前路减压植骨融合术与颈椎间盘置换手术对颈椎相邻节段退变的影响

目的探讨颈椎间盘置换手术与前路减压植骨融合术(anterior cervical decompression and fusion,ACDF)对颈椎相邻节段退变的影响。方法回顾性分析2015年4月～2017年4月于本院接受治疗的94例颈椎病患者,依据其手术情况分为两组:观察组47例均采用颈椎间盘置换术治疗,对照组47例均采用ACDF手术治疗,对比两组患者的手术疗效,以及术后相邻节段退变情况。结果两组术后NDI、JOA评分均有显著改善,但组间对比无统计学差异(P0.05)。术后24个月,观察组相邻节段退变率为17.0%,显著低于对照组的31.9%,具有统计学差异(P0.05)。两组于术后随访期间,均未发生假体松动、假体移位以及钢板断裂等并发症。结论两种术式均可取得显著疗效,但颈椎间盘置换手术可显著减轻术后颈椎相邻节段的退变程度。     

颈椎间盘置换治疗颈椎病术后相邻节段退变的临床观察

[目的]观察颈椎间盘置换治疗颈椎病术后相邻节段退变的临床疗效。[方法]采用随机分配法将2010年7月~2013年7月来本院进行治疗的80例患者随机分为两组,置换组采用颈椎间盘置换术进行治疗,融合组采用前路颈椎间盘切除融合术,术后在不同时间对两组患者进行随访,分析两组患者术后相邻节段退变情况。[结果]置换组患者的JOA评分较术前相比平均提高了5.33分,与融合组的5.27分比较差异无统计学意义;对邻近节段颈椎间盘的退变情况分析,得出在最后一次随访时即术后24个月时,置换组有7例出现退变,退变率为17.5%,融合组有14例出现退变,退变率为35.0%,两组均无死亡患者。[结论]颈椎间盘置换治疗颈椎病在具有良好疗效的同时,降低了相邻节段的退变率,值得在临床上推广应用。     

颈椎人工椎间盘置换后对相邻节段退变的影响

目的:观察单节段颈椎人工椎间盘置换术后相邻节段退变情况。方法:截止到2010年10月在我院行单节段颈椎人工椎间盘置换术后随访20个月以上且资料完整、既往无颈椎手术史的患者80例,置换节段为C3/4 8例,C4/5 15例,C5/6 49例,C6/7 8例;41例为Bryan Disc置换术,39例为ProDisc-C置换术。对比术前和末次随访时X线片、MRI相邻节段退变情况。相邻节段退变定义为X线片上椎间隙高度丢失与术前相比大于10%,形成肉眼可见新生骨赘或原有骨赘增大,前纵韧带钙化;在MRI T2加权像上采用Miyazaki颈椎间盘退变分级方法观察相邻节段椎间盘退变情况。结果:随访20~64个月,平均38个月。末次随访时X线片上160个相邻节段中,8个下相邻节段因肩部X线遮挡而显示不清,符合条件的152个相邻节段中21个(13.8%)出现退变,其中Bryan Disc置换术组退变发生率为10.0%,ProDisc-C置换术组退变发生率为18.1%;47例患者获得了MRI随访,94个相邻节段中14个(14.9%)椎间盘退变分级加重1级,其中Bryan Disc置换术组退变加重发生率为12.5%,ProDisc-C置换术组退变加重发生率为22.7%。未出现相邻节段疾病。结论:颈椎人工椎间盘置换术后平均38个月随访相邻节段退变表现加重者不足15%,不同类型的假体对相邻节段退变的影响可能存在一定差异。     

颈椎人工椎间盘置换术可以减少相邻节段退变和相邻节段疾病

在过去的近60年间,前路减压融合术已经成为治疗颈椎间盘退变性疾病的标准术式。但融合术后出现的相邻节段退变加速、继而出现新的症状的问题,引发人们越来越多的关注。     

颈椎人工椎间盘置换术对相邻节段继发性退变的影响

颈椎人工椎间盘置换术的设计理念是通过保留颈椎手术节段的活动性,减少以往前路减压融合术带来的相邻节段的退变加速。经过将近10年的临床应用和长期随访,我们对于这个先进理念的认识也逐渐深入。从文献报告的数据可以看出,不论是中期随访还是远期随访,颈椎人工椎间盘置换术确实减     

人工颈椎间盘置换术后邻近节段退变情况的早中期随访

目的研究人工颈椎间盘置换术治疗颈椎病的临床疗效及邻近节段退变情况。方法 2008年1月-2010年10月,采用人工颈椎间盘置换术治疗颈椎病患者39例。其中男20例,女19例;年龄32～60岁,平均45.7岁。病程1个月～10年,平均30个月。其中脊髓型颈椎病26例,神经根型颈椎病11例,混合型颈椎病2例(神经根型加脊髓型)。单节段病变27例,双节段病变12例。使用Prestige假体9例、Prodisc-C假体4例、Discover假体26例。采用日本骨科协会(JOA)评分评价患者神经功能恢复情况,测量置换节段及邻近节段活动度(Cobb角变化),并采用Kellgren X线颈椎退变分级评估法对邻近节段颈椎间盘退变情况进行评价。结果所有患者均顺利完成手术,术后切口均Ⅰ期愈合。39例均获随访,随访时间12～36个月,平均23.1个月。末次随访时患者JOA评分较术前显著提高(P<0.05),置换节段及置换节段相邻上、下位节段活动度与术前比较差异均无统计学意义(P>0.05)。根据Kellgren X线椎间盘退变分级评价结果显示,末次随访时有5例患者出现退变情况改变,其中从无(0级)退变为轻度(1、2级)3例,由轻度1级退变到轻度2级1例,由轻度2级退变到中度(3级)1例,退变发生率为12.8%,但退变情况分级与术前比较差异无统计学意义(χ2=1.793,P=0.406)。术后15个月(32例患者)邻近椎间盘未发生退变情况。结论人工颈椎间盘置换术治疗颈椎病有良好疗效,可较好地保留置换节段及邻近节段活动度,并可能对邻近节段的椎间盘起保护作用。     

单节段人工颈椎间盘置换术后小关节退变的长期临床研究

【摘要】 目的：分析人工颈椎间盘置换（artificial cervical disc replacement，ACDR）术后颈椎小关节退变的危险因素，评价其对颈椎节段运动和临床疗效的影响。方法：回顾性分析我科2003年1月~2008年1月行单节段Bryan人工颈椎间盘ACDR术的颈椎退行性疾病患者70例，其中男性43例，女性27例；术后随访时间129±14（105~165）个月；年龄55.7±8.4（37~76）岁。术前、术后及末次随访时通过颈椎动力位X线片测量手术节段活动度和颈椎整体活动度；术前、末次随访时通过CT影像根据颈椎小关节定量评分系统评估颈椎小关节退变程度。术前及末次随访同时进行日本骨科协会（Japanese Orthopaedic Association，JOA）评分及颈椎功能障碍指数量表（neck disability index，NDI）评估患者临床症状，在末次随访时进行Odom标准评价分级和颈痛的视觉模拟评分（visual analogue scale，VAS）。结果：术前小关节无或轻度退变患者41例，中度退变患者28例，重度退变患者1例；末次随访时，小关节轻度退变患者16例，中度患者退变35例，重度关节退变患者19例。通过斯皮尔曼双变量相关性检验发现小关节退变与性别、年龄有相关性。高龄、男性是小关节退变增加的危险因素，手术节段与小关节退变程度无相关性。患者术前和末次随访时手术节段活动度不存在统计学差异（9.7°±4.5° vs 8.7°±5.4°，P>0.05），术前和末次随访时颈椎整体活动度不存在统计学差异（46.5°±15.2° vs 46.1°±13.0°，P>0.05）。患者术前及末次随访时小关节退变评分具有统计学差异（1.5±0.8分 vs 2.6±1.2分，P<0.05）；术前与末次随访时JOA评分具有统计学差异（13.5±1.9分 vs 16.5±1.4分，P<0.05）；术前与末次随访时NDI存在统计学差异（0.27±0.08 vs 0.16±0.10，P<0.05）。末次随访时Odom分级为优秀的有35例患者，为良好的有29例，为尚可的有6例，没有分级为差的患者，末次随访时VAS评分为3.47±1.55分。ACDR术后末次随访小关节退变程度与手术节段活动度呈负相关（r=-0.392，P=0.001），与整体活动度也呈负相关（r=-0.388，P=0.001），与JOA评分、NDI、Odom分级、VAS评分无显著性相关（P>0.05）。结论：高龄和男性是ACDR术后小关节退变的危险因素，小关节的退变程度与患者术后的颈椎活动度存在负相关，小关节退变程度与临床症状的缓解程度无关。     

颈前路融合术后相邻节段退变120例

目的：探讨颈椎前路减压融合术后相邻节段退变的因果关系。方法：对237例患者行前路椎间节段减压植骨融合术（87例）,椎体次全切除减压植骨融合术（109例）,椎间节段减压、椎体次全切除减压植骨融合术（41例）。通过影像学检查,观察不同手术方法术后相邻节段退变发生情况。结果：术后随访时间2.6~13年,平均6.8年;发生相邻节段明显退变的120例（50.6%）,头侧相邻节段退变发生率明显高于尾侧邻近节段（P＜0.05）,其中27例（22.2%）需2次翻修手术。结论：颈椎前路融合术后可导致颈椎相邻节段的退变。     

颈椎融合加速相邻节段退变：真实还是虚构？

颈椎融合会加速相邻节段退变吗?人工颈椎间盘置换能防止相邻节段退变吗?这是当今脊柱外科领域争论的热点问题。     

颈椎融合与非融合手术对相邻节段退变的影响

经过50多年的发展和完善历程后,颈前路减压植骨融合术(ACDF)已成为治疗颈椎退行性疾病、创伤、肿瘤等多种疾病最有效的手段和"金标准",但随着随访时间的延长、大量病例的积累和一系列临床     

The change of adjacent segment after cervical disc arthroplasty compared with anterior cervical discectomy and fusion: a meta-analysis of randomized controlled trials

Background Context

Many meta-analyses have been performed to study the efficacy of cervical disc arthroplasty (CDA) compared with anterior cervical discectomy and fusion (ACDF); however, there are few data referring to adjacent segment within these meta-analyses, or investigators are unable to arrive at the same conclusion in the few meta-analyses about adjacent segment. With the increased concerns surrounding adjacent segment degeneration (ASDeg) and adjacent segment disease (ASDis) after anterior cervical surgery, it is necessary to perform a comprehensive meta-analysis to analyze adjacent segment parameters.

颈椎融合术后邻近节段退变的相关影响因素

目的 :探讨颈椎融合术后邻近节段退变(adjacent segment degeneration,ASD)的相关影响因素。方法:收集2009年1月31日~2011年1月31日在我科行颈椎前路减压植骨融合钢板内固定术治疗的患者,按照纳入和排除标准,共有235例患者纳入本研究,其中男126例,女109例,手术时年龄33~70岁,随访时间5~7年。在术前、术后1周以及末次随访时均行颈椎标准正侧位X线片及MRI检查,记录患者的年龄、性别、随访时间、融合节段数等,通过X线片测量并计算术前颈椎管率、手术前后颈椎弧弦距、钢板边缘至手术节段椎体边缘的距离(plate to disc distance,PDD)等影像学指标。根据X线片上Kellgren退变分级法和MRI上Miyazaki椎间盘退变分级法,将患者分为无ASD组和影像学ASD组。采用t检验及χ2检验比较两组间各指标的差异,用Logistic回归分析ASD的相关影响因素。结果 :末次随访时共有107例患者(45.53%)出现影像学ASD。影像学ASD组患者手术时年龄为39~70岁(53.47±6.33岁),术后弧弦距为0~10.30mm(5.58±2.34mm),上、下PPD均5mm 50例,上或下PPD5mm 43例,上、下PPD均≥5mm 14例;无ASD组患者年龄为33~61岁(47.56±5.39岁),术后弧弦距0.10~11.21mm(7.63±2.85mm),上、下PPD均5mm 39例,上或下PPD5mm 62例,上、下均≥5mm 27例,两组患者手术时年龄、术后弧弦距、PDD差异均有统计学意义(P0.05);两组性别比、融合节段数、术前弧弦距、术前与术后弧弦距的差值以及术前颈椎管率均无统计学差异(P0.05)。Logistic回归分析结果显示手术时年龄、PDD、术后弧弦距与ASD发生率均有显著相关性(P0.05)。结论:手术时年龄、术后颈椎弧弦距、PDD与颈椎融合术后影像学ASD显著性相关,手术时年龄越大、术后颈椎生理前凸恢复不佳以及PDD5mm更容易发生ASD。     

Evidence-based analysis of adjacent segment degeneration and disease after ACDF: a systematic review

Background context

Follow-up studies of patients undergoing anterior cervical discectomy and interbody fusion (ACDF) have demonstrated varying degrees of radiographic degeneration at adjacent levels, with most cases being asymptomatic (adjacent segment degeneration, ASDeg) and far fewer being symptomatic (adjacent segment disease, ASDz). Controversy remains as to whether these conditions are related to altered biomechanics or represent the natural history of cervical spondylosis at the adjacent segment.

Purpose

To provide an evidence-based analysis of the peer-reviewed literature on clinical studies of ASDeg and ASDz after ACDF.

Study design/setting

Systematic review of existing literature.

Methods

The MEDLINE database was queried for clinical studies reporting ASDeg and/or ASDz after ACDF. Articles written in the English language with a minimum follow-up of 2 years were independently reviewed and analyzed by two authors, and the level of evidence was assigned. Data were pooled to generate summary outcomes and organized by number of levels, technique, and graft/implants.

Results

Of the 238 articles returned from the MEDLINE database query, 14 met inclusion criteria. An average of 168 patients was enrolled per study with an average follow-up of 106.5 months. Graft materials, cage design, plate fixation system, and length of fusion varied widely. Additionally, no clear standard was seen for radiographic assessment modalities (eg, plain lateral radiograph, flexion-extension radiographs, computed tomography, or magnetic resonance imaging). Validated clinical outcome measures were used in 43% (6/14) of the studies. The average incidence of ASDeg was 47.33% (459.14/970) with a range from 16% to 96%. The frequency-weighted average for ASDz was 11.99% (263.70/2,199) with a range from 1.80% to 36.00%. Follow-up ranged from 24 to 296 months with no reliable commonalities, which prohibited a meta-analysis.

Conclusions

This review highlights the heterogeneous methodology of the peer-reviewed literature on ASDeg and ASDz after ACDF and the paucity of high-level clinical data published on these conditions. Despite the low level of evidence to define the incidence of ASDeg and ASDz, it is clear that radiographic ASDeg is more common than symptomatic ASDz, indicating that adjacent segment pathology remains subclinical in a large subset of patients. This analysis underscores the need for standardized radiographic measures in the assessment of ASDeg and validated clinical outcome measures for ASDz after ACDF. Consistent methodology and multi-surgeon collaboration may improve the quality of clinical data on ASDeg and ASDz and elucidate the true etiology and incidence of these conditions.     

Bryan颈椎人工椎间盘置换术后5年随访结果

目的:观察Bryan颈椎人工椎间盘置换术后5年随访结果。方法:我院从2003年12月开展Bryan颈椎人工椎间盘置换术,术后达到5年的患者共70例,其中57例获得57～69个月(平均60个月)随访。单节段置换47例,双节段置换9例,3节段置换1例。C3/4 5例、C4/5 10例、C5/6 45例、C6/7 8例。术前和末次随访时进行mJOA、VAS、NDI评分,末次随访时进行Odom′s分级评估临床疗效;术前和末次随访时,在过伸过屈侧位X线片上测量置换节段活动度,在侧位X线片上采用McAfee异位骨化分级方法评定异位骨化情况,在MRIT2加权像上采用Miyazaki颈椎间盘退变分级方法评定相邻节段椎间盘退变情况,在MRI中矢状位T2加权像上测量相邻节段突出椎间盘对椎管的侵占率。结果:(1)mJOA评分术前为13.4±1.9分,末次随访时16.1±1.1分,平均改善率为75.0%;上肢痛VAS评分术前为3.3±1.9分,末次随访时0.9±1.2分;颈肩痛VAS评分术前为3.0±1.5分,末次随访时1.6±1.4分;NDI评分术前为14.8±8.6分,末次随访时5.7±4.2分;以上指标末次随访时与术前比较均有统计学差异(P<0.05)。末次随访时Odom′s分级优21例,良27例,可7例,差2例。(2)28例患者获得X线随访,术前置换节段活动度为6.9°±3.0°,末次随访时为7.2°±3.7°,无统计学差异(P>0.05);末次随访时,30个手术节段中12个(40%)出现异位骨化,其中3个(10%)节段丧失活动度。(3)25例患者获得MRI随访,末次随访时50个相邻节段中7个(14%)椎间盘退变分级加重1级,但无相关临床症状出现;相邻节段突出椎间盘对椎管侵占率的年度平均增幅为0.3%～0.5%。结论:Bryan颈椎人工椎间盘置换术后平均5年随访的临床和影像学结果满意,手术节段活动度得到较好保留,相邻节段退变发生率较低,无相邻节段疾病发生。     

颈椎人工椎间盘置换与椎间盘切除融合术后邻近节段退变比较研究的Meta分析

目的 :通过Meta分析系统评价颈椎人工间盘置换术(cervical total disc replacement,TDR)与颈前路椎间盘切除融合术(anterior cervical discectomy and fusion,ACDF)对邻近节段退变(adjacent segment degeneration,ASDeg)、邻近节段病(adjacent segment disease,ASDis)发生的影响。方法 :根据Cochrane系统评价指南,通过Pub Med、Medline、EMBASE、Cochrane图书馆、中国生物医学文献数据库(CBM)和万方数据库(Wanfang Database)检索2002年1月~2016年6月之间关于TDR和ACDF术后出现ASDeg、ASDis的随机对照试验(randomized controlled trials,RCTs),由两名研究人员独立筛选文章。纳入文献的方法学质量和偏倚风险通过Cochrane系统评价指南进行评价,提取数据包括ASDeg、ASDis以及再手术率的相关信息,研究结果以ASDeg和ASDis的发生作为直接结果,以邻近节段再手术率作为间接结果评估邻近节段病变的发生,并根据随访时间和研究地点分层进行亚组分析,最终对整篇Meta分析通过证据质量分级和推荐强度系统(the grades of recommendation,assessment,development and evaluation,GRADE)进行质量评估。结果 :共纳入了11篇RCTs,包括2632名研究对象。对于整体的ASD(包括直接和间接结果),TDR的发生率明显低于ACDF(OR=0.6;95%CI[0.38,0.73];P0.00001),差异有统计学意义。ASDeg和再手术率方面,TDR相对于ACDF具有明显优势(分别为OR=0.58,95%CI[0.46,0.72],P0.00001和OR=0.52,95%CI[0.30,0.87],P=0.01)。以随访时间5年为分界点,不论随访5年还是≥5年,在ASDeg发生率上,TDR的优势都比ACDF显著(分别为OR=0.63,P=0.001;OR=0.49,P=0.0002),并且这种优势可能随时间延长有扩大趋势。以研究地点分层,不论在美国(7篇RCTs)还是中国(4篇RCTs),TDR在邻近节段退变(ASDeg)发生率上均有优势(P0.0001,P=0.03)。根据GRADE评分,该Meta分析的质量级别为中等质量。结论:与ACDF相比,TDR在降低ASDeg和再手术率方面具有优势。     

颈椎前路融合术后相邻节段退变的手术治疗

目的：探讨颈椎前路减压融合术后相邻节段退变的手术治疗方法与效果。方法：自2000年3月至2011年3月,采用手术治疗颈椎前路减压融合术后相邻节段退变患者27例,男16例,女11例;年龄48—72岁,平均55．3岁。术后通过JOA评分、影像学检查,评价手术疗效。结果：所有病例获得随访,时间1．8～712年,平均3．6年。病变节段减压充分、脊髓膨隆良好,内固定无松动,无颈椎节段不稳发生。术后神经根性痛消失,神经功能明显改善。术前、术后3d、末次随访JOA评分分别为9．15±3．46,13．96±2．79,13．52±2．91,手术前后比较差异有统计学意义（P〈0．05）。椎间高度和生理曲度与术前比较均有明显改善（P〈0．05）。结论：对于有脊髓神经症状体征的相邻节段退变应尽早手术治疗,以解除脊髓压迫,重建脊柱稳定,根据受压部位不同,采用合理的手术方法大多能获得满意的效果。     

Effect of cervical dynamics on adjacent segment degeneration after anterior cervical fusion with cages

The objective of this study is to evaluate the effect of anterior cervical discectomy and fusion (ACDF) on the motion of the cervical spine and dynamic stress (tendency to kyphosis) on adjacent segments and on the overall spinal alignment which may predispose to symptomatic disc diseases at other levels. Twenty consecutive patients underwent ACDF with a mean follow-up of 28 months (range 13-38). Preoperative and postoperative clinical assessments were done by using the neck disability index (NDI) and the Japanese Orthopedic Association (JOA) score. In all cases, at the last follow-up control, a neuro-radiographic assessment [cervical spine static and dynamic X-ray and magnetic resonance imaging (MRI)] was done. The angle of the operated disc space, the disc space angle of contiguous segments, and their range of motion (ROM) and the kyphotic Cobb angle (C2-7) were measured by computer software. The study was done at Sant'Andrea Hospital, Rome, Italy in the period from November 2003 to November 2005. We observed that: the mean Cobb angle improved significantly (p < 0.001) from 3.4 degrees (kyphosis) to postoperative 14.5 degrees . This normalization of angle showed a direct effect on improvement of myelopathic patients, but it had a statistically nonsignificant effect on adjacent segments degeneration (ASD). The mean segmental ROM of adjacent segments did not show significant instability. The mean was 11.1 degrees at upper and 10.2 degrees at lower levels (close to normal). In six cases, the ROM was higher than normal: five of these patients demonstrated symptomatic adjacent segment pathology. Postoperative improvement of mean JOA and NDI scores was statistically significant (p < 0.001). Anyway, symptomatic ASD was observed in five patients (20%): in four of them, the higher disc spaces and in one, the lower disc spaces were involved. In four cases, the preoperative MRI showed slight and asymptomatic disc degeneration at the same levels involved subsequently. This ASD was significantly related to the increased ROM at the segments involved. Follow-up X-rays showed solid fusion with absence of movement in all but one case (at 13-month follow-up), who showed slight movement in the operated level in spite of clinical improvement. The follow-up MRI showed, in all cases, good decompression in the treated levels. Compensatory increase in ROM of the contiguous motion segments in patients subjected to ACDF may lead to ASD especially in those cases with asymptomatic adjacent subclinical degenerative disease. If these preliminary results will be confirmed by larger series, it could be reasonable in young selected patients with soft disc herniation to adopt total disc arthroplasty instead of fusion after cervical micro-discectomy.     

颈椎前路融合术后邻近节段退变的危险因素研究进展

颈椎前路椎间盘切除融合术（anterior cervical discectomy and fusion,ACDF）应用于临床近百年,取得了良好的临床疗效,被认为是治疗颈椎病的金标准。但融合术后邻近节段退变（adjacent segment degeneration,ASDeg）受到越来越多的关注,关于其发生机制的争论主要集中在融合术导致邻近节段生物应力的改变与年龄相关的自然退变。融合术后发生ASDeg将严重影响手术的中远期疗效,部分患者甚至需要二次手术治疗。为了降低甚至避免ASDeg的发生,临床上出现许多新的技术,诸如保留运动节段的人工椎间盘置换术,新兴的细胞移植技术等,但临床疗效仍需要大量的研究进行证实。因此,发现融合术后发生ASDeg的危险因素对于临床开展融合手术具有重要的意义。目前对于ASDeg危险因素的研究仍无统一认识,本文将从颈椎前路融合术后发生ASDeg的危险因素的研究进展及相应应对措施作一综述,以指导临床实践。