多节段脊髓型颈椎病伴后凸畸形不同入路方式的选择及疗效

Selection and outcome of anterior vs posterior approach for multilevel cervical spondylotic myelopathy combined with cervical kyphosis

中文关键词:  脊髓型颈椎病  后凸畸形  外科治疗

英文关键词:Cervical spondylotic myelopathy  Kyphosis  Surgical treament

中文摘要:

  【摘要】 目的：探讨多节段脊髓型颈椎病伴后凸畸形的术式选择及疗效。方法：回顾性分析2013年6月~2015年6月手术治疗的59例伴有后凸畸形的多节段脊髓型颈椎病患者的临床及影像学资料，其中55例获得随访。依据颈椎后凸Cobb角大小并结合影像学特点，分为轻度后凸（Cobb角>5°但<20°）、中度后凸（Cobb角20°～40°）和重度后凸（Cobb角>40°）3组。依据致压因素和颈椎后凸角度采用前路或者后路手术治疗，其中轻度组29例，前路手术11例，后路手术18例；中度组18例，前路手术14例，后路手术4例；重度组8例，均行前路减压重建手术。比较各组内前路和后路手术时间、术中出血量、后凸矫正率及神经功能改善率的差异，比较组间前路手术后凸矫正率及神经功能改善率，比较轻度后凸组与中度后凸组间后路手术神经功能改善率。结果：轻度组和中度组中前、后路手术时间无统计学差异（P>0.05），术中出血量后路手术大于前路手术（P<0.05）。重度组1例术后6h发生颈部血肿，中度组1例术后12h发生硬膜外血肿；喉返神经牵拉伤4例，其中轻度组1例，中度组1例，重度组2例；11例出现术后四肢麻木、无力症状加重，轻度组2例，中度组5例，重度组4例；9例术后1周左右出现颈肩部疼痛症状加重，轻度组4例，中度组3例，重度组2例。3组间随访时间无统计学差异（P>0.05）。轻度组中，末次随访时前路手术后凸畸形矫正率高于后路手术（P<0.05），JOA评分改善率前路手术与后路手术无统计学差异（P>0.05）。中度组中，末次随访时后凸畸形矫正率前路手术高于后路手术（P<0.05），JOA评分改善率前、后路手术无统计学差异（P>0.05）。末次随访时，轻度组的前路手术后凸畸形矫正率为223.1%，明显高于中度组（135.1%）与重度组（120.4%）（P<0.05）。末次随访时，3组间前路手术JOA评分改善率无统计学差异（P>0.05），轻度组与中度组后路手术JOA评分改善率无统计学差异（P>0.05）。结论：伴有轻、中度后凸畸形的多节段脊髓型颈椎病，手术入路依据脊髓受压情况而定，后凸畸形不影响神经功能的改善；而重度后凸畸形，则应当兼顾减压和矫形，前路手术可同时达到减压和矫形的目的，获得较为满意的神经功能改善。

英文摘要:

  【Abstract】 Objectives: To investigate the different surgical procedures and the clinical outcomes for cervical spondylotic myelopathy combined with cervical kyphosis. Methods: Between June 2013 and June 2015, fifty-five adult patients with multilevel cervical spondylotic myelopathy combined with cervical kyphosis undergoing different surgical procedures were reviewed retrospectively. According to cervical kyphosis Cobb angle and the imaging characteristics, all pateints were divided into mild(Cobb angle >5°, <20°), moderate(Cobb angle 20°-40°) and severe groups(Cobb angle >40°)． Based on the main pressure and kyphosis angle, anterior or posterior procedure was used accordingly. The mild group included 29 cases, anterior procedure was performed in 11 cases, posterior procedure in 18 cases. The moderate group included 18 cases, anterior procedure was performed in 14 cases, posterior procedure in 4 cases. The severe group included 8 cases, all were by anterior procedure. Preoperative Japanese Orthopaedic Association(JOA) score was used to evaluate the neurological function, and cervical kyphosis Cobb angle, the operation time and blood loss, the last follow-up assessment of cervical kyphosis Cobb angle and kyphosis correction rate, the last follow-up JOA score and JOA mean recovery rate were recorded and compared among these groups.Results: There was no difference in term of the average operation time between mild and moderate groups; intraoperatie blood loss of anterior approach was less than that of posterior approach(P<0.05). Complications: 1 case in mild group was noted cervical hematoma in 6 hours after operation, 1 case of epidural hematoma in moderate group in 12 hours after operation; laryngeal recurrent nerve injury occured in 4 cases in 3 days of postoperation; 11 cases with postoperative limb numbness and weakness deteriorated in 7 days; neck shoulder pain worsened in 9 cases in 7 days. In mild group: the correction rate of anterior approach was higher than that of posterior surgery(P>0.05), JOA mean recovery rate at last follow-up showed no difference(P>0.05). In moderate group: the correction rate of anterior approach at last follow-up was higher than that of posterior approach(P<0.05), JOA mean recovery rate showed no difference(P>0.05). Anterior surgery correction rate at last follow-up was: mild group(223.1%), moderate group(135.1%) and severe group(120.4%)(P<0.05). There was no difference in terms of JOA mean recovery rate at last follow-up for anterior approach in three groups(P>0.05). Conclusions: To multilevel cervical spondylotic myelopathy combined with mild or moderate cervical kyphosis, surgery approach is based on the compression of spinal cord, cervical kyphosis has no difference on neurological function improvement, for severe kyphosis, decompression and correction should be considered, anterior approach can achieve the purpose of this treatment target, at the same time get more satisfactory neurologicical improvement.