双节段脊髓型颈椎病经ACDF手术治疗后颈椎矢状平衡变化
发布时间：2019-05-15 12:13
【摘要】：目的:脊髓型颈椎病(CSM)由于椎体不稳,静态、动态压迫因素致脊髓受损,引起相应部位感觉、运动障碍。常为多节段受累,发病较慢,40~60岁多见。颈椎矢状失平衡与颈椎病发病有着密切关系,颈椎矢状参数可评估其严重程度。但是,颈椎矢状参数由于X线片显示不清,照射与手术矫形体位不一致,限制其临床应用;同时目前缺乏对于颈前路双节段手术后矢状平衡的研究。本研究的目的是通过颈椎CT矢状重建图像测量术前、术后颈椎矢状参数,比较并探讨术后参数变化同颈前路双节段患者术后功能恢复的关系。方法:纳入2012年1月至2014年7月在我院脊柱科收治的双节段脊髓型颈椎病患者共58人,病变节段为颈5/6、颈6/7,磁共振图像示病变同症状定位节段相符。手术指征:1、颈椎病出现明显脊髓、神经症状,经保守治疗3个月无效的患者;2、外伤或其他因素作用导致颈椎病突然加重的患者;3、颈椎节段不稳,颈痛明显,四肢运动功能障碍。排除标准:1、既往颈椎手术病史;2、椎体骨质破坏、椎体炎症病变活动期及难以耐受手术的基础病;3、脊髓变性、肌肉萎缩。共56名患者达到相应标准。所有病人均行颈前路椎间盘切除植骨融合内固定术。对病人术后1、3、6、12月及每年定期随访。所有患者于术前及随访时均行影像学检查及临床评估,影像学检查应用颈椎CT矢状重建图,范围包括第一胸椎完整像及胸骨柄。对术前及末次随访结果进行分析,影像学参数涉及颈椎矢状参数,包括T1 slope(胸1倾斜角)、C2-7 SVA(颈2-7垂直轴距离)、C2-7 Cobb。临床指标为颈部VAS评分、上肢VAS评分、颈椎JOA评分。按术前T1 slope中位数分2组,大于中位数的为高T1 slope组,小于中位数的为低T1 slope组;并比较两组术后临床、影像指标的差异。比较术后颈椎矢状参数、临床指标的变化。对术后颈椎各矢状参数改变量间,颈椎矢状参数改变量与临床指标改变量间进行相关性检验。数据的统计分析应用SPSS16完成,检验标准为双侧P值小于0.05。结果:56名纳入研究的患者各数据完整。一般资料:患者平均年龄为60.9岁(40-78岁)。男性为38名,女性为18名。平均随访时间为29.1月(12-36月)。颈椎矢状参数发生如下变化,C2-C7 SVA由25.16±1.01 mm降为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。所有颈椎矢状参数术后变化均有统计学意义(P0.01)。临床指标在术后有以下变化,颈部VAS评分由4.14±0.84降至2.34±1.49,上肢VAS评分由1.35±0.94降至1.04±0.87,颈椎JOA评分由10.14±2.68增至14.77±1.70。颈部VAS评分、颈椎JOA评分术后改变均有统计学意义(P0.01),上肢VAS评分术后变化无明显统计学差异(P=0.82)。根据术前T1 slope的中位数分为2组。两组患者术后脊髓的功能得到改善,JOA评分由术前的10.14±2.68,增加至末次随访时为14.77±1.70。高T1 slope组范围为23.4-43.6°,均值为26.65±3.47°;共有28人,其中男性18人,女性10人,平均年龄为61.66±7.31岁。低T1 slope组范围为12.7-23.4°,均值为20.13±1.76°;共有28人,其中男性20人,女性8人,平均年龄为60.14±7.83岁。两组年龄、性别比无明显统计学差异(P=0.74)、(P=0.62)。比较两组颈椎矢状参数,高T1 slope组术后C2-7 SVA(21.68±1.12)大于低T1 slope组(19.82±1.56),差异有统计学差异(P0.01);高T1 slope组术后C2-7 Cobb(24.18±0.60)与低T1 slope组(23.93±1.04),差异无明显统计学差异(P=0.89)。比较两组术后临床功能恢复,高T1 slope组术后JOA评分(13.89±1.91)、JOA改善率(52.8%)小于低T1 slope组(15.64±0.83)、(78.7%),差异均有统计学意义(P0.01);高T1 slope组术后颈部VAS(2.00±1.49)、上肢VAS评分(0.75±0.84)与低T1 slope组(2.68±1.44)、(1.32±0.82),差异均无统计学意义(P=0.66)、(P=0.31)。在颈椎各矢状参数改变量间进行相关性分析,C2-7 SVA与C2-7 Cobb存在负相关(r=-0.45,P0.01),C2-7 Cobb与T1 slope存在正相关(r=0.26,P0.01)。在颈椎矢状参数改变量同临床指标改变量比较中,C2-7 SVA与JOA评分存在负相关(r=-0.31,P0.01),C2-7 SVA与JOA改善率存在负相关(r=-0.17,P0.01)。C2-7 Cobb与颈部VAS评分存在负相关(r=-0.42,P0.01)。结论:颈椎矢状参数同脊柱矢状平衡密切相关。当颈椎后方结构无破坏时,颈椎通过增加前凸平衡T1 slope造成的颈椎前倾。ACDF术后颈椎前倾不大,可人为增加颈椎前凸。颈椎矢状平衡可以预测脊髓型颈椎病人的临床预后。通过分组比较,高T1 slope的患者术后临床症状恢复较差。脊柱外科医生应该加深对颈椎矢状参数的了解,通过评估患者术前矢状失平衡的轻重,来制定个人化的手术方案。
[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 掳 with a mean value of 26.65 to 3.47 掳; 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 掳 with a mean value of 20.13 to 1.76 掳; 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.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R687.3
本文编号：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 掳 with a mean value of 26.65 to 3.47 掳; 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 掳 with a mean value of 20.13 to 1.76 掳; 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.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R687.3
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