雙節(jié)段脊髓型頸椎病經(jīng)ACDF手術(shù)治療后頸椎矢狀平衡變化
發(fā)布時(shí)間：2019-05-15 12:13
【摘要】：目的:脊髓型頸椎病(CSM)由于椎體不穩(wěn),靜態(tài)、動(dòng)態(tài)壓迫因素致脊髓受損,引起相應(yīng)部位感覺、運(yùn)動(dòng)障礙。常為多節(jié)段受累,發(fā)病較慢,40~60歲多見。頸椎矢狀失平衡與頸椎病發(fā)病有著密切關(guān)系,頸椎矢狀參數(shù)可評估其嚴(yán)重程度。但是,頸椎矢狀參數(shù)由于X線片顯示不清,照射與手術(shù)矯形體位不一致,限制其臨床應(yīng)用;同時(shí)目前缺乏對于頸前路雙節(jié)段手術(shù)后矢狀平衡的研究。本研究的目的是通過頸椎CT矢狀重建圖像測量術(shù)前、術(shù)后頸椎矢狀參數(shù),比較并探討術(shù)后參數(shù)變化同頸前路雙節(jié)段患者術(shù)后功能恢復(fù)的關(guān)系。方法:納入2012年1月至2014年7月在我院脊柱科收治的雙節(jié)段脊髓型頸椎病患者共58人,病變節(jié)段為頸5/6、頸6/7,磁共振圖像示病變同癥狀定位節(jié)段相符。手術(shù)指征:1、頸椎病出現(xiàn)明顯脊髓、神經(jīng)癥狀,經(jīng)保守治療3個(gè)月無效的患者;2、外傷或其他因素作用導(dǎo)致頸椎病突然加重的患者;3、頸椎節(jié)段不穩(wěn),頸痛明顯,四肢運(yùn)動(dòng)功能障礙。排除標(biāo)準(zhǔn):1、既往頸椎手術(shù)病史;2、椎體骨質(zhì)破壞、椎體炎癥病變活動(dòng)期及難以耐受手術(shù)的基礎(chǔ)病;3、脊髓變性、肌肉萎縮。共56名患者達(dá)到相應(yīng)標(biāo)準(zhǔn)。所有病人均行頸前路椎間盤切除植骨融合內(nèi)固定術(shù)。對病人術(shù)后1、3、6、12月及每年定期隨訪。所有患者于術(shù)前及隨訪時(shí)均行影像學(xué)檢查及臨床評估,影像學(xué)檢查應(yīng)用頸椎CT矢狀重建圖,范圍包括第一胸椎完整像及胸骨柄。對術(shù)前及末次隨訪結(jié)果進(jìn)行分析,影像學(xué)參數(shù)涉及頸椎矢狀參數(shù),包括T1 slope(胸1傾斜角)、C2-7 SVA(頸2-7垂直軸距離)、C2-7 Cobb。臨床指標(biāo)為頸部VAS評分、上肢VAS評分、頸椎JOA評分。按術(shù)前T1 slope中位數(shù)分2組,大于中位數(shù)的為高T1 slope組,小于中位數(shù)的為低T1 slope組;并比較兩組術(shù)后臨床、影像指標(biāo)的差異。比較術(shù)后頸椎矢狀參數(shù)、臨床指標(biāo)的變化。對術(shù)后頸椎各矢狀參數(shù)改變量間,頸椎矢狀參數(shù)改變量與臨床指標(biāo)改變量間進(jìn)行相關(guān)性檢驗(yàn)。數(shù)據(jù)的統(tǒng)計(jì)分析應(yīng)用SPSS16完成,檢驗(yàn)標(biāo)準(zhǔn)為雙側(cè)P值小于0.05。結(jié)果:56名納入研究的患者各數(shù)據(jù)完整。一般資料:患者平均年齡為60.9歲(40-78歲)。男性為38名,女性為18名。平均隨訪時(shí)間為29.1月(12-36月)。頸椎矢狀參數(shù)發(fā)生如下變化,C2-C7 SVA由25.16±1.01 mm降為20.75±1.64 mm,C2-7 Cobb角由19.20±1.04增至24.05±0.84,T1 slope由23.38±4.27增至25.66±2.09。所有頸椎矢狀參數(shù)術(shù)后變化均有統(tǒng)計(jì)學(xué)意義(P0.01)。臨床指標(biāo)在術(shù)后有以下變化,頸部VAS評分由4.14±0.84降至2.34±1.49,上肢VAS評分由1.35±0.94降至1.04±0.87,頸椎JOA評分由10.14±2.68增至14.77±1.70。頸部VAS評分、頸椎JOA評分術(shù)后改變均有統(tǒng)計(jì)學(xué)意義(P0.01),上肢VAS評分術(shù)后變化無明顯統(tǒng)計(jì)學(xué)差異(P=0.82)。根據(jù)術(shù)前T1 slope的中位數(shù)分為2組。兩組患者術(shù)后脊髓的功能得到改善,JOA評分由術(shù)前的10.14±2.68,增加至末次隨訪時(shí)為14.77±1.70。高T1 slope組范圍為23.4-43.6°,均值為26.65±3.47°;共有28人,其中男性18人,女性10人,平均年齡為61.66±7.31歲。低T1 slope組范圍為12.7-23.4°,均值為20.13±1.76°;共有28人,其中男性20人,女性8人,平均年齡為60.14±7.83歲。兩組年齡、性別比無明顯統(tǒng)計(jì)學(xué)差異(P=0.74)、(P=0.62)。比較兩組頸椎矢狀參數(shù),高T1 slope組術(shù)后C2-7 SVA(21.68±1.12)大于低T1 slope組(19.82±1.56),差異有統(tǒng)計(jì)學(xué)差異(P0.01);高T1 slope組術(shù)后C2-7 Cobb(24.18±0.60)與低T1 slope組(23.93±1.04),差異無明顯統(tǒng)計(jì)學(xué)差異(P=0.89)。比較兩組術(shù)后臨床功能恢復(fù),高T1 slope組術(shù)后JOA評分(13.89±1.91)、JOA改善率(52.8%)小于低T1 slope組(15.64±0.83)、(78.7%),差異均有統(tǒng)計(jì)學(xué)意義(P0.01);高T1 slope組術(shù)后頸部VAS(2.00±1.49)、上肢VAS評分(0.75±0.84)與低T1 slope組(2.68±1.44)、(1.32±0.82),差異均無統(tǒng)計(jì)學(xué)意義(P=0.66)、(P=0.31)。在頸椎各矢狀參數(shù)改變量間進(jìn)行相關(guān)性分析,C2-7 SVA與C2-7 Cobb存在負(fù)相關(guān)(r=-0.45,P0.01),C2-7 Cobb與T1 slope存在正相關(guān)(r=0.26,P0.01)。在頸椎矢狀參數(shù)改變量同臨床指標(biāo)改變量比較中,C2-7 SVA與JOA評分存在負(fù)相關(guān)(r=-0.31,P0.01),C2-7 SVA與JOA改善率存在負(fù)相關(guān)(r=-0.17,P0.01)。C2-7 Cobb與頸部VAS評分存在負(fù)相關(guān)(r=-0.42,P0.01)。結(jié)論:頸椎矢狀參數(shù)同脊柱矢狀平衡密切相關(guān)。當(dāng)頸椎后方結(jié)構(gòu)無破壞時(shí),頸椎通過增加前凸平衡T1 slope造成的頸椎前傾。ACDF術(shù)后頸椎前傾不大,可人為增加頸椎前凸。頸椎矢狀平衡可以預(yù)測脊髓型頸椎病人的臨床預(yù)后。通過分組比較,高T1 slope的患者術(shù)后臨床癥狀恢復(fù)較差。脊柱外科醫(yī)生應(yīng)該加深對頸椎矢狀參數(shù)的了解,通過評估患者術(shù)前矢狀失平衡的輕重,來制定個(gè)人化的手術(shù)方案。
[Abstract]:Objective: The cervical spondylotic myelopathy (CSM), due to the instability of the vertebral body, the static and dynamic compression factors, caused the spinal cord to be damaged, causing the corresponding parts to feel and dyskinesia. It is often involved in multiple sections, with slow onset, and more in 40-60 years of age. Cervical sagittal balance is closely related to the pathogenesis of cervical spondylosis, and the sagittal parameters of the cervical spine can be used to assess the severity of cervical spondylosis. However, the sagittal parameters of the cervical spine are not clear due to the X-rays, and the irradiation is not consistent with the orthopedic position of the operation, and the clinical application is limited; meanwhile, the study on the sagittal balance after the operation of the anterior cervical double-section is not currently available. The aim of this study was to compare and discuss the relationship between the postoperative parameters and the postoperative functional recovery of the patients with the anterior and posterior segment of the cervical spine by the sagittal reconstruction of the cervical spine by the sagittal reconstruction of the cervical spine. Methods: A total of 58 patients with cervical spondylotic myelopathy from January 2012 to July 2014 were treated with two sections of cervical spondylotic myelopathy. The level of the lesion was 5/6 and the neck was 6/7. Indications of operation:1. The cervical spondylosis has obvious spinal cord and neurological symptoms, and is treated with conservative treatment for 3 months;2, the effect of trauma or other factors leads to a sudden increase of cervical spondylosis;3. the cervical segment is unstable, the neck pain is obvious, and the limbs motion dysfunction. Exclusion criteria:1, history of previous cervical surgery;2, vertebral bone destruction, active and hard-to-operate underlying disease in the vertebral body;3, spinal degeneration, muscle atrophy. A total of 56 patients met the appropriate criteria. All patients underwent anterior cervical discectomy and fusion with internal fixation. The patients were followed up at 1,3,6, and 12 months after operation and regular follow-up. Imaging and clinical evaluation were performed at the pre-operative and follow-up of all patients, and the sagittal reconstruction of the cervical spine was applied in the imaging examination, including the first thoracic full image and the sternal stem. The results of the last follow-up were analyzed and the imaging parameters involved the sagittal parameters of the cervical spine, including T1 slope (chest 1 tilt angle), C2-7SVA (neck 2-7 vertical axis distance), C2-7Cobb. The clinical indicators were the neck VAS score, the upper limb VAS score, and the cervical JOA score. The median was higher than that of the high T1 slope group, and the difference between the two groups of post-operative clinical and image indexes was compared. The changes of the sagittal and clinical parameters of the cervical spine were compared. The relationship between the changes of the sagittal and sagittal parameters of the cervical spine and the change of the clinical index was carried out. The statistical analysis of the data was completed using the SPSS16 and the test criteria were two-sided P-values of less than 0.05. Results: The data of 56 patients who were included in the study were complete. General data: The average age of the patient was 60.9 years (40-78 years). The male is 38 and the female is 18. The mean follow-up time was 29.1 months (12-36 months). The sagittal parameters of the cervical spine were changed as follows. The C2-C7 SVA was reduced from 25.16-1.01 mm to 20.75-1.64 mm, and the C2-7 Cobb angle was increased from 19.20-1.04 to 24.05-0.84, and T1 slope increased from 23.38-4.27 to 25.66-2.09. All the changes of the sagittal parameters of the cervical spine were statistically significant (P0.01). The clinical index had the following changes after operation, and the VAS score of the neck decreased from 4.14 to 2.34 and 1.49, and the VAS score of the upper limb was decreased from 1.35 to 1.04 to 1.04 and the cervical JOA score increased from 10.14 to 14.77 to 1.70. The VAS scores of the neck and the postoperative changes of the JOA score of the cervical spine were of statistical significance (P0.01). There was no significant difference in the postoperative changes of the VAS scores of the upper limbs (P = 0.82). The median of the pre-op T1 lope was divided into 2 groups. The function of the spinal cord in the two groups was improved, and the JOA score increased from 10.14 to 2.68 before the operation and 14.77 to 1.70 at the last follow-up. The high T1 slope group ranged from 23.4 to 43.6 擄 with a mean value of 26.65 to 3.47 擄; a total of 28, including 18 males and 10 females, with an average age of 61.66 and 7.31 years. The low T1 slope group ranged from 12.7 to 23.4 擄 with a mean value of 20.13 to 1.76 擄; a total of 28, including 20 males and 8 females, with an average age of 60.14 to 7.83 years. There was no significant difference in sex ratio between the two groups (P = 0.74) (P = 0.62). The sagittal and sagittal parameters of the two groups were compared. The postoperative C2-7SVA (21.68-1.12) was higher than that of the low T1-lope (19.82-1.56) group, and the difference was statistically different (P0.01). The difference between C2-7Cobb (24.18-0.60) and the low-T1-lope (23.93-1.04) in the high-T1-lope group was no significant difference (P = 0.89). The postoperative JOA score (13.89% 1.91) and the improvement rate of JOA (52.8%) were lower than that of the low T1 slope (15.64-0.83), (78.7%), and the difference was statistically significant (P 0.01), and the neck VAS (2.00-1.49) in the high T1-lope group. The VAS score of upper extremity (0.75-0.84) and the low T1-lope (2.68-1.44), (1.32-0.82), no significant difference (P = 0.66), (P = 0.31). There was a negative correlation between C2-7SVA and C2-7Cobb (r =-0.45, P0.01) and the positive correlation between C2-7Cobb and T1 slope (r = 0.26, P0.01). There was a negative correlation between C2-7SVA and JOA (r =-0.31, P0.01), and there was a negative correlation between C2-7SVA and JOA (r =-0.17, P0.01). There was a negative correlation between C2-7Cobb and the neck VAS score (r =-0.42, P0.01). Conclusion: The sagittal parameters of the cervical spine are closely related to the sagittal balance of the spine. When the posterior structure of the cervical vertebra is not damaged, the cervical vertebra anteversion by increasing the front convex balance T1 slope. The anterior cervical anteversion of the ACDF is not small, and the lordosis of the cervical spine can be artificially increased. The sagittal balance of the cervical spine can predict the clinical outcome of the cervical spondylotic myelopathy. By grouping, the post-operative clinical symptoms of high T1-lope were poor. The spinal surgeon should deepen the understanding of the sagittal parameters of the cervical spine and develop a personalized surgical protocol by assessing the severity of the pre-operative sagittal balance of the patient.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2015
【分類號】：R687.3
本文編號：2477496
[Abstract]:Objective: The cervical spondylotic myelopathy (CSM), due to the instability of the vertebral body, the static and dynamic compression factors, caused the spinal cord to be damaged, causing the corresponding parts to feel and dyskinesia. It is often involved in multiple sections, with slow onset, and more in 40-60 years of age. Cervical sagittal balance is closely related to the pathogenesis of cervical spondylosis, and the sagittal parameters of the cervical spine can be used to assess the severity of cervical spondylosis. However, the sagittal parameters of the cervical spine are not clear due to the X-rays, and the irradiation is not consistent with the orthopedic position of the operation, and the clinical application is limited; meanwhile, the study on the sagittal balance after the operation of the anterior cervical double-section is not currently available. The aim of this study was to compare and discuss the relationship between the postoperative parameters and the postoperative functional recovery of the patients with the anterior and posterior segment of the cervical spine by the sagittal reconstruction of the cervical spine by the sagittal reconstruction of the cervical spine. Methods: A total of 58 patients with cervical spondylotic myelopathy from January 2012 to July 2014 were treated with two sections of cervical spondylotic myelopathy. The level of the lesion was 5/6 and the neck was 6/7. Indications of operation:1. The cervical spondylosis has obvious spinal cord and neurological symptoms, and is treated with conservative treatment for 3 months;2, the effect of trauma or other factors leads to a sudden increase of cervical spondylosis;3. the cervical segment is unstable, the neck pain is obvious, and the limbs motion dysfunction. Exclusion criteria:1, history of previous cervical surgery;2, vertebral bone destruction, active and hard-to-operate underlying disease in the vertebral body;3, spinal degeneration, muscle atrophy. A total of 56 patients met the appropriate criteria. All patients underwent anterior cervical discectomy and fusion with internal fixation. The patients were followed up at 1,3,6, and 12 months after operation and regular follow-up. Imaging and clinical evaluation were performed at the pre-operative and follow-up of all patients, and the sagittal reconstruction of the cervical spine was applied in the imaging examination, including the first thoracic full image and the sternal stem. The results of the last follow-up were analyzed and the imaging parameters involved the sagittal parameters of the cervical spine, including T1 slope (chest 1 tilt angle), C2-7SVA (neck 2-7 vertical axis distance), C2-7Cobb. The clinical indicators were the neck VAS score, the upper limb VAS score, and the cervical JOA score. The median was higher than that of the high T1 slope group, and the difference between the two groups of post-operative clinical and image indexes was compared. The changes of the sagittal and clinical parameters of the cervical spine were compared. The relationship between the changes of the sagittal and sagittal parameters of the cervical spine and the change of the clinical index was carried out. The statistical analysis of the data was completed using the SPSS16 and the test criteria were two-sided P-values of less than 0.05. Results: The data of 56 patients who were included in the study were complete. General data: The average age of the patient was 60.9 years (40-78 years). The male is 38 and the female is 18. The mean follow-up time was 29.1 months (12-36 months). The sagittal parameters of the cervical spine were changed as follows. The C2-C7 SVA was reduced from 25.16-1.01 mm to 20.75-1.64 mm, and the C2-7 Cobb angle was increased from 19.20-1.04 to 24.05-0.84, and T1 slope increased from 23.38-4.27 to 25.66-2.09. All the changes of the sagittal parameters of the cervical spine were statistically significant (P0.01). The clinical index had the following changes after operation, and the VAS score of the neck decreased from 4.14 to 2.34 and 1.49, and the VAS score of the upper limb was decreased from 1.35 to 1.04 to 1.04 and the cervical JOA score increased from 10.14 to 14.77 to 1.70. The VAS scores of the neck and the postoperative changes of the JOA score of the cervical spine were of statistical significance (P0.01). There was no significant difference in the postoperative changes of the VAS scores of the upper limbs (P = 0.82). The median of the pre-op T1 lope was divided into 2 groups. The function of the spinal cord in the two groups was improved, and the JOA score increased from 10.14 to 2.68 before the operation and 14.77 to 1.70 at the last follow-up. The high T1 slope group ranged from 23.4 to 43.6 擄 with a mean value of 26.65 to 3.47 擄; a total of 28, including 18 males and 10 females, with an average age of 61.66 and 7.31 years. The low T1 slope group ranged from 12.7 to 23.4 擄 with a mean value of 20.13 to 1.76 擄; a total of 28, including 20 males and 8 females, with an average age of 60.14 to 7.83 years. There was no significant difference in sex ratio between the two groups (P = 0.74) (P = 0.62). The sagittal and sagittal parameters of the two groups were compared. The postoperative C2-7SVA (21.68-1.12) was higher than that of the low T1-lope (19.82-1.56) group, and the difference was statistically different (P0.01). The difference between C2-7Cobb (24.18-0.60) and the low-T1-lope (23.93-1.04) in the high-T1-lope group was no significant difference (P = 0.89). The postoperative JOA score (13.89% 1.91) and the improvement rate of JOA (52.8%) were lower than that of the low T1 slope (15.64-0.83), (78.7%), and the difference was statistically significant (P 0.01), and the neck VAS (2.00-1.49) in the high T1-lope group. The VAS score of upper extremity (0.75-0.84) and the low T1-lope (2.68-1.44), (1.32-0.82), no significant difference (P = 0.66), (P = 0.31). There was a negative correlation between C2-7SVA and C2-7Cobb (r =-0.45, P0.01) and the positive correlation between C2-7Cobb and T1 slope (r = 0.26, P0.01). There was a negative correlation between C2-7SVA and JOA (r =-0.31, P0.01), and there was a negative correlation between C2-7SVA and JOA (r =-0.17, P0.01). There was a negative correlation between C2-7Cobb and the neck VAS score (r =-0.42, P0.01). Conclusion: The sagittal parameters of the cervical spine are closely related to the sagittal balance of the spine. When the posterior structure of the cervical vertebra is not damaged, the cervical vertebra anteversion by increasing the front convex balance T1 slope. The anterior cervical anteversion of the ACDF is not small, and the lordosis of the cervical spine can be artificially increased. The sagittal balance of the cervical spine can predict the clinical outcome of the cervical spondylotic myelopathy. By grouping, the post-operative clinical symptoms of high T1-lope were poor. The spinal surgeon should deepen the understanding of the sagittal parameters of the cervical spine and develop a personalized surgical protocol by assessing the severity of the pre-operative sagittal balance of the patient.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2015
【分類號】：R687.3
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