单节段Discover人工颈椎间盘置换术与颈前路减压融合术治疗颈椎病的长期疗效对比

Comparison of the long-term clinical effects between single-level Discover artificial cervical disc replacement and anterior cervical decompression and fusion in the treatment of cervical spondylosis

中文关键词:  颈椎病  人工颈椎间盘置换术  颈前路减压融合术  长期随访  临床疗效

英文关键词:Cervical spondylosis  Artificial cervical disc replacement  Anterior cervical discectomy and fusion  Long-term follow-up  Clinical efficacy

中文摘要:

  【摘要】 目的：比较单节段Discover人工颈椎间盘置换术（artificial cervical disc replacement，ACDR）与颈前路椎间盘切除减压融合术（anterior cervical discectomy and fusion，ACDF）治疗颈椎病的长期临床疗效。方法：回顾性分析2009年1月～2011年12月在西京医院行单节段ACDR和ACDF治疗的颈椎病患者的临床资料。ACDR组（n=21例）男性15例，女性6例，年龄33~58岁（44.0±7.5岁）；采用Discover假体，C4/5 2例，C5/6 17例，C6/7 2例。ACDF组（n=25例）男性20例，女性5例，年龄33~63岁（48.2±8.5岁）；C3/4 1例，C4/5 3例， C5/6 18例，C6/7 3例。采用日本矫形外科学会（Japanese Orthopedic Association，JOA）评分法、疼痛视觉模拟评分法（visual analogue scale，VAS）和颈椎功能障碍指数（neck disability index，NDI）对两组患者术前/术后3个月、1年、2年、5年及末次随访时的神经功能和临床疗效进行评估；利用X线、CT及MRI影像学资料测量和评估ACDR组手术节段活动度（range of motion，ROM）、末次随访时的异位骨化（heterotopic ossification，HO）以及末次随访时两组患者手术邻近节段退变（adjacent segment degeneration，ASD）情况，并进行统计学分析。结果：ACDR组随访时间138.9±12.0个月，ACDF组随访时间136.9±10.8个月，两组无统计学差异（P>0.05）。两组患者术后各随访时间点JOA评分、上肢痛VAS评分、颈痛VAS评分和NDI均较术前显著性改善，与同组术前比较均有统计学差异（P<0.05），末次随访与术后2年比较均无统计学差异（P>0.05）；两组同时间点比较均无统计学差异（P>0.05）。ACDR组术后3个月、1年、2年时手术节段ROM与术前比较显著性增加（P<0.05），术后5年和末次随访时与术前比较均无统计学差异（P>0.05）。ACDR组末次随访时13例（61.9%）手术节段发生HO，其中McAfee分级Ⅰ级1例，Ⅱ级3例，Ⅲ级6例，Ⅳ级3例。ACDR组17个（40.5%）邻近节段发生退变，ACDF组34个（68.0%）邻近节段发生退变，两组ASD发生率有统计学差异（P<0.05）。末次随访时ACDR组无二次手术患者，ACDF组2例因ASD导致二次手术。两组二次手术率有统计学差异（0 vs 8%，P<0.05）。结论：与ACDF术式相比，单节段ACDR治疗颈椎病能够获得一致的、良好的长期临床疗效，并在减少ASD发生方面具有优势。然而，随时间延长ACDR手术节段HO发生率较高，造成手术节段活动度降低。

英文摘要:

  【Abstract】 Objectives： To evaluate the long-term clinical efficacies of single-level Discover artificial cervical disc replacement(ACDR) and anterior cervical discectomy and fusion(ACDF) in the treatment of cervical spondylosis. Methods: The clinical data of patients with cervical spondylosis who underwent single-level ACDR or ACDF in Xijing Hospital from January 2009 to December 2011 were reviewed. ACDR group consisted of 21 patients(15 males and 6 females), aged 44.0±7.5(33-58) years old and treated with Discover prosthesis, involving C4/5 in 2 cases, C5/6 in 17 cases, and C6/7 in 2 cases. ACDF group consisted of 25 patients(20 males and 5 females), aged 48.2±8.5(33-63) years old, involving C3/4 in 1 case, C4/5 in 3 cases, C5/6 in 18 cases, and C6/7 in 3 cases. Japanese Orthopedic Association(JOA) score, visual analogue scale(VAS) and neck disability index(NDI) were used to assess the patients′ neurological functions and the clinical effects before surgery, at 3 months after surgery, and 1, 2, and 5 years after surgery, as well as the last follow-up. The range of motion(ROM) at the index level of ACDR group and final follow-up heterotopic ossification(HO) of ACDR group and adjacent segments degeneration(ASD) conditions of both groups were measured and evaluated with cervical spinal radiographs, CT scan and MRI, and statistical analyses were performed. Results: The mean follow-up time was 138.9±12.0 months in ACDR group and 136.9±10.8 months in ACDF group, and there was no statistical difference between the two groups(P>0.05). The postoperative follow-up JOA, VAS-Arm, and VAS-Neck scores and NDI of the two groups were all significantly improved compared with those before operation(P<0.05), respectively, there was no statistical difference between the scores at the last follow-up and 2 years after surgery in the same group(P>0.05), and there was no statistical difference between the two groups at the same time point(P>0.05). In the ACDR group, the range of motion(ROM) at the index level at the 3 month, 1 year and 2 years after surgery was significantly improved compared with that before surgery(P<0.05), and which at postoperative 5 years and final follow-up was not statistically different from that before operation(P>0.05). At the final follow-up, 13 cases(61.9%) in ACDR group occurred HO at the operated level, of which 1 case was of grade Ⅰ, 3 cases of grade Ⅱ, 6 cases of grade Ⅱ, and 3 cases of grade Ⅳ according to McAfee′s classification. The ASD rate in ACDR group(17/42, 40.5%) and ACDF group(34/50, 68.0%) was statistically different(P<0.05). At the last follow-up, there were 0 case of secondary operation in ACDR group and 2 cases in ACDF group caused by ASD were in need of secondary operations. The secondary operation rate between groups was statistically different(0 vs 8%, P<0.05). Conclusions: Single-level ACDR has the same and good long-term clinical efficacy comparing with ACDF, which also superiors in reducing the incidence of ASD in the treatment of cervical spondylosis. However, the incidence of HO at the index level may gradually increase over time, resulting in the reduction of the ROM at the index level.