颈椎后路单开门椎管扩大椎板成形术与全椎板切除侧块螺钉内固定术治疗无骨折脱位型颈椎脊髓损伤

关键词：颈椎  脊髓损伤  椎板成形术  椎板切除术  内固定器

Keywords:Cervical vertebrae  Spinal cord injuries  Laminoplasty  Laminectomy  Internal fixators

摘要：

      目的 比较颈椎后路单开门椎管扩大椎板成形术与全椎板切除侧块螺钉内固定术治疗无骨折脱位型颈椎脊髓损伤（CSCI）的临床疗效。方法 采用倾向性评分匹配法（PSM）回顾性分析2018年5月—2022年12月收治的27例无骨折脱位型CSCI患者资料，其中17例采用颈椎后路单开门椎管扩大椎板成形术治疗（A组），10例采用颈椎后路全椎板切除侧块螺钉内固定术治疗（B组）。记录2组患者手术时间、住院时间、术中出血量及颈椎矢状位参数[C_2~7 Cobb角、颈椎曲度和C_2~7矢状面垂直轴（SVA）]。采用视觉模拟量表（VAS）评分评估颈部轴性疼痛程度。采用美国脊髓损伤协会（ASIA）评分评估脊髓神经功能。采用脊髓独立性评估（SCIM）评分、健康调查简表（SF-36）评分、欧洲五维健康量表（EQ-5D）评分评估患者生活质量。结果 所有手术顺利完成，所有患者随访时间> 24个月。2组手术时间、住院时间、术中出血量差异均无统计学意义（P > 0.05）。2组术后24个月颈痛VAS评分较术前明显改善，且A组改善优于B组，差异均有统计学意义（P < 0.05）。B组SF-36评分改善优于A组，差异有统计学意义（P < 0.05）；2组的ASIA、SCIM和EQ-5D评分改善差异均无统计学意义（P > 0.05）。术后24个月，A组C_2~7 Cobb角显著低于术前，B组显著高于术前，差异均有统计学意义（P < 0.05）；A组颈椎曲度显著高于术前，差异有统计学意义（P < 0.05），B组术后与术前差异无统计学意义（P > 0.05）；A组C_2~7 SVA略高于术前，B组略低于术前，差异均无统计学意义（P > 0.05）。2组颈椎矢状位参数（C_2~7 Cobb角、颈椎曲度和C_2~7 SVA）变化值组间差异均有统计学意义（P < 0.05）。结论 对于多节段无骨折脱位型CSCI，2种术式在恢复神经功能方面疗效相当，颈椎后路单开门椎管扩大椎板成形术在提升患者生活质量方面表现更佳，颈椎后路全椎板切除侧块螺钉内固定术在维持矢状面平衡方面更为可靠。应根据患者预期生活质量和并发症情况进行个性化术式选择。

Abstract:

      Objective To compare the therapeutic effects between cervical posterior single-door laminoplasty and laminectomy with lateral mass screw fixation in the treatment of cervical spinal cord injury（CSCI） without fracture and dislocation. Methods From May 2018 to December 2022，the data of 27 patients with CSCI without fracture and dislocation were analyzed retrospectively using propensity score matching（PSM）. Among them，17 patients were treated with cervical posterior single-door laminoplasty（group A），and the remaining 10 with cervical posterior laminectomy with lateral mass screw fixation（group B）. The operation time，hospital stay，intraoperative blood loss and cervical sagittal parameters（C₂-₇ Cobb angle，cervical curvature and C₂-₇ sagittal vertical axis[SVA]） of the 2 groups were recorded. The intensity of cervical pain was evaluated using the visual analogue scale（VAS） score. The spinal nerve function was assessed using the American Spinal Injury Association（ASIA） score. The spinal cord independence measure（SCIM） score，the 36-item short-form health survey（SF-36） score，and the EuroQol five-dimensional health scale（EQ-5D） score were used to evaluate the patients’ quality of life. Results All the surgeries were successfully completed，and all the patients were followed-up for more than 24 months. There were no statistically significant differences in the operation time，hospital stay and intraoperative blood loss between the 2 groups（P > 0.05）. In both groups，the VAS scores of neck pain at postoperative 24 months showed significant improvement compared to the preoperative levels，and group A showed better improvement than group B，with statistically significant differences（P < 0.05）. The improvement of SF-36 scores in group B was better than that in group A，and the difference was statistically significant（P < 0.05）. There were no statistically significant differences in the improvement of ASIA score，SCIM score，and EQ-5D score between the 2 groups（P > 0.05）. At postoperative 24 months，the C₂-₇ Cobb angle in group A was significantly lower than the preoperative level，while in group B was significantly higher than the preoperative level，and the differences were statistically significant（P < 0.05）；and the cervical curvature in group A was significantly higher than the preoperative level，and the difference was statistically significant（P < 0.05），while there was no statistically significant difference in group B（P > 0.05）；and the C₂-₇ SVA in group A was slightly higher than the preoperative level，while in group B was slightly lower than the preoperative level，but the differences were not statistically significant（P > 0.05）. The change of cervical sagittal parameters（C₂-₇ Cobb angle，cervical curvature and C₂-₇ SVA） between the 2 groups were statistically significant（P < 0.05）. Conclusions For the multi-segment CSCI without fracture and dislocation，the 2 surgical methods have comparable efficacy in restoring neurological function. The cervical posterior single-door laminoplasty has better performance in improving patients’quality of life，while the cervical posterior laminectomy with lateral mass screw fixation is more reliable in maintaining sagittal balance. Personalized surgical procedure selection should be based on the patient’s expected quality of life and complications situation.