两种后路减压术治疗脊髓型颈椎病比较

Comparison of two posterior decompressions in the treatment of cervical spondylotic myelopathy

摘要:

[目的] 比较颈椎后路单开门椎管扩大成形术与颈椎后路椎管减压侧块螺钉内固定术治疗脊髓型颈椎病 （cervical spondylotic myelopathy, CSM） 的临床疗效。[方法] 回顾性分析 2019 年 3 月—2021 年 12 月行后路减压手术治疗的 66 例 CSM 患者，依据医患沟通结果，33 例采用颈椎后路单开门椎管扩大成形，33 例采用颈椎后路椎管减压侧块螺钉内固定术。比较两组围手术期、随访及影像结果。[结果]两组手术时间、失血量、切口长度、 术中透视次数、切口愈合等级、下地行走时间和住院时间的差异均无统计学意义（P＞0.05）。单开门组 C₅神经根麻痹发生率显著低于减压固定组（6.1% vs 27.3%, P=0.022）。轴性症状发生率两组间差异无统计学意义（24.2% vs 15.2%, P=0.357）。所有患者随访时间均在 12 个月以上，随时间推移，两组患者 JOA 评分、NDI 评分和锥体束征均显著改善（P＜0.05），相应时间点，两组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，末次随访时两组患者颈椎前凸角无显著变化 （P＞0.05），颈椎 ROM 显著减小 （P＜0.05），最小椎管矢状径显著增加 （P＜0.05）。术前两组颈椎前凸角、颈椎 ROM 差异无统计学意义（P＞0.05），末次随访时，单开门组颈椎 ROM [(39.5±7.8)° vs (12.6± 1.9)°, P＜0.05] 显著优于减压固定组，但颈椎前凸角显著小于后者 [(17.9±9.8)° vs (21.4±7.9)° , P＜0.05]，两组最小椎管矢状径差异无统计学意义（P＞0.05）。[结论] 两种手术均可以改善患者的神经功能，单开门椎管扩大成形术可以减少 ROM 的丢失，降低术后 C₅神经根麻痹的发生，而颈椎后路椎管减压侧块螺钉固定术可以减少颈椎前凸角的丢失，维持颈椎稳定。

Abstract:

[Objective] To compare the clinical efficacy of posterior cervical unilateral open-door laminoplasty (ODL) versus posterior cervical total laminectomy with lateral mass screw fixation (CTL) for the treatment of cervical spondylotic myelopathy (CSM). [Methods] A retrospective study was performed on 66 patients who underwent posterior decompression surgeries for CSM from March 2019 to December 2021. According to doctor-patient communication, 33 patients underwent ODL, while the remaining 33 patients received CTL. The perioper- ative, follow-up and imaging documents were compared between the two groups. [Results] There were no significant differences in operation time, blood loss, incision length, intraoperative fluoroscopy times, incision healing grade, postoperative walking time and hospital stay be- tween the two groups (P＜0.05). The incidence of C₅ nerve root paralysis in the ODL group was significantly lower than that in CTL group (6.1% vs 27.3%, P=0.022), nevertheless, there was no a significant difference in the incidence of axial symptoms between the two groups postoperatively (24.2% vs 15.2%, P=0.357). As time went during the follow-up period lasted for more than 12 months, the JOA and NDI scores, as well as pyramidal tract sign significantly improved in both groups (P＜0.05), which were not statistically significant between the two groups at any time points accordingly (P＞0.05). Radiographically, the cervical lordotic angle remained unchanged significantly (P＞0.05), while the cervical range of motion (ROM) significantly decreased (P＜0.05), and the minimal sagittal diameter of spinal canal significantly in- creased in both groups postoperatively compared with those preoperatively (P＜0.05). There was no significant difference in cervical lordotic angle and cervical ROM between the two groups before surgery (P＞0.05). The ODL group had significantly greater cervical ROM than the CTL group [(39.5±7.8)° vs (12.6±1.9)°, P＜0.05], but the former had significantly less cervical lordotic angle than the latter [(17.9±9.8)° vs (21.4±7.9)°, P＜0.05], and there was no significant difference in minimal sagittal diameter of spinal canal between the two groups at the latest follow-up (P＞0.05). [Conclusion] Both posterior decompression procedures do improve the neurological function. By comparison, the ODL has advantages of decreasing loss of ROM and reducing the incidence of postoperative C₅ nerve root paralysis, while CTL had benefit of re- ducing loss of cervical lordotic angle and maintaining cervical stability.