两种前路术式治疗严重颈椎后纵韧带骨化症的疗效及神经功能恶化率对比

Comparative study of the clinical outcomes and incidence rates of postoperative neurological deterioration between two anterior surgical procedures in the treatment of severe cervical ossification of the posterior longitudinal ligament

中文关键词:  后纵韧带骨化症  椎体骨化物复合体可控前移融合术  颈前路椎体次全切除术  疗效  神经功能恶化

英文关键词:Ossification of the posterior longditudinal ligament  Anterior controllable antedisplacement and fusion  Anterior cervical corpectomy and fusion  Clinical outcomes  Neurological deterioration

中文摘要:

  【摘要】 目的：比较颈椎椎体骨化物复合体可控性前移融合术（anterior controllable antedisplacement and fusion，ACAF）与颈前路椎体次全切除减压融合术（anterior cervical corpectomy and fusion，ACCF）治疗严重颈椎后纵韧带骨化症（ossification of the posterior longitudinal ligament，OPLL）的疗效及术后神经功能恶化率。方法：回顾性分析2018年3月～2019年3月在我院接受颈前路手术治疗的72例严重OPLL患者（椎管侵占率≥50%）的临床资料，其中35例采用ACAF治疗（ACAF组），37例采用ACCF治疗（ACCF组），术后随访6～12个月。收集两组患者手术时年龄、性别、随访时间，术后2周内神经功能恶化发生情况、原因及预后，术前、术后2周内及末次随访时采用JOA评分评估神经功能，同时在术前和末次访时的颈椎CT和MRI检查图片上观察骨化物类型，测量椎管侵占率、椎管最狭窄处的减压宽度、椎管面积及脊髓前后径。结果：两组患者手术时年龄、性别比、随访时间、骨化物类型、术前椎管侵占率、椎管面积、脊髓前后径、JOA评分等均无统计学差异（P>0.05）。术后2周内，ACCF组有10例出现神经功能恶化，发生率为27.0%，其中6例系术中损伤脊髓，2例为硬膜外血肿压迫脊髓，2例为骨化物残留；ACAF组2例出现神经功能恶化，发生率为5.7%，均因骨化物残留所致。两组术后神经功能恶化率有统计学差异（P<0.05）。末次随访时，ACAF组减压宽度大于ACCF组（18.5±2.5mm vs 16.9±1.9mm），差异有统计学意义（P<0.05）；椎管面积及脊髓前后径两组间比较差异无统计学意义（144.9±31.2mm2 vs 142.1±22.3mm2，P>0.05；5.5±0.5mm vs 5.2±1.4mm，P>0.05）；两组患者JOA评分较术前均明显改善，ACAF组JOA评分改善率大于ACCF组[（79.5±8.7）% vs （68.9±20.3）%，P<0.05]。结论：相较于ACCF，ACAF治疗严重颈椎OPLL能够获得更加满意的临床疗效，且降低了术后神经功能恶化率；但在开展ACAF早期仍存在发生术后神经功能恶化的潜在风险。

英文摘要:

  【Abstract】 Objectives: To compare the clinical outcomes and incidence rates(IR) of postoperative neurological deterioration between anterior controllable antedisplacement and fusion(ACAF) and anterior cervical corpectomy and fusion(ACCF) in the treatment of severe cervical ossification of the posterior longitudinal ligament(OPLL). Methods: We retrospectively analyzed 72 cases who underwent anterior surgery for severe cervical OPLL(occupying rate≥50%) in our department from March 2018 to March 2019. Among them, 35 cases were treated with ACAF(ACAF group), and the other 37 cases were treated with ACCF(ACCF group). The patients were followed up for 6-12 months. Data of the two groups of patients were collected, including age at surgery, gender, follow-up time, and incidence of neurological deterioration within 2 weeks after operation and the cause and prognosis. JOA score was used to assess the neurologic function before operation, within 2 weeks after operation, and at the final follow-up, and meanwhile, the types of ossification were observed and the occupying rate, decompression width at the narrowest part of spinal canal, spinal canal area, and anteroposterior(AP) diameter of the spinal cord were measured on cervical CT and MRIs before operation and at final follow-up. Results: There was no significant difference in the age at surgery, gender ratio, follow-up time, ossification type, preoperative occupying rate, spinal canal area, AP diameter of the spinal cord, and JOA score between the two groups(P>0.05). A total of 10 cases in ACCF group suffered neurological deterioration within 2 weeks after surgery(IR=27.0%), including 6 cases of intraoperative spinal cord injury, 2 cases of epidural hematoma compressing spinal cord, and 2 cases of residual ossification mass. In contrast, there were only 2 cases in ACAF group occurred neurological deterioration due to residual ossification mass(IR=5.7%). There was significant difference in the incidence rate of neurological deterioration between the two groups(P<0.05). At final follow-up, the decompression width was larger in ACAF group than that in ACCF group(18.5±2.5mm vs 16.9±1.9mm), with significant difference(P<0.05); There was no significant difference in the spinal canal area and AP diameter of the spinal cord between the two groups(144.9±31.2mm2 vs 142.1±22.3mm2, P>0.05; 5.5±0.5mm vs 5.2±1.4mm, P>0.05). The JOA scores of both groups significantly improved after surgery, and ACAF group achieved higher improvement rate of JOA scores than did ACCF group[(79.5±8.7)% vs (68.9±20.3)%, P<0.05]. Conclusions: Comparing with ACCF, ACAF can achieve better clinical outcomes and reduce the incidence rate of postoperative neurological deterioration in the treatment of severe cervical OPLL. However, there is still a potential risk of postoperative neurological deterioration in the early practice of ACAF.