Hilibrand A S, Carlson G D, Palumbo M A, Jones P K, Bohlman H H
Department of Orthopaedic Surgery, University Hospitals Spine Institute, Case Western Reserve University School of Medicine, Cleveland, Ohio 44106, USA.
J Bone Joint Surg Am. 1999 Apr;81(4):519-28. doi: 10.2106/00004623-199904000-00009.
We studied the incidence, prevalence, and radiographic progression of symptomatic adjacent-segment disease, which we defined as the development of new radiculopathy or myelopathy referable to a motion segment adjacent to the site of a previous anterior arthrodesis of the cervical spine.
A consecutive series of 374 patients who had a total of 409 anterior cervical arthrodeses for the treatment of cervical spondylosis with radiculopathy or myelopathy, or both, were followed for a maximum of twenty-one years after the operation. The annual incidence of symptomatic adjacent-segment disease was defined as the percentage of patients who had been disease-free at the start of a given year of follow-up in whom new disease developed during that year. The prevalence was defined as the percentage of all patients in whom symptomatic adjacent-segment disease developed within a given period of follow-up. The natural history of the disease was predicted with use of a Kaplan-Meier survivorship analysis. The hypothesis that new disease at an adjacent level is more likely to develop following a multilevel arthrodesis than it is following a single-level arthrodesis was tested with logistic regression.
Symptomatic adjacent-segment disease occurred at a relatively constant incidence of 2.9 percent per year (range, 0.0 to 4.8 percent per year) during the ten years after the operation. Survivorship analysis predicted that 25.6 percent of the patients (95 percent confidence interval, 20 to 32 percent) who had an anterior cervical arthrodesis would have new disease at an adjacent level within ten years after the operation. There were highly significant differences among the motion segments with regard to the likelihood of symptomatic adjacent-segment disease (p<0.0001); the greatest risk was at the interspaces between the fifth and sixth and between the sixth and seventh cervical vertebrae. Contrary to our hypothesis, we found that the risk of new disease at an adjacent level was significantly lower following a multilevel arthrodesis than it was following a single-level arthrodesis (p<0.001). More than two-thirds of all patients in whom the new disease developed had failure of nonoperative management and needed additional operative procedures.
Symptomatic adjacent-segment disease may affect more than one-fourth of all patients within ten years after an anterior cervical arthrodesis. A single-level arthrodesis involving the fifth or sixth cervical vertebra and preexisting radiographic evidence of degeneration at adjacent levels appear to be the greatest risk factors for new disease. Therefore, we believe that all degenerated segments causing radiculopathy or myelopathy should be included in an anterior cervical arthrodesis. Although our findings suggest that symptomatic adjacent-segment disease is the result of progressive spondylosis, patients should be informed of the substantial possibility that new disease will develop at an adjacent level over the long term.
我们研究了有症状的相邻节段疾病的发病率、患病率及影像学进展情况，我们将其定义为在前次颈椎前路融合术部位相邻运动节段出现新的神经根病或脊髓病。
连续纳入374例患者，他们共接受了409次颈椎前路融合术以治疗神经根型颈椎病或脊髓型颈椎病，或两者皆有，术后随访最长21年。有症状的相邻节段疾病的年发病率定义为在给定随访年份开始时无疾病的患者中在该年出现新疾病的患者所占百分比。患病率定义为在给定随访期内出现有症状的相邻节段疾病的所有患者所占百分比。采用Kaplan-Meier生存分析预测疾病的自然史。采用逻辑回归检验相邻节段出现新疾病在多节段融合术后比单节段融合术后更有可能发生这一假设。
术后十年中有症状的相邻节段疾病的发病率相对恒定，为每年2.9%（范围为每年0.0%至4.8%）。生存分析预测，接受颈椎前路融合术的患者中有25.6%（95%可信区间为20%至32%）在术后十年内会在相邻节段出现新疾病。不同运动节段出现有症状的相邻节段疾病的可能性有高度显著差异（p<0.0001）；最大风险位于第5和第6颈椎以及第6和第7颈椎之间的间隙。与我们的假设相反，我们发现多节段融合术后相邻节段出现新疾病的风险显著低于单节段融合术后（p<0.001）。所有出现新疾病的患者中超过三分之二非手术治疗失败，需要额外的手术治疗。
有症状的相邻节段疾病可能在颈椎前路融合术后十年内影响超过四分之一的患者。涉及第5或第6颈椎的单节段融合术以及相邻节段已有的影像学退变证据似乎是出现新疾病的最大危险因素。因此，我们认为所有导致神经根病或脊髓病的退变节段均应纳入颈椎前路融合术。尽管我们的研究结果提示有症状的相邻节段疾病是进行性脊柱退变的结果，但仍应告知患者长期来看相邻节段出现新疾病的可能性很大。
