颈脊髓中央损伤综合征手术治疗的预后及相关影响因素分析

Analysis of prognosis and influencing factors of surgical treatment for central cord syndrome

中文关键词:  脊髓中央损伤综合征  手术治疗  预后  相关因素

英文关键词:Central cord syndrome  Surgical treatment  Prognosis  Factors

中文摘要:

  【摘要】 目的：分析颈脊髓中央损伤综合征（central cord syndrome，CCS）手术治疗的预后及相关影响因素。方法：回顾性分析2017年1月~2019年12月在我院骨科经手术治疗的CCS病例，收集所有患者的年龄、性别、致伤原因、入院时美国脊髓损伤协会（American Spinal Injury Association，ASIA）运动评分、ASIA感觉（针刺觉）评分、日本骨科协会（Japanese Orthopaedic Association，JOA）评分、手内肌肌力评分及影像学资料信息[包括椎前高信号、后方韧带复合体、椎间盘突出、后纵韧带骨化、髓内高信号范围、椎管最狭窄处矢状径、椎管最狭窄处百分比（maximum canal compromise，MCC）和脊髓最大受压百分比（maximum spinal cord compression， MSCC）等]、受伤至手术时间、手术方式、住院时间、随访时ASIA神经功能评分、随访时JOA评分等资料，评估患者神经功能改善情况；将JOA评分改善率＞50%定义为预后好，≤50%定义为预后差，分析影响手术治疗预后的相关因素。结果：共纳入48例CCS患者，其中男性36例（75%），女性12例（25%），年龄54.76±9.78岁。入院时ASIA运动评分67.23±21.98分，ASIA感觉评分96.58±13.39分；JOA评分9.19±3.08分，手内肌肌力评分7.04±4.50分。19例（39.58%）存在病理征。伤后5.46±2.10d接受手术治疗，其中前路手术21例，后路手术27例。术后随访12~34个月，所有患者均未发生明显手术相关并发症或神经功能恶化，末次随访时ASIA运动评分89.67±13.65分，ASIA感觉评分104.88±7.94分，JOA评分13.73±3.25分，较入院时均有不同程度的提高（P＜0.05）。多元回归分析显示ASIA运动评分、ASIA感觉评分和JOA评分的改善率与后纵韧带骨化（β=-0.447、P<0.001；β=0.524、P=0.001；β=-0.196、P<0.001）和入院ASIA感觉评分（β=0.526、P=0.011；β=0.894、P=0.02；β= -0.784、P<0.001）有显著相关性。预后好与预后差患者的年龄、椎前高信号、后纵韧带骨化、椎管最狭窄处矢状径、MCC、入院手内肌评分、入院ASIA运动评分和入院JOA评分有统计学差异（P＜0.05），多元回归分析显示良好预后（JOA评分改善率＞50%）与年龄（β=5.889、P=0.015）、椎前高信号（β=15.799、P＜0.001）、MCC（β=6.747、P=0.009）、入院手内肌评分（β=9.012、P=0.003）、入院ASIA运动评分（β=4.837、P=0.028）、入院ASIA感觉评分（β=5.205、P=0.023）和入院JOA评分（β=6.446、P=0.011）存在显著相关性。受试者工作特征（receiver operating characteristic，ROC）曲线分析显示无椎前高信号[曲线下面积（area under curve，AUC）=0.756, 95%CI 0.585～0.928，P=0.006]、MCC<45.41%（AUC=0.731，95%CI 0.566～0.896，P=0.010）、入院手内肌评分>11分AUC=0.77，95%CI 0.628～0.913，P=0.003）、入院ASIA运动评分>75分（AUC=0.804，95%CI 0.683～0.924，P=0.001）、入院JOA评分>8.59分（AUC=0.755，95%CI 0.614～0.897，P=0.005）可作为良好预后的预测因子。结论：手术治疗CCS安全有效，无椎前高信号、MCC低（<45.41%）、入院手内肌评分高（>11分）、入院ASIA运动评分高（>75分）和入院JOA评分高（>8.59分）是CCS患者手术预后良好的预测因子。

英文摘要:

  【Abstract】 Objectives: To analyze the prognosis and influencing factors of surgical treatment for central cord syndrome(CCS). Methods: The CCS patients underwent surgical treatment at the Department of Orthopaedics of our hospital between January 2017 and December 2019 were retrospectively analyzed. Data including age, gender, cause of injury, and American Spinal Injury Association(ASIA) motor score, ASIA sensory(acupuncture) score, Japanese Orthopaedic Association(JOA) score, and intrinsic hand muscle strength score on admission, and preoperative imaging data such as prevertebral hyperintensity, posterior ligament complex, intervertebral disc herniation, ossification of posterior longitudinal ligament(OPLL), intramedullary hyperintensity range, sagittal diameter of the narrowest part of the spinal canal, the percentage of maximum canal compromise(MCC) at the narrowest part of spinal canal, and the percentage of maximum spinal cord compression(MSCC), and the time from injury to surgery, surgical method, length of hospital stay, and follow-up ASIA neurological score and JOA score for improvement evaluation of neurological function were collected; and the relevant factors affecting the prognosis of surgical treatment were analyzed by defining the improvement rate of JOA score>50% as good prognosis and ≤50% as poor prognosis. Results: 48 CCS patients were included, consisting of 36 males(75%) and 12 females(25%), with an average age of 54.76±9.78 years. The ASIA motor score was 67.23±21.98, sensory score was 96.58±13.39, JOA score was 9.19±3.08, and intrinsic hand muscle strength score was 7.04±4.50 on admission, and the presence of pathological signs accounted for 39.58%(19/48). The time from injury to surgery of the patients was 5.46±2.10d, and 21 cases received anterior surgery and 27 underwent posterior surgery. During the postoperative follow-up of 12-34 months, all the patients had no significant postoperative surgery-related complications or neurological deterioration. The follow-up motor score(89.67±13.65), sensory score(104.88±7.94), and JOA score(13.73±3.25) were all improved to varying degrees compared with the admission scores(P<0.05). Multiple regression analysis showed that the improvement rates of ASIA motor score, ASIA sensory score and JOA score were significantly correlated with OPLL(β=-0.447, P<0.001; β=0.524, P=0.001; β=-0.196, P<0.001) and ASIA sensory score on admission(β=0.526, P=0.011; β=0.894, P=0.02; β=-0.784, P<0.001). There were statistical differences between the good prognosis patients and poor prognosis patients in terms of age, prevertebral hyperintensity, OPLL, sagittal diameter of the narrowest part of the spinal canal, MCC percentage of the narrowest part of the spinal canal, and intrinsic hand muscle strength score, ASIA motor score and JOA score on admission(P<0.05), and multiple regression analysis showed age(β=5.889, P=0.015), prevertebral hyperintensity(β=15.799, P＜0.001), MCC percentage of the narrowest part of spinal canal(β=6.747, P=0.009), intrinsic hand muscle strength score(β=9.012, P=0.003), ASIA motor score(β=4.837, P=0.028), ASIA sensory score(β=5.205, P=0.023) and JOA score(β=6.446, P=0.011) affecting the prognosis. Receiver operating characteristic(ROC) curve also showed that no prevertebral hyperintensity[area under curve(AUC)=0.756, 95%CI 0.585-0.928, P=0.006)], the MCC percentage of the narrowest part of spinal canal <45.41%(AUC=0.731, 95%CI 0.566-0.896, P=0.010), the score of intrinsic hand muscle strength >11(AUC=0.77, 95%CI 0.628-0.913, P=0.003), and the motor score >75 on admission(AUC=0.804, 95%CI 0.683-0.924, P=0.001), and JOA score >8.59 on admission(AUC=0.755, 95%CI 0.614-0.897, P=0.005) could be used as the threshold of good prognosis. Conclusions: Surgical treatment for CCS is safe and effective. No prevertebral hyperintensity, low MCC percentage(<45.41%) of the narrowest part of spinal canal, high score of intrinsic hand muscle strength(>11), and high ASIA motor score(>75) and JOA score(>8.59) on admission are the predictors of good prognosis in CCS patients.