显微镜与直视下颈椎前路椎间盘切除融合术比较△

Comparison of anterior cervical discectomy and fusion under microscope versus direct vision

摘要:

[目的]比较显微镜与直视颈椎前路椎间盘切除融合术（anterior cervical discectomy fusion, ACDF）治疗脊髓型颈椎病的临床疗效。[方法] 回顾性分析本院 2015 年 6 月—2018 年 11 月采用 ACDF 治疗脊髓型颈椎病 65 例患者的临床资料。根据医患术前沟通结果，30 例采用显微镜下 ACDF，35 例采用传统直视下 ACDF。比较两组患者围手术期、随访和影像资料。[结果]两组患者均顺利完成手术；显微镜组仅 1 例喉返神经损伤；传统组 2 例脑脊液漏，3 例喉返神经损伤；均未引发严重不良后果。显微组手术时间、术中出血量均显著优于传统组（P＜0.05），两组间切口长度、透视次数、切口愈合等级、术后下地行走时间和住院时间的差异均无统计学意义（P＜0.05）。两组患者均获随访 12~48 个月，平均（20.2±8.0）个月，随时间推移，两组患者锥体束征显著改善 （P＜0.05），VAS 和 NDI 评分均显著降低 （P＜0.05），而 JOA 评分显著增加 （P＜0.05）。术后 6 个月和末次随访时，两组 VAS 和 NDI 评分的差异无统计学意义（P＞0.05），但是，显微镜组的 JOA 评分显著优于传统组（P＜0.05）。影像方面， 与术前相比，术后即刻两组责任段椎管面积、椎间隙高度和颈前凸角均显著增加（P＜0.05）。与术后即刻相比，末次随访时两组上述影像指标均无显著变化（P＞0.05）。相应时间点，两组间影像指标的差异均无统计学意义（P＞0.05）。末次随访时椎间融合显微镜组为 26/30（86.7%），传统组为 30/35（85.7%），两组间差异无统计学意义（P＞0.05）。[结论] 显微镜下 ACDF 较传统直视下手术更为精准，具有出血量少、手术时间短和功能恢复好的优点。

Abstract:

[Objective] To compare the clinical efficacy of anterior cervical discectomy fusion (ACDF) under microscope versus direct vision for cervical spondylotic myelopathy. [Methods] A retrospective study was conducted on 65 patients who received ACDF for cervical spondylotic myelopathy from June 2015 to November 2018 in our hospital. According to the results of preoperative communication between doctors and patients, 30 patients were treated with ACDF under microscope, while the remaining 35 patients had ACDF performed under di- rect vision traditionally. Perioperative, follow- up and imaging data were compared between the two groups. [Results] All patient in both groups had operation conducted successfully. The microscopy group got recurrent laryngeal nerve injury in 1 case only, whereas the direct vision group had dural injury in 2 cases and recurrent laryngeal nerve injury in 3 cases, while none of them caused serious adverse conse- quences. The microscopy group proved significantly superior to the direct vision group in terms of operative time and intraoperative blood loss (P＜0.05), nevertheless there were no significant differences in incision length, number of fluoroscopy, incision healing grade, postopera- tive ambulation time and hospital stay between the two groups (P＞0.05). As time went during the followed-up ranged from 12 to 48 months with an average of (20.2±8.0) months, the pyramidal tract signs improved significantly (P＜0.05), VAS and NDI scores decreased significantly (P＜0.05), while JOA score increased significantly (P＜0.05) in both groups. Although there were no statistically significant differences in VAS and NDI scores between the two groups at 6 months postoperatively and the latest follow-up (P＜0.05), the microscopy group was signifi- cantly superior to the direct vision group in term of JOA score (P＜0.05). Radiographically, the area of the spinal canal in the responsible seg- ment, the height of the intervertebral space and the cervical lordosis were significantly increased immediately postoperatively compared with those preoperatively in both groups (P＜0.05) , whereas which remained unchanged at the latest follow-up compared with those immediately postoperatively (P＞0.05) . At any corresponding time points, there was no significant difference in abovesaid imaging indexes between the two groups (P＞0.05) . At the latest follow-up, the fusion rate was of 26/30 (86.7%) in the microscopy group, whereas 30/35 (85.7%) in the di- rect vision group, without a statistically significant difference between the two groups (P＞0.05) . [Conclusion] Compared with traditional op- eration under direct vision, ACDF under microscope is more accurate, and has the advantages of less blood loss, shorter operation time and better functional recovery.