人工颈椎间盘置换术与颈椎前路椎间盘切除融合术治疗单节段颈椎病的长期疗效

Long-term outcomes of artificial cervical disc replacement versus anterior cervical discectomy and fusion for single-level cervical spondylosis

中文关键词:  单节段颈椎病  人工颈椎间盘置换术  颈前路融合术  长期随访  异位骨化  邻椎病

英文关键词:Single-segment cervical spondylosis  Artificial cervical disc replacement  Anterior cervical fusion  Long-term follow-up  Heterotopic ossification  Adjacent segment disease

中文摘要:

  【摘要】 目的：比较人工颈椎间盘置换术（artificial cervical disc replacement，ACDR）与颈椎前路椎间盘切除融合术（anterior cervical discectomy and fusion，ACDF）治疗单节段颈椎病的长期疗效。方法：回顾性分析2009年1月~2012年8月海军军医大学第二附属医院骨科收治并获10年以上随访的C5/6单节段颈椎病患者资料，根据手术方式分为ACDR组和ACDF组，ACDR组（n=30例）男性20例，女性10例，年龄41.5±4.4岁（32~50岁），采用Discover人工颈椎间盘假体，随访129.4±6.7个月；ACDF组（n=27例）男性19例，女性8例，年龄39.2±5.3岁（31~50岁），随访127.0±4.1个月。两组患者性别、年龄、随访时间、体重指数（body mass index，BMI）、颈椎病分型、病程、手术时间和术中出血量等一般资料无统计学差异（P>0.05）。在术前和末次随访时采用日本骨科学会（Japanese Orthopaedic Association，JOA）评分及颈椎功能障碍指数（neck disability index，NDI）评价患者神经功能；在颈椎侧位X线片上测量C2~C7 Cobb角，评估ACDR手术节段异位骨化（heterotopic ossification，HO）McAfee等级，在颈椎屈伸侧位X线片上测量颈椎整体活动度（range of motion，ROM）和节段ROM，在颈椎MRI平扫T2加权像上评估椎间盘Pfirrmann分级。记录随访期间神经功能恶化、脑脊液漏、内置物松动、邻椎病（adjacent segment disease，ASD）等并发症。结果：末次随访时两组JOA评分及NDI较术前均显著性改善（P<0.05）；同一时间点两组之间均无统计学差异（P>0.05）。两组患者手术前后和同时间点组间C2~C7 Cobb角对比均无显著性差异（P>0.05）。ACDF组颈椎整体ROM术前47.1°±13.8°，末次随访时38.3°±12.8°，差异有统计学意义（P<0.05）；ACDR组末次随访时（45.8°±13.5°）较术前（46.3°±13.4°）无显著性变化（P>0.05）。末次随访时ACDR组手术节段ROM（9.2°±2.0°）较术前（10.0°±1.4°）显著性下降（P<0.05）；手术上邻节段（C4/5）和下邻节段（C6/7）ROM均较ACDF组低（P<0.05），非邻节段（C3/4）ROM与ACDF组无显著性差异（P>0.05）。末次随访时两组上邻、下邻和非邻节段椎间盘Pfirrmann分级较术前均升高（P<0.05），ACDR组上邻、下邻节段Pfirrmann分级均低于ACDF组（P<0.05），而非邻节段Pfirrmann分级与ACDF组无统计学差异（P>0.05）。末次随访时，ACDR组HO发生14例（46.7%）（McAfee Ⅰ级2例，Ⅱ级5例，Ⅲ级7例），无ASD发生；2例（6.7%）出现假体下沉伴前移，患者无不适，未予外科处理；ACDF组2例（7.4%）因ASD行二次手术治疗，再手术率与ACDR组无统计学差异（P>0.05）。结论：ACDR与ACDF治疗C5/6单节段颈椎病的长期疗效和安全性无显著性差异。ACDR术后HO发生率较高，但无McAfee Ⅳ级骨化。ACDR在控制邻近节段ROM和退变升高方面优于ACDF。

英文摘要:

  【Abstract】 Objectives: To compare the long-term efficacies of artificial cervical disc replacement(ACDR) and anterior cervical discectomy and fusion(ACDF) in treating single-level cervical spondylosis. Methods: A retrospective analysis was conducted on the patients with C5/6 single-segment cervical spondylosis admitted and treated at the Department of Orthopedics at the Second Affiliated Hospital of Naval Medical University between January 2009 and August 2012, with follow-up periods exceeding 10 years. Based on surgical approach, the patients were divided into an ACDR group and an ACDF group. The ACDR group comprised 30 patients(20 males and 10 females), with a mean age of 41.5±4.4 years(range, 32 to 50 years), and the patients received the Discover artificial cervical disc prosthesis. The ACDF group included 27 patients(19 males and 8 females), with a mean age of 39.2±5.3 years(range, 31 to 50 years). The follow-up periods were 129.4±6.7 months for the ACDR group and 127.0±4.1 months for the ACDF group. There were no statistically significant differences between the two groups in terms of gender, age, body mass index(BMI), classification of cervical spondylosis, disease duration, operative time, and intraoperative blood loss(P>0.05). Neurological function was assessed preoperatively and at final follow-up using the Japanese Orthopaedic Association(JOA) score and neck disability index(NDI). The C2-C7 Cobb angle was measured on lateral cervical radiographs, and heterotopic ossification(HO) at the ACDR surgical level was graded according to the McAfee classification. The global cervical range of motion(ROM) and segmental ROM were measured on flexion-extension lateral radiographs. Intervertebral disc Pfirrmann grading was assessed according to T2-weighted MRI scans. Complications during follow-up, including neurological deterioration, cerebrospinal fluid leakage, implant loosening, and adjacent segment disease(ASD), were recorded. Results: At final follow-up, both JOA scores and NDI showed significant improvement compared to preoperative values in both groups(P<0.05). However, there were no statistically significant differences in JOA scores or NDI between the two groups at the same time points(P>0.05). No significant differences were found in the C2-C7 Cobb angle within or between groups before and after surgery(P>0.05). The global cervical ROM in the ACDF group decreased significantly from 47.1°±13.8° preoperatively to 38.3°±12.8° at final follow-up(P<0.05). In contrast, the global cervical ROM in the ACDR group showed no significant change(45.8°±13.5° at final follow-up vs 46.3°±13.4° preoperatively, P>0.05). The ROM at the surgical segment in the ACDR group significantly decreased from 10.0°±1.4° preoperatively to 9.2°±2.0° at final follow-up(P<0.05). The ROMs at both superior(C4/5) and inferior(C6/7) adjacent segments were significantly lower in the ACDR group compared to the ACDF group(P<0.05), while no significant difference was found at the non-adjacent segment(C3/4)(P>0.05). Pfirrmann grades at the superior, inferior, and non-adjacent segments increased significantly from preoperation to final follow-up in both groups(P<0.05). However, the Pfirrmann grades at both the superior and inferior adjacent segments were significantly lower in the ACDR group compared to the ACDF group(P<0.05), whereas no significant difference was observed at the non-adjacent segment(P>0.05). At final follow-up, HO occurred in 14(46.7%) cases in the ACDR group(2 cases of McAfee grade Ⅰ, 5 cases of grade Ⅱ, and 7 cases of grade Ⅲ), while none ASD was observed. Two patients(6.7%) in the ACDR group exhibited prosthesis subsidence with anterior migration, but were asymptomatic and did not require surgical intervention. In the ACDF group, two patients(7.4%) underwent secondary surgery due to ASD. The reoperation rate showed no statistically significant difference between the two groups(P>0.05). Conclusions: There is no significant difference in long-term efficacy and safety between ACDR and ACDF for treating C5/6 single-level cervical spondylosis. The incidence of HO after ACDR is high, but without McAfee Grade Ⅳ ossification. ACDR exhibits reduced ROM and lower degeneration grades in the adjacent segment than ACDF.