Koeppen Daniel, Piepenbrock Claudia, Kroppenstedt Stefan, Čabraja Mario
Department of Orthopedic Surgery and Traumatology, Bundeswehrkrankenhaus Berlin, Berlin, Germany.
Joint Spine Centre, Vivantes Auguste Viktoria Klinikum, Berlin, Germany.
PLoS One. 2017 Apr 21;12(4):e0174527. doi: 10.1371/journal.pone.0174527. eCollection 2017.
Decompression and maintaining or restoring a cervical lordosis are major goals in the surgical treatment of cervical spondylotic myelopathy (CSM). Numerous studies support the assumption that cervical lordosis is a key factor for neurological recovery and pain reduction. However, even kyphotic patients can be asymptomatic. The balance of the spine is subject of an increasing number of publications. The main purpose of the study was to evaluate the validity of lordotic alignment on the course of CSM and to set this parameter in context with well-validated tools, namely the modified Japanese Orthopaedic Association scoring system (mJOAS) and the visual analogue scale (VAS), to predict and measure the clinical outcome after surgery.
This is a retrospective study with prospectively collected data of a heterogeneous cohort. The authors analyzed the records of 102 patients suffering from CSM that underwent decompressive surgery and instrumentation. Clinical outcome was assessed by using the mJOAS, VAS and Odom's criteria. The radiological analysis involved comparison of pre- and postoperative radiographs. The patients were divided into subgroups to be able to compare the influence of various amounts of correction (3 Delta-groups: <0°, 1-7° and ≥8°) and final lordosis (4 Omega-groups: 0-7°, 8-14°, 15-21°, ≥22°).
219 levels were fused in 102 patients. Surgery improved the clinical outcome of all groups significantly. A lordotic profile was achieved in all analyzed groups. Patients that showed small lordosis after surgery (<8°) did not have an inferior clinical outcome compared to patients with larger cervical lordosis (>14°). The comparison of Odom's criteria showed that preoperatively kyphotic patients benefitted more from surgery than lordotic patients (p = 0.029), but no differences could be seen comparing neck pain and neurological improvement. The improvement of pain and neurological impairment measured by VAS and mJOAS supports the statistical impact and validity of the data despite comparatively small numbers of patients. The lack of postoperative kyphosis is a major limitation of the study to encompass the impact of sagittal alignment on clinical outcome.
Decompression and stabilization appear to be key elements of surgical treatment of CSM. While the achievement of cervical lordosis remains a major goal of surgery, clinical improvement is not hindered in patients who show small lordosis. However, kyphosis should be eliminated in symptomatic patients. The terms "balance" and "physiologic lordosis" remain complex entities without clear definition. To check the results of our study controlled randomized trials to validate and determine the exact role of cervical balance on the course of CSM would be helpful.
减压并维持或恢复颈椎前凸是脊髓型颈椎病（CSM）手术治疗的主要目标。众多研究支持颈椎前凸是神经功能恢复和疼痛减轻的关键因素这一假设。然而，即使是后凸畸形的患者也可能无症状。脊柱平衡问题在越来越多的出版物中受到关注。本研究的主要目的是评估颈椎前凸对线在CSM病程中的有效性，并将该参数与经过充分验证的工具，即改良日本骨科协会评分系统（mJOAS）和视觉模拟量表（VAS）相结合，以预测和衡量手术后的临床结果。
这是一项回顾性研究，收集了来自异质性队列的前瞻性数据。作者分析了102例接受减压手术和内固定的CSM患者的记录。通过使用mJOAS、VAS和奥多姆标准评估临床结果。影像学分析包括术前和术后X线片的比较。将患者分为亚组，以便能够比较不同矫正量（3个Δ组：<0°、1 - 7°和≥8°）和最终颈椎前凸（4个Ω组：0 - 7°、8 - 14°、15 - 21°、≥22°）的影响。
102例患者共融合了219个节段。手术显著改善了所有组的临床结果。所有分析组均实现了前凸形态。术后颈椎前凸较小（<8°）的患者与颈椎前凸较大（>14°）的患者相比临床结果并不差。奥多姆标准的比较显示，术前后凸畸形的患者比前凸畸形的患者从手术中获益更多（p = 0.029），但在比较颈部疼痛和神经功能改善方面未发现差异。尽管患者数量相对较少，但通过VAS和mJOAS测量的疼痛和神经功能障碍的改善支持了数据的统计学影响和有效性。术后无后凸畸形是本研究的一个主要局限性，无法全面评估矢状面排列对临床结果的影响。
减压和稳定似乎是CSM手术治疗的关键要素。虽然实现颈椎前凸仍然是手术的主要目标，但颈椎前凸较小的患者临床改善并未受到阻碍。然而，有症状的患者应消除后凸畸形。“平衡”和“生理性颈椎前凸”这些术语仍然是复杂的概念，没有明确的定义。进行对照随机试验以验证和确定颈椎平衡在CSM病程中的确切作用，将有助于检验我们的研究结果。
