多节段脊髓型颈椎病前路与后路减压比较

Comparison of anterior decompression versus posterior counterpart for multilevel cervical spondylotic myelopathy

摘要:

[目的]比较颈椎前路选择性椎体次全切除融合术与后路单开门椎板成形侧块固定治疗多节段脊髓型颈椎病（multi- level cervical spondylotic myelopathy, MCSM） 的临床效果。[方法] 回顾性分析 2013 年 4 月—2017 年 3 月手术治疗的 62 例 MC- SM 患者的临床资料，依据术前医患沟通结果，32 例行选择性前路椎体次全切除融合术（前路组），30 例行后路单开门椎板成形侧块固定术 （后路组），比较两组围手术期、随访和影像资料。[结果]虽然前路组手术时间 [(168.4±36.4) min vs (118.5±33.8) min , P＜0.05]、术中出血量 [(686.5±133.6) ml vs (387.0±99.6) ml, P＜0.05] 显著多于后路组，但切口长度 [(7.1±0.7) cm vs (10.7±0.7) cm, P＜0.05]、并发症发生率 [(7/32) vs (24/30), P＜0.05] 显著低于后者。两组患者平均随访时间（34.9±12.6）个月，两组恢复完全负重活动时间差异无统计学意义（P＞0.05）。随时间推移，两组 ASIA 评级、NDI 评分、JOA 评分和锥体束征均显著改善（P＜0.05）。 各相应时间点，两组间上述指标的差异均无统计学意义（P＞0.05）。影像方面，与术前相比，末次随访时前路组颈椎前凸角显著改善（P＜0.05），而后路组无明显变化（P＞0.05）。术前两组患者间颈椎前凸角的差异无统计学意义（P＞0.05），末次随访时前路组颈椎前凸角 [(13.6±5.5)° vs (9.4±5.0)°, P＜0.05] 显著优于后路组。与术前相比，末次随访时两组患者颈椎最小椎管矢状径均显著增加 （P＜0.05）。术前及末次随访时两组患者间颈椎最小椎管矢状径的差异均无统计学意义（P＞0.05）。[结论]两组手术均能有效缓解 MCSM 患者的疼痛，获得满意的临床疗效，前路组可改善颈椎前凸角，并发症发生率低，但后路组手术时间短、术中出血量相对少。

Abstract:

[Objective] To compare the clinical outcomes of selective anterior cervical corpectomy fusion versus posterior unilateral open-door laminectomy and lateral mass fixation for multilevel cervical spondylotic myelopathy (MCSM). [Methods] A retrospective study was conducted on 62 patients who underwent surgical treatment for MCSM from April 2013 to March 2017. Based on preoperative doctor-pa- tient communication, 32 patients underwent anterior cervical corpectomy fusion (anterior group), while the remaining 30 patients underwent posterior unilateral open-door laminoplasty and lateral mass fixation (posterior group). Perioperative period, follow-up and imaging data of the two groups were compared. [Results] Although the anterior group spent significantly longer operative time [(168.4±36.4) min vs (118.5± 33.8) min, P＜0.05], with more intraoperative blood loss [(686.5±133.6) ml vs (387.0±99.6) ml, P＜0.05] than the posterior group, the former proved significantly superior to the latter in terms of incision length [(7.1±0.7) cm vs (10.7±0.7) cm, P＜0.05] and complication rate [(7/32) vs (24/30), P＜0.05]. All patients in both groups were followed up for (34.9±12.6) months on an average, with no a significant difference in the time to resume full weight- bearing activities between the two groups (P＞0.05). The ASIA neurological functional grade, NDI score, JOA score and pyramidal tract sign significantly improved over time in both groups (P＜0.05), which proved not statistically significant between the two groups at anyone of time points accordingly (P＞0.05). Radiographically, cervical lordosis was significantly improved at the latest fol- low-up compared to that preoperatively in the anterior group (P＜0.05), whereas remained unchanged in the posterior group (P＞0.05). Al- though there was no significant difference in the cervical lordosis angle between the two groups before surgery (P＞0.05), the anterior group was significantly superior to the posterior group at the last follow-up [(13.6±5.5)° vs (9.4±5.0)°, P＜0.05]. At the last follow-up the minimum sagittal diameter of the cervical canal significantly increased in both groups compared with those preoperatively (P＜0.05), which were not sig- nificantly different between the 2 groups at corresponding time points (P＞0.05). [Conclusion] Both surgical procedures do effectively re- lieve the pain, improve neurological function and obtain satisfactory clinical efficacy for MCSM. By contrast, the anterior surgery improve the cervical lordosis with low complication rate, while the posterior technique consumes short operation time with relatively less intraoperative blood loss.