手术时机对无骨折脱位型颈脊髓损伤的疗效影响

Influence of surgical timings on the therapeutic effect of cervical spinal cord injury without fracture and dislocation

中文关键词:  无骨折脱位型颈脊髓损伤  早期手术  延迟手术  前路颈椎间盘切除椎间融合术  后路颈椎手术

英文关键词:Cervical spinal cord injury without fracture and dislocation  Early surgery  Delayed surgery  Anterior cervical discectomy and fusion(ACDF)  Posterior cervical surgery

中文摘要:

  【摘要】目的：比较无骨折脱位型颈脊髓损伤（cervical spinal cord injury without fracture and dislocation，CSCIwoFD）患者早期手术与延迟手术对神经功能恢复的影响。方法：回顾性分析2020年8月~2023年1月我院收治确诊为CSCIwoFD并接受手术治疗的104例患者，按受伤到接受手术的时间将患者分为早期手术组（≤7d）和延迟手术组（＞7d）。早期手术组54例患者，男性39例，女性15例，年龄25~69岁（49.5±12.1岁）。延迟手术组50例患者，男性34例，女性16例，年龄24~72岁（54.6±9.3岁）。两组患者性别、年龄及受伤原因等资料比较无显著性差异（P＞0.05）。比较两组患者手术指标，包括手术方式、融合节段数、手术时长、术中出血量、术后引流量、术后6个月X线片骨融合率。统计并比较两组患者术前、术后3个月、6个月、1年及2年时的日本骨科协会（Japanese Orthopaedic Association，JOA）评分、美国脊髓损伤协会（American Spinal Cord Injury Association，ASIA）运动评分（ASIA motor score，AMS）和ASIA感觉评分（ASIA sensory score，ASS），同时比较两组的JOA评分、AMS、ASS改善率（recovery rate，RR）。通过R语言等工具进行Pearson分析，明确相关影像学指标如椎管最狭窄处百分比（maximum canal compromise，MCC）、脊髓最大受压程度（maximum spinal cord compression，MSCC）等与年龄、性别、手术方式等因素及脊髓功能评分及其相应改善率是否存在线性关系，并进行组间对比。对住院时间、出院后恢复工作时间、住院治疗费用、治疗后2年的患者满意度进行分析和对比。结果：两组融和节段数、手术时长、术中出血量、术后引流量等手术指标差异均无统计学意义（P＞0.05）。影像学指标方面，早期手术组MSCC[（21.28±8.63）%]高于延迟手术组[（18.24±9.29）%]，差异有统计学意义（P＜0.05），但两组之间MCC的差异无统计学意义（P＞0.05）。MSCC与术后神经功能恢复参数，包括JOA评分及JOA评分RR、AMS和AMS RR均呈显著正相关，MSCC与ASS RR之间的相关性较弱。未观察到MSCC与年龄、性别或手术方法之间存在显著相关性，而与手术时机存在轻度正相关。疗效评估方面，两组术后随访JOA评分、ASS和AMS均较术前有所提高，且早期手术组的评分优于延迟手术组，其中两组在治疗后2年的JOA评分分差为2.71分，满足JOA评分的最小临床重要差异（MCID）。两组术后1年和2年JOA评分RR、ASS RR和AMS RR的差异均有统计学意义（P＜0.05）。早期手术组中，经Pearson分析显示，MSCC与术后3个月JOA评分RR呈正相关（γ=0.527，P＜0.05），与术后3个月AMS RR呈正相关（γ=0.277，P＜0.05）。结论：早期手术和延迟手术均可以使CSCIwoFD患者的脊髓功能得到改善，其中接受早期手术治疗的患者改善程度更高。影像学指标方面，MSCC与早期手术患者的运动功能恢复呈正相关。在创伤应激状态稳定的情况下，尽可能在7d以内进行手术干预可以最大限度地改善患者的预后。

英文摘要:

  【Abstract】 Objectives: To compare the effects of early versus delayed surgical intervention on neurological recovery in patients with cervical spinal cord injury without fracture and dislocation(CSCIwoFD). Methods: 104 patients with CSCIwoFD who underwent surgery between August 2020 and January 2023 were analyzed retrospectively. Based on the time from injury to surgery, the patients were divided into an early surgery group(≤7d) and a delayed surgery group(＞7d). Early surgery group consisted of 54 patients, including 39 males and 15 females, aged 25-69(49.5±12.1) years old; Delayed surgery group consisted of 50 patients, including 34 males and 16 females, aged 24-72(54.6±9.3) years old. No significant differences were observed between the two groups in general data(P>0.05). The surgical indexes were compared, including operation approach, number of fused segment, operative time, intraoperative blood loss, postoperative drainage volume, and bone fusion rate on X-ray images 6 months after operation. The Japanese Orthopaedic Association(JOA) score, American Spinal Cord Injury Association(ASIA) Motor Score(AMS), and ASIA Sensory Score(ASS), were compared between the two groups before operation, at postoperative 3 and 6 months, and 1 and 2 years, along with their respective recovery rates(JOA score RR, AMS RR, and ASS RR). Radiological parameters, including maximum canal compromise(MCC), maximum spinal cord compression(MSCC), were analyzed for linear correlations with age, gender, operation approach and other indexes, as well as functional scores and their improvement rates using Pearson analysis. Additional comparisons between the two groups included length of hospital stay, time to return to work, treatment costs, and patient satisfaction at 2 years post-treatment. Results: No significant differences were observed between the two groups in surgical parameters(P>0.05). Radiologically, MSCC was higher in the early surgery group[(21.28±8.63)% vs (18.24±9.29)%] with statistical significance(P<0.05), while MCC wasn′t statistically different between groups(P>0.05). MSCC showed a significant positive correlation with postoperative neurological recovery parameters, including JOA scores and RR, AMS and AMS RR, while its correlation with ASS RR was weaker. MSCC did not correlate significantly with age, gender, or surgical approach but exhibited a mild positive correlation with surgical timing. Both groups showed postoperative improvement in JOA score, ASS, and AMS, with the early surgery group demonstrating superior scores. The between-group difference in JOA scores at 2 years was 2.71 points, meeting the minimal clinically important difference(MCID). Significant differences in JOA score RR, ASS RR, and AMS RR between groups were observed at 1 and 2 years postoperatively(P<0.05). In the early surgery group, MSCC positively correlated with JOA score RR (γ=0.527, P<0.05) and AMS RR (γ=0.277, P<0.05) at 3 months. Conclusions: Both early and delayed surgery can improve spinal cord function in CSCIwoFD patients, with greater improvement observed in the early surgery group. MSCC is positively correlated with favorable motor recovery in patients undergoing early intervention. Provided the patient′s traumatic stress state is stable, surgical intervention within 7d is recommended to maximize neurological outcomes.