 探讨颈前路椎间盘切除植骨融合内固定术治疗因颈椎间盘突出致颈椎管狭窄患者遭受颈椎挥鞭样损伤的临床疗效。方法：回顾性分析2010年1月~2018年12月在我院行颈前路颈椎间盘切除植骨融合内固定术的50例颈椎挥鞭样损伤患者的临床资料，其中男32例，女18例，年龄35~75岁（53.6±13.6岁）。根据术前颈椎MRI T2加权相中矢状位上目标节段纤维性椎管最小矢状径分为狭窄组（最小矢状径≤13mm，32例）和非狭窄组（最小矢状径＞13mm，18例），两组间年龄及性别无统计学差异。狭窄组随访25.6±7.4个月，非狭窄组27.4±8.3个月，两组随访时间差异无统计学意义。记录两组患者术前及术后1个月、1年及末次随访时ASIA评分的总分、感觉评分、运动评分，计算术后1个月、1年及末次随访时的日本骨科协会（Japanese Orthopedic Association，JOA）评分改善率和末次随访时的手术改善率，记录相关并发症的发生情况。结果：ASIA评分总分，每组术后各时间点与术前比较均有显著性增加（P＜0.05）；术前和术后1个月时两组间差异均无统计学意义，但术后1年及末次随访时差异均有统计学意义（P＜0.05）。ASIA上肢运动评分，每组术后各时间点与术前比较均有显著性增加（P＜0.05），术前及术后各时间点两组间比较差异均有统计学意义（P＜0.05）。ASIA下肢运动评分，每组术后各时间点与术前比较均有显著性增加（P＜0.05），术前及术后各时间点两组间比较差异无统计学意义（P＞0.05）。ASIA感觉评分，每组术后各时间点与术前比较均有显著性增加（P＜0.05）；术前两组间差异无统计学意义（P＞0.05），术后各时间点两组间比较差异有统计学意义（P＜0.05）。每组患者术后各时间点JOA评分与术前相比均明显改善（P＜0.05）。术后1个月狭窄组与非狭窄组JOA评分改善率分别为37.3%和55.9%，术后1年分别为61.3%和73.6%，末次随访分别为77.3%和91.1%，上述各时间点两组间比较差异有统计学意义（P＜0.05）。末次随访时，狭窄组手术改善率为88%（28/32），非狭窄组为（94%）（17/18），差异有统计学意义（P＜0.05）。两组术后各出现4例颈部轴性疼痛；狭窄组13例、非狭窄组11例术后出现吞咽疼痛或吞咽异物感，行对症治疗后改善；狭窄组出现1例椎前血肿和2例C5神经根麻痹，经神经营养、消肿等对症治疗后好转。随访期间，两组患者均未发生内固定松动或摔倒等意外突发事件。结论:颈前路椎间盘切除植骨融合内固定术治疗颈椎挥鞭样损伤患者能够获得满意的疗效，但外伤前合并有颈椎间盘突出致颈椎管狭窄的患者术后短期疗效相对较差。

英文摘要:

  【Abtract】 Objectives: To investigate the clinical efficacy of anterior cervical discectomy and fusion in treating cervical whiplash injury in patients with cervical spinal canal stenosis caused by cervical disc herniation. Methods: The clinical data of 50 patients with whiplash injury of the cervical spine who were treated in our hospital from January 2010 to December 2018 with anterior cervical discectomy and fusion were retrospectively analyzed. There were 32 males and 18 females, aged 35-75 years(53.6±13.6 years). According to the minimum sagittal diameter of fibrous spinal canal at the target segment in the sagittal position on MRI T2WI before surgery, the patients were divided into stenosis group(minimal sagittal diameter≤13mm, 32 patients) and non-stenosis group(minimal sagittal diameter>13mm, 18 patients). There were no statistical differences in age and gender between the two groups. No significant difference of follow-up was found between the stenosis group(25.6±7.4 months) and non-stenosis group(27.4±8.3 months). The total American Spinal Injury Association(ASIA) score, sensory score, and motor score before operation and at postoperative 1 month and 1 year and final follow-up were recorded; the improvement rate of Japanese Orthopedic Association(JOA) score at postoperative 1 month and 1 year and final follow-up, and surgical improvement rate at final follow-up were calculated; and the occurrence of related complications were recorded. Results: The total ASIA scores at postoperative 1 month, 1 year and final follow-up in the two groups were statistically different from those before operation(P＜0.05), respectively; there were no significant differences between the two groups at preoperation and 1 month after operation(P＞0.05) and there were significant differences between groups at postoperative 1 year and final follow-up(P＜0.05). The ASIA motor scores of the upper extremity at postoperative time points increased significantly than those before operation in both groups respectively(P＜0.05), and there were statistical differences between groups before operation and at postoperative time points(P＜0.05). The ASIA motor scores of the lower extremity at postoperative time points also increased significantly than those before operation in both groups respectively(P＜0.05), while no significant difference was found between groups before operation and at postoperative time points(P＞0.05). The ASIA sensory scores at postoperative time points all increased significantly than those before operation in both groups respectively(P＜0.05), and there were statistical differences between groups before operation and at postoperative time points(P＜0.05). The JOA scores in each group at postoperative time points all improved than those before operation(P＜0.05). The improvement rates of JOA score in stenosis group and non-stenosis group were 37.3% and 55.9% at 1 month after surgery, 61.3% and 73.6% at 1 year after surgery, and 77.3% and 91.1% at final follow-up, with significant differences between groups at different time points(P＜0.05). The surgical improvement rate was 88%(28/32) in the stenosis group and 94%(17/18) in the non-stenosis group at final follow-up, and the difference was statistically significant(P<0.05). Four patients in each group developed axial pain in the neck; 13 patients(stenosis group) and 11 patients(non-stenosis group) developed swallowing pain or swallowing foreign body sensation postoperatively, which improved after symptomatic treatment; One case of prevertebral hematoma and two cases of C5 nerve root palsy in the stenosis group, which improved after symptomatic treatment such as neurotrophic and debulking. During follow-up, no unexpected emergencies such as loosening of internal fixation or falls occurred in either group. Conclusions: Anterior cervical discectomy and fusion can achieve satisfactory outcomes in treating patients with whiplash-like injuries of cervical spine. However, the short-term postoperative outcome is inferior in patients with cervical spinal canal stenosis caused by cervical disc herniation before trauma than those without stenosis.