Macki Mohamed, Basheer Azam, Lee Ian, Kather Ryan, Rubinfeld Ilan, Abdulhak Muwaffak M
Departments of1Neurosurgery and.
2General Surgery, Henry Ford Hospital, Detroit, Michigan.
J Neurosurg Spine. 2018 Jan;28(1):33-39. doi: 10.3171/2017.5.SPINE161064. Epub 2017 Oct 27.
OBJECTIVE In the past, spine surgeons have avoided the transoral approach to the atlantoaxial segment because of concerns for unacceptable patient morbidity. The objective of this study was to measure 30-day postoperative complications, especially surgical site infection (SSI), after transoral versus posterior approach to atlantoaxial fusion. METHODS The source population was provided by the American College of Surgeons National Surgical Quality Improvement Program database, which was queried for all patients who underwent atlantoaxial fusion for degenerative/spondylotic disease and/or trauma between 2005 and 2014. To eliminate bias from unequal sample sizes, patients who underwent the transoral approach were matched with patients who underwent the posterior approach (generally 1:5 ratio) based on age ± 5 years and modified frailty index score (a measure of preoperative comorbidity burden). Because of rare SSI incidence, adjusted odds ratios (OR) of SSI were calculated using penalized maximum likelihood estimation. RESULTS A total of 318 patients were included in the study. There were no statistically significant differences between the transoral cohort (n = 56) and the posterior cohort (n = 262) in terms of 30-day postoperative individual complications, including SSI (1.79% vs 1.91%; p = 0.951) and composite complications (10.71% vs 6.87%; p = 0.323). Controlling for sex and smoking, the odds of SSI in the transoral approach were almost equal to the odds in the posterior approach (OR 1.17; p = 0.866). While the unplanned reoperation rate of 5.36% after transoral surgery was higher than the 1.53% rate after posterior surgery, the difference approached, but did not reach, statistical significance (p = 0.076). CONCLUSIONS Transoral versus posterior surgery for atlantoaxial fusion did not differ in 30-day unexpected outcomes. Therefore, spinal pathology, rather than concern for postoperative complications, should adjudicate the technical approach to the atlantoaxial segment.
目的 过去，脊柱外科医生因担心患者出现不可接受的发病率而避免采用经口入路治疗寰枢椎节段。本研究的目的是比较经口入路与后路入路进行寰枢椎融合术后30天的并发症，尤其是手术部位感染（SSI）。方法 研究人群来自美国外科医师学会国家外科质量改进计划数据库，查询2005年至2014年间因退行性/脊柱关节病和/或创伤接受寰枢椎融合术的所有患者。为消除样本量不等带来的偏差，根据年龄±5岁和改良虚弱指数评分（术前合并症负担的一种衡量指标），将接受经口入路的患者与接受后路入路 的患者进行匹配（通常为1:5的比例）。由于SSI发生率较低，使用惩罚最大似然估计计算SSI的调整优势比（OR）。结果 本研究共纳入318例患者。经口入路组（n = 56）和后路入路组（n = 262）在术后30天的个体并发症方面，包括SSI（1.79%对1.91%；p = 0.951）和复合并发症（10.71%对6.87%；p = 0.323），无统计学显著差异。在控制性别和吸烟因素后，经口入路发生SSI的几率几乎与后路入路相等（OR 1.17；p = 0.866）。虽然经口手术后5.36%的计划外再手术率高于后路手术后1.53%的再手术率，但差异接近但未达到统计学显著性（p = 0.076）。结论 经口入路与后路入路进行寰枢椎融合术在术后30天的意外结果方面无差异。因此，应根据脊柱病变情况而非对术后并发症的担忧来决定寰枢椎节段的技术入路。
