Ambati Vardhaan S, Macki Mohamed, Chan Andrew K, Michalopoulos Giorgos D, Le Vivian P, Jamieson Alysha B, Chou Dean, Shaffrey Christopher I, Gottfried Oren N, Bisson Erica F, Asher Anthony L, Coric Domagoj, Potts Eric A, Foley Kevin T, Wang Michael Y, Fu Kai-Ming, Virk Michael S, Knightly John J, Meyer Scott, Park Paul, Upadhyaya Cheerag, Shaffrey Mark E, Buchholz Avery L, Tumialán Luis M, Turner Jay D, Sherrod Brandon A, Haid Regis W, Bydon Mohamad, Mummaneni Praveen V
1Department of Neurological Surgery, University of California, San Francisco, California.
2Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York.
Neurosurg Focus. 2023 Sep;55(3):E2. doi: 10.3171/2023.6.FOCUS23295.
The authors sought to compare 3-level anterior with posterior fusion surgical procedures for the treatment of multilevel cervical spondylotic myelopathy (CSM).
The authors analyzed prospective data from the 14 highest enrolling sites of the Quality Outcomes Database CSM module. They compared 3-level anterior cervical discectomy and fusion (ACDF) and posterior cervical laminectomy and fusion (PCF) surgical procedures, excluding surgical procedures crossing the cervicothoracic junction. Rates of reaching the minimal clinically important difference (MCID) in patient-reported outcomes (PROs) were compared at 24 months postoperatively. Multivariable analyses adjusted for potential confounders elucidated in univariable analysis.
Overall, 199 patients met the inclusion criteria: 123 ACDF (61.8%) and 76 PCF (38.2%) patients. The 24-month follow-up rates were similar (ACDF 90.2% vs PCF 92.1%, p = 0.67). Preoperatively, ACDF patients were younger (60.8 ± 10.2 vs 65.0 ± 10.3 years, p < 0.01), and greater proportions were privately insured (56.1% vs 36.8%, p = 0.02), actively employed (39.8% vs 22.8%, p = 0.04), and independently ambulatory (14.6% vs 31.6%, p < 0.01). Otherwise, the cohorts had equivalent baseline modified Japanese Orthopaedic Association (mJOA), Neck Disability Index (NDI), numeric rating scale (NRS)-arm pain, NRS-neck pain, and EQ-5D scores (p > 0.05). ACDF patients had reduced hospitalization length (1.6 vs 3.9 days, p < 0.01) and a greater proportion had nonroutine discharge (7.3% vs 22.8%, p < 0.01), but they had a higher rate of postoperative dysphagia (13.5% vs 3.5%, p = 0.049). Compared with baseline values, both groups demonstrated improvements in all outcomes at 24 months (p < 0.05). In multivariable analyses, after controlling for age, insurance payor, employment status, ambulation status, and other potential clinically relevant confounders, ACDF was associated with a greater proportion of patients with maximum satisfaction on the North American Spine Society Patient Satisfaction Index (NASS) (NASS score of 1) at 24 months (69.4% vs 53.7%, OR 2.44, 95% CI 1.17-5.09, adjusted p = 0.02). Otherwise, the cohorts shared similar 24-month outcomes in terms of reaching the MCID for mJOA, NDI, NRS-arm pain, NRS-neck pain, and EQ-5D score (adjusted p > 0.05). There were no differences in the 3-month readmission (ACDF 4.1% vs PCF 3.9%, p = 0.97) and 24-month reoperation (ACDF 13.5% vs PCF 18.6%, p = 0.36) rates.
In a cohort limited to 3-level fusion surgical procedures, ACDF was associated with reduced blood loss, shorter hospitalization length, and higher routine home discharge rates; however, PCF resulted in lower rates of postoperative dysphagia. The procedures yielded comparably significant improvements in functional status (mJOA score), neck and arm pain, neck pain-related disability, and quality of life at 3, 12, and 24 months. ACDF patients had significantly higher odds of maximum satisfaction (NASS score 1). Given comparable outcomes, patients should be counseled on each approach's complication profile to aid in surgical decision-making.
作者旨在比较三级前路与后路融合手术治疗多节段脊髓型颈椎病（CSM）的效果。
作者分析了质量结果数据库CSM模块中14个入组率最高的研究点的前瞻性数据。他们比较了三级颈椎前路椎间盘切除融合术（ACDF）和颈椎后路椎板切除融合术（PCF），排除了跨越颈胸交界的手术。比较术后24个月患者报告结局（PROs）达到最小临床重要差异（MCID）的比例。多变量分析对单变量分析中阐明的潜在混杂因素进行了调整。
总体而言，199例患者符合纳入标准：123例ACDF患者（61.8%）和76例PCF患者（38.2%）。24个月的随访率相似（ACDF为90.2%，PCF为92.1%，p = 0.67）。术前，ACDF患者更年轻（60.8±10.2岁对65.0±10.3岁，p < 0.01），有更高比例的患者为私人保险（56.1%对36.8%，p = 0.02）、在职（39.8%对22.8%，p = 0.04）和能独立行走（14.6%对31.6%，p < 0.01）。除此之外，两组患者的基线改良日本骨科协会（mJOA）评分、颈部残疾指数（NDI）、数字评分量表（NRS）-手臂疼痛评分、NRS-颈部疼痛评分和EQ-5D评分相当（p > 0.05）。ACDF患者的住院时间缩短（1.6天对3.9天，p < 0.01），且有更高比例的患者为非常规出院（7.3%对22.8%，p < 0.01），但他们术后吞咽困难的发生率更高（13.5%对3.5%，p = 0.049）。与基线值相比，两组在24个月时所有结局均有改善（p < 0.05）。在多变量分析中，在控制了年龄、保险支付方、就业状况、行走状态和其他潜在的临床相关混杂因素后，ACDF组在24个月时北美脊柱协会患者满意度指数（NASS）达到最大满意度（NASS评分为1）的患者比例更高（69.4%对53.7%，OR 2.44，95%CI 1.17 - 5.09，校正p = 0.02）。除此之外，两组在mJOA、NDI、NRS-手臂疼痛、NRS-颈部疼痛和EQ-5D评分达到MCID方面的24个月结局相似（校正p > 0.05）。3个月再入院率（ACDF为4.1%，PCF为3.9%，p = 0.97）和24个月再次手术率（ACDF为13.5%，PCF为18.6%，p = 0.36）无差异。
在仅限于三级融合手术的队列中，ACDF与失血量减少、住院时间缩短和常规家庭出院率较高相关；然而，PCF导致术后吞咽困难发生率较低。两种手术在3个月、12个月和24个月时在功能状态（mJOA评分）、颈部和手臂疼痛、颈部疼痛相关残疾和生活质量方面均产生了相当显著的改善。ACDF患者达到最大满意度（NASS评分为1）的几率显著更高。鉴于结局相当，应向患者告知每种手术方法的并发症情况，以协助手术决策。
