后路内镜下椎板-椎间孔开窗髓核摘除术与前路内镜下颈椎间盘切除融合术治疗单节段神经根型颈椎病的疗效对比

Comparison of the efficacy between posterior cervical endoscopic laminoforaminotomy with discectomy and endoscopic anterior cervical discectomy and fusion in the treatment of single-level cervical spondylotic radiculopathy

中文关键词:  脊柱内镜  椎板-椎间孔开窗髓核摘除术  颈前路椎间盘切除融合术  神经根型颈椎病  临床疗效

英文关键词:Spinal endoscopy  Key-hole  Anterior cervical discectomy and fusion  Cervical spondylotic radiculopathy  Clinical efficacy

中文摘要:

  【摘要】 目的：比较后路脊柱内镜下椎板-椎间孔开窗髓核摘除术（Key-hole）与前路内镜下颈椎间盘切除融合术（endoscopic anterior cervical discectomy and fusion，Endo-ACDF）治疗单节段神经根型颈椎病（cervical spondylotic radiculopathy，CSR）的临床疗效。方法：回顾分析2022年2月~2024年1月在我院骨科治疗的41例单节段CSR患者，其中男24例，女17例，年龄56.8±13.2岁（32~81岁），随访时间13.9±1.0个月（12～16个月）。根据手术方式分为Key-hole组（n=19）与Endo-ACDF组（n=22）。两组患者的性别、年龄、体质指数（body mass index，BMI）、手术节段无统计学差异（P>0.05）。记录两组患者手术时间、切口长度、术中出血量、术后住院时间及并发症情况；术前、术后1周及末次随访时应用颈肩疼痛视觉模拟量表（visual analogue scale，VAS）评分、日本骨科协会（Japanese Orthopaedic Association，JOA）评分、颈椎功能障碍指数（neck disable index，NDI）进行评价，末次随访根据改良MacNab标准评定疗效；术前与末次随访进行X线片、CT及MRI检查，于侧位X线片测量病变节段椎间隙高度、颈椎生理曲度（C2-7 Cobb角），于CT矢状位图像测量患侧椎间孔高度、椎间孔面积，于MRI轴位图像测量椎管面积。结果：所有患者手术顺利，Key-hole组1例术中发生硬膜损伤，术后嘱患者头低足高位，抗生素预防继发感染，未发生脑脊液漏相关反应及继发感染。Endo-ACDF组1例发生声音嘶哑，术后给予雾化吸入、营养神经等处理，出院时症状好转，末次随访时症状消失。与Endo-ACDF组相比，Key-hole组手术时间更短（79.57±8.1min vs 88.05±4.82min），失血量更少[30.00（25.00，30.00）mL vs 65.00（60.00，70.00）mL]，切口更小（2.3±0.1cm vs 4.1±0.3cm），术后住院时间更短[5.00（4.00，5.00）d vs 6.00（5.00，7.00）d]（P<0.05）。术后1周和末次随访时两组JOA评分、VAS评分及NDI均较术前显著性改善（P<0.05），两组间上述指标未见明显差异（P>0.05）。末次随访两组患者改良MacNab标准分级未见明显差异（P>0.05）。末次随访两组椎管面积、椎间孔面积及颈椎前凸角较术前均明显改善（P<0.05）；而末次随访Key-hole组椎间孔高度较术前无明显变化（P>0.05），椎间隙高度较术前缩小（P<0.05）。末次随访时，Endo-ACDF组的椎间隙高度、椎管面积、颈椎Cobb角优于Key-hole组，Key-hole组末次随访的椎间孔面积大于Endo-ACDF组，差异有统计学意义（P<0.05）。结论：后路内镜下Key-hole技术与Endo-ACDF治疗单节段CSR均可取得满意疗效，Key-hole技术手术时间更短，切口更小，失血更少，术后住院时间更短，对椎间孔减压更彻底；Endo-ACDF更侧重于恢复椎间隙高度及颈椎生理曲度，对椎管减压更彻底。

英文摘要:

  【Abstract】 Objectives: To compare the clinical efficacy of posterior cervical endoscopic laminoforaminotomy with discectomy(key-hole) and endoscopic anterior cervical discectomy and fusion(Endo-ACDF) in the treatment of single-level cervical spondylotic radiculopathy(CSR). Methods: A retrospective analysis was conducted on 41 patients with single-level CSR treated at the Department of Orthopedics of our hospital from February 2022 to January 2024. There were 24 males and 17 females, with a mean age of 56.8±13.2years(range, 32-81 years) and a mean follow-up of 13.9±1.0months(range, 12-16 months). Patients were divided into a key-hole group(n=19) and an Endo-ACDF group(n=22) according to the surgical approach. No statistically significant differences were found between the two groups in sex, age, body mass index(BMI), or surgical segment(P>0.05). The operative time, incision length, intraoperative blood loss, postoperative hospital stay, and complications were recorded. Pain and functional outcomes were evaluated preoperatively, at 1 week postoperatively, and at the final follow-up using the visual analogue scale(VAS) for neck and shoulder pain, the Japanese Orthopaedic Association(JOA) score, and the neck disability index(NDI). Clinical efficacy at the final follow-up was assessed according to the modified MacNab criteria. Radiographic evaluation included X-ray, CT, and MRI examinations preoperatively and at the final follow-up. The intervertebral disc height at the affected segment and the cervical physiological curvature(Cobb angle) were measured on lateral radiographs. The foraminal height and foraminal area on the affected side were measured on sagittal CT images, and the spinal canal area was measured on axial MRI images. Results: All surgeries were completed successfully. In the key-hole group, one patient experienced an intraoperative dural injury; postoperatively, the patient was placed in a Trendelenburg position and administered prophylactic antibiotics. No cerebrospinal fluid leak-related complications or secondary infections occurred. In the Endo-ACDF group, one patient developed hoarseness; aerosol inhalation, neurotrophic medications, and other symptomatic treatments were administered. The hoarseness improved at discharge and had resolved completely by the final follow-up. Compared with the Endo-ACDF group, the key-hole group had significantly shorter operative time(79.57±8.1min vs. 88.05±4.82min), less intraoperative blood loss[30.00(25.00, 30.00)mL vs. 65.00(60.00, 70.00)mL], smaller incision length(2.3±0.1cm vs. 4.1±0.3cm), and shorter postoperative hospital stay[5.00(4.00, 5.00)d vs. 6.00(5.00, 7.00)d](P<0.05). At 1 week postoperatively and at the final follow-up, the JOA scores, VAS scores, and NDI were significantly improved in both groups compared with preoperative values(P<0.05), and no significant differences in these parameters were observed between the two groups(P>0.05). At the final follow-up, no significant difference was found between the two groups in the modified MacNab criteria(P>0.05). At the final follow-up, the spinal canal area, foraminal area, and cervical Cobb angle were significantly improved in both groups compared with preoperative measurements(P<0.05). However, at the final follow-up, the key-hole group showed no significant change in foraminal height compared with the preoperative value(P>0.05), while a slight decrease in intervertebral disc height was observed(P<0.05). At the final follow-up, the Endo-ACDF group showed significantly greater intervertebral disc height, spinal canal area, and C2-7 Cobb angle compared with the key-hole group, whereas the key-hole group exhibited a significantly larger foraminal area than the Endo-ACDF group(P<0.05). Conclusions: Both posterior endoscopic key-hole and Endo-ACDF achieve satisfactory outcomes in the treatment of single-level CSR. The key-hole technique offers advantages of shorter operative time, smaller incision, less blood loss, shorter postoperative hospital stay, and more thorough foraminal decompression; Endo-ACDF is more effective in restoring intervertebral disc height and cervical physiological curvature, and it provides more thorough spinal canal decompression.