零切迹融合器在颈前路椎间盘切除融合术治疗多节段脊髓型颈椎病中的应用价值

Application value of zero-profile devices in anterior cervical discectomy and fusion in the treatment of multilevel cervical spondylotic myelopathy

中文关键词:  多节段脊髓型颈椎病  颈前路椎间盘切除融合术  零切迹颈椎间融合器  钛板

英文关键词:Multilevel cervical spondylotic myelopathy  Anterior cervical discectomy and fusion(ACDF)  Zero-profile  Titanium plate

中文摘要:

  【摘要】 目的：探讨零切迹融合器（Zero-P VA）在颈前路椎间盘切除融合（anterior cervical discectomy and fusion，ACDF）术治疗多节段脊髓型颈椎病（multilevel cervical spondylotic myelopathy，MCSM）中的应用价值。方法：回顾性分析2018年8月～2020年8月期间在我科行ACDF治疗的55例MCSM患者的临床资料，其中应用Zero-P VA治疗27例（Zero-P组），应用传统融合器＋钛板固定治疗28例（钛板组）。观察两组患者的手术时间、术中出血量、融合节段椎间高度和颈椎Cobb角。采用颈部疼痛视觉模拟评分（VAS）、颈椎功能障碍指数（neck disability index，NDI）、日本骨科协会（Japanese Orthopaedic Association，JOA）评分、Bazaz吞咽困难评分及植骨融合率进行临床疗效对比分析。结果：55例患者均顺利完成手术并获得完整随访，随访时间14～35个月，平均23.17±4.75个月。与术前相比较，两组患者术后VAS评分、NDI指数和JOA评分均有明显的改善，差异均有统计学意义（P＜0.05），但两组之间无统计学差异（P＞0.05）。Zero-P组手术时间3节段为95.47±5.24min，4节段为115.12±7.53min，较钛板组手术时间（3节段130.85±6.97min和4节段155.69±9.28min）显著缩短，差异有统计学意义（P＜0.05）；术中出血量两组差异无统计学意义（P＞0.05）。Zero-P组颈椎Cobb角在术后3个月时为16.71°±1.28°，末次随访时为15.69°±0.26°，均优于术前（10.53°±1.36°），差异有统计学意义（P＜0.05）；钛板组颈椎Cobb角术后3个月时为16.95°±2.64°，末次随访时为16.01°±1.71°，优于术前（10.67°±0.41°），差异有统计学意义（P＜0.05）；而两组之间各时间点颈椎Cobb角的差异均无统计学意义（P＞0.05）。Zero-P组术后1例（3.70%）发生椎前异物感，术后1个月完全消失，无吞咽困难发生，未见相邻节段退变加速。钛板组术后4例（14.29%）发生椎前异物感，于术后2～4个月逐渐消失；术后3例（10.71%）发生吞咽困难，其中轻度1例（3.57%），中度2例（7.14%），3例患者在术后3～6个月逐渐好转，1例（3.57%）出现声音嘶哑，于术后2年取出钛板，患者声音嘶哑无明显改善；2例（7.14%）患者出现相邻节段（C2/3）退变加速，均未出现临床症状，予以保守观察。两组的吞咽困难发生率及相邻节段退变发生率间存在显著性差异（P＜0.05）。术后3个月时，Zero-P组植骨融合率为88.89%，钛板组植骨融合率为92.86%，末次随访时两组患者均达到有效植骨融合，但两组间植骨融合率无明显差异（P＞0.05）。两组患者均无硬脊膜损伤、食管损伤、神经根损伤、椎前血肿、伤口感染、假关节形成等并发症。结论：在ACDF治疗多节段脊髓型颈椎病中，使用零切迹融合器能够达到与传统融合器+钛板固定一致的临床疗效，和重塑颈椎曲度并恢复颈椎间隙高度的作用，并且手术时间短，术后患者吞咽困难、相邻节段退变发生率低。

英文摘要:

  【Abstract】 Objectives: To investigate the application value of Zero-P VA in anterior cervical discectomy and fusion(ACDF) in the treatment of multilevel cervical spondylotic myelopathy(MCSM). Methods: 55 patients with MCSM who underwent multilevel ACDF in our department from August 2018 to August 2020 were analyzed retrospectively, including 27 cases treated with Zero-P VA(Zero-P group) and 28 cases treated with traditional fusion cage+titanium plate(titanium plate group). The main indicators of observation were operative time, intraoperative blood loss, intervertebral height of fusion segment, and cervical Cobb angle. The clinical efficacy was compared and analyzed by neck pain visual analogue scale(VAS), neck disability index(NDI), the Japanese Orthopaedic Association(JOA) score, Bazaz dysphagia score, and bone graft fusion rate. Results: All 55 patients completed the operation successfully and finished the follow-up. The follow-up period was 14-35 months, with an average of 23.17±4.75 months. After operation, the VAS, NDI, and JOA scores of both groups were significantly improved comparing with those before operation(P<0.05), while there was no significant difference of each indicator between the two groups (P>0.05). The operative time of three segments was 95.47±5.24mins and four segments was 115.12±7.53mins in Zero-P group, which were significantly shorter than those of 130.85±6.97mins for three segments and 155.69±9.28mins for four segments in titanium plate group(P<0.05), while the intraoperative blood loss between the two groups had no significant difference(P>0.05). The Cobb angle of cervical spine in Zero-P group was 16.71°±1.28° at 3 months after operation and 15.69°±0.26° at final follow-up, significantly improved than the 10.53±1.36° before operation(P<0.05). In the titanium plate group, the Cobb angle was 16.95°±2.64° at 3 months after operation and 16.01°±1.71° at final follow-up, also significantly improved than the 10.67°±0.41° before operation. Yet, the Cobb angles between the two groups at each time point had no significant differences(P>0.05). In Zero-P group, 1 case(3.70%) developed prevertebral foreign body sensation and disappeared completely in one month after operation, and no case of dysphagia occurred or accelerated degeneration of adjacent segments. In the titanium plate group, 4 cases(14.29%) developed prevertebral foreign body sensation and gradually disappeared in 2-4 months after operation; Dysphagia occurred in 3 cases(10.71%), including mild(1 case, 3.57%) and moderate(2 cases, 7.14%) symptoms, which gradually improved in 3-6 months after operation, and 1 case (3.57%) occurred hoarseness, whose titanium plate was removed 2 years after operation, and the hoarseness did not improve significantly; Two cases(7.14%) had accelerated degeneration of adjacent segments(C2/3) without any clinical symptoms, thereby they were observed conservatively. There were significant differences in the incidence of dysphagia and adjacent segment degeneration between the two groups(P<0.05). At 3 months after operation, the bone graft fusion rate was 88.89% in Zero-P group and 92.86% in titanium plate group, and at final follow-up, both groups of patients achieved effective bone graft fusion. However, there was no significant difference in the rate of bone graft fusion between the two groups(P＞0.05). There were no complications such as dural tear, esophageal injury, nerve root injury, prevertebral hematoma, wound infection or pseudoarthrosis in both groups. Conclusions: In the treatment of multilevel cervical spondylotic myelopathy through ACDF, Zero-P VA can achieve similar clinical effect as of the traditional fusion cage plus titanium plate, restore the lordosis of the cervical spine and the height of cervical intervertebral space effectively, which also advantages in shorter operative time, rarer postoperative dysphagia and lower incidence of adjacent segment degeneration.