颈后路单开门术后早期神经功能恶化患者长期预后及影响因素分析

Long-term follow-up prognosis and influencing factors analysis of neurological deterioration during early stage after laminoplasty

中文关键词:  颈后路椎管扩大椎板成形术  保留一侧肌肉韧带复合体  术后神经功能恶化  长期随访

英文关键词:Expansive open-door laminoplasty  Preservation of unilateral muscle-ligament complex  Neurological deterioration  Long-term follow-up

中文摘要:

  【摘要】 目的：探讨颈后路术后早期（术后3个月）发生神经功能恶化患者长期随访的预后情况及相关危险因素。方法：回顾性分析17例在2006年1月~2012年12月间在我科接受保留一侧肌肉韧带复合体的颈后路椎管扩大成形术后早期神经功能恶化（术后3个月随访时mJOA评分较术前下降≥1分）的患者，以术后10年随访时mJOA评分是否恢复至术前水平将患者分为未恢复组（n=5）及恢复组（n=12），收集两组患者的基线信息、围术期资料及术后3个月、1年和10年时的改良日本骨科协会（modified Japanese Orthopaedic Association，mJOA）评分、颈椎功能障碍指数（neck disability index，NDI）、视觉模拟量表（visual analog scale，VAS）评分和影像学数据[包括Cobb角、颈椎活动度（range of motion，ROM）以及C2-C7矢状面轴向距离（sagittal vertical axis，SVA）]。比较两组患者历次随访时上述指标的差异并进行回归分析，并比较发生早期神经功能恶化时两组患者mJOA评分不同项目是否存在差异。结果：未恢复组患者合并颈椎后纵韧带骨化（ossification of longitudinal ligament，OPLL）比例明显高于恢复组，两组间在年龄、性别、体重指数、合并症、合并脊髓T2高信号、合并发育性颈椎管狭窄等基线信息以及围术期手术时间、出血量、住院时间等均无统计学差异（P>0.05）。未恢复组中1例患者发生脑脊液漏及C5神经根麻痹，恢复组中1例患者发生脑脊液漏，两组间差异无统计学意义。在术后3个月发生早期神经功能恶化后，所有患者完善影像学检查后未见减压不充分，均未行二期手术治疗。未恢复组与恢复组患者术前mJOA评分分别为13.30±2.46分及14.71±1.41分，差异无统计学意义。在发生早期神经功能恶化后，恢复组患者术后1年随访mJOA评分较术后3个月随访明显改善且与术前水平无显著性差异，术后10年随访时显著性高于术前及历次随访；未恢复组患者术后1年和10年随访时mJOA评分与术后3个月发生神经功能早期恶化时无统计学差异。两组间VAS评分及NDI评分在术前及历次随访无统计学差异；两组组内术前及历次随访时的VAS评分及NDI亦无统计学差异。恢复组历次随访时Cobb角较术前均有所增加，术后10年随访时SVA较术前增加明显；未恢复组历次随访时Cobb角及SVA与术前相比差异均无统计学意义。恢复组ROM在术后历次随访中均较术前显著性减小，未恢复组术后较术前无统计学差异。两组间术前及历次随访时Cobb角、ROM及SVA均无显著性差异。未恢复组患者发生早期神经功能恶化时更易累及下肢运动功能。对两组患者进行Logistic回归分析显示术前合并OPLL是发生术后早期神经功能恶化且术后10年难以恢复的危险因素。结论：术前合并OPLL的患者术后发生早期神经功能恶化后长期随访期更难以恢复。

英文摘要:

  【Abstract】 Objectives: To explore the long-term follow-up prognosis and risk factors in patients with neurological function deterioration after expansive open-door laminoplasty at early postoperative stage(within 3 months). Methods: A retrospective analysis was conducted on 17 patients who experienced neurological function deterioration(the mJOA score decreased by ≥1 point at postoperative 3 months′ follow-up compared with that before operation) at early stage after receiving laminoplasty with the preservation of unilateral muscle-ligament complex in our department between January 2006 and December 2012. The patients were divided into non-recovery group(n=5) and recovery group(n=12) based on whether the mJOA score of one patient recovered to one′s preoperative level at postoperative 10-year follow-up. The baseline data, perioperative information, postoperative 3-month, 1-year and 10-year mJOA score, neck disability index(NDI) score, and visual analog scale(VAS) score, as well as the imaging data[Cobb angle, range of motion(ROM) of the cervical spine, and sagittal vertical axis(SVA) of C2-C7] were collected and compared for regression analysis. The differences between different mJOA categories involved between the two groups were also compared. Results: The proportion of patients with ossification of longitudinal ligament(OPLL) in the non-recovery group was significantly higher than that in the recovery group. There were no statistically significant differences between the two groups in baseline information such as age, gender, BMI, comorbidities, spinal cord T2 high singnal intensity and developmental cervical canal stenosis, as well as perioperative information such as operative time, blood loss and the length of hospital stay(P>0.05). One patient in the non-recovery group had experienced cerebrospinal fluid leakage and C5 nerve root palsy and 1 patient in the recovery group had experienced cerebrospinal fluid leakage, and the difference wasn′t with statistical significance between the two groups. After neurological deterioration occurred within postoperative 3 months, imaging examinations were conducted on all the patients and found none insufficient decompression, therefore no secondary surgical treatment was performed. The preoperative mJOA scores of the non-recovery group and recovery group were 13.30±2.46 and 14.71±1.41, respectively, with no statistically significant difference between the two groups. After early postoperative neurological function deterioration, the mJOA score at 1-year follow-up in the recovery group significantly improved compared to that at 3-month follow-up, which wasn′t significantly different from the preoperative level, and the mJOA score at 10-year follow-up was significantly higher than the values before surgery and at previous follow-up visits. However, in the non-recovery group, the 1-year and 10-year follow-up mJOA scores weren′t statistically different from the value at 3-month follow-up. There was no statistically significant difference in VAS scores and NDI scores between the two groups before surgery and at each follow-up; The intragroup comparison of VAS scores and NDI scores in both groups showed no significant difference between different time points. In the recovery group, the Cobb angle increased at each follow-up compared to the preoperative value, and SVA increased significantly at the 10-year follow-up. In the non-recovery group, there was no statistically significant difference in Cobb angle and SVA at each follow-up compared with the preoperative values. The ROMs at postoperative follow-up visits of the recovery group decreased significantly compared to that of preoperation, while no such difference was found in the non-recovery group. In addition, there were no significant differences in Cobb angle, ROM, and SVA between the two groups at preoperation and each follow-up. It was found that the patients in the non-recovery group were more likely to have the sensory function of lower extremity affected in neurological deterioration at postoperative early stage. The logistic regression results suggested that OPLL before operation was a risk factor for early postoperative neurological deterioration that was hard to recovery at 10 years of follow-up. Conclusions: The patients with cervical OPLL before operation who suffer from early postoperative neurological deterioration after laminoplasty tend to be more difficult to recover in the long-term follow-up.