Qin Rongqing, Chen Xiaoqing, Zhou Pin, Li Ming, Hao Jie, Zhang Feng
Medical College of Nantong University, Nantong, 226001, Jiangsu, China.
Department of Orthopedics, Affiliated Hospital of Nantong University, Nantong, 226001, Jiangsu, China.
Eur Spine J. 2018 Jun;27(6):1375-1387. doi: 10.1007/s00586-017-5451-6. Epub 2018 Jan 15.
The purpose of this research is to compare the clinical efficacy, postoperative complication and surgical trauma between anterior cervical corpectomy and fusion versus posterior laminoplasty for the treatment of oppressive myelopathy owing to cervical ossification of the posterior longitudinal ligament (OPLL).
Systematic review and meta-analysis.
An comprehensive search of literature was implemented in three electronic databases (Embase, Pubmed, and the Cochrane library). Randomized or non-randomized controlled studies published since January 1990 to July 2017 that compared anterior cervical corpectomy and fusion (ACCF) versus posterior laminoplasty (LAMP) for the treatment of cervical oppressive myelopathy owing to OPLL were acquired. Exclusion criteria were non-human studies, non-controlled studies, combined anterior and posterior operative approach, the other anterior or posterior approaches involving cervical discectomy and fusion and laminectomy with (or without) instrumented fusion, revision surgeries, and cervical myelopathy caused by cervical spondylotic myelopathy. The quality of the included articles was evaluated according to GRADE. The main outcome measures included: preoperative and postoperative Japanese Orthopedic Association (JOA) score; neuro-functional recovery rate; complication rate; reoperation rate; preoperative and postoperative C2-C7 Cobb angle; operation time and intraoperative blood loss; and subgroup analysis was performed according to the mean preoperative canal occupying ratio (Subgroup A:the mean preoperative canal occupying ratio < 60%, and Subgroup B:the mean preoperative canal occupying ratio ≥ 60%).
A total of 10 studies containing 735 patients were included in this meta-analysis. And all of the selected studies were non-randomized controlled trials with relatively low quality as assessed by GRADE. The results revealed that there was no obvious statistical difference in preoperative JOA score between the ACCF and LAMP groups in both subgroups. Also, in subgroup A (the mean preoperative canal occupying ratio < 60%), no obvious statistical difference was observed in the postoperative JOA score and neurofunctional recovery rate between the ACCF and LAMP groups. But, in subgroup B (the mean preoperative canal occupying ratio ≥ 60%), the ACCF group illustrated obviously higher postoperative JOA score and neurofunctional recovery rate than the LAMP group (P < 0.01, WMD 1.89 [1.50, 2.28] and P < 0.01, WMD 24.40 [20.10, 28.70], respectively). Moreover, the incidence of both complication and reoperation was markedly higher in the ACCF group compared with LAMP group (P < 0.05, OR 1.76 [1.05, 2.97] and P < 0.05, OR 4.63 [1.86, 11.52], respectively). In addition, the preoperative cervical C2-C7 Cobb angle was obviously larger in the LAMP group compared with ACCF group (P < 0.05, WMD - 5.77 [- 9.70, - 1.84]). But no statistically obvious difference was detected in the postoperative cervical C2-C7 Cobb angle between the two groups. Furthermore, the ACCF group showed significantly more operation time as well as blood loss compared with LAMP group (P < 0.01, WMD 111.43 [40.32,182.54], and P < 0.01, WMD 111.32 [61.22, 161.42], respectively).
In summary, when the preoperative canal occupying ratio < 60%, no palpable difference was tested in postoperative JOA score and neurofunctional recovery rate. But, when the preoperative canal occupying ratio ≥ 60% ACCF was associated with better postoperative JOA score and the recovery rate of neurological function compared with LAMP. Synchronously, ACCF in the cure for cervical myelopathy owing to OPLL led to more surgical trauma and more incidence of complication and reoperation. On the other hand, LAMP had gone a diminished postoperative C2-C7 Cobb angle, that might be a cause of relatively higher incidence of postoperative late neurofunctional deterioration. In brief, when the preoperative canal occupying ratio < 60%, LAMP seems to be effective and safe. However, when the preoperative canal occupying ratio ≥ 60%, we prefer to choose ACCF while complications could be controlled by careful manipulation and advanced surgical techniques. No matter which option you choose, benefits and risks ought to be balanced.
本研究旨在比较颈椎前路椎体次全切除融合术与后路椎板成形术治疗颈椎后纵韧带骨化症（OPLL）所致压迫性脊髓病的临床疗效、术后并发症及手术创伤。
系统评价与荟萃分析。
在三个电子数据库（Embase、Pubmed和Cochrane图书馆）中进行全面的文献检索。纳入1990年1月至2017年7月发表的比较颈椎前路椎体次全切除融合术（ACCF）与后路椎板成形术（LAMP）治疗OPLL所致颈椎压迫性脊髓病的随机或非随机对照研究。排除标准为非人体研究、非对照研究、前后联合手术入路、涉及颈椎间盘切除融合术和（或不伴）器械融合的椎板切除术的其他前路或后路手术入路、翻修手术以及颈椎病性脊髓病所致的颈椎脊髓病。根据GRADE评估纳入文章的质量。主要观察指标包括：术前和术后日本骨科协会（JOA）评分；神经功能恢复率；并发症发生率；再次手术率；术前和术后C2-C7 Cobb角；手术时间和术中出血量；并根据术前平均椎管占位率进行亚组分析（A组：术前平均椎管占位率<60%，B组：术前平均椎管占位率≥60%）。
本荟萃分析共纳入10项研究，包含735例患者。所有纳入研究均为非随机对照试验，根据GRADE评估质量相对较低。结果显示，在两个亚组中，ACCF组和LAMP组术前JOA评分无明显统计学差异。此外，在A组（术前平均椎管占位率<60%）中，ACCF组和LAMP组术后JOA评分和神经功能恢复率无明显统计学差异。但是，在B组（术前平均椎管占位率≥60%）中，ACCF组术后JOA评分和神经功能恢复率明显高于LAMP组（分别为P<0.01，加权均数差[WMD]1.89[1.50,2.28]和P<0.01，WMD 24.40[20.10,28.70]）。此外，ACCF组并发症和再次手术的发生率均明显高于LAMP组（分别为P<0.05，比值比[OR]1.76[1.05,2.97]和P<0.05，OR 4.63[1.86,11.52]）。另外，LAMP组术前颈椎C2-C7 Cobb角明显大于ACCF组（P<0.05，WMD -5.77[-9.70,-1.84]）。但两组术后颈椎C2-C7 Cobb角无明显统计学差异。此外，ACCF组手术时间和出血量明显多于LAMP组（分别为P<0.01，WMD 111.43[40.32,182.54]，和P<0.01，WMD 111.32[61.22,161.42]）。
综上所述，当术前椎管占位率<60%时，术后JOA评分和神经功能恢复率无明显差异。但是，当术前椎管占位率≥60%时，与LAMP相比，ACCF术后JOA评分和神经功能恢复率更好。同时，ACCF治疗OPLL所致颈椎脊髓病会导致更多的手术创伤以及更高的并发症和再次手术发生率。另一方面，LAMP术后C2-C7 Cobb角减小，这可能是术后晚期神经功能恶化发生率相对较高的原因。简而言之，当术前椎管占位率<60%时，LAMP似乎有效且安全。然而，当术前椎管占位率≥60%时，我们更倾向于选择ACCF，同时可通过仔细操作和先进的手术技术控制并发症。无论选择哪种方案，都应权衡利弊。
