王麒翔 于洋
[摘要] 目的 比較前后路手術(shù)治療頸椎后縱韌帶骨化老年患者的療效并分析影響手術(shù)效果的因素。 方法 本研究將回顧性分析2016年1月至2020年1月在錦州醫(yī)科大學(xué)附屬第一醫(yī)院行手術(shù)治療的老年后縱韌帶骨化患者32例,根據(jù)術(shù)式的不同分為行前路減壓融合術(shù)的前路組15例;行后路單開門椎管擴(kuò)大成形術(shù)的后路組17例,采用日本骨科協(xié)會(huì)評(píng)分(Japanese orthopaedic association,JOA)及疼痛數(shù)字等級(jí)評(píng)分(Numerical Rating Scale,NRS)來評(píng)估手術(shù)療效,比較兩組手術(shù)時(shí)間、術(shù)中出血量、住院時(shí)間、并發(fā)癥情況,分析手術(shù)療效的影響因素。 結(jié)果 兩組患者手術(shù)后JOA評(píng)分均明顯提高(P<0.01)、術(shù)后神經(jīng)改善率無統(tǒng)計(jì)學(xué)差異(P>0.05)、術(shù)后NRS評(píng)分降低(P<0.01),前路組術(shù)中出血量少于后路組(P<0.05),但后路組的手術(shù)時(shí)間較前路組的短(P<0.05),兩組間住院時(shí)間比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05),術(shù)前后路組患者骨化節(jié)段數(shù)多于前路組(P<0.01),兩組的年齡、性別、并發(fā)癥等方面比較,差異無統(tǒng)計(jì)學(xué)意義(P>0.05),在兩種術(shù)式中,男性患者較女性患者術(shù)后神經(jīng)改善率低(P<0.01),術(shù)前JOA評(píng)分<10分患者較≥10分患者的術(shù)后神經(jīng)改善率低(P<0.01)、術(shù)前脊髓高信號(hào)患者較無高信號(hào)患者術(shù)后神經(jīng)改善率低(P<0.01)。 結(jié)論 前路減壓融合術(shù)與后路單開門椎管擴(kuò)大成形術(shù)對(duì)治療頸椎后縱韌帶骨化老年患者均能取得滿意效果;患者男性、術(shù)前JOA低評(píng)分、脊髓高信號(hào)是導(dǎo)致手術(shù)療效差的影響因素。
[關(guān)鍵詞] 頸椎后縱韌帶骨化;前路手術(shù);后路手術(shù);手術(shù)療效
[中圖分類號(hào)] R445? ? ? ? ? [文獻(xiàn)標(biāo)識(shí)碼] B? ? ? ? ? [文章編號(hào)] 1673-9701(2021)14-0084-04
Comparison of the efficacy of anterior and posterior operation in elderly patients with ossification of cervical posterior longitudinal ligament and its influencing factors
WANG Qixiang1? ?YU Yang2
1.Faculty of Graduate, Jinzhou Medical University, Liaoning, Jinzhou? ?121000, China; 2.Department of Spinal Surgery, The First Affiliated Hospital of Jinzhou Medical University, Liaoning, Jinzhou? ?121000, China
[Abstract] Objective To compare the curative effects of anterior and posterior operation for elderly patients with ossification of cervical posterior longitudinal ligament (OPLL), and to analyze the factors affecting the surgical effect. Methods 32 elderly patients with ossification of OPLL who underwent surgery in the First Affiliated Hospital of Jinzhou Medical University from January 2016 to January 2020 were retrospectively analyzed. According to different surgical methods, they were divided into the anterior group (anterior cervical decompression and fusion, n=15) and the posterior group (open-door laminoplasty through posterior approach, n=17). Seventeen patients in the posterior group were evaluated by Japanese Orthopaedic Association (JOA) and Numerical Rating Scale (NRS). The operation time, intraoperative blood loss, hospitalization time and complications were compared between the two groups, and the influencing factors of the operation effect were analyzed. JOA scores of patients in both groups were significantly improved after operation (P<0.01). There was no significant difference in the postoperative nerve improvement rate(P>0.05). NRS score decreased after operation(P<0.01). The amount of bleeding in the anterior group was less than that in the posterior group (P<0.05), but the operation time of posterior group was shorter than that of anterior group(P<0.05). There was no significant difference in hospital stay between the two groups(P>0.05). The number of ossification segments in posterior group was more than that in anterior group before operation(P<0.01). There was no significant difference in age, gender and complications between the two groups (P>0.05). Among the two operative methods, the postoperative neurological improvement rate of male patients was lower than that of female patients(P<0.01). The neurological improvement rate of patients with preoperative JOA score less than 10 points was lower than that of patients with score ≥10(P<0.01). The neurological improvement rate of patients with high signal intensity of spinal cord before operation was lower than that of patients without high signal intensity after operation(P<0.01). Conclusion Anterior cervical decompression and fusion and open-door laminoplasty through posterior approach can achieve satisfactory results in the treatment of elderly patients with ossification of CPLL. Male patients, low preoperative JOA score and high signal intensity of spinal cord are the influencing factors leading to poor surgical effects.
[Key words] Ossification of cervical posterior longitudinal ligament; Anterior surgery; posterior surgery; Surgical effect
頸椎后縱韌帶骨化(Ossification of posterior longitudinal ligament,OPLL)是一種病因不明,后縱韌帶異常改變壓迫后方脊髓及神經(jīng)根導(dǎo)致出現(xiàn)相應(yīng)癥狀的疾病,男性多見[1],主要表現(xiàn)為脊髓型頸椎病的癥狀,包括出現(xiàn)四肢的肌力下降、皮膚感覺異常、行走時(shí)出現(xiàn)踩棉花感。我國上海長征醫(yī)院通過對(duì)7210名退行性頸脊髓病患者的CT觀察發(fā)現(xiàn):OPLL的患病率為18.2%,其中男19.73%,女15.65%,好發(fā)年齡主要集中70~79歲[2]。對(duì)于出現(xiàn)癥狀且影響日常生活的OPLL患者,手術(shù)治療是十分必要的,前、后路手術(shù)是目前臨床治療OPLL的常用術(shù)式[3-4],兩者均能取得一定的手術(shù)療效,但是老年OPLL患者往往病情較重,手術(shù)耐受差,選擇哪種術(shù)式仍存在爭(zhēng)議。本研究將比較前路與后路手術(shù)治療老年OPLL患者的療效并分析影響手術(shù)效果的因素,為臨床上治療老年頸椎OPLL患者術(shù)式的選擇提供參考。
1 對(duì)象與方法
1.1研究對(duì)象
選擇2016年1月至2020年7月錦州醫(yī)科大學(xué)附屬第一醫(yī)院收治的老年OPLL患者32例,根據(jù)手術(shù)方式的不同分為前路(15例)、后路(17例)兩組,其中前路組男10例,女5例,后路組男11例,女6例,兩組患者一般情況資料見表1。納入標(biāo)準(zhǔn):(1)2016年1月至2020年1月被診斷為頸椎OPLL并在我院接受手術(shù)治療的患者;(2)隨訪時(shí)間至少半年;(3)無脊椎手術(shù)史;(4)無頸椎感染和腫瘤病史;(5)患者年齡≥60周歲;(6)癥狀由頸椎OPLL壓迫脊髓所引起。排除標(biāo)準(zhǔn):(1)有脊柱既往手術(shù)史;(2)有頸椎感染和腫瘤病史;(3)隨訪時(shí)間不滿半年;(4)不符合頸椎OPLL癥的診斷標(biāo)準(zhǔn)[5];(5)不能準(zhǔn)確的獲取術(shù)后相關(guān)數(shù)據(jù);(6)其他部位OPLL。(7)患者年齡<60周歲。
1.2 方法
全部手術(shù)均由同一主刀醫(yī)師完成。
1.2.1 前路組? 患者麻醉成功后,取仰臥位,消毒鋪巾,沿前路頸部橫紋逐層切開,對(duì)受壓節(jié)段實(shí)施減壓,擴(kuò)大減壓直達(dá)骨化灶,直視下用咬骨鉗將骨化灶咬除,四周充分游離,后行自體髂骨或鈦網(wǎng)融合及鋼板固定,清洗傷口,放置引流管,逐層縫合切口。
1.2.2 后路組? 患者麻醉成功后,取俯臥位,消毒鋪巾,沿頸后路正中縱向切口逐層切開,暴露C3~C7關(guān)節(jié)突與椎板交界處,選擇脊髓受壓嚴(yán)重側(cè)“開門”,用超聲骨刀沿小關(guān)節(jié)內(nèi)側(cè)緣切開椎板全層,將對(duì)側(cè)相節(jié)段作為門軸側(cè),保留內(nèi)層皮質(zhì)骨,掀開椎板后清除粘連部分,在開門側(cè)用鈦板固定,清洗傷口,放置引流管,逐層縫合切口。
1.3 觀察指標(biāo)
(1)比較兩組患者的年齡、性別、骨化物范圍情況。(2)比較兩組患者的手術(shù)時(shí)間、出血量、并發(fā)癥、手術(shù)前后NRS[6](疼痛數(shù)字等級(jí)評(píng)分:將患者疼痛程度用0~10數(shù)字表示,由患者自行選擇疼痛數(shù)字,0代表無痛,10代表生不如死的疼痛)、JOA(根據(jù)患者的四肢、軀干感覺運(yùn)動(dòng)功能及膀胱功能對(duì)患者進(jìn)行評(píng)分,最低分為0,最高分為17,評(píng)分越高代表患者神經(jīng)功能越好)評(píng)分,并計(jì)算末次隨訪神經(jīng)改善率(%)=(末次隨訪JOA評(píng)分-術(shù)前JOA評(píng)分)/(17-術(shù)前JOA評(píng)分)×100%[7]。(3)分析手術(shù)療效的影響因素。
1.4 統(tǒng)計(jì)學(xué)分析
所有數(shù)據(jù)均使用SPSS 22.0統(tǒng)計(jì)學(xué)軟件進(jìn)行數(shù)據(jù)分析。計(jì)量資料采用t檢驗(yàn)。計(jì)數(shù)資料采用χ2檢驗(yàn)。P<0.05表示差異有統(tǒng)計(jì)學(xué)意義。
2 結(jié)果
2.1 圍手術(shù)期情況
兩組患者均順利完成手術(shù),前路組術(shù)中出血量少于后路組(P<0.05),但手術(shù)時(shí)間較后路組長(P<0.05);兩組間住院時(shí)間無統(tǒng)計(jì)學(xué)差異(P>0.05),前路組中并發(fā)腦脊液漏2例,C5神經(jīng)根麻痹3例,后路組中并發(fā)切口感染2例,腦脊液漏3例,C5神經(jīng)根麻痹1例,兩組間并發(fā)癥發(fā)生情況比較,無統(tǒng)計(jì)學(xué)差異(P>0.05)。
2.2隨訪情況
兩組患者末次隨訪時(shí)較手術(shù)前JOA評(píng)分均明顯提高(P<0.01),NRS評(píng)分較手術(shù)前下降(P<0.05),疼痛得以緩解,兩組間術(shù)前、末次隨訪時(shí)JOA評(píng)分、NRS疼痛評(píng)分及神經(jīng)改善率比較,差異無統(tǒng)計(jì)學(xué)意義(P>0.05),兩種術(shù)式均能取得良好的療效。
2.3手術(shù)療效影響因素
分別分析患者性別、年齡、術(shù)前JOA評(píng)分及術(shù)前是否有脊髓高信號(hào)對(duì)術(shù)后神經(jīng)功能改善率的影響,以此來推測(cè)影響手術(shù)療效的影響因素。老年男性患者較女性患者改善率低(P<0.01);術(shù)前JOA評(píng)分越低的老年患者術(shù)后神經(jīng)功能改善率越低(P<0.01);術(shù)前脊髓高信號(hào)術(shù)后改善率差(P<0.01);患者年齡對(duì)術(shù)后神經(jīng)功能影響無統(tǒng)計(jì)學(xué)意義(P>0.05)。
3 討論
目前對(duì)于治療有癥狀頸椎OPLL的術(shù)式選擇仍然存在較大爭(zhēng)議,但實(shí)際臨床工作中后入路較前入路運(yùn)用更多,這可能與后入路術(shù)式療效確切,操作相對(duì)簡單安全,臨床醫(yī)生更容易學(xué)習(xí)有關(guān)。后路手術(shù)雖不能切除骨化灶達(dá)到直接減壓的目的,但其在擴(kuò)大椎管的同時(shí)保留了椎管后方結(jié)構(gòu),維持了脊柱的穩(wěn)定性并且保留部分活動(dòng)度。Nakashima等[8]對(duì)101名行單開門椎管擴(kuò)大成形術(shù)的頸椎OPLL患者做了回顧性分析,發(fā)現(xiàn)術(shù)后10年內(nèi)需要再次手術(shù)的風(fēng)險(xiǎn)百分比為1%,再手術(shù)主要原因是因?yàn)楣腔锢^續(xù)增大。Lee等[9]對(duì)11篇文獻(xiàn)進(jìn)行薈萃分析,共納入行椎管成形術(shù)的頸椎OPLL患者429例,其中術(shù)后骨化進(jìn)展率為62.5%,術(shù)后2年再次出現(xiàn)神經(jīng)根癥狀概率為8.3%,隨著時(shí)間的推移,OPLL會(huì)繼續(xù)發(fā)展,手術(shù)效果會(huì)越來越差。后路手術(shù)的臨床療效是確切的,但有OPLL繼續(xù)進(jìn)展的風(fēng)險(xiǎn),對(duì)于年輕的頸椎OPLL患者不建議行該術(shù)式,以后可能因?yàn)楣腔镌龃髮?dǎo)致需要再次手術(shù)。
前路手術(shù)優(yōu)點(diǎn)是可以直接解除來自脊髓前方的壓迫;手術(shù)創(chuàng)口小,出血量少;有利于維持頸椎生理曲度,并且能恢復(fù)椎間隙高度,減輕神經(jīng)根癥狀,但是其操作相對(duì)復(fù)雜,醫(yī)生學(xué)習(xí)曲線長。Yudoyono等[10]在對(duì)913例頸椎OPLL患者進(jìn)行回顧性研究后發(fā)現(xiàn)前路手術(shù)較后路具有更高的并發(fā)癥發(fā)生率,雖然前路手術(shù)較后路并發(fā)癥發(fā)生率高,但是后路手術(shù)具有更高的手術(shù)切口感染率[11]。本研究發(fā)現(xiàn)兩者并發(fā)癥之間無統(tǒng)計(jì)學(xué)差異,這可能是因?yàn)闃颖玖窟^少導(dǎo)致的。有學(xué)者建議對(duì)于椎管占位率≥50%或骨化范圍小的患者應(yīng)首選前路手術(shù)[12-13],這與本研究的觀點(diǎn)相吻合,也有學(xué)者建議當(dāng)椎管占位率≥60%時(shí)選擇前路手術(shù)[14]。Moon等[15]在對(duì)前路與后路手術(shù)治療頸椎OPLL的長短期療效比較的研究中得出,前路術(shù)式可提供更好的長期(>48個(gè)月)療效。有文獻(xiàn)報(bào)道一名行前路手術(shù)的頸椎OPLL患者,術(shù)后1年影像學(xué)檢查未發(fā)現(xiàn)OPLL,但在第2年發(fā)現(xiàn)新發(fā)OPLL并伴有神經(jīng)根癥狀,期間再次行前后路手術(shù),癥狀好轉(zhuǎn)[16],說明前路手術(shù)在將骨化物已切除干凈的情況下仍有復(fù)發(fā)可能,但畢竟這種情況報(bào)道較少,仍然建議年輕頸椎OPLL患者在有條件的情況下首選前路手術(shù)。
綜上所述,前路減壓融合術(shù)與后路單開門椎管擴(kuò)大成形術(shù)對(duì)治療頸椎后縱韌帶骨化老年患者均能取得滿意效果,前路減壓融合術(shù)出血量相對(duì)較少,更適用于骨化節(jié)段少的老年OPLL患者,但手術(shù)難度較大,手術(shù)時(shí)間長;后路單開門椎管擴(kuò)大成形術(shù)手術(shù)時(shí)間短,操作相對(duì)簡單,更適用于骨化節(jié)段多的老年OPLL患者,但術(shù)中出血量較多;男性患者、術(shù)前JOA低評(píng)分、脊髓高信號(hào)是導(dǎo)致手術(shù)療效差的影響因素。老年OPLL患者往往具有病情較重,手術(shù)耐受差等特點(diǎn),在能耐受手術(shù)的情況下,建議首選后路手術(shù)。本研究因納入的樣本量有限,具有一定的局限性,還待以后并大樣本量進(jìn)一步研究。
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(收稿日期:2020-11-12)