选择性融合联合单开门椎管扩大椎板成形术治疗局部不稳的颈椎后纵韧带骨化症的疗效

Laminoplasty with selective fusion in the treatment of cervical ossification of the posterior longitudinal ligament with local instability

中文关键词:  选择性融合  单开门椎管扩大椎板成形术  颈椎后纵韧带骨化症  颈椎不稳

英文关键词:Selective fusion  Laminoplasty  Cervical ossification of the posterior longitudinal ligament  Cervical instability

中文摘要:

  【摘要】 目的：比较三种颈椎后路术式治疗存在局部不稳的颈椎后纵韧带骨化症（ossification of the posterior longitudinal ligament，OPLL）患者的临床疗效，探讨选择性融合联合单开门椎管扩大椎板成形术的临床应用价值。方法：回顾分析我院2014年6月~2017年6月收治的存在局部不稳的颈椎OPLL患者107例，其中男性61例，女性46例；年龄68.1±10.2岁（33~84岁），随访时间2.1±1.3年（0.5~3.5年）。所有患者证实存在OPLL及颈椎局部不稳，且存在颈脊髓压迫相关症状体征，其中38例行单纯颈后路单开门椎管扩大椎板成形术（A组），35例行选择性融合联合单开门椎管扩大椎板成形术（B组），34例行传统颈后路椎板切除固定术式（C组）。分别于术前、术后2d及末次随访时采用日本矫形外科学会（Japanese Orthopaedic Association，JOA）评分并计算Hirabayashi改善率，对患者的神经功能情况进行评估；拍摄颈椎正侧位及过屈过伸位X线片测量颈椎的曲度（C2-7 Cobb角）、颈椎整体活动度（C2-7 range of motion，C2-7 ROM）和颈椎不稳节段的活动度，统计内固定相关并发症。通过颈椎MRI评估患者颈髓高信号的情况并计算高信号强度比值（high signal intensity ratio，HSIR）。比较三组患者颈椎整体活动度和不稳节段的活动度，比较存在颈髓高信号患者的术前、术后HSIR及三组之间的差异。结果：三组患者均取得了满意的神经功能改善，末次随访时JOA评分分别为14.93±3.18分、15.22±2.79分和14.72±3.02分，Hirabayashi改善率分别为（66.35±13.48）%、（70.06±14.14）%和（64.14±18.05）%。三组患者术前颈椎曲度分别为7.43°±3.69°、7.66°±2.99°、6.96°±4.38°，组间比较无统计学差异（F=13.19，P=0.071），末次随访时颈椎曲度与术前相比基本一致（5.58°±4.26°、5.73°±3.81°、5.49°±4.33°），随访期间未发现颈椎曲度明显改变、后凸等情况。随访期间未出现内固定相关并发症。末次随访时A、B两组患者颈椎整体活动度（C2-7 ROM）无统计学差异（17.63°±8.31°和18.72°±9.52°，P=0.089），C组患者末次随访颈椎整体活动度明显差于A、B两组患者（3.90°±7.74° vs 17.6°±8.3°，P=0.012；3.90°±7.74°和18.72°±9.52°，P=0.003）；B组、C组患者术后颈椎不稳节段活动度明显降低，末次随访时已完全融合。共有71例（71.03%）患者出现颈椎MRI T2加权高信号表现，存在高信号的节段与存在不稳的节段一致。三组患者HSIR值末次随访时均较术前明显降低（1.33±0.18 vs 1.68±0.11，1.12±0.12 vs 1.71±0.14和1.20±0.33 vs 1.65±0.18，P=0.001），但与A组患者相比，B组和C组患者的降低程度均较显著，差异存在统计学意义（P＜0.05）。结论：选择性融合联合单开门椎管扩大椎板成形术是治疗存在局部不稳的颈椎OPLL患者的有效方法，可以在广泛减压颈脊髓压迫的同时增加颈椎的节段稳定性，同时保留颈椎一定的活动度、减少术后轴性症状发生。

英文摘要:

  【Abstract】 Objectives: To compare the clinical efficacy of three different cervical posterior approaches for the treatment of patients with cervical ossification of the posterior longitudinal ligament(OPLL) with local instability, and to explore the clinical application value of selective fusion combined with laminoplasty in the treatment of such patients. Methods: We retrospectively analyzed 107 cervical OPLL patients with local instability from June 2014 to June 2017, and there were 61 males and 46 females, with the average age of 68.1±10.2 years(33-84 years). The follow-up time was 2.1±1.3 years(range: 6 months to 3.5 years). All included patients were confirmed with OPLL and local cervical instabilityusing radiographic examination. Of all patients, 38 underwent laminoplasty alone (group A), 35 underwent selective fusion combined with laminoplasty(group B), and 34 underwent posterior cervical laminectomy and fixation(Group C). JOA score was used to evaluate the neurological function of patients before surgery, the day after surgery, 3 months, 6 months, 1 year after surgery and at the final follow-up. Flexion-extension X-ray was used to evaluate the sagittal alignment of the cervical spine(C2-7 Cobb angle), the range of motion(ROM) of the cervical spine(C2-7 ROM) and unstable segments, and implant related complications. The cervical MRI was used to evaluate the high signal of cervical spinal cord and calculate the high signal intensity ratio(HSIR). The ROM of the cervical spine and unstable segment in these three groups were compared respectively, and the differences between the preoperative and postoperative HSIR were compared. Results: At the last follow-up, the JOA scores in three groups were 14.93±3.18, 15.22±2.79, and 14.72±3.02, respectively. Hirabayashi improvement rate was (66.35±13.48)%, (70.06±14.14)% and (64.14±18.05)%. Satisfactory neurological improvement was achieved in all three groups, and no implant related complications occurred during follow-up. The cervical lordosis of the three groups of patients before surgery were 7.43°±3.69°, 7.66°±2.99°, 6.96°±4.38°, respectively. And there was no significant difference between the groups(F=13.19, P=0.071). During follow-up, no significant changes in cervical sagittal alignment were found(5.58°±4.26°, 5.73°±3.81°, 5.49°±4.33°). At the last follow-up, there was no significant difference in the overall cervical spine mobility (C2-7 ROM) between the two groups of A and B (17.63°±8.31° and 18.72°±9.52°, P=0.089). The overall cervical spine mobility of the patients in group C was significantly worse than that in patients of groups A and B at the last follow-up (3.90°±7.74° and 17.6°±8.3°, P=0.012; 3.90°±7.74° and 18.72°±9.52°, P=0.003). Patients in group B and group C had significantly reduced postoperative ROM, and had been fully fused at the last follow-up. A total of 71 cases(71.03%) showed increased signal intensity in T2-weighted MRI. High signals levels were consistent with instable levels. At final follow-up, the HSIR values of the three groups were significantly lower than those before surgery(1.33±0.18 vs 1.65±0.18, 1.12±0.12 vs 1.71±0.14 and 1.20±0.33 vs 1.65±0.18, P=0.001), compared with patients in group A, the reduction in groups B and C was more significant. Conclusions: Selective fusion combined with laminoplasty is an effective method for treating cervical OPLL patients with local instability. It can widely decompress the cervical spinal cord and increase the segment stability of the cervical spine, and it can also retain the movement of the cervical spine and reduce the occurrence of postoperative axial symptoms.