颈椎单椎体次全切除是否切除后纵韧带的比较△（开放获取）

Single-segment corpectomy and instrumented fusion with or without posterior longitudinal ligament removal

摘要:

[目的]比较颈椎单椎体次全切除融合术（anterior cervical corpectomy and fusion, ACCF）是否切除后纵韧带（posteri- or longitudinal ligament, PLL）的临床疗效。[方法]回顾性分析 2017 年 3 月—2022 年 3 月本院行颈椎单椎体 ACCF 治疗脊髓型颈病 81 例患者的临床资料。依据术前影像 PLL 是否钙化以及术中探查情况，38 例保留 PLL （保留组），43 例切除 PLL （切除组）。比较两组围手术期、随访及影像资料。[结果]所有患者均顺利完成手术，两组透视次数、切口总长度、下地行走时间、切口愈合等级及住院时间的差异均无统计学意义（P＞0.05），但是，保留组在早期并发症发生率 （13.2% vs 34.9%, P=0.024）、手术时间 [(110.3±11.4) min vs (147.2±13.4) min, P＜0.001] 及失血量 [(61.7±10.2) ml vs (133.7±12.0) ml, P＜0.001] 均明显优于切除组。随访时间平均（22.6±13.1）个月，两组恢复完全负重活动时间的差异无统计学意义（P＞0.05）。随时间推移，两组的 NDI 和 JOA 评分，及锥体束征均显著改善（P＜0.05）。保留组术后 3 个月 [(10.5±1.9) vs (11.4±2.5), P＜0.001]、6 个月 [(12.4±2.5) vs (13.7±2.1), P= 0.026] 及末次随访时 [(13.3±2.2) vs (14.8±1.7), P＜0.001] 的 JOA 评分均显著不及切除组，但是，相应时间点两组间 NDI 评分、锥体束征的差异均无统计学意义（P＞0.05）。影像方面，与术前相比，末次随访时两组颈椎前凸角和最小椎管矢状径均显著增加（P＜ 0.001），而颈椎 ROM 均显著减少（P＜0.001）。末次随访时，两组颈椎前凸角及 ROM 的差异无统计学意义（P＞0.05），而保留组责任段最小椎管矢状径显著小于切除组 [(9.0±0.8) mm vs (9.8±0.9) mm, P＜0.001]。[结论] 行颈椎单椎体 ACCF 时，应依据术前影像资料及术中所见确定是否切除 PLL。切除 PLL 虽可更好减压，但手术创伤大，并发症风险大。

Abstract:

[Objective] To compare the clinical outcomes of anterior cervical corpectomy and fusion (ACCF) with or without posterior longitudinal ligament (PLL) removal for cervical spondylotic myelopathy (CSM). [Methods] A retrospective study was done on 81 patients who received single-segment ACCF for CSM in our hospital from March 2017 to March 2022. According to whether calcification of PLL was seen on preoperative images and the intraoperative findings, the PLL was retained in 38 patients (the retained group), whereas was resected in the other 43 patients (the resected group). The perioperative, follow-up and imaging data of the two groups were compared. [Results] All patients in both groups had corresponding surgical procedures conducted successfully. Although there were no statistically significant differences between the two groups in the number of fluoroscopy, the total incision length, postoperative ambulation time, incision healing grade and hospital stay (P＞0.05), the retained group proved significantly superior to the resected group in terms of the early complication rate (13.2% vs 34.9%, P=0.024), operation time [(110.3±11.4) min vs (147.2±13.4) min, P＜0.001] and intraoperative blood loss [(61.7±10.2) ml vs (133.7±12.0) ml, P＜0.001]. The follow-up period lasted for (22.6±13.1) months in a mean, and there was no significant difference between the two groups in the time to return to full weight-bearing activities (P＞0.05). The NDI and JOA scores and pyramidal tract signs improved significantly over time in both groups (P＜0.05). The retained group proved significantly inferior to the resected group regarding JOA score at 3 months postoperatively [(10.5±1.9) vs (11.4±2.5), P＜0.001], 6 months [(12.4±2.5) vs (13.7±2.1), P=0.026], and at the latest followup [(13.3±2.2) vs (14.8±1.7), P＜0.001], but there were no statistically significant differences in NDI scores and pyramidal tract signs between the two groups at any time points accordingly (P＞0.05). Radiologically, the cervical lordosis and minimum sagittal diameter of the spinal canal significantly increased (P＜0.001), while the cervical ROM significantly reduced in both groups at the last follow-up compared with those preoperatively (P＜0.001). At the last follow-up, there were no statistically significant differences in the cervical lordosis and ROM between the two groups (P＞0.05), however, the retained group was significantly less than the resected group in term of minimum sagittal diameter of the responsible segment [(9.0±0.8) mm vs (9.8±0.9) mm, P＜0.001]. [Conclusion] As singlesegment ACCF is performed for CSM, PLL should be resected according to preoperative imaging data and intraoperative findings. Although PLL resection does provide better decompression, it leads to more iatrogenic trauma and high risk of complications.