【作者】 韩成日；

【导师】 李锋；

【作者基本信息】 华中科技大学 ， 骨科， 2013， 博士

【摘要】 目的：1.比较Centerpiece支撑颈椎后路单开门椎管扩大椎板成形术与锚定法椎板成形术治疗多节段脊髓型颈椎病的疗效2.比较Centerpiece支撑颈椎后路单开门椎管扩大椎板成形术与颈椎前路椎体次全切植骨融合术治疗多节段后纵韧带骨化症的疗效比较3.椎板成形术与颈椎前路减压术治疗多节段脊髓型颈椎病的meta分析方法：1. Centerpiece支撑椎板成形术与锚定法椎板成形术治疗多节段脊髓型颈椎病的疗效比较：将2010年10月至2012年10月在华中科技大学同济医学院附属同济医院确诊为多节段脊髓型颈椎病后手术治疗并成功随访的67名患者为研究对象。其中接受Centerpiece支撑椎板成形术的45例为实验组（C组），接受锚定法椎板成形术的22例为对照组（A组）。观察一般指标（患者的性别、年龄、神经症状时间及随访时间）、神经症状指标（术前、术后JOA分数及术后JOA改善率）、影像学指标（术前术后椎管矢状径、术后椎管扩大率、术前术后ROM及术后ROM保存率）和并发症的发病率及严重程度。改良了椎板成形术后并发症严重程度评价表并应用于本研究评价两组的并发症发病情况。2. Centerpiece支撑椎板成形术与颈椎前路椎体次全切植骨融合术治疗多节段后纵韧带骨化症的疗效比较：2010年10月至2012年10月在华中科技大学同济医学院附属同济医院确诊为多节段后纵韧带骨化症后接受Centerpiece支撑椎板成形术的17例（LAMP组）与接受颈椎前路椎体次全切植骨融合内固定术的11例（CORP组）为研究对象。观察患者的一般指标、神经症状指标、影像学指标及并发症发病情况。3.椎板成形术与颈椎前路减压融合术治疗多节段脊髓型颈椎病的疗效及手术安全性的Meta分析：首先设计关键问题，在EMBASE、PubMed、The Cochrane library数据库采用关键词检索文献，通过纳入排除工作选出符合标准的文献。从选出的文献提取JOA改善率、ROM保存率、手术时间及术中出血量的相关数据造出结果提取表。将相同指标的数据用RevMan5.1软件进行Meta分析，分别评价JOA改善率、手术时间及术中出血量。不能进行数据合并的指标，进行描述性分析。结果：1. Centerpiece支撑椎板成形术与锚定法椎板成形术治疗多节段脊髓型颈椎病的疗效比较：分共有67例符合纳入标准成功随访，其中男48例，女19例，年龄40-79岁，平均年龄为60.3岁。采用Centerpiece支撑方法行手术治疗的患者为45例（C组），采用锚定法行手术治疗的患者为22例（A组）。在患者年龄、随访时间及手术阶段两组之间未发现统计学差异。C组的神经症状出现时间为38.2月，A组为10.4月，有统计学的差异(p<0.05)。C组的术前平均JOA分数为10.1，A组术前平均JOA分数为9.7，两组之间无统计学差异。C组和A组的平均JOA改善率（RR）各为66.4%及61.2%，C组的平均JOA改善率稍微高于A组，但未见统计学差异（p>0.05）。C组的平均手术时间为185.8分钟，A组为191.0分钟；C组和A组的平均出血量为440.0ml及515.9ml，两组之间在手术时间及出血量未发现明显的差异。C组与A组之间在术前及术后C5水平椎管矢状径无明显差异，但术后椎管扩大率有明显统计学的差异：A组均为60.5%，C组均为47.5%（p<0.05）。两组的术前术后ROM保存率无明显差异。两组的术前术后ROM及其保存率无明显差异。67例患者中22例（32.8%）患者到末次随访时有轴性症状，11例（16.4%）患者诉颈椎运动障碍，10例（14.9%）患者有C5神经根麻痹。轴性症状的发病率在C组（33.3%）稍微高于A组（31.8%），但无统计学差异。A组的C5神经根麻痹发病率(27.3%)明显高于C组（8.9%）(p<0.05)。评估颈椎活动障碍症状以患者的主诉为主进行，A组（18.2%）稍微高于C组（15.6%），但无统计学差异。本研究采用新造的颈椎后路椎管成形术并发症重症度评分表，分析并发症的重症度分布情况。有轴性症状的22例患者中50%为Ⅲ度；Ⅴ度为4.5%。颈椎活动障碍症状发现于11例患者中45.4%为Ⅰ度；Ⅲ度为9.1%；Ⅴ度为9.1%。在10例患者C5神经根麻痹存在，其中60%为Ⅱ度；未见可屈肘关节不可抬上臂的病例（Ⅳ度）。2. Centerpiece支撑椎板成形术与锚定法椎板成形术治疗多节段脊髓型颈椎病的疗效比较：确诊后纵韧带骨化，行手术治疗的28名患者中男21例，女7例，平均年龄为60.4岁，平均随访时间为18.6月。其中椎板成形术的患者17例（LAMP组），椎体次全切植骨融合术的患者11例（CORP组）。两组之间平均年龄、随访时间及神经症状出现时间未发现明显的差异。全体28名患者的平均术前JOA分数为9.7，术后恢复到14.4，其JOA改善率为64.2%。CORP组的术前JOA分数为9.0，术后JOA分数为14.3，平均JOA改善率为65.5%。LAMP组的平均术前JOA分数为10.2，术后JOA分数均为14.5，其平均JOA改善率为63.4%。术前、术后JOA分数及JOA改善率两组之间无统计学差异，但CORP组的改善率稍微高于LAMP组。平均术中出血量及手术时间两组之间有明显的差异。CORP组的平均手术时间为332.9分钟明显高于LAMP组的平均手术时间为194.6分钟（(p<0.05）。CORP组的平均出血量也高于LAMP组，分别为754.5ml,376.5ml (p<0.05).两组之间手术节段数有明显的差异：CORP组为2.5节段，LAMP组为4.2节段，CORP组明显少于LAMP组（p<0.05）。在术前术后颈椎X线平片上，全体的平均术前ROM为32.8°，术后平均ROM为19.6°，平均ROM保存率为63.8%。CORP组的术前平均ROM为27.7°，术后减少到16.7°；LAMP组的术前平均ROM为36.0°，术后减少到21.5°。两组的ROM保存率各有63.0%及64.5%，未发现统计学差异。平均术前C2-C7角度在CORP组术前为11.5°术后增加到16.2°，而LAMP组的术前为13.6°术后减少到9.1°（p<0.05）。在末次随访时，CORP组未发生反弓现象，而LAMP组中有3例反弓病例。CORP组在手术当中3例发生脑脊液漏；4例在手术之后诉食管异物感及吞咽困难；出现声音嘶哑的有3例。LAMP组的17名患者中有6例术后发生轴性症状，有3例出现C5神经根麻痹。3.椎板成形术与颈椎前路减压融合术治疗多节段脊髓型颈椎病的疗效及手术安全性的Meta分析：检索后共有7篇纳入系统分析。所纳入的7项研究中5项研究的资料比较LAMP组与ADF组的JOA改善率。异质性检验：Chi2=16.21，I2=69%，P=0.006，两组差异有统计学意义，合并标准化均值差(SMD)为-0.27，95%CI为-0.65~1.10,两组之间的差异无统计学意义，即两组的JOA改善率无明显差异。所纳入的7项研究中5项均报道了手术时间。异质性检验：Chi2=35.93，I2=89%，P<0.00001，两组差异有统计学意义，Meta分析结果显示两组之间的合并SMD为-1.39，95%CI为-2.16~-0.0.62。两组之间的差异有统计学意义，即LAMP组的手术时间短于ADF组。所纳入的7项研究中5项均报道了术中出血量。异质性检验：Chi2=9.39，I2=57%，P=0.05，两组差异有统计学意义，Meta分析结果显示两组之间的合并SMD为-0.63，95%CI为-1.04~-0.33。两组之间的差异有统计学意义，即LAMP组的术中出血量少于ADF组。纳入比较的7项研究中3项报道了实验组与对照组的颈椎活动度变化。但2项研究未报道标准偏差，因此无法进行Meta分析。两项研究的随访时间长于10年，其中一项未发现两组之间的统计学差异，另一项研究报道了LAMP组的ROM保存率低于ADF组（p<0.05）。另一项研究随访时间5年，报道两组之间无统计学差异。结论：1.在多节段脊髓型颈椎病治疗，Centerpiece支撑椎板成形术与锚定法椎板成形术之间的JOA改善率、手术时间及出血量无明显差异；Centerpiece支撑方法比锚定法对椎管扩大率的控制性好、C5神经根麻痹发病率低以及颈椎运动障碍症状发生率低。2.在多节段后纵韧带骨化症治疗，Centerpiece支撑椎管成形术与颈前路椎体次全切植骨融合内固定术相比，手术时间短且出血量少，两组之间JOA改善率无明显差异。在颈椎后凸畸形存在的情况下颈椎前路椎体次全切植骨融合内固定术优于椎板成形术。3. Meta分析示在3年以上随访椎板成形术的神经功能恢复程度与颈前路减压融合术相似，手术时间短、出血量少；两组的ROM保存率无明显差异。更多还原

【Abstract】 Objectives:1. To compare the clinical efficacy of laminoplasty with Centerpiece fixation versusanchor fixation for MCSM.2. To compare the clinical efficacy of laminoplasty with Centerpiece fixation versusanterior cervical subtotal corpectomy and fusion for MOPLL.3. To evaluate clinical efficacy and safety of cervical laminoplasty and anterior cervicaldecompression and fusion for multilevel cervical spondylotic myelopathyMethods：1. Laminoplasties with Centerpiece fixation and with Anchor method for MCSM werecompared. Between October2010and October2012,67patients underwent cervicalexpansive laminoplasty for multilevel cervical spondylotic myelopathy in OrthopedicDepartment of Tongji Hospital were enrolled in this study. Among them45patientsunderwent laminoplasty with Centerpiece fixation (Group C) and22patients underwentlaminoplasty with Anchor fixation (Group A). Common preoperative findings (sex, ageand symptom duration), neurological findings (pre and postoperative JOA scores andrecovery rate of JOA score), radiological findings (pre and postoperative AP diameter,enlargement rate of AP diameter, pre and postoperative ROM and preservation rate ofROM) and incidence of complication were observed. In this part we designed newtables of evaluation of complication severity for laminoplasty and applied to evaluatecomplications of two groups in this study.2. Laminoplasty with Centerpiece and corpectomy with fusion for multilevel OPLL werecompared.28patients who underwent surgical treatment for MOPLL from October 2010to October2012in Orthopaedic department of Tongji hospital, were enrolled inthis study. From them,17patients received laminoplasty with Centerpiece fixation(Group LAMP) and11patients received anterior cervical corpectomy and fusion(Group CORP). The common preoperative clinical findings, neurological findings,radiological findings and complication were observed.3. Clinical efficacies and operation safeties of laminoplasty and ADF for MCSM werecompared by meta-analysis method. After designing the key question, we formulatedthe search strategy. The databases used in this search were EMBASE, PubMed and TheCochrane library. And the literature search was performed with key words. Accordingthe inclusion and exclusion criteria, appropriate literatures were selected out. Thenvalues of recovery rate of JOA score, preservation rate of ROM, operation time andintraoperative blood loss were extracted from selected literatures. These data wereanalysed using the Revman5.1with meta-analysis method. If the indicators could notbe combined, the descriptive systematic review was used to evaluate them.Results:1. In first part,67patients were successfully followed up, including48cases of male and19cases of female. The mean age at surgery was60.3years. Group C was consisted of45cases and Group A was22cases. In preoperative clinical findings, there was nostatistical difference. The symptom period of Group C (38.2months) was significantlylong than of Group A (10.4months). Preoperative JOA score of Group C was10.1andof Group A was9.7, there was no statistical difference between two groups (p>0.05).Recovery rate of JOA score of Group C and Group A were66.4%and61.2%respectively, no significant difference recognized between two groups (p>0.05). Theaverage operation time of Group C (185.8min) similar with Group A (191.0min) andthe intraoperative blood loss had no difference between two groups (440.0mland515.9ml respectively). The sagittal diameters on C5level of two groups had nostatistical difference, but the enlargement rate of AP diameters were significantly different; Group A60.5%，Group C27.5%(p<0.05). In22cases (32.8%) of total67patients appeared axial symptoms, and11cases (16.4%) complained neck movementdisorder, and10cases (14.9%) had C5palsy at the time of last follow-up. Theincidence of C5palsy in Group A (27.3%) significantly higher than in Group C (8.9%)(p<0.05). Former two complications had no statistical difference in incidence. In thecurrent study we applied new designed evaluation table of laminoplasty complicationsand observed severity deviation of complications. Among22cases with axial symptom,50%were grade Ⅲ,4.5%were grade Ⅴ. In11cases with neck movement disorder,45.4%were grade Ⅰ,9.1%were grade Ⅲ,9.1%were grade Ⅴ. In10cases with C5palsy,60%were grade Ⅱ, no observed grade Ⅳ.2. In second part,28patients were enrolled in this study, male21, female7, the mean agewas60.4years, average follow-up time was18.6months. From them, Group LAMPincluded17cases and Group CORP11cases, between two groups there was nosignificant difference in preoperative common clinical findings. The averagepreoperative JOA score of28cases was9.7, which increased to14.4(mean RR of JOAwas64.2%) after surgery. Mean pre and postoperative JOA score of Group CORP were9.0and14.3, and its recovery rate was65.5%. And the pre and postoperative JOA scoreof Group LAMP were10.2and14.5, and its recovery rate was63.4%, which has nostatistical difference with Group CORP. the intraoperative blood loss of Group CORP(754.5ml in average) was larger than Group LAMP (376.5ml in average) and theoperative time of Group CORP (332.9minutes in average) was longer than GroupLAMP (194minutes in average)(p<0.05). The number of segment of Group CORP was2.5and of Group LAMP was4.2(p<0.05). In the cervical X-ray examination, averagepreoperative ROM was32.8o, postoperative was19.6o, the preservation rate of ROMwas63.8%in average. Preoperative ROM of Group CORP of27.7o decreased to16.7oafter surgery and in Group LAMP36.0o before surgery decreased to21.5o after surgery.The preservation rates of two groups were63.0%and64.5%respectively, and there was no significant difference between two groups. Mean C2-C7angle of GroupCORP was11.5o before surgery, which increased to16.2o after surgery, on the contrary,C2-C7angle of Group LAMP of13.6o decreased to9.1o(p<0.05). At the last follow-upthere was no kyphotic complication in Group CORP, but there were3cases withkyphotic changes in Group LAMP. Group CORP had complications as followed:3cases with CSF leak,4cases with dysphasia and3cases with dysphonia. And GroupLAMP had6cases with axial symptom and3cases with C5nerve rood palsy.3. In third Part, through the including and excluding process,7citations enrolled tocurrent analysis.5literature compared JOA recovery rate between LAMP group andADF group. Results of heterogeneity test were as followed: Chi2=16.21，I2=69%，P=0.006, there was statistical heterogeneity. The results of Meta-analysis showed thatsynthesized standard mean difference (SMD) was-0.27，95%CI为-0.65~1.10, thedifference in JOA recovery rate between two groups was no statistically significant.5literatures compared operation time between LAMP group and ADF group. Results ofheterogeneity test were as followed: Chi2=35.93, I2=89%, P<0.00001, there wasstatistical heterogeneity. The results of Meta-analysis showed that synthesized SMDwas-1.39,95%CI was-2.16~-0.62, the difference in operation time between twogroups was statistically significant. This says the operation time of LAMP group shorterthan of ADF group. These5literatures also compared intraoperative blood loss betweentwo groups. Results of heterogeneity test were as followed: Chi2=9.39, I2=57%, P=0.05,there was statistical heterogeneity. The results of Meta-analysis showed thatsynthesized SMD was-0.63,95%CI was-1.04~-0.33, the difference in operation timebetween two groups was statistically significant. This means the intraoperative bloodloss of LAMP group less than of ADF group. Although3of8literatures reported ROMchange of two groups, but2of them didn’t record the standard deviation, someta-analysis was not allowed. Two literatures reported follow-up results more than10years, one of them revealed no difference in ROM between two groups, and another one reported statistical difference. And another one literature, which follow-up timewas5years, reported no significant difference in ROM between two groups.Conclusion:1. For the multilevel cervical spondylotic myelopathy, there was no difference in RR ofJOA, operation time and blood loss between Centerpiece fixation laminoplasty andanchor fixation laminoplasty. The enlargement of AP diameter of spinal canal wasbetter controlled in Centerpiece group than anchor group and the incidence of C5palsywas lower.2. Both laminoplasty with Centerpiece fixation and cervical corpectomy with titaniummesh lead to significant neurological recovery in multilevel OPLL, and there was nosignificant difference in neurological recovery rate between two groups. Laminoplastycohort with Centerpiece fixation tended to have shorter operation time and less bloodloss than cervical corpectomy cohort. So it is believed that laminoplasty may be thepreferred method of treatment for multilevel OPLL in the absence of preoperativekyphosis.3. In neurological recovery rate there was no significant difference between two methodsfor multilevel cervical spondylotic myelopathy at more than3year follow-up. Theoperative time of laminoplasty shorter than anterior decompression and fusion, andintraoperative blood loss also less. In the preservation of region of motion was nodifference between two methods. In conclusion laminoplasty is preferred and safer thananterior decompression and fusion for multilevel cervical spondylotic myelopathy.更多还原