内镜下Key-hole入路颈椎间盘切除术与前路颈椎间盘切除融合术治疗单节段神经根型颈椎病的长期疗效对比

Comparison of long-term prognosis of percutaneous endoscopic cervical discectomy via posterior key-hole approach(PECD) versus anterior cervical discectomy and fusion(ACDF) in the treatment of single-segment cervical spondylotic radiculopathy

中文关键词:  神经根型颈椎病  经皮内镜下颈椎后路Key-hole入路椎间盘切除术  前路颈椎间盘切除融合术  倾向评分匹配

英文关键词:Cervical spondylotic radiculopathy  Percutaneous endoscopic cervical discectomy via posterior key-hole approach  Anterior cervical discectomy and fusion  Propensity score matching

中文摘要:

  【摘要】 目的：对比经皮内镜下后路Key-hole入路椎间盘切除术（percutaneous endoscopic cervical discectomy，PECD）与前路颈椎间盘切除融合术（anterior cervical discectomy and fusion，ACDF）治疗单节段神经根型颈椎病的长期临床疗效，为临床手术方案的选择提供参考依据。方法：回顾性分析2015年6月～2018年8月于我院接受手术治疗的324例单节段神经根型颈椎病患者的临床资料，根据手术方式分为PECD组（72例）和ACDF组（252例）。采用倾向评分匹配（propensity score matching，PSM）法按1∶2比例平衡两组患者的混杂变量（年龄、性别、体重指数、病程、吸烟史、饮酒史、合并症、手术节段、术前上肢肌力分级、术前颈椎前凸角），匹配后PECD组42例、ACDF组84例患者纳入最终分析。收集两组患者的围手术期指标（手术时间、术中出血量、切口长度、住院时间），术前及术后7d、3个月、12个月、24个月、末次随访时（60~78个月）的功能评分[上肢视觉模拟评分（arm visual analog scale，A-VAS）、颈部视觉模拟评分（neck visual analog scale，N-VAS）、日本骨科协会评分（Japanese Orthopaedic Association score，JOA）、颈椎功能障碍指数（neck disability index，NDI），影像学指标[椎间盘高度指数（disc height index，DHI）、颈椎活动度（range of motion，ROM）、椎间盘灰度比值（ratio of grey scale，RVG）、矢状位平移（sagittal translation，ST）]，并记录并发症发生情况及末次随访时改良MacNab疗效评定结果。末次随访时基于临床症状与影像学资料评估邻近节段退变/病变。结果：所有患者均完成随访，平均随访时间5.6±0.8年。PECD组的手术时间、术中出血量、切口长度、住院时间均显著优于ACDF组（P<0.001）。两组患者术后各时间点的A-VAS、N-VAS、JOA评分及NDI指数均较术前显著改善（P<0.001），且PECD组术后7d的各项功能评分改善程度显著优于ACDF组（P<0.05）；术后12个月、24个月及末次随访时，两组上述功能评分比较差异无统计学意义（P>0.05）。影像学结果显示，ACDF组术后各时间点手术节段DHI显著高于PECD组（P<0.05）；PECD组术后各时间点颈椎整体活动度（global range of motion，GROM）、相邻节段ROM均显著优于ACDF组（P<0.05）；末次随访时，ACDF组相邻节段RVG下降幅度显著大于PECD组（P<0.05）。两组患者术后ST均<3mm，颈椎节段稳定性良好。PECD组并发症发生率为 9.52%（4/42），ACDF组为10.71%（9/84），两组比较差异无统计学意义（P>0.05）。末次随访时，PECD组改良MacNab优良率为92.86%（39/42），ACDF组为89.29%（75/84），两组比较差异无统计学意义（P>0.05）。结论：PECD与ACDF治疗单节段神经根型颈椎病均能获得满意的长期临床疗效，PECD具有创伤小、术后恢复快、对颈椎运动功能影响小及减少相邻节段退变的优势。

英文摘要:

  【Abstract】 Objectives: To compare the long-term clinical efficacy and prognosis of percutaneous endoscopic cervical discectomy via posterior key-hole approach(PECD) and anterior cervical discectomy and fusion(ACDF) in the treatment of single-segment cervical spondylotic radiculopathy(CSR), so as to provide reference for the selection of clinical surgical schemes. Methods: The clinical data of 324 patients with single-segment CSR who underwent surgical treatment in our hospital from June 2015 to August 2018 were retrospectively analyzed. The patients were divided into a PECD group(72 cases) and an ACDF group(252 cases) according to the surgical method. Propensity score matching(PSM) was used at a 1:2 ratio to balance the confounding variables(age, gender, body mass index, disease duration, smoking history, drinking history, underlying health conditions, surgical segment, preoperative upper limb muscle strength classification, preoperative cervical lortosis angle) between the two groups. After PSM matching, 42 patients in the PECD group and 84 patients in the ACDF group were included in the final analysis. Perioperative indicators(operative time, intraoperative blood loss, incision length, hospital stay) of the two groups were collected. Functional scores[arm visual analog scale(A-VAS) score, neck visual analog scale(N-VAS) score, Japanese Orthopaedic Association(JOA) score, neck disability index(NDI)] and imaging indicators[disc height index(DHI), range of motion(ROM), ratio of grey scale(RVG), sagittal translation(ST)] were recorded before surgery and at 7d, 3 months, 12 months, 24 months after surgery and final follow-up(60-78 months). The occurrence of complications and the modified MacNab efficacy evaluation results at final follow-up were also recorded. Adjacent segment degeneration/disease at final follow-up was evaluated based on clinical symptoms and available radiographic findings. Results: All patients completed follow-up, with an average time of 5.6±0.8 years. The operative time, intraoperative blood loss, incision length and hospital stay in the PECD group were significantly better than those in the ACDF group(P<0.001). The A-VAS, N-VAS, JOA scores and NDI of both groups at each time point after surgery were significantly improved compared with those before surgery(P<0.001), and the improvement degree of each functional score in the PECD group at 7d after surgery was significantly better than that in the ACDF group(P<0.05); There was no significant difference in the above functional scores between the two groups at 12 months, 24 months after surgery and the final follow-up(P>0.05). Imaging results showed that the DHI of the surgical segment in the ACDF group at each time point after surgery was significantly higher than that in the PECD group(P<0.05); The global range of motion(GROM) and adjacent segment ROM of the cervical spine in the PECD group at each time point after surgery were significantly better than those in the ACDF group(P<0.05); At final follow-up, the decrease range of RVG in adjacent segments of the ACDF group was significantly larger than that of the PECD group(P<0.05). The postoperative ST of both groups was <3mm, indicating a good cervical segmental stability. The complication rate was 9.52%(4/42) in the PECD group and 10.71%(9/84) in the ACDF group, with no significant difference between the two groups(P>0.05). At final follow-up, the excellent and good rate of modified MacNab was 92.86%(39/42) in the PECD group, and 89.29%(75/84) in the ACDF group, with no significant difference between the two groups(P>0.05). Conclusions: Both PECD and ACDF can achieve satisfactory long-term clinical efficacy in the treatment of single-segment CSR. PECD has the advantages of less trauma, faster postoperative recovery, less impact on cervical motor function and reducing adjacent segment degeneration.