经肌间隙入路与后正中入路颈椎单开门椎管扩大椎板成形术治疗颈椎后纵韧带骨化症的疗效比较

The outcomes of modified laminplasty through posterior paraspinal approach compared with traditional laminplasty using posterior midline approach in the treatment of patients with cervical ossification of the posterior longitudinal ligament

中文关键词:  后纵韧带骨化症  颈椎单开门椎管扩大椎板成形术  肌间隙入路  临床疗效

英文关键词:Ossification of the posterior longitudinal ligament  Cervical laminoplasty  Cervical posterior intermuscular paraspinal approach  Outcomes

中文摘要:

  【摘要】 目的：比较经肌间隙入路单开门椎管扩大椎板成形术与传统后正中入路单开门椎管扩大椎板成形术治疗颈椎后纵韧带骨化症（ossification of the posterior longitudinal ligament，OPLL）的临床疗效。方法：2011年6月～2014年9月在我院行颈椎单开门椎管扩大椎板成形术治疗的颈椎OPLL患者共计32例，其中14例患者采用经肌间隙入路（A组），年龄42～70岁（56.9±9.8岁）；18例患者采用传统后正中入路（B组），年龄40～73岁（56.7±9.0岁）。两组患者的年龄、性别、脊髓受压累及节段及开门节段比较均无统计学差异（P＞0.05）。记录两组的手术时间、术中出血量、术后引流量及术后并发症发生情况；记录两组患者术前和术后3个月、1年、2年及末次随访时日本骨科协会（Japanese Orthopedic Association，JOA）评分、颈痛视觉模拟评分（visual analogue score，VAS）、颈椎功能障碍指数（neck disability index，NDI）及SF-36评分，评估其手术效果。术前和术后3个月、1年、2年及末次随访时通过颈椎X线片测量颈椎矢状面C2-7 Cobb角、颈椎活动度（range of motion，ROM）。术前及末次随访时在颈椎横断面MRI上测量颈后伸肌群肌肉面积，计算术后颈后伸肌群肌肉萎缩率。结果：所有患者均获得随访，A组随访时间为52~66个月（59.4±4.2个月），B组为56~68个月（61.4±3.8个月），两组随访时间无统计学差异（P＞0.05）。两组患者术后引流量无统计学差异（P＞0.05）；但A组术中出血量较B组大（339.0±183.1ml vs 277.0±171.4ml）、手术时间较B组长（197.0±28.9min vs 149.0±25.3min），差异均有统计学意义（P＜0.05）。A组轴性症状发生率（14.3%，2/14）明显低于B组（38.9%，7/18）（P＜0.05）。两组患者术后3个月、1年、2年及末次随访时JOA评分、VAS评分、NDI及SF-36评分与术前比较均有明显改善（P＜0.05），两组VAS、NDI及SF-36评分组内术后各时间点间比较均无统计学差异（P＞0.05）；两组在术后1年、2年JOA评分均较术后3个月增加（P＜0.05），但末次随访时较术后2年有所降低，且B组降低有统计学意义（P＜0.05）。两组间比较，术前JOA评分、VAS评分、NDI及SF-36评分差异无统计学意义（P＞0.05）；在术后1年、2年及末次随访时，A组NDI、SF-36评分均优于B组（P＜0.05），术后3个月、1年、2年时两组间JOA评分无统计学差异（P＞0.05），但末次随访时B组JOA评分较A组差（P＜0.05）。术后3个月、1年、2年及末次随访时，B组患者C2-7 Cobb角较术前降低；且在术后1年、2年及末次随访时较A组低（P＜0.05）；两组术后3个月、1年、2年及末次随访时颈椎C2-7 ROM均较术前明显降低（P＜0.05）；且在术后3个月、1年、2年及末次随访时，B组颈椎C2-7 ROM均较A组差（P＜0.05）。末次随访时A组颈后伸肌总萎缩率为（28.3±4.8）%，B组为（41.6±9.2）%，差异有统计学意义（P＜0.05）。结论：经肌间隙入路单开门椎管扩大椎板成形术与传统后正中入路单开门椎管扩大椎板成形术治疗颈椎OPLL神经功能改善结果一致。但长期随访结果显示经肌间隙入路单开门椎管扩大椎板成形术在对轴性症状的减少、生活质量的改善、颈椎曲度及神经功能改善的维持等方面均优于传统后正中入路单开门椎管扩大椎板成形术。

英文摘要:

  【Abstract】 Objectives: To compare the clinical outcomes of modified laminplasty through posterior paraspinal approach and traditional laminplasty using posterior midline approach in the treatment of patients with cervical ossification of the posterior longitudinal ligament(OPLL). Methods: 32 patients with cervical OPLL at our hospital between June 2011 and September 2014 were treated by posterior laminplasty. Of all patients, 14 were of the modified laminplasty group as Group A(mean age, 56.9 years; range 42 to 70 years), and 18 were of the traditional laminplasty group as Group B(mean age, 56.7 years; range 40 to 73 years). There were no differences in age, gender, spinal cord compression levels and surgical levels between the two groups(P＞0.05). The operation time, blood loss, postoperative complications were recorded. The visual analogue scale(VAS), neck disability index(NDI), short form 36 questionnaire(SF-36) and Japanese Orthopedic Association(JOA) scores were recorded before operation, and 3 months, 1 year and, 2 years postoperative and at the last follow-up. The cervical sagittal alignment, cervical range of motion(ROM) for C2-C7 were measured by cervical X-ray radiographs before operation, and 3 months, 1 year and, 2 years postoperative and at the last follow-up. The area of cervical extensors was measured by MRI before operation and at the last follow-up, and the atrophy ratio were calculated. Results: All patients were followed up. The follow-up time is 59.4±4.2 months in group A, and 61.4±3.8 months in group B. There was no difference between the two groups(P＞0.05). Besides, there was no difference in postoperative drainage between the two groups(P＞0.05). All patients had an improvement of neurological function without serious complications in both groups, but group A had longer operation time(197.0±28.9min vs 149.0±25.3min) and more blood loss(339.0±183.1ml vs 277.0±171.4ml) compared to group B(P<0.05), while group A had a lower rate of axial pain (14.3% vs 38.9%) compared to group B(P<0.05). In both groups, the JOA, VAS, NDI and SF-36 scores at 3 months, 1 year, 2 years after operation and last follow-up were all improved compared with preoperation. At the follow-up of 1 and 2 years, the JOA scores of the two groups increased significantly compared with preoperation(P<0.05), but at the last follow-up, the JOA scores of the two groups decreased, and in group B the difference was statistically significant(P<0.05). There were no differences in JOA, VAS, NDI and SF-36 scores before operation. At 1 year, 2 years postoperative and last follow-up, NDI and SF-36 scores of group A were better than group B significantly(P＜0.05). There were no differences in JOA scores at 3 months, 1 year, 2 years postoperative between the two groups. However, at the last follow-up, the JOA scores in group A was better than group B significantly(P＜0.05). At postoperative 3 months, 1 year, 2 years and last follow-up, the C2-7 Cobb angle of group B significantly decreased than that before operation (P＜0.05). At postoperative 1 year, 2 years and last follow-up, there were significant difference in C2-7 Cobb angle between the two groups (P＜0.05). In both groups, the cervical ROM at the follow-up 3 months, 1 year, 2 years and last follow-up were all decreased compared with preoperation(P<0.05), and the difference was statistically significant between the two groups at 3 months, 1 year, 2 years and the last follow-up(P<0.05). There were significant differences in cervical extensors atrophy rate of both sides between the two group at the last follow-up[(28.3±4.8)% vs (41.6±9.2)%, P<0.05]. Conclusions: The modified laminplasty through posterior paraspinal approach and traditional laminplasty using posterior midline approach in the treatment of patients with cervical OPLL had a similar outcome in improving neurological function. But there were lesser axis symptom rate, higher life quality, better cervical alignment, lesser decrease in neurological function in modified laminplasty compared to traditional laminplasty.