Treatment options and efficacy evaluation for multilevel cervical spondylotic myelopathy

doi:10.3969/j.issn.2095-4344.2014.40.009

Abstract

Abstract:

BACKGROUND: Operation is an important measure to improve the function of spinal cord and to stop the pathological progress of multilevel cervical spondylotic myelopathy. There are controversies how to select the optimum operation mode, to reduce postoperative complications and to elevate clinical curative effects.

OBJECTIVE: To systematically review patients’ profiles of multilevel cervical spondylotic myelopathy, and to evaluate the effects of simple anterior approach, simple posterior approach and one stage posterior anterior combined approach on cervical spinal curvature index and functional recovery in patients.

METHODS: 148 sample profiles of patients, who received multilevel cervical spondylotic myelopathy operation in The Affiliated Hospital of Qingdao University and Qingdao Municipal Hospital from February 2000 to February 2008, and met the inclusion and exclusion criteria, were selected. They were divided into simple anterior approach group, simple posterior approach group and one stage posterior anterior combined approach group. The differences in the functional recovery were assessed after treatment using different therapeutic methods.

RESULTS AND CONCLUSION: Cervical spinal curvature index was highest in the simple posterior approach group before treatment (P < 0.01). Cervical spinal curvature index was highest in the one stage posterior anterior combined approach group after treatment (P < 0.01). Changes in cervical spinal curvature index were most obvious in the simple anterior approach group before and after treatment (P < 0.01). No significant difference in Japanese Orthopaedic Association Scores was detected among three groups after treatment (P > 0.05). Significant differences in improvement rate of Japanese Orthopaedic Association Scores were detectable after treatment between the one stage posterior anterior combined approach group and simple anterior approach and simple posterior approach groups (P < 0.001). Significant differences in cervical dysfunction index and SF-36 scores were detectable among the three groups before and after treatment (P < 0.05). Results indicated that compared with the simple anterior approach and simple posterior approach, decompression through one stage posterior anterior combined approach is a reliable and effective operative procedure for treatment of multilevel cervical spondylotic myelopathy.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

全文链接：

Key words: cervical vertebrae, spinal cord, treatment outcome, comparative effectiveness research

CLC Number:

R318

Hou Zeng-tao, Zhao Ai-lin, Guo Chuan-you, Chen Bo-hua. Treatment options and efficacy evaluation for multilevel cervical spondylotic myelopathy[J]. Chinese Journal of Tissue Engineering Research, 2014, 18(40): 6444-6450.

Figures/Tables 1

2.1 各组患者一般资料比较所有患者的手术入路选择在排除年龄、性别差异后比较差异无显著意义(P > 0.05)。表1说明接受多节段脊髓型颈椎病手术治疗的患者多集中在中、老年患者。十分有意思的统计现象是本文纳入的患者中接受颈椎后路手术和一期后前联合入路手术的患者中以男性居多，而接受颈椎前路手术的患者中男女比例差异无显著性意义(P > 0.05)。3组患者在年龄、吸烟史及从发病到接受手术的持续时间方面无差异显著性意义(P > 0.05)。接受一期后前联合入路手术的患者术前有更少的合并病，与其他2组的合并病率统计差异有显著性意义(P < 0.05)。在手术的麻醉方式的选择上，2所医院在单纯后路手术和一期后前路联合手术时均采用全身麻醉，而单纯前路手术的患者中有69.6%选择了颈丛阻滞麻醉，麻醉方式差异有显著性意义(P < 0.001)。单纯前路组比一期后前路联合入路手术组中更多的患者接受了超过2个节段前路椎间盘的减压手术治疗(P < 0.001)。一期后前联合入路手术组比单纯后路手术组有更多的患者接受了5节段的后路减压治疗(P < 0.01)。在3个手术治疗组中，一期后前联合入路手术组的平均手术时间最长，手术出血量最多，与单纯前路或单纯后路组比较差异有显著性意义(P < 0.001)。单纯后路手术组发生术后并发症的可能更大(P < 0.05)，手术失败再手术的概率更高(P < 0.01)，术后并发症包括颈脊髓损伤(4例)，喉上神经或喉返神经损伤(4例)，颈部血肿(3例)，食道瘘(2例)，脑脊液漏(5例)，椎动脉损伤(2例)，颈椎轴性症状(2例)，神经根麻痹(2例)，术后再关门(3例)，颈椎僵硬及生理曲度改变(7例)等。 2.2 不同治疗方法修复多节段脊髓型颈椎病患者颈椎曲率指数的变化单纯后入路组的治疗前颈椎曲率指数最高，与单纯前入路组及一期后前联合入路组相比差异有显著性意义(P < 0.01)。治疗后评估可见一期后前联合入路组的颈椎曲率指数最高，与单纯前入路组及单纯后入路组相比差异有显著性意义(P < 0.01)。单纯前入路手术组的治疗前后的颈椎曲率指数变化最为明显(P < 0.01)。在校正了年龄和性别差异后(校正后：5.2±1.2，P < 0.01)，颈椎前入路组患者颈椎曲率指数变化差异有显著性意义(P < 0.01)。同时再校正诸如是否吸烟、发病到接受手术的持续时间合并症、术前JOA评分、失血量、手术持续时间、前路或后路椎间盘手术节段等多种因素后(校正后：6.7±3.0，P=0.004)，颈椎曲率指数的差异依单纯后入路组、一期后前联合入路手术组至单纯前入路手术组的趋势逐步提高(P < 0.01；表2)。 2.3 不同治疗方法修复多节段脊髓型颈椎病患者的JOA脊髓功能评分单纯后入路手术组治疗前JOA评分高于其他2组(P < 0.05)，治疗后3组患者的JOA评分差异无显著性意义(P > 0.05)，但治疗后一期后前联合入路手术组的JOA改善率与单纯前路或后路手术组相比较差异有显著性意义(P < 0.001)。在校正了年龄和性别差异后(校正后：51.2±2.1，P < 0.001)的1组，一期后前联合入路手术组的JOA改善率最高。再校正是否吸烟、发病到接受手术的持续时间、合并症、治疗前JOA评分、失血量、手术持续时间、前路或后路椎间盘手术节段等多种因素后(校正后：53.2±10.2，P < 0.01)，2组JOA改善率呈现从单纯前入路手术组、单纯后入路手术组到一期后前联合入路手术组逐步提高的趋势(P < 0.01；表3)。 2.4 不同治疗方法修复多节段脊髓型颈椎病患者的颈椎功能障碍指数和SF-36评分 3组患者的随访颈椎功能障碍指数评分与其治疗前颈椎功能障碍指数评分比较差异有显著性意义(P < 0.01)，但3组治疗前颈椎功能障碍指数评分及随访时的颈椎功能障碍指数评分差异无显著性意义 (P > 0.05)。3组患者治疗前与随访时的SF-36躯体评分及SF-36精神评分差异无显著性意义(P > 0.05；表4)。"

References

[1] Seifert V, Stolke D. Multisegmental cervical spondylosis: treatment by spondylectomy, microsurgical decompression, and osteosynthesis. Neurosurgery. 1991;29(4):498-503.
[2] Edwards CC 2nd, Riew KD, Anderson PA, et al. Cervical myelopathy. current diagnostic and treatment strategies. Spine J. 2003;3(1):68-81.
[3] Lian XF, Xu JG, Zeng BF, et al. Noncontiguous anterior decompression and fusion for multilevel cervical spondylotic myelopathy: a prospective randomized control clinical study. Eur Spine J. 2010;19(5):713-719.
[4] Woods BI, Hohl J, Lee J, et al. Laminoplasty versus laminectomy and fusion for multilevel cervical spondylotic myelopathy. Clin Orthop Relat Res. 2011;469(3):688-695.
[5] Cabraja M, Abbushi A, Koeppen D, et al. Comparison between anterior and posterior decompression with instrumentation for cervical spondylotic myelopathy: sagittal alignment and clinical outcome. Neurosurg Focus. 2010; 28(3):E15.
[6] Guo Q, Bi X, Ni B, et al. Outcomes of three anterior decompression and fusion techniques in the treatment of three-level cervical spondylosis. Eur Spine J. 2011;20(9): 1539-1544.
[7] Kristof RA, Kiefer T, Thudium M, et al. Comparison of ventral corpectomy and plate-screw-instrumented fusion with dorsal laminectomy and rod-screw-instrumented fusion for treatment of at least two vertebral-level spondylotic cervical myelopathy. Eur Spine J. 2009;18(12):1951-1956.
[8] Shibuya S, Komatsubara S, Oka S, et al. Differences between subtotal corpectomy and laminoplasty for cervical spondylotic myelopathy. Spinal Cord. 2010;48(3):214-220.
[9] Aryan HE, Sanchez-Mejia RO, Ben-Haim S, et al. Successful treatment of cervical myelopathy with minimal morbidity by circumferential decompression and fusion. Eur Spine J. 2007;16(9):1401-1409.
[10] Konya D, Ozgen S, Gercek A, et al. Outcomes for combined anterior and posterior surgical approaches for patients with multisegmental cervical spondylotic myelopathy. J Clin Neurosci. 2009;16(3):404-409.
[11] Vernon H, Mior S. The Neck Disability Index: a study of reliability and validity. J Manipulative Physiol Ther. 1991; 14(7):409-415.
[12] Lin Q, Zhou X, Wang X, et al. A comparison of anterior cervical discectomy and corpectomy in patients with multilevel cervical spondylotic myelopathy. Eur Spine J. 2012;21(3): 474-481.
[13] Konya D, Ozgen S, Gercek A, et al. Outcomes for combined anterior and posterior surgical approaches for patients with multisegmental cervical spondylotic myelopathy. J Clin Neurosci. 2009;16(3):404-409.
[14] Baba H, Uchida K, Maezawa Y, et al. Lordotic alignment and posterior migration of the spinal cord following en bloc open-door laminoplasty for cervical myelopathy: a magnetic resonance imaging study. J Neurol. 1996;243(9):626-632.
[15] Takeshita K, Murakami M, Kobayashi A, et al. Relationship between cervical curvature index (Ishihara) and cervical spine angle (C2--7). J Orthop Sci. 2001;6(3):223-226.
[16] Hirabayashi K, Miyakawa J, Satomi K, et al. Operative results and postoperative progression of ossification among patients with ossification of cervical posterior longitudinal ligament. Spine (Phila Pa 1976). 1981;6(4):354-364.
[17] Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30(6):473-483.
[18] Martin-Benlloch JA, Maruenda-Paulino JI, Barra-Pla A, et al. Expansive laminoplasty as a method for managing cervical multilevel spondylotic myelopathy. Spine (Phila Pa 1976). 2003;28(7):680-684.
[19] Iencean SM. Alternating cervical laminoplasty for cervical spondylotic myelopathy. J Bone Joint Surg Br. 2007;89(5): 639-641.
[20] Schultz KD Jr, McLaughlin MR, Haid RW Jr, et al. Single-stage anterior-posterior decompression and stabilization for complex cervical spine disorders. J Neurosurg. 2000;93(2 Suppl):214-221.
[21] DiAngelo DJ, Foley KT, Vossel KA, et al. Anterior cervical plating reverses load transfer through multilevel strut-grafts. Spine (Phila Pa 1976). 2000;25(7):783-795.
[22] Sasso RC, Ruggiero RA Jr, Reilly TM, et al. Early reconstruction failures after multilevel cervical corpectomy. Spine (Phila Pa 1976). 2003;28(2):140-142.
[23] Zdeblick TA, Hughes SS, Riew KD, et al. Failed anterior cervical discectomy and arthrodesis. Analysis and treatment of thirty-five patients. J Bone Joint Surg Am. 1997;79(4): 523-532.
[24] Mummaneni PV, Dhall SS, Rodts GE, et al. Circumferential fusion for cervical kyphotic deformity. J Neurosurg Spine. 2008;9(6):515-521.
[25] McAfee PC, Bohlman HH, Ducker TB, et al. One-stage anterior cervical decompression and posterior stabilization. A study of one hundred patients with a minimum of two years of follow-up. J Bone Joint Surg Am. 1995;77(12):1791-1800.
[26] McAfee PC, Bohlman HH. One-stage anterior cervical decompression and posterior stabilization with circumferential arthrodesis. A study of twenty-four patients who had a traumatic or a neoplastic lesion. J Bone Joint Surg Am. 1989; 71(1):78-88.
[27] O'Shaughnessy BA, Liu JC, Hsieh PC, et al. Surgical treatment of fixed cervical kyphosis with myelopathy. Spine (Phila Pa 1976). 2008;33(7):771-778.
[28] Sodeyama T, Goto S, Mochizuki M, et al. Effect of decompression enlargement laminoplasty for posterior shifting of the spinal cord. Spine (Phila Pa 1976). 1999;24(15): 1527-1532.