脊柱外科杂志  2017, Vol.15 Issue(6): 344-347   PDF    
应用Zero-P行颈前路椎间融合术治疗外伤性颈椎椎间盘突出并脊髓损伤
周锋, 钟传礼, 朱世卿     
重庆市渝北区人民医院脊柱外科, 重庆 401120
摘要: 目的 比较应用Zero-P和钛板并Cage行颈前路椎间融合术治疗外伤性颈椎椎间盘突出并脊髓损伤的临床疗效。方法 回顾性分析本院2012年2月-2015年11月收治的78例外伤性颈椎椎间盘突出并脊髓损伤患者临床资料。其中38例行前路椎间盘切除、钛板并Cage内固定融合(Cage组),40例应用Zero-P行颈前路椎间融合术(Zero-P组)。比较2组患者术前及术后随访期间Frankel分级、颈椎曲度、椎间融合率、吞咽困难发生率等情况。结果 所有患者随访12~37(15.76±3.80)个月。2组患者术后Frankel分级均较术前明显改善,差异有统计学意义(P < 0.05),2组间比较差异无统计学意义(P > 0.05)。2组术后颈椎曲度均较术前明显改善,与术前相比差异有统计学意义(P < 0.05),2组间比较差异无统计学意义(P > 0.05),且至末次随访时颈椎曲度无丢失。术后3个月,Zero-P组融合率高于Cage组,吞咽困难发生率显著低于Cage组,差异有统计学意义(P < 0.05)。末次随访时2组融合率差异无统计学意义(P > 0.05)。结论 传统钛板并Cage内固定融合术与应用Zero-P行椎间融合术治疗外伤性颈椎椎间盘突出并脊髓损伤均可显著改善患者脊髓功能,但Zero-P具有术后早期即可获得较高融合率及术后吞咽困难发生率低的优点。
关键词: 颈椎     椎间盘移位     脊髓损伤     脊柱融合术     内固定器    
Anterior cervical interbody fusion with Zero-P for treatment of traumatic cervical disc herniation with spinal cord injury
ZHOU Feng, ZHONG Chuan-li, ZHU Shi-qing     
Department of Spinal Surgery, Yubei District People's Hospital of Chongqing, Chongqing 401120, China
Abstract: Objective To compare the clinical efficacy of anterior cervical interbody fusion with Zero-P and titanium plate combined with Cage in the treatment of traumatic cervical disc herniation (TCDH) with spinal cord injury. Methods The clinical data of 78 TCDH patients with spinal cord injury from February 2012 to November 2015 were retrospectively analyzed. Thirty-eight patients were treated by anterior cervical discectomy and Cage plate internal fixation and fusion(Cage group), and the other 40 by anterior cervical interbody fusion with Zero-P internal fixator(Zero-P group). Frankel classification, cervical curvature, intervertebral fusion rate and the occurrence of dysphagia were compared between the 2 groups before operation and postoperative follow-up period. Results All the patients were followed up for 12-37(15.76±3.80)months. The Frankel classification was significantly improved compared with the preoperation in the 2 groups, and the difference was statistically significant(P < 0.05);but there was no significant difference between the 2 groups(P > 0.05). The cervical curvature was also significantly improved compared with pre-operation in the 2 groups, and the difference was statistically significant(P < 0.05); but there was no significant difference between the 2 groups(P > 0.05); and there was no loss of the curvature until the final follow-up. Postoperative 3 months, the fusion rate of Zero-P group was higher than that of Cage group, and the incidence of dysphagia was significantly lower than that in Cage group; the difference was statistically significant(P < 0.05). There was no significant difference in fusion rate between the 2 groups at the final follow-up(P > 0.05). Conclusion Anterior cervical interbody fusion with Zero-P and titanium plate combined with Cage are effective treatments for TCDH with spinal cord injury, but the Zero-P internal fixator has advantages of high fusion rate at early post-operation and a lower dysphagia incidence.
Key words: Cervical vertebrae     Intervertebral disc displacement     Spinal cord injuries     Spinal fusion     Internal fixators    

外伤性颈椎脊髓损伤是一种高致残性疾病,患者椎体、韧带及附件受累,脊髓结构功能受到不同程度影响,尤其是存在颈椎椎间盘突出的患者,硬膜外出血等情况会加重,严重者甚至出现肢体瘫痪等症状。前路椎间盘切除、钛板并Cage内固定融合术是治疗颈椎椎间盘突出的传统术式,椎体前方固定钢板可有效避免椎间融合器的移位,提高融合率,但同时也带来了吞咽困难等并发症。2008年以来,采用Zero-P行颈前路椎间融合术开始应用于临床颈椎椎间盘突出症的治疗,研究发现其可减少吞咽困难等并发症的发生[1]。目前,将Zero-P应用于治疗外伤性颈椎椎间盘突出并脊髓损伤的报道并不多见,本研究的目的是比较应用Zero-P和钛板并Cage行颈前路椎间融合术治疗外伤性颈椎椎间盘突出并脊髓损伤的临床疗效。

1 资料与方法 1.1 一般资料

回顾性分析本院2012年2月—2015年11月收治的78例外伤性颈椎椎间盘突出并脊髓损伤患者临床资料,其中男48例,女30例;年龄18~59(45.67±3.98)岁;从受伤至入院时间为2~18(9.06±1.02)h。致伤原因:高空坠落伤25例,交通事故49例,其他4例。所有患者均有不同程度的感觉运动障碍,入院后均行MRI及X线等影像学检查,排除骨折脱位、肿瘤及骨结核等情况。主要损伤节段为C3/C4、C4/C5及C5/C6,其中单节段病变52例,双节段26例。38例行前路椎间盘切除、钛板并Cage内固定融合(Cage组),40例应用Zero-P行颈前路椎间融合术(Zero-P组)。两组患者基线资料相似,具有可比性。

1.2 治疗方法

所有患者均全麻并仰卧位,常规行手术区域消毒,于颈前右侧入路,充分暴露椎体前方及椎间盘,在C形臂X线机透视下确定损伤椎体,将椎间盘切除减压,切除产生压迫症状的骨赘及髓核等。Zero-P组依据椎间隙高度选取Zero-P融合器,采用同种异体骨填充后置入椎间隙,经透视确定内置物位置合适后将锁定钉拧入,关闭切口。Cage组将Caspar撑开器置入椎间隙,把在减压过程中得到的自体骨及人工骨填入Cage后置入椎间隙,前方用钛板固定,留置引流管,关闭切口。两组患者术后均常规应用抗生素、脱水治疗,术后1 d引流量 < 50 mL时将引流管拔除,术后2 d后在颈托保护下下床活动。

1.3 疗效评价

比较两组患者术前及随访期间Frankel分级[2]、颈椎曲度、椎间融合率、吞咽困难发生率。于术前、术后3个月及末次随访时摄颈椎X线片并测量颈椎曲度(Cobb角)。侧位X线片示上下椎体间有骨小梁形成或融合器周围无透亮带为植骨融合标志。BYDS吞咽困难评估标准[3],无:临床未出现进食困难;轻度:偶有进食困难;中度:进食某些食物时困难;重度:进食大部分食物均困难。

1.4 统计学处理

采用SPSS 19.0软件对数据进行统计学分析,连续变量用x±s表示,两组间比较采用Tukey SHD分析;等级资料采用秩和检验;计数资料用率(%)表示,采用χ2检验。对两组Frankel分级、椎间融合率、吞咽困难发生率进行比较,以P < 0.05为差异有统计学意义。

2 结果

所有患者手术过程顺利,术中未发生严重并发症。所有病例均获得随访,随访时间为12 ~ 37(15.76±3.80)个月,随访中未见内置物松动或断裂等情况发生,固定节段均获得骨性融合。

术后12个月,2组患者Frankel分级较术前均显著改善,差异有统计学意义(P < 0.05),Cage组Frankel分级改善率为92.11%(35/38),Zero-P组Frankel分级改善率为92.50%(37/40),组间比较差异无统计学意义(P > 0.05,表 1)。2组术后颈椎曲度均较术前明显改善,与术前相比差异有统计学意义(P < 0.05),2组间比较差异无统计学意义(P > 0.05),且至末次随访时颈椎曲度无丢失(表 2)。2组患者术后末次随访均获得骨性融合,但术后3个月时Zero-P组椎间融合率高于Cage组,差异有统计学意义(P < 0.05,表 2)。Cage组术后有7例(18.42%)患者出现吞咽困难,其中轻度3例,中度4例;末次随访仍有3例患者未缓解。Zero-P组术后3例(7.50%)患者出现轻度吞咽困难,并于术后5个月内自行缓解;2组间比较差异有统计学意义(P < 0.05)。典型病例影像学资料见图 12

表 1 Frankel分级 Table 1 Frankel classification

表 2 统计数据 Table 2 Statistical data

女,52岁,C4/C5/C6椎间盘突出并脊髓损伤,采用Zero-P行椎间融合术a:术前MRI显示C4/C5/C6椎间盘突出并脊髓损伤b:术后48 h X线片示内固定位置良好c:术后3个月X线片示颈椎生理曲度恢复,植骨融合d:术后24个月MRI示内固定位置良好,无断裂 Female, 52 years old, C4/C5/C6 herniation and spinal cord injury, Zero-P interbody fusion a:Preoperative MRI suggests that C4/C5/C6 disc herniation with spinal cord injury b:Roentgenograph at postoperative 48 h shows internal fixation at good position c:Roentgenograph at postoperative 3 months shows recovery of cervical curvature and bone fusion d:MRI at postoperative 24 months shows internal fixation at good position without breakage 图 1 Zero-P组典型病例影像学资料 Figure 1 Imaging data of a typical case in Zero-P group

男,56岁,C3/C4/C5/C6脊髓型颈椎病,采用Cage行椎间融合术a:术前MRI示C3/C4/C5/C6椎间盘突出并脊髓损伤b:术后48 h X线片示内固定位置良好c:术后3个月X线片示颈椎生理曲度稍有恢复,但植骨未融合d:术后24个月MRI示Cage位置良好,植骨融合,颈椎生理曲度改善 Men, 56 years old, C3/C4/C5/C6 cervical spondylotic myelopathy, interbody fusion with Cage a:Preoperative MRI suggests that C3/C4/C5/C6 disc herniation with spinal cord injury b:Roentgenograph at postoperative 48 h shows internal fixation at good position c:Roentgenograph at postoperative 3 months shows little recovery of cervical curvature without bone fusion d:MRI at postoperative 24 months shows that Cage in good position, bone fusion and improvement of cervical physiological lordosis 图 2 Cage组典型病例影像学资料 Figure 2 Imaging data of a typical case in Cage group
3 讨论

近年来随着MRI及CT检查的普及,颈部无骨折脱位报道日渐增加[4],当颈椎突然遭遇外来暴力急性压迫及牵拉时,致使颈椎瞬间产生一过性移位或半脱位。无骨折脱位颈脊髓损伤的实质为外伤致颈椎椎间盘突出产生对脊髓的压迫损伤。手术治疗外伤性颈脊髓损伤的主要目的是解除脊髓压迫,减轻水肿,并使颈椎稳定性得以重建,减少继发性损害,促进功能恢复。颈前路椎间盘切除减压融合术可实现直接减压,促进颈椎生理曲度和椎间隙高度的恢复[5]

有文献报道,传统钛板并Cage内固定融合术与应用Zero-P行椎间融合术治疗颈椎病,在融合率方面无显著差别[6-7],但本研究结果显示Zero-P组术后3个月椎间融合率显著优于Cage组。植骨块的不稳定是影响融合的重要原因,Zero-P系统组织相容性良好,其表面的齿状结构有利于促进颈椎术后稳定性的重建[8],且手术过程中椎体与螺纹之间的咬合力在自攻螺钉的拧入过程中得以加强,提高了即刻稳定性。椎体稳定性的提高有利于颈椎高度及生理曲度的恢复,最大程度减少应力遮挡[9]。此外,Zero-P系统弹性模量和人体骨相当,进一步降低了应力遮挡,加速愈合。

与单纯植骨和置入Cage相比,钛板固定能显著提高植骨融合率,但即使钛板切迹很小,术后仍有可能产生吞咽困难等并发症,可能原因为术中软组织牵拉及钛板对食管产生刺激。而Zero-P系统的设计则兼备了钛板与Cage的优势[10-11],并可以整体置入椎间隙中,很大程度上减少术中软组织牵拉,在获得脊髓功能恢复的同时可显著减少吞咽困难的发生[12]。本研究结果显示,Zero-P组术后吞咽困难发生率显著低于Cage组。

综上所述,传统钛板并Cage内固定融合术与应用Zero-P行椎间融合术治疗外伤性颈椎椎间盘突出并脊髓损伤均可显著改善患者脊髓功能,但Zero-P具有术后早期即可获得较高融合率及术后吞咽困难发生率低的优点。本研究尚存在样本量较少,随访间隔较长等不足,且缺乏远期疗效分析,有待于在下一步研究中完善。

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