摘要
目的 探讨显微镜和可动式椎间盘镜（mobile microendoscopic discectomy,MMED）下行颈椎前路减压的可行性,并对比其临床疗效.方法 回顾性分析2015年5月至2017年2月采用显微镜或MMED辅助下行颈椎前路减压治疗30例脊髓型颈椎病患者资料,均采用常规颈前横切口,安置椎间撑开器,镜下减压后在直视下行融合固定.显微镜组15例,男4例,女11例;年龄32～71岁,平均（54.00±11.10）岁;前路颈椎间盘切除融合术（anterior cervical discectomy and fusion,ACDF）12例,前路颈椎次全切除融合术（anterior cervical corpectomy and fusion,ACCF）3例.MMED组15例,男9例,女6例;年龄39～73岁,平均（59.60±11.10）岁;ACDF 13例,ACCF 2例.记录手术时间和术中出血量;两组患者术后随访时间6～18个月,采用日本骨科协会（Japanese Orthopaedic Association,JOA）评分并计算神经功能改善率评估临床疗效;采用颈椎功能障碍指数（neck disabilitv index,NDI）评定颈椎功能.结果 两组患者均在镜下顺利完成减压,且未有神经症状加重.显微镜术中需分别调整镜头和器械方向,MMED镜头可随器械同步移动,更容易显露椎体后缘和椎管左、右侧.显微镜组手术时间90～180 min,平均（124.67±36.42）min;MMED组手术时间80～130 min,平均（110.00±15.12） min;两组差异无统计学意义（t=1.440,P=0.161）.显微镜组术中出血量20～200 ml,平均（66.00±49.11）ml;MMED组术中出血30～150 ml,平均（60.00±35.25） ml;两组差异无统计学意义（t=0.384,P=0.704）.显微镜组JOA评分由术前（8.67±3.20）分改善至末次随访时（15.93±1.53）分,两者比较差异有统计学意义（t=8.687,P=0.000）;神经功能改善率分级,优12例、良3例,优良率100％;NDI自术前18.00％±9.75％降至末次随访时5.93％±2.58％,两者比较差异有统计学意义（t=5.137,P=0.000）.MMED组JOA评分自术前（8.87±3.11）分改善至末次随访时（15.53±1.69）分,两者比较差异有统计学意义（t=9.413,P=0.000）;神经功能改善率分级,优11例、良4例,优良率100％;NDI自术前17.13％±8.00％降至5.80％±2.43％,两者比较差异有统计学意义（t=5.592,P=0.000）.显微镜组和MMED组末次随访时JOA评分（t=0.680,P=0.502）、神经功能改善率分级（P=1.000）和NDI（t=0.146,P=0.885）的差异均无统计学意义.结论 显微镜和MMED均可为颈椎前路减压提供清晰、放大的视野,有利于充分减压,进而获得优良的临床疗效,但MMED适应证较窄,且有陡峭的学习曲线,临床应用需慎重.
Objective To explore the feasibility of anterior cervical decompression assisted with the microscope and mobile microendoscopic discectomy （MMED）,and to compare their clinical efficacy.Methods From May 2015 to February 2017,thirty patients with cervical spondylotic myelopathy （CSM） underwent anterior cervical decompression assisted with microscope or MMED.Among them,conventional transverse anterior cervical incisions were used,and intervertebral distractors were placed in order to complete the decompression,then the fusion and fixation procedure were conducted under direct vision,and the operative time and intraoperative blood loss were recorded.Of 30 cases,15 cases were in microscope cohort （anterior cervical discectomy and fusion,ACDF 12 cases;anterior cervical corpectomy and fusion,ACCF 3 cases）,including 4 males and 11 females with a mean age of 54.00±11.10 years （range,32-71 years）.Another 15 cases were in MMED cohort （ACDF 13 cases,ACCF 2 cases）,including 9 males and 6 females with a mean age of 59.60± 11.10 years （range,39-73 years）.Neurological and cervical function were evaluated before surgery and at the follow-up according to the Japanese Orthopaedic Association （JOA） and the neck disability index （NDI） scores,and the neurologic improvement grade （NIG） was used to evaluate the neurological function.Results Both the microscope and MMED cohort underwent decompression successfully,and the visual field was clear.No neurological symptoms became worse.For the microscope,its lens and the instrument had to be adjusted separately,whereas MMED lens could move synchronously with the instrument.It was easier for MMED to reveal the posterior edge of the vertebral body and the left and right side of the spinal canal.The operation time of the microscope cohort was 90-180 min,with an average of 124.67±36.42 min;the M MED cohort was operated for 80-130 min with an average of 110.00± 15.12 min,and there was no significant difference between the two cohorts （t=1.440,P=0.161）.The intraoperative blood loss for microscope cohort was 20-200 ml,with an average of 66.00±49.11 ml;MMED cohort was 30-150 ml with an average of 60.00±35.25 ml;there was no significant difference between the two cohorts （t=0.384,P=0.704）.The JOA score of the microsurgery cohort improved from 8.67±3.20 preoperatively to 15.93± 1.53 at the latest follow-up,and its difference was significant （t=8.687,P=0.000）.According to NIG,neurological improvement was excellent in 12 cases and good in 3 cases,giving an excellent to good rate of 100%.NDI was reduced from 18.00%±9.75% preoperatively to 5.93%±2.58% at the latest follow-up,with significant difference （t=5.137,P=0.000）.The JOA score in MMED cohort improved from 8.87±3.11 preoperatively to 15.53±1.69 at the latest follow-up,and its difference was significant （t=9.413,P=0.000）.and Among these 15 patients,11 were excellent and 4 were good,giving an excellent-good rate 100%.NDI decreased from 17.13%± 8.00% preoperatively to 5.80%±2.43% at the latest follow-up,and its difference was significant （t=5.592,P=0.000）.There was no significant difference in JOA （t=0.680,P=0.502）,NIG （P=1.000） and NDI （t=0.146,P=0.885） between the two cohorts at the latest follow-up.Conclusion Both microscope and MMED could provide a clear and magnified field of view,which was beneficial for adequate decompression during the anterior cervical surgery to ensure better clinical results.Compare to the microscope,MMED has relatively narrow indications and steep learning curve,so the surgeon should select cases strictly.
作者
黎宁
徐宝山
许海委
程招军
姜洪丰
刘越
吉宁
张春虹
Li Ning;Xu Baoshan;Xu Haiwei;Cheng Zhaojun;Jiang Hongfeng;Liu Yue;Ji Ning;Zhang Chunhong(Graduate School of Tianjin Medical University,Tianjin 300070,Chin;Department of Minimal Invasive Spine Surgery,Tianjin Hospital,Tianfin 300211,China)
出处
《中华骨科杂志》
CAS
CSCD
北大核心
2018年第15期935-942,共8页
Chinese Journal of Orthopaedics
基金
国家自然科学基金面上项目（31670983,81272046,31500781）
天津市自然科学基金（15JCYBJC25300）
关键词
颈椎
脊髓压迫症
外科手术
微创性
Cervical-vertebrae
Spinal cord compression
Surgical procedures, minimally invasive
