自体骨、同种异体骨和人工骨应用于颈前路椎间盘切除融合术的效果比较

Comparison of the efficacies between autograft, allograft, and synthetic bone graft in anterior cervical discectomy and fusion

中文关键词:  前路颈椎融合术  自体髂骨  同种异体骨  羟基磷灰石  融合率

英文关键词:Anterior cervical discectomy and fusion  Autogenous iliac bone  Allograft  Hydroxyapatite  Fusion rate

中文摘要:

  【摘要】 目的：比较自体髂骨、同种异体骨和羟基磷灰石（hydroxyapatite，HA）人工骨在前路颈椎间盘切除融合术（anterior cervical discectomy and fusion，ACDF）应用的临床效果和影像学结果。方法：回顾性分析2015年1月~2019年12月于南方医科大学第三附属医院接受ACDF患者的临床资料。共纳入107例患者、164节段。根据使用的植骨材料不同分为自体髂骨组（37例、53个节段）、同种异体骨组（46例、70个节段）和HA人工骨组（24例、41个节段）。术前和末次随访时采用疼痛视觉模拟量表（visual analogue scale，VAS）评分、颈椎功能障碍指数（neck disability index，NDI）、日本骨科协会（Japanese Orthopedic Association，JOA）评分评估患者颈椎疼痛和功能情况。在颈椎矢状面X线片测量手术节段高度和矢状面参数[C2-C7矢状面轴向距离（SVA）和C2-C7 Cobb角]，评估融合器下沉情况。根据Odom标准进行满意程度评估，采用Brantigan评分评估颈椎椎间融合状态，采用多因素Logistic回归分析植骨不融合的危险因素。结果：三组患者的性别比例、年龄、病程、体质量指数（BMI）、合并糖尿病和终板异常比例、单/非单节段比例、手术时间和出血量均无统计学差异（P>0.05）。三组临床随访时间有统计学差异（自体髂骨组41.6±18.4个月，同种异体骨组26.9±15.7个月，HA人工骨组 31.3±8.4个月，P<0.05）。三组患者末次随访时的颈痛VAS评分、NDI和JOA评分均较术前显著性改善（P<0.05），HA人工骨组末次随访时的VAS评分和NDI显著性高于自体髂骨组和同种异体骨组（P<0.05）；三组患者VAS评分改善程度无显著性差异（P>0.05），同种异体骨组的NDI和JOA评分改善程度显著性优于自体髂骨组和HA人工骨组（P<0.05）。末次随访时自体髂骨组、同种异体骨组和HA人工骨组患者满意程度优良率分别为81.1%（30/37）、84.8%（39/46）和54.2%（13/24），HA人工骨组的满意率较低（P<0.05）；融合率分别为94.3%（50/53）、81.4%（57/70）和31.7%（13/41），融合器下沉发生率分别为3.8%（3/53）、4.3%（3/70）和58.5%（24/41），HA人工骨组的融合率显著性较低（P<0.05），融合器下沉发生率显著性较高（P<0.05）。末次随访时，HA人工骨组的手术节段高度显著性较低（P<0.05），三组患者的SVA和C2－C7 Cobb角无显著性差异（P>0.05）。多因素Logistic回归分析显示同种异体骨和人工骨的使用为植骨不融合的危险因素。HA人工骨组有2例患者（8.3%）因假关节形成接受翻修手术治疗。结论：同种异体骨植骨的临床效果良好，患者满意率和植骨融合率较高，融合器下沉风险较低，可作为自体骨替代材料应用于ACDF；HA人工骨植骨的临床效果相对较差，患者满意率和植骨融合率较低，融合器下沉率较高，且有较高的翻修手术风险。

英文摘要:

  【Abstract】 Objectives: To compare the clinical and radiographic outcomes of autograft, allograft, and hydroxyapatite(HA) synthetic bone graft in anterior cervical discectomy and fusion(ACDF). Methods: A retrospective analysis of patients who underwent ACDF in the Third Affiliated Hospital of Southern Medical University from January 2015 to December 2019 was conducted and 107 patients were included involving 164 segments. The patients were divided into autogenous iliac bone group(n=37 involving 53 segments), allograft group(n=46 involving 70 segments), and HA group(n=24 involving 41 segments). The visual analogue scale(VAS) score, neck disability index(NDI), and Japanese Orthopedic Association(JOA) score were used to evaluate the pain and function of cervical spine before operation and at final follow-up. The height of operated segment and sagittal parameters[(C2-C7 sagittal vertical axis(SVA) and C2-C7 Cobb angle] were measured on the sagittal X-ray films of cervical spine to evaluate the subsidence of cage. The clinical outcome was evaluated according to Odom criteria, and fusion status was assessed according to Brantigan score. Multivariate Logistic regression was used to analyze the risk factors of bone graft poor fusion. Results: There was no statistical difference between the three groups in terms of sex distribution, age, duration of disease, body mass index(BMI), rate of diabetes and lesion of endplate, ratio of single and non-single segment operation, operation time, and blood loss(P>0.05). There was statistical difference in the clinical follow-up between autogenous iliac bone group, allograft group, and HA group(41.6±18.4 months vs 26.9±15.7 months vs 31.3±8.4 months, P<0.05). The VAS score, NDI, and JOA score were significantly ameliorated in all the three groups at final follow-up than those before operation(P<0.05). And the final follow-up VAS and NDI were significantly higher in HA group than the other groups(P<0.05). No significant difference was found in the improvement of VAS between the three groups(P>0.05) while the improvement of NDI and JOA in allograft group was better than the other groups(P<0.05). Of the autogenous iliac bone group, allograft group, and HA group, the rates of excellent or good according to Odom criteria were 81.1%(30/37), 84.8%(39/46), and 54.2%(13/24) respectively at final follow-up, and it was significantly lower in HA group(P<0.05); The fusion rates were 94.3%(50/53), 81.4%(57/70), and 31.7%(13/41) and the rates of subsidence of cage were 3.8%(3/53), 4.3%(3/70), and 58.5%(24/41) respectively. The fusion rate of HA group was significantly lower among the three groups(P<0.05), and the rate of cage subsidence was significantly bigger(P<0.05). At final follow-up, the height of operated segment was significantly lower in HA group(P<0.05) and there was no significant difference in sagittal parameters between the three groups(P>0.05). Multivariable analysis confirmed that usage of allograft and HA synthetic bone was the risk factors of poor fusion. Two patients in HA group(8.3%) received revision surgery because of pseudoarthrosis. Conclusions: Bone allograft had a good clinical outcome, high degree of patient-reported satisfaction, high fusion rate, and low risk of subsidence of cage, which could become a decent substitute of autograft in ACDF. HA bone graft had an inferior clinical outcome, low degree of patient-reported satisfaction, low fusion rate, and high risk of subsidence of cage and revision surgery.