内镜下颈椎管成形术治疗脊髓型颈椎病术后颈椎矢状位参数变化及其与手术邻近节段退变的关系

Relationship between changes in cervical sagittal parameters and adjacent segment degeneration after cervical microendoscopic laminoplasty for cervical spondylotic myelopathy

中文关键词:  脊髓型颈椎病  内镜下颈椎管成形术  矢状位序列  邻近节段退变

英文关键词:Cervical spondylotic myelopathy  Cervical microendoscopic laminoplasty  Sagittal alignment  Adjacent segment degeneration

中文摘要:

  【摘要】 目的：探究内镜下颈椎管成形术（cervical microendoscopic laminoplasty，CMEL）治疗脊髓型颈椎病（cervical spondylotic myelopathy，CSM）术后颈椎矢状位参数变化及其与手术邻近节段退变（adjacent segment degeneration，ASD）的关系。方法：回顾性分析2019年1月~2023年6月我院经CMEL治疗的111例CSM患者的临床资料，收集整理患者的一般资料（年龄、性别、病变节段数、糖尿病、颈椎MRI T2WI脊髓强信号、手术时间等），记录患者术前、术后12个月疼痛视觉模拟评分（visual analogue scale，VAS）、颈部功能障碍指数（neck disability index，NDI）、日本骨科协会（Japanese Orthopaedic Association，JOA）评分，通过X线片测量术前、术后12个月颈椎矢状位参数[C2-7Cobb角、C2-7矢状位轴向距离（sagittal vertical axis，SVA）、T1倾斜角（T1 slope，T1S）、胸廓入口角（thoracic inlet angle，TIA）]。采用Pearson分析手术前后颈椎矢状位参数与JOA、NDI、VAS评分差值的相关性。根据随访期间是否出现ASD，将患者分为ASD组与非ASD组，比较两组间的上述参数，并将有统计学差异的颈椎矢状位参数按照三分位法，以相关分类为自变量，以术后ASD为因变量，通过多因素Logistic回归模型分析相关参数与术后ASD发生风险的关系。采用限制性立方样条（restricted cubic splines，RCS）模型分析术后C2~C7 Cobb角及T1S与术后ASD的剂量-反应关系。通过C-Statistics、净重新分类指数（net reclassification index or improvement，NRI）、综合判别改善指数（integrated discrimination improvement，IDI）联合评价各指标对术后ASD的预测效能。结果：术前和术后12个月C2~C7 Cobb角、C2~C7 SVA、JOA评分、NDI指数、VAS评分比较差异均有统计学意义（P<0.05），T1S、TIA无统计学差异（P>0.05）。Pearson分析显示，C2~C7 Cobb角差值与JOA评分差值呈正相关（P<0.05），与NDI、VAS评分差值呈负相关（P<0.05）；C2~C7 SVA、T1S、TIA差值与JOA评分、NDI、VAS评分差值均无相关性（P>0.05）。ASD组（n=40）和非ASD组（n=71）患者的年龄、T2WI强信号、术前JOA评分、术前颈部疼痛VAS评分、术前上肢疼痛VAS评分、术前NDI、术后12个月C2~C7 Cobb角、术后12个月T1S均有统计学差异（P<0.05），性别、BMI、吸烟、饮酒、糖尿病、病变节段数、手术时间、术中出血量、术前各颈椎矢状位参数、术后12个月C2~C7 SVA、术后12个月TIA无统计学差异（P>0.05）。按照三分位法，术后12个月C2~C7 Cobb角<15.30°分为Q1组、15.30°~18.65°为Q2组和>18.65°为Q3组；术后12个月T1S<22.45°为Q4组、22.45°~25.60°为Q5组和>25.60°为Q6组；以术后12个月C2~C7 Cobb角及T1S分类为自变量，术后ASD为因变量，多因素Logistic回归分析显示，调整混杂因素后，与Q1组相比，Q3组患者术后ASD发生风险显著性降低（P<0.05），与T1S分类Q4组相比，Q6组患者术后ASD发生风险显著性降低（P<0.05）。RCS分析显示，术后12个月C2~C7 Cobb角、术后12个月T1S与术后ASD风险的关联强度呈非线性剂量-反应关系（P<0.05）。联合评价显示，各指标中加入术后12个月C2~C7 Cobb角和T1S后预测能力最优，C-Statistics、NRI、IDI结果具有一致性。结论：CSM患者CMEL术后C2~C7 Cobb角增大，C2~C7 SVA缩小；C2~C7 Cobb角与患者临床症状的改善显著相关。术后12个月C2~C7 Cobb角和T1S与ASD风险呈非线性剂量-反应关系。颈椎矢状位参数联合临床指标对ASD风险的预测效能最优。

英文摘要:

  【Abstract】 Objectives: To explore the changes of cervical sagittal parameters after cervical microendoscopic laminoplasty(CMEL) of cervical spondylotic myelopathy(CSM) and their relationship with adjacent segment degeneration(ASD). Methods: The clinical data of CSM patients(n=111) treated with CMEL in our Hospital from January 2019 to June 2023 were retrospectively analyzed. The clinical data(age, gender, number of diseased segments, diabetes mellitus, cervical MRI T2WI spinal cord strong signal, operation time, etc) of patients were collected, and the visual analogue scale(VAS), neck disability index(NDI), Japanese Orthopaedic Association(JOA) of patients before and at 12 months after operation were recorded, and the sagittal parameters [C2-7 Cobb angle, C2-7 sagittal vertical axis(SVA), T1 slope(T1S), thoracic inlet angle(TIA)] of cervical spine were measured before and at 12 months after operation on X-ray images. Pearson analysis was used to analyze the correlation between the difference of cervical sagittal parameters before and after surgery and the difference of JOA, NDI and VAS scores. Patients were divided into ASD group(n=40) and non ASD group(n=71) according to whether ASD occurred during the follow-up period, and the above parameters were compared between the two groups, and the cervical sagittal parameters with statistical differences between the two groups were analyzed by the multivariate logistic regression model, with the correlation classification as the independent variable and the postoperative ASD as the dependent variable according to the triad method. Restricted cubic splines(RCS) model was used to analyze the dose-response relationship between postoperative C2-C7 Cobb angle and T1S and the risk of postoperative ASD. C-Statistics, net reclassification index or improvement(NRI) and integrated discrimination improvement(IDI) were used to evaluate the predictive efficacy of each index for postoperative ASD. Results: There were statistically significant differences in C2-C7 Cobb angle, C2-C7 SVA, JOA score, NDI index and VAS score between before operation and 12 months after operation(P<0.05), but there were no statistically significant differences in T1S and TIA(P>0.05). Pearson analysis showed that C2-C7 Cobb angle difference was positively correlated with JOA score difference(P<0.05), and negatively correlated with NDI and VAS score differences(P<0.05); There was no correlation between C2-C7 SVA, T1S, TIA differences and JOA score, NDI, VAS score differences(P>0.05). There were significant differences in age, T2WI strong signal, preoperative JOA score, preoperative neck pain VAS score, preoperative upper limb pain VAS score, preoperative NDI index, C2-C7 Cobb angle 12 months after operation, and T1S 12 months after operation between ASD group(n=40) and non ASD group(n=40)(P<0.05), and there were no significant differences between groups in gender, BMI, smoking, drinking, diabetes, number of diseased segments, operation time, intraoperative blood loss, preoperative cervical sagittal parameters, C2-C7 SVA 12 months after operation, and TIA 12 months after operation(P>0.05). According to the triad method, 12 months after operation, the C2-C7 Cobb angle<15.30° was divided into Q1 group, 15.30°-18.65° was Q2 group and >18.65° was Q3 group; 12 months after operation, T1S<22.45° was Q4 group, 22.45°-25.60° was Q5 group and >25.60° was Q6 group; With C2-C7 Cobb angle and T1S classification as independent variables and postoperative ASD as dependent variables, multivariate logistic regression analysis showed that after adjusting for confounding factors, the risk of postoperative ASD in group Q3 was significantly lower than that in group Q1(P<0.05), and that in group Q6 was significantly lower than that in group Q4 according to T1S classification(P<0.05). RCS analysis showed that there was a non-linear dose-response relationship between C2-C7 Cobb angle at 12 months after surgery, T1S at 12 months after surgery and postoperative ASD risk(P<0.05). The joint evaluation showed that the prediction ability of cervical sagittal parameters(C2-C7 Cobb angle and T1S at 12 months after operation) was the best, and the results of C-statistics, NRI and IDI were consistent. Conclusions: The C2-C7 Cobb angle increases and C2-C7 SVA shortens in patients with CSM after CMEL; C2-C7 Cobb angle is significantly correlated with the improvement of clinical symptoms. There is a nonlinear dose-response relationship between C2-C7 Cobb angle and T1S and ASD risk 12 months after operation. Cervical sagittal parameters combined with clinical indicators have the best predictive effect on ASD risk.