小切口前路零切迹自锁融合器治疗四节段颈椎病的临床疗效分析
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摘要
目的探讨小切口前路零切迹自锁融合器治疗四节段颈椎病临床疗效。方法回顾性分析2012年3月至2016年3月,在我院因颈椎病行四节段前路椎间隙减压零切迹自锁融合器固定融合的患者24例,记录所有患者的手术时间、术中出血量及并发症发生情况。比较术前及术后随访时颈部疼痛视觉模拟评分(visual analogue scale,VAS),颈椎日本骨科协会(Japanese orthopaedic association,JOA)评分及颈椎功能障碍指数(neck disabilitv index,NDI),采用Odom标准评价末次随访时患者临床疗效的主观满意度;同时采用X线及CT进行影像学评价,比较术前,术后随访时颈椎曲度,活动度,融合节段高度,C_(2～7)矢状位力线(C_(2～7) sagittal vertical axis,SVA),T_1倾斜角(T_1 slope)等参数,并计算末次随访时的融合率。结果 24例均获完整随访,随访21～68个月,平均(40.6±5.3)个月,手术时间110～230 min,平均(133±24.2) min。术中出血65～300 ml,平均(85.5±33.6) ml,术后1个月随访时VAS、JOA、NDI评分分别为(1.7±1.75)分,(10.5±1.58)分及(13.4±6.02)分;末次随访时分别为(1.9±2.23)分,(12.8±1.61)分及(14.7±5.91)分;术后1个月及末次随访时的评分与术前VAS评分(4.1±2.53)分,JOA评分(8.3±1.05)分及NDI评分(30.1±7.25)分比较差异均有统计学意义(P<0.05);根据Odom标准,末次随访时优良率为87.5%。术后1个月及末次随访时颈椎整体曲度分别为(17.8±5.76)°、(15.3±5.87)°较术前颈椎曲度(8.9±7.85)°有明显改善,差异有统计学意义(P<0.05);术后1个月及末次随访时融合节段高度分别为(80.5±6.55) mm、(78.8±5.83) mm,均高于术前的(72.4±8.46) mm,差异有统计学意义(P<0.05);术后1个月及末次随访时C_(2～7)SVA及T_1 slope分别为(24.5±8.67) mm、(28.1±7.32)°;(23.9±7.17) mm、(27.9±8.11)°均较术前(21.4±9.63) mm、(23.6±6.56)°改善,差异有统计学意义(P<0.05)。随访期间所有患者无内固定相关并发症。末次随访时融合率达89.7%。并发症包括吞咽困难7例,C_5神经根麻痹4例,轴性痛6例。结论零切迹自锁融合器行四节段颈椎前路椎间隙减压融合内固定术(anterior cervical discectomy and fusion,ACDF)能取得良好的临床疗效,能够获得坚强的融合,并改善颈椎曲度及矢状位力线。但是四节段ACDF,其手术适应证选择较窄,对手术技巧要求较高,仍然具备一定的难度及风险。
Objective To investigate clinical results of the treatment of 4-level cervical spondylosis in patients by anterior decompression and fusion approach with self-locking and zero-profile cages. Methods From March 2012 to March 2016, a total of 24 patients with 4-level cervical spondylosis who received anterior cervical decompression, internal fixation were included in our study. Operation time, intraoperative blood loss and postoperational complications were recorded. Recording the neck pain VAS score, the Japanese Orthopedic Association (JOA) score and Neck disability Index (NDI) score to investigate the clinical outcomes pre-operation and postoperation. Surgical results according to Odom's criteria were evaluated at the final follow-up. Meanwhile, X-ray and CT were used to evaluate the whole cervical Cobb's angle, range motion of cervical spine, height of fusion segment (FSH), C__(2-7) sagittal vertical axis (SVA) and T_1 slope pre-and post-operation. Fusion rates were evaluated at the final follow-up. Results The mean follow-up was (40.6 ± 5.3) months (range: 21-68 months). The average operation time was (133 ± 24.2) min (range: 110-230 min). The average bleeding volume was (85.5 ± 33.6) ml (range: 65-300 ml). Neurological function was significantly improved after operation. VAS scores were significantly lower at 1 month (1.7 ± 1.75) and the last follow-up (1.9 ± 2.23) post-operatively comparing with those preoperatively (4.1 ± 2.53) (P < 0.05). JOA scores at 1 month (10.5 ± 1.58) and the last follow-up (12.8 ± 1.61) were significantly higher post-operatively comparing with those pre-operatively (8.3 ± 1.05) (P < 0.05). NDI scores 1 month after operation and at the last follow-up were (13.4 ± 6.02) and (14.7 ± 5.91) respectively, which were significantly lower comparing with those pre-operatively (30.1 ± 7.25). According to the Odom criteria, the share of patients with excellent and good clinical outcomes was 87.5 %. The C__(2-7) Cobb's angle (cervical lordosis) was (8.9 ± 7.85) ° before surgery, (17.8 ± 5.76) ° 1 month after surgery, (15.3 ± 5.87) ° at the final follow-up examination, which were improved significantly after surgery compared with that before surgery (P < 0.05). FSH increased from (72.4 ± 8.46) mm pre-operatively to (80.5 ± 6.55) mm postoperatively at 1 month after surgery and (78.8 ± 5.83) mm at the last follow-up. Pre-operative FSH improved significantly after surgery at 1 month and last follow-up postoperatively (P < 0.05). Pre-operative C__(2-7) SVA (21.4 ± 9.63 mm) improved significantly at 1 month (24.5 ± 8.67 mm) and last follow-up (23.9 ± 7.17 mm) post-operatively (P < 0.05). The pre-operative T_1-slope (23.6 ± 6.56) ° also improved significantly at 1 month after surgery (28.1 ± 7.32) ° and the last follow-up (27.9 ± 8.11) ° (P < 0.05). No instrument-related complications happened during the follow-up. At the final follow-up, the fusion rate was 89.7%. Complications included dysphagia (7 cases), C_5 palsy (4 cases), axial neck pain (6 cases). Conclusions Anterior cervical discectomy and fusion with self-locking cages is effective and safe for 4-level cervical spondylotic myeloradiculopathy. It allows to restore cervical lordosis and normal cervical alignment with good fusion rate and satisfactory clinical outcomes. However, surgical skills required are relatively high as narrow indications. Difficulties and risks still exist.
Objective To investigate clinical results of the treatment of 4-level cervical spondylosis in patients by anterior decompression and fusion approach with self-locking and zero-profile cages. Methods From March 2012 to March 2016, a total of 24 patients with 4-level cervical spondylosis who received anterior cervical decompression, internal fixation were included in our study. Operation time, intraoperative blood loss and postoperational complications were recorded. Recording the neck pain VAS score, the Japanese Orthopedic Association (JOA) score and Neck disability Index (NDI) score to investigate the clinical outcomes pre-operation and postoperation. Surgical results according to Odom's criteria were evaluated at the final follow-up. Meanwhile, X-ray and CT were used to evaluate the whole cervical Cobb's angle, range motion of cervical spine, height of fusion segment (FSH), C__(2-7) sagittal vertical axis (SVA) and T_1 slope pre-and post-operation. Fusion rates were evaluated at the final follow-up. Results The mean follow-up was (40.6 ± 5.3) months (range: 21-68 months). The average operation time was (133 ± 24.2) min (range: 110-230 min). The average bleeding volume was (85.5 ± 33.6) ml (range: 65-300 ml). Neurological function was significantly improved after operation. VAS scores were significantly lower at 1 month (1.7 ± 1.75) and the last follow-up (1.9 ± 2.23) post-operatively comparing with those preoperatively (4.1 ± 2.53) (P < 0.05). JOA scores at 1 month (10.5 ± 1.58) and the last follow-up (12.8 ± 1.61) were significantly higher post-operatively comparing with those pre-operatively (8.3 ± 1.05) (P < 0.05). NDI scores 1 month after operation and at the last follow-up were (13.4 ± 6.02) and (14.7 ± 5.91) respectively, which were significantly lower comparing with those pre-operatively (30.1 ± 7.25). According to the Odom criteria, the share of patients with excellent and good clinical outcomes was 87.5 %. The C__(2-7) Cobb's angle (cervical lordosis) was (8.9 ± 7.85) ° before surgery, (17.8 ± 5.76) ° 1 month after surgery, (15.3 ± 5.87) ° at the final follow-up examination, which were improved significantly after surgery compared with that before surgery (P < 0.05). FSH increased from (72.4 ± 8.46) mm pre-operatively to (80.5 ± 6.55) mm postoperatively at 1 month after surgery and (78.8 ± 5.83) mm at the last follow-up. Pre-operative FSH improved significantly after surgery at 1 month and last follow-up postoperatively (P < 0.05). Pre-operative C__(2-7) SVA (21.4 ± 9.63 mm) improved significantly at 1 month (24.5 ± 8.67 mm) and last follow-up (23.9 ± 7.17 mm) post-operatively (P < 0.05). The pre-operative T_1-slope (23.6 ± 6.56) ° also improved significantly at 1 month after surgery (28.1 ± 7.32) ° and the last follow-up (27.9 ± 8.11) ° (P < 0.05). No instrument-related complications happened during the follow-up. At the final follow-up, the fusion rate was 89.7%. Complications included dysphagia (7 cases), C_5 palsy (4 cases), axial neck pain (6 cases). Conclusions Anterior cervical discectomy and fusion with self-locking cages is effective and safe for 4-level cervical spondylotic myeloradiculopathy. It allows to restore cervical lordosis and normal cervical alignment with good fusion rate and satisfactory clinical outcomes. However, surgical skills required are relatively high as narrow indications. Difficulties and risks still exist.
引文
[1]Klineberg E.Cervical spondylotic myelopathy:a review of the evidence[J].Orthop Clin North Am,2010,41(2):193-202.
[2]Fu MC,Gruskay JA,Samuel AM,et al.Outpatient anterior cervical discectomy and fusion is associated with fewer shortterm complications in one-and two-level cases:a propensityadjusted analysis[J].Spine,2017,42(14):1044-1049.
[3]Zhu B,Xu Y,Liu X,et al.Anterior approach versus posterior approach for the treatment of multilevel cervical spondylotic myelopathy:a systemic review and meta-analysis[J].Eur Spine J,2013,22(7):1583-1593.
[4]Lin D,Zhai W,Lian K,et al.Anterior versus posterior approach for four-level cervical spondylotic myelopathy[J].Orthopedics,2013,36(11):1431-1436.
[5]Sun YF,Li L,Zhao JH,et al.Comparison between anterior approaches and posterior approaches for the treatment of multilevel cervical spondylotic myelopathy:a meta-analysis[J].Clin Neurol Neurosur,2015,134:28-36.
[6]Sasso RC.Salvage of long strut graft failure following multilevel corporectomy and arthrodesis//Clark CR,eds.The cervical spine[M].4th ed.Philadelphia:Lippincott Williams&Wilkins.2004:1212-1217.
[7]Hussain M,Nassr A,Natarajan RN,et al.Biomechanical effects of anterior,posterior,and combined anterior-posterior instrumentation techniques on the stability of a multilevel cervical corpectomy construct:a finite element model analysis[J].Spine J,2011,11(4):324-330.
[8]Fountas KN,Kapsalaki EZ,Nikolakakos LG,et al.Anterior cervical discectomy and fusion associated complications[J].Spine,2007,32(21):2310-2317.
[9]Ya n B,N i e L.C l i n i c a l c o m p a r i s o n o f Z e r o-p r o f i l e interbodyfusion device and anterior cervical plate interbody fusion intreating cervical spondylosis[J].Int J Clin Exp Med,2015,8(8):13854-13858.
[10]Odom GL,Finney W,Woodhall B.Cervical disk lesions[J].J Am Med Assoc,1958,166(1):23-28.
[11]Bazaz R,Lee MJ,Yoo JU.Incidence of dysphagia after anterior cervical spine surgery:a prospective study[J].Spine,2002,27(22):2453-2458.
[12]Liu B,Zhu D,Yang J,et al.Can multilevel anterior cervical discectomy and fusion result in decreased lifting capacity of the shoulder[J]?World Neurosurg,2015,84(6):1636-1644.
[13]Pitzen TR,Chrobok J,Stulik J,et al.Implant complications,fusion,loss of lordosis,and outcome after anterior cervical plating with dynamic or rigid plates:two year result of a multicentric,randomized,controlled study[J].Spine,2009,34(7):641-646.
[14]Vanek P,Bradac O,Delacy P,et al.Anterior interbody fusion of the cervical spine with Zero-P spacer:prospective comparative study-clinical and radiological results at a minimum 2 years after surgery[J].Spine,2013,38(13):E792-797.
[15]Lee SH,Son ES,Seo EM,et al.Factors determining cervical spine sagittal balance in asymptomatic adults:correlation with spinopelvic balance and thoracic inlet alignment[J].Spine J,2015,15(4):705-712.
[16]Huang DN,Yu M,Xu NF,et al.The relationship between changes of cervical sagittal alignment after anterior cervical discectomy and fusion and spinopelvic sagittal alignment under russouly classification:a four year follow-up study[J].BMCMusculoskelet Disord,2017,18(1):87.
[17]Kim CH,Chung CK,Jahng T,et al.Segmental kyphosis after cervical interbody fusion with stand-alone polyetheretherketone(peek)cages[J].J Spinal Disord Tech,2015,28(1):E17-24.
[18]Gum JL,Glassman SD,Douglas LR,et al.Correlation between cervical spine sagittal alignment and clinical outcome after anterior cervical discectomy and fusion[J].Am J Orthop,2012,41(6):E81-84.
[19]Xiao R,Miller JA,Lubelski D,et al.Quality of life outcomes following cervical decompression for coexisting Parkinson,Sdisease and cervical spondylotic myelopathy[J].Spine J,2016,16(11):1358-1366.
[20]Samartzis D,Shen FH,Matthews DK,et al.Comparison of allograft to autograft in multilevel anterior cervical discectomy and fusion with rigid plate fixation[J].Spine J,2003,3(6):451-459.
[21]Wang JC,McDonough PW,Kanim LE,et al.Increased fusion rates with cervical plating for three-level anterior discectomy and fusion[J].Spine,2001,26(6):643-647.
[22]Bohlman HH,Emery SE,Goodfellow DB,et al.Robinson anterior cervical discectomy and arthrodesis for cervical radiculopathy.L ong-term follow-up of one hundred and twentytwo patients[J].J Bone Joint Surg Am,1993,75(9):1298-1307.
[23]Geisler FH,Caspar W,Pitzen T,et al.Reoperation in patients after anterior cervical plate stabilization in degenera-tive disease[J].Spine,1998,23(8):911-920.
[24]Chang SW,Kakaria UK,Mauqhan PH.Four-level anterior cervical discectomy and fusion with plate fixation:radiographic and clinical results[J].Neurosurgery,2010,66(4):639-646.
[25]Sun M,Kong L,Jiang Z,et al.Microscope enhanced the efficacy and safety of anterior cervical surgery for managing cervical ossification of the posterior longitudinal ligament[J].Med Sci Monit,2017,23:3088-3094.
[26]Bello JP,Pérez-Lorensu PJ,Roldán-Delgado H,et al.Role of multimodal intraoperative neurophysiological monitoring during positioning of patient prior to cervical spine surgery[J].Clin Neurophysiol,2015,126(6):1264-1270.
[2]Fu MC,Gruskay JA,Samuel AM,et al.Outpatient anterior cervical discectomy and fusion is associated with fewer shortterm complications in one-and two-level cases:a propensityadjusted analysis[J].Spine,2017,42(14):1044-1049.
[3]Zhu B,Xu Y,Liu X,et al.Anterior approach versus posterior approach for the treatment of multilevel cervical spondylotic myelopathy:a systemic review and meta-analysis[J].Eur Spine J,2013,22(7):1583-1593.
[4]Lin D,Zhai W,Lian K,et al.Anterior versus posterior approach for four-level cervical spondylotic myelopathy[J].Orthopedics,2013,36(11):1431-1436.
[5]Sun YF,Li L,Zhao JH,et al.Comparison between anterior approaches and posterior approaches for the treatment of multilevel cervical spondylotic myelopathy:a meta-analysis[J].Clin Neurol Neurosur,2015,134:28-36.
[6]Sasso RC.Salvage of long strut graft failure following multilevel corporectomy and arthrodesis//Clark CR,eds.The cervical spine[M].4th ed.Philadelphia:Lippincott Williams&Wilkins.2004:1212-1217.
[7]Hussain M,Nassr A,Natarajan RN,et al.Biomechanical effects of anterior,posterior,and combined anterior-posterior instrumentation techniques on the stability of a multilevel cervical corpectomy construct:a finite element model analysis[J].Spine J,2011,11(4):324-330.
[8]Fountas KN,Kapsalaki EZ,Nikolakakos LG,et al.Anterior cervical discectomy and fusion associated complications[J].Spine,2007,32(21):2310-2317.
[9]Ya n B,N i e L.C l i n i c a l c o m p a r i s o n o f Z e r o-p r o f i l e interbodyfusion device and anterior cervical plate interbody fusion intreating cervical spondylosis[J].Int J Clin Exp Med,2015,8(8):13854-13858.
[10]Odom GL,Finney W,Woodhall B.Cervical disk lesions[J].J Am Med Assoc,1958,166(1):23-28.
[11]Bazaz R,Lee MJ,Yoo JU.Incidence of dysphagia after anterior cervical spine surgery:a prospective study[J].Spine,2002,27(22):2453-2458.
[12]Liu B,Zhu D,Yang J,et al.Can multilevel anterior cervical discectomy and fusion result in decreased lifting capacity of the shoulder[J]?World Neurosurg,2015,84(6):1636-1644.
[13]Pitzen TR,Chrobok J,Stulik J,et al.Implant complications,fusion,loss of lordosis,and outcome after anterior cervical plating with dynamic or rigid plates:two year result of a multicentric,randomized,controlled study[J].Spine,2009,34(7):641-646.
[14]Vanek P,Bradac O,Delacy P,et al.Anterior interbody fusion of the cervical spine with Zero-P spacer:prospective comparative study-clinical and radiological results at a minimum 2 years after surgery[J].Spine,2013,38(13):E792-797.
[15]Lee SH,Son ES,Seo EM,et al.Factors determining cervical spine sagittal balance in asymptomatic adults:correlation with spinopelvic balance and thoracic inlet alignment[J].Spine J,2015,15(4):705-712.
[16]Huang DN,Yu M,Xu NF,et al.The relationship between changes of cervical sagittal alignment after anterior cervical discectomy and fusion and spinopelvic sagittal alignment under russouly classification:a four year follow-up study[J].BMCMusculoskelet Disord,2017,18(1):87.
[17]Kim CH,Chung CK,Jahng T,et al.Segmental kyphosis after cervical interbody fusion with stand-alone polyetheretherketone(peek)cages[J].J Spinal Disord Tech,2015,28(1):E17-24.
[18]Gum JL,Glassman SD,Douglas LR,et al.Correlation between cervical spine sagittal alignment and clinical outcome after anterior cervical discectomy and fusion[J].Am J Orthop,2012,41(6):E81-84.
[19]Xiao R,Miller JA,Lubelski D,et al.Quality of life outcomes following cervical decompression for coexisting Parkinson,Sdisease and cervical spondylotic myelopathy[J].Spine J,2016,16(11):1358-1366.
[20]Samartzis D,Shen FH,Matthews DK,et al.Comparison of allograft to autograft in multilevel anterior cervical discectomy and fusion with rigid plate fixation[J].Spine J,2003,3(6):451-459.
[21]Wang JC,McDonough PW,Kanim LE,et al.Increased fusion rates with cervical plating for three-level anterior discectomy and fusion[J].Spine,2001,26(6):643-647.
[22]Bohlman HH,Emery SE,Goodfellow DB,et al.Robinson anterior cervical discectomy and arthrodesis for cervical radiculopathy.L ong-term follow-up of one hundred and twentytwo patients[J].J Bone Joint Surg Am,1993,75(9):1298-1307.
[23]Geisler FH,Caspar W,Pitzen T,et al.Reoperation in patients after anterior cervical plate stabilization in degenera-tive disease[J].Spine,1998,23(8):911-920.
[24]Chang SW,Kakaria UK,Mauqhan PH.Four-level anterior cervical discectomy and fusion with plate fixation:radiographic and clinical results[J].Neurosurgery,2010,66(4):639-646.
[25]Sun M,Kong L,Jiang Z,et al.Microscope enhanced the efficacy and safety of anterior cervical surgery for managing cervical ossification of the posterior longitudinal ligament[J].Med Sci Monit,2017,23:3088-3094.
[26]Bello JP,Pérez-Lorensu PJ,Roldán-Delgado H,et al.Role of multimodal intraoperative neurophysiological monitoring during positioning of patient prior to cervical spine surgery[J].Clin Neurophysiol,2015,126(6):1264-1270.