目的 探讨脊髓型颈椎病患者行单开门扩大成形术后轴性痛发生特点、病理机制及危险因素。方法 回顾性分析2012-01至2015-01武警特色医学中心骨科行单开门扩大成形联合开门侧微型钛板固定治疗的79例脊髓型颈椎病患者,随访时间均在24个月以上,减压范围不低于4个节段。比较术后轴性痛组和非轴性痛两组患者间,术前合并颈椎失稳与否、术后颈椎曲度、前凸指数、屈伸活动度、椎管正中矢径、Pavlov比值、椎板开门角、硬膜囊面积不同变化幅度内病例分布构成比,单因素Logistic回归分析上述指标对PAP发作的影响程度,选取初筛P<0.10的参数,再经多元Logistic回归分析进一步验证与PAP发作的相关性。评估术前已合并和未合并颈椎失稳两组间,术后屈伸度不同矫正范围内患者所占比例。结果 单因素Logistic回归分析示术前有颈椎失稳、椎板开门角大小、术后屈伸度和颈椎前凸指数变化程度均与术后轴性痛发生相关(P<0.10)。多元Logistic回归分析示术后屈伸度明显下降和术前有颈椎失稳系预测术后轴性痛发作的独立危险因素(P<0.05)。术后轴性痛患者术前合并颈椎失稳比例高于非轴性痛组,差异有统计学意义(P<0.05)。术后轴性痛患者颈椎屈伸活动度显著下降比例高于非轴性痛组,差异有统计学意义(P<0.05)。术前有颈椎失稳患者,其术后屈伸度显著下降比例高于术前无失稳组,差异有统计学意义(P<0.05)。结论 脊髓型颈椎病患者如术前合并颈椎失稳,更易因后路单开门扩大成形术后屈伸度显著下降而继发轴性痛。建议微型钛板仅用于固定非失稳节段,而术前失稳节段可选择侧块或椎弓根钉棒固定,以减少继发术后失稳和轴性痛发生可能。

Objective To investigate the clinical features, pathological mechanism and predisposing factors of postoperative axial pain (PAP) after unilateral expansive laminoplasty for treating cervical stenotic myelopathy (CSM). Methods The clinical data on 79 CSM patients with no less than four segments who underwent unilateral expansive laminoplasty secured with consecutive mini-plates on the open side was retrospectively analyzed. These patients were followed up for a minimum of 24 months. The constituent ratios of preoperative cervical instability, postoperative corrected amplitudes of Cobb angle of cervical curvature, the lordosis index, range of motion between flexion and extension, mid-sagittal canal diameter, Pavlov ratio, open-laminar angle, cross-sectional area of the dural sac within different realms were compared between PAP and non-PAP groups. Univariate logistic regression analysis was used to confirm the influence of these parameters on the occurrence of PAP. Multivariate logistic non-linear regression analysis was conducted to further verify the correlation between the onset of PAP and parameters of P<0.10 filtered by preliminary confirmation based on univariate logistic regression analysis. The proportion of patients with different alteration degrees of intervertebral motion of cervical segments between preoperative unsteadiness and steadiness groups was calculated. Results Twelve patients with PAP received conservative treatment and achieved rehabilitation during the final follow-up. The results of univariate logistic regression analysis suggested preoperative cervical instability, the open-laminar angle, correction of the postoperative range of motion and lordosis index were related to the incidence of PAP (P<0.10). Obvious decrease of postoperative motion and preoperative instability were independent risk factors for predicting the occurrence of PAP via multivariate logistic regression analysis (P<0.05). The proportion of preoperative cervical instability in the PAP group was higher than in the non-PAP group, with statistically significant difference (P<0.05). The incidence of pronounced decrease of the range of motion in the PAP group was higher than in the non-PAP group, and the difference was of statistical significance (P<0.05). The rate of notable decrease of the range of motion in the preoperative unsteadiness group was significantly higher than in the steadiness group. Conclusions PAP is more likely to reoccur regularly accompanied by excessive loss of the range of motion after surgery if preoperative unsteadiness is due to the treatment of CSM. It is proposed that mini-plates should be used to fix steadiness segments, however, the hybrid system of lateral mass or pedicle screws and rods can be applied in preoperative unsteady segments to reduce the incidence of postoperative cervical instability and PAP.