颈椎前路Hybrid手术不同组合方式治疗连续三节段颈椎病的疗效对比

The clinical effects of cervical anterior Hybrid surgery for the treatment of contiguous 3-level cervical degenerative disc disease: a comparative study among different constructs

中文关键词:  三节段颈椎病  Hybrid手术  颈前路椎间盘切除减压融合术  组合方式  手术效果

英文关键词:3-level cervical degenerative disc disease  Hybrid surgery  Anterior cervical discectomy and fusion  Constructs  Operative outcome

中文摘要:

  【摘要】目的：比较不同组合方式颈椎前路Hybrid手术[颈前路椎间盘切除减压融合术（anterior cervical discectomy and fusion，ACDF）+人工颈椎间盘置换术（cervical disc arthroplasty，CDA）]治疗连续三节段颈椎病的临床疗效。方法：回顾性分析2012年6月~2018年12月因连续三节段颈椎病于我科行手术治疗的病例，根据手术方式的不同分为FFF组（连续三节段ACDF患者）、1A2F组（单节段CDA+双节段ACDF患者）和2A1F组（双节段CDA+单节段ACDF患者）。根据纳入排除标准，共98例患者纳入研究，其中FFF组22例，年龄58.95±9.28岁，随访时间为29.23±14.79个月；1A2F组47例，年龄51.70±8.23岁，随访时间为36.09±16.72个月；2A1F组29例，年龄48.72±7.76岁，随访时间为36.58±14.81个月。对比分析三组患者术前与术后3d、3个月、6个月、12个月及末次随访时颈部及上肢疼痛视觉模拟评分（visual analog scale，VAS）、日本骨科协会（Japanese Orthopedic Association，JOA）脊髓功能评分及颈椎残障功能指数（neck disability index，NDI）评分。同时于术前与术后3d、3个月、6个月、12个月及末次随访时在颈椎侧位及过伸过屈位X线片上测量颈椎C2-C7曲度、手术节段曲度、颈椎C2-C7活动度、手术节段活动度、上位邻近节段活动度，末次随访时结合颈椎CT评估ACDF节段融合情况。结果：三组患者术后各时间点颈痛VAS评分、上肢痛VAS评分和JOA评分均较术前显著改善（P<0.05），三组之间无显著性差异（P＞0.05）。术后3个月时FFF组NDI评分为17.86±2.55分，显著高于1A2F组的15.13±3.76分和2A1F组的15.55±4.07分（P<0.05），余时间点三组之间无显著性差异（P＞0.05）。三组患者术后3d时颈椎C2-C7曲度和手术节段曲度均较术前显著改善（P<0.05）。末次随访时，FFF组颈椎C2-C7曲度和手术节段曲度均较术前显著降低（P<0.05），1A2F组和2A1F组与术前相比无显著性差异（P>0.05），三组之间无显著性差异（P＞0.05）。术后6个月、12个月及末次随访时，FFF组颈椎C2-C7活动度及手术节段活动度均显著低于1A2F组和2A1F组（P<0.05）。术后12个月时，2A1F组颈椎C2-C7活动度高于1A2F组（P<0.05）。术后12个月及末次随访时，2A1F组手术节段活动度高于1A2F组（P<0.05）。末次随访时，FFF组、1A2F组和2A1F组上位邻近节段活动度分别为11.97°±2.27°、9.80°±2.99°和8.45°±2.26°，三组之间及两两比较均有显著性差异（P<0.05）。末次随访时FFF组、1A2F组和2A1F组融合率分别为81.82%（18/22）、91.49%（43/47）和96.55%（28/29），差异无统计学意义（P>0.05）。结论：相较于单纯三节段ACDF，颈椎前路Hybrid手术能够获得与其一致的临床疗效，但在早期颈椎功能康复、颈椎整体活动度及对邻近节段影响方面更具优势，且双节段CDA+单节段ACDF组合方式比单节段CDA+双节段ACDF更优。

英文摘要:

  【Abstract】 Objectives: To explore the clinical effects of anterior cervical Hybrid surgery [anterior cervical discectomy and fusion(ACDF) + cervical disc arthroplasty(CDA)] for the treatment of contiguous 3-level cervical degenerative disc disease among different constructs. Methods: Between June 2012 and December 2018, data of patients with contiguous three levels cervical degenerative disc disease who underwent 3-level ACDF or 3-level anterior cervical Hybrid surgery in our hospital were reviewed. The patients were divided into FFF group(3-level ACDF), 1A2F group (1-level CDA and 2-level ACDF), and 2A1F group(2-level CDA and 1-level ACDF). According to the inclusion and exclusion criteria, a total of 98 patients were included with 22 patients in FFF group, 47 patients in 1A2F group, and 29 patients in 2A1F group. The average age in FFF group, 1A2F group and 2A1F group was 58.95±9.28 years, 51.70±8.23 years and 48.72±7.76 years, respectively. The average follow-up time in FFF group, 1A2F group and 2A1F group was 29.23±14.79 months, 36.09±16.72 months and 36.58±14.81 months, respectively. The differences of visual analog scale(VAS) scores of the neck and arm, the Japanese Orthopedic Association(JOA) scores and neck disability index(NDI) among groups were compared preoperatively and at 3 days, 3 months, 6 months, 12 months postoperatively and at the final follow-up. Cervical lordosis(CL), Cobb angle of surgical levels, range of motion(ROM) of the total cervical spine, ROM of surgical levels and ROM of the adjacent segments were measured via lateral X-rays in flexion-extension and neutral positions preoperatively and at 3 days, 3 months, 6 months, 12 months postoperatively and at the final follow-up. Fusion conditions were assessed according to flexion-extension X-rays and CT at the final follow-up. Results: After surgery, all patients in the three groups showed significant increase in JOA scores(P<0.05) and significant decrease in VAS scores of the neck and arm(P<0.05), yet there were no differences among the three groups(P>0.05). The NDI score in FFF group at 3 months postoperatively was 17.86±2.55, which was significantly higher than that of 1A2F and 2A1F groups(P<0.05), 15.13±3.76 and 15.55±4.07, respectively. The Cobb angles of the total cervical spine and the surgical levels were increased significantly at 3 days postoperatively compared with the value preoperatively in all three groups(P<0.05). However, at the final follow-up, the Cobb angles of the total cervical spine and the surgical levels were significantly lower than those preoperatively in FFF group(P<0.05). There were no significant differences of the Cobb angles of the total cervical spine and the surgical levels at the final follow-up among the three groups(P>0.05). The ROMs of the total cervical spine and the surgical levels in FFF group at 6, 12 months postoperatively and the final follow-up were significantly lower than those in 1A2F and 2A1F groups(P<0.05). The ROM of the total cervical spine in 2A1F group was significantly higher than those in 1A2F group at 12 months postoperatively(P<0.05). The ROMs of the surgical levels in 2A1F group were significantly higher than those in 1A2F group at 12 months postoperatively and the final follow-up(P<0.05). At the final follow-up, the ROMs of the superior adjacent segment of FFF group, 1A2F group and 2A1F group were 11.97°±2.27°, 9.80°±2.99° and 8.45°±2.26°, respectively, of which significant differences were observed among the three groups and between each two groups(P<0.05). At the final follow-up, fusion rate was 81.82%(18/22) in FFF group, 91.49%(43/47) in 1A2F group and 96.55%(28/29) in 2A1F group, without significant difference among groups(P>0.05). Conclusions: Compared with 3-level ACDF, the clinical outcomes of 3-level Hybrid surgery were satisfied. In addition, the Hybrid groups had a higher ROMs of the cervical spine and lower influence on the superior adjacent segment, especially in the group of 2-level CDA and 1-level ACDF construct.