目的:比较前路可控前位融合(ACAF)的临床效果,一种新的手术技术,基于2年的随访,采用椎板成形术治疗多节段严重颈椎后纵韧带骨化症(OPLL)。
方法:回顾性分析2015年3月至2017年3月收治的53例(ACAF21例,椎板成形术32例)多节段重度OPLL引起的颈椎病(占位率≥50%)患者的临床资料,比较ACAF组与椎板成形术组的临床资料。手术时间,失血,记录两组的并发症。术前和术后评估影像学参数:X射线上的宫颈曲度,可用于脐带的空间(SAC)和计算机断层扫描(CT)上的占用率(OR),磁共振成像(MRI)上最窄水平的脊髓前后(AP)直径和脊髓弯曲度。日本骨科协会(JOA)评分用于评估神经系统恢复。统计学分析两组间的差异。采用Mann-WhitneyU检验和卡方检验对分类变量进行比较。非配对t检验用于比较连续数据。
结果:所有患者随访至少24个月。ACAF组手术时间更长(286.5vs178.2分钟,P<0.05)。失血量没有显着差异(291.6对318.3mL,P>0.05)。ACAF组较椎板成形术组并发症少(ACAF组C5麻痹1例[4.7%],脑脊液[CSF]漏1例[4.7%];C5麻痹4例[12.5%],2例[6.3%]脑脊液漏出,椎板成形术组和轴性症状4例[12.5%])。末次随访时平均JOA评分(14.6vs12.8,P<0.05)和改善率(63.8%vs47.8%,P<0.05),ACAF组明显优于椎板成形术组。术后OR(16.7%vs40.9%,P<0.05),SAC(150.8对110.5mm2,P<0.05),AP脊髓直径(5.5对4.2毫米,P<0.05),和宫颈前凸(12.7°vs4.7°,P<0.05),ACAF组改善更明显,两组之间有显著差异。值得注意的是,ACAF组MRI显示脊髓弯曲度较好。
结论:这项研究表明,ACAF被认为优于椎板成形术治疗多节段重度OPLL,因为前路直接减压和更好的脊髓弯曲导致令人满意的神经系统结局和低并发症发生率。
OBJECTIVE: To compare the clinical outcomes of anterior controllable antedisplacement fusion (ACAF), a new surgical technique, with laminoplasty for the treatment of multilevel severe cervical ossification of the posterior longitudinal ligament (OPLL) based on a 2-year follow-up.
METHODS: Clinical data of 53 patients (21 by ACAF and 32 by laminoplasty) who have accepted surgery for treatment of cervical myelopathy caused by multilevel severe OPLL (occupying rate ≥ 50%) from March 2015 to March 2017 were retrospectively reviewed and compared between ACAF group and laminoplasty group. Operative time, blood loss, and complications of the two groups were recorded. Radiographic parameters were evaluated pre- and postoperatively: cervical lordosis on X-ray, space available for the cord (SAC) and the occupying ratio (OR) on computed tomography (CT), and the anteroposterior (AP) diameter of the spinal cord at the narrowest level and the spinal cord curvature on magnetic resonance imaging (MRI). Japanese Orthopaedic Association (JOA) scoring was used to evaluate neurologic recovery. Statistical analysis was conducted to analyze the differences between two groups. The Mann-Whitney U test and chi square test were used to compare categorical variables. unpaired t test was used to compare continuous data.
RESULTS: All patients were followed up for at least 24 months. The operative time was longer in ACAF group (286.5 vs 178.2 min, P < 0.05). The blood loss showed no significant difference (291.6 vs 318.3 mL, P > 0.05). Less complications were observed in ACAF group than in laminoplasty group (one case [4.7%] of C5 palsy and one case [4.7%] of cerebrospinal fluid [CSF] leakage in ACAF group; four cases [12.5%] of C5 palsy, two cases [6.3%] of CSF leakage, and four cases [12.5%] of axial symptoms in laminoplasty group). The mean JOA score at last follow-up (14.6 vs 12.8, P < 0.05) and the improvement rate (IR) (63.8% vs 47.8%, P < 0.05) in ACAF group were superior to those in laminoplasty group significantly. The postoperative OR (16.7% vs 40.9%, P < 0.05), SAC (150.8 vs 110.5 mm2 , P < 0.05), AP spinal cord diameter (5.5 vs 4.2 mm, P < 0.05), and cervical lordosis (12.7° vs 4.7°, P < 0.05) were improved more considerably in ACAF group, with significant differences between two groups. Notably, the spinal cord on MRI showed a better curvature in ACAF group.
CONCLUSIONS: This study showed that ACAF is considered superior to laminoplasty for the treatment of multilevel severe OPLL as anterior direct decompression and better curvature of the spinal cord led to satisfactory neurologic outcomes and low complication rate.