颈后路单侧显露选择性通道辅助下椎管扩大椎板成形术治疗多节段颈椎退行性疾病的疗效观察

The effect of posterior unilateral exposure and selective channel-assisted laminoplasty in the treatment of multilevel degenerative cervical spondylosis

中文关键词:  椎管扩大椎板成形术  选择性通道辅助  单侧显露  疗效

英文关键词:Laminoplasty  Selective channel-assisted  Unilateral exposure  Effect

中文摘要:

  【摘要】 目的：评价颈后路单侧显露选择性通道辅助下椎管扩大椎板成形术（selective channel-assisted laminoplasty，SCA-LP）治疗多节段颈椎行性疾病的安全性与有效性，并对比3种颈椎后路单开门椎管扩大椎板成形术（laminoplasty，LP）的临床疗效。方法：回顾性分析2020年3月~2021年7月共114例行颈后路LP的患者资料，其中男62例、女52例，年龄58.27±7.36岁。其中多节段脊髓型颈椎病52例、颈椎管狭窄症25例、颈椎后纵韧带骨化症37例。39例患者接受了颈后路单侧显露SCA-LP，33例患者接受了颈后路单侧显露完全保留对侧椎旁肌的椎管扩大椎板成形术（muscle-preserved laminoplasty，MP-LP），42例患者接受了常规的颈后路单开门LP。随访12~28个月（18.46±5.75个月）。比较三组患者的年龄、性别、体重指数（body mass index，BMI）。记录并比较三组的手术时间、术中出血量、术后引流量及平均住院日。于术前、术后即刻、术后2个月、术后12个月及末次随访时采用疼痛视觉模拟量表（visual analog scale，VAS）评分评估颈部和上肢疼痛程度，颈椎功能障碍指数（neck disability index，NDI）评价患者颈椎功能，日本骨科学会（Japanese Orthopedic Association，JOA）评分评估神经功能状况。在术前、术后即刻、术后2个月、术后12个月及末次随访时的颈椎侧位X线片上测量C2-C7 Cobb角、CT横断面上测量骨性椎管面积，比较三种手术方法对C2-C7 Cobb角的影响及椎管面积的增加程度（比较每个节段的增加程度及每例患者的平均增加程度）。结果：三组患者的年龄、性别、BMI差异无统计学意义（P>0.05）。所有患者均顺利完成手术，术后均未发生神经损伤、感染等并发症。手术时间及平均住院日MP-LP组均最短、SCA-LP组次之、LP组最长，术中出血量及术后引流量MP-LP组均最少、SCA-LP组次之、LP组最多，三组间的差异均有统计学意义（P<0.05）。三组患者术后各时间点NDI及JOA评分均较术前有明显改善（P<0.05），术前、术后即刻、术后2个月、术后12个月及末次随访时的NDI及JOA评分三组间均无统计学差异（P>0.05）。LP组中，术后即刻的颈痛VAS评分要高于术前，术后12个月及末次随访时低于术前，差异均有统计学意义（P<0.05）；术后2个月的颈痛VAS评分与术前比较无统计学差异（P>0.05）。SCA-LP组、MP-LP组术后即刻的颈痛VAS评分与术前的差异均无统计学意义（P>0.05），术后2个月、12个月及末次随访均显著低于术前（P<0.05）。术后即刻及术后2个月随访，SCA-LP组、MP-LP组的颈痛VAS评分均显著低于LP组（P<0.05）；术后12个月及末次随访三组的颈痛VAS评分差异无统计学意义（P>0.05）。三组术后即刻的C2-C7 Cobb角均较术前无统计学差异（P>0.05），LP组术后2个月、12个月及末次随访的C2-C7 Cobb角均显著小于术前（P<0.05），SCA-LP组、MP-LP组术后2个月的C2-C7 Cobb角均与术前无统计学差异（P>0.05），SCA-LP组、MP-LP组术后12个月及末次随访的C2-C7 Cobb角均显著小于术前（P<0.05）。三组间术前及术后即刻C2-C7 Cobb角差异无统计学意义（P>0.05），术后2个月、12个月及末次随访的C2-C7 Cobb角SCA-LP组、MP-LP组均大于LP组（P<0.05）。三组间术后即刻、2个月、12个月及末次随访的平均椎管面积增加百分比差异无统计学意义（P>0.05）。SCA-LP组中所有患者的C7（100%）、12例患者的C6（30.77%）、6例患者的C3（15.38%）需要通道下制作铰链。术后即刻、2个月、12个月及末次随访SCA-LP组和LP组患者C7的椎管面积增加程度均优于MP-LP组（P<0.05）；三组间C3~C6椎管面积增加程度的差异无统计学意义（P>0.05）。结论：与常规的颈后路单开门LP相比，两种改良术式均能有效减少铰链侧肌肉韧带的损伤，术后加速康复，减少术后早期轴性颈痛的发生率。与MP-LP相比，SCA-LP能更有效地增加手术节段的椎管面积。

英文摘要:

  【Abstract】 Objectives: To evaluate the clinical safety and effectiveness of posterior unilateral exposure and selective channel-assisted laminoplasty(SCA-LP) in the treatment of multi-level degenerative cervical spondylosis and to compare the clinical outcomes of three types of posterior open-door laminoplasty. Methods: A total of 114 patients underwent posterior laminoplasty(LP) from March 2020 to July 2021 were analyzed retrospectively, including 62 males and 52 females, with an average age of 58.27±7.36 years. Among them, there were 52 cases of multilevel cervical spondylotic myelopathy(MCSM), 25 cases of cervical canal stenosis(CCS), and 37 cases of ossification of posterior longitudinal ligament(OPLL). 39 patients received unilateral exposure and SCA-LP (SCA-LP group), 33 patients received unilateral exposure and contralateral paravertebral musle-preserved(MP) LP(MP-LP group) and 42 patients were treated with traditional open-door LP(LP group). The patients were followed up for 12-28 months(18.46±5.75 months). Patient characteristics such as age, gender and body mass index(BMI) were compared between groups. Surgical parameters such as the operative time, blood loss, amount of post-operative drainage, and average length of hospital stay were collected and compared. At before operation, immediately after operation, 2 and 12 months postoperatively, and final follow-up, clnical parameters such as visual analog scale(VAS) assessing neck and arm pains, neck disability index(NDI) assessing cervical function and Japanese Orthopedic Association(JOA) scores assessing neurological status were recorded and compared between groups respectively; and C2-C7 Cobb angle and the cross-sectional area of spinal canal were measured on lateral X-ray films of cervical spine to compare the effects of the three surgical methods on C2-C7 Cobb angle and the increase of spinal canal area(the increase of each segment and the average increase of each patient). Results: There were no significant differences in age, gender and BMI between the three groups(P>0.05). All patients underwent the operation uneventfully, and no serious complications such as nerve injury or infection occurred. MP-LP group was the shortest and LP group was the longest in operative time and average length of hospital stay, and MP-LP group was the smallest and LP group was the biggest in the volume of blood loss and postoperative drainage, with signicant differences(P<0.05). The postoperative NDI and JOA scores of the three groups of patients were significantly improved compared with those before operation(P<0.05), and no significant differences were found in NDI and JOA scores between the three groups before operation, immediately after operation, 2 and 12 months after operation and at the last follow-up(P>0.05). In the LP group, the VAS score of neck pain immediately after operation was higher than that before operation, and at 12 months after operation and final follow-up it was lower than that before operation, and the differences were statistically significant(P<0.05); and no difference was found between 2 months after operation and before operation(P>0.05). In the SCA-LP group and MP-LP group, the VAS score of neck pain immediately after operation was not statistically different from that before operation(P>0.05) and it was significantly lower at 2 months, 12 months after operation and the last follow-up than that before operation(P<0.05). The VAS score of neck pain in the SCA-LP group and MP-LP group was lower than that in LP group immediately after operation and at 2-month follow-up(P<0.05), and there was no significant difference between the three groups at 12 months after operation and the last follow-up(P>0.05). The C2-C7 Cobb angle immediately after operation in the three groups had no significant differences than before operation(P>0.05); In LP group, it was smaller at 2 and 12 months after operation and the last follow-up than before operation(P<0.05). In the SCA-LP group and MP-LP group, at 2 months after operation it was not significantly different from that before operation(P>0.05), and it was significantlly lower at 12 months after operation and the last follow-up than that before operation(P<0.05). There was no significant difference between the three groups in the differences of C2-C7 Cobb angle between before operation and immediately after operation(P>0.05). The C2-C7 Cobb angle in the SCA-LP group and MP-LP group was significantly bigger than that in LP group at 2 and 12 months after operation and the last follow-up(P<0.05). There was no significant difference in the increased percentage of average area of spinal canal between the three groups immediately after operation, 2 and 12 months after operation and at the last follow-up(P>0.05). In the SCA-LP group, C7(100%) of all the patients, C6(30.77%) of 12 patients, and C3(15.38%) of 6 patients needed to make hinge under the channel. The increase of C7 spinal canal area in the SCA-LP group and LP group was larger than that in MP-LP group immediately after operation, 2 and 12 months after operation and the last follow-up(P<0.05); There was no significant difference in the increase of C3-C6 spinal canal area between the three groups(P>0.05). Conclusions: Comparing with LP, the two improved surgical methods can effectively reduce the injury of muscles and ligaments on the hinge side, enhance recovery after surgery, lower the incidence of early postoperative axial neck pain. SCA-LP can increase the area of the spinal canal of operative segment more effectively than MP-LP.