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中华临床医师杂志(电子版)

中华临床医师杂志(电子版) ›› 2022, Vol. 16 ›› Issue (06) : 558 -565. doi: 10.3877/cma.j.issn.1674-0785.2022.06.017

临床研究

T1倾斜角-颈椎前凸角（T1S-CL）在三节段颈椎前路椎间盘切除融合术中的意义
肖士鹏1, 徐帅2,†(), 李士春1, 云才1   
  1. 1. 100043　北京，首都医科大学石景山教学医院骨科
    2. 100044　北京，北京大学人民医院脊柱外科
  • 收稿日期:2022-04-08 出版日期:2022-06-15
  • 通信作者: 徐帅
  • 基金资助:
    北京大学人民医院研究与发展基金(RDY2021-12)

The significance of T1 slope minus cervical lordosis in consecutive three-level anterior cervical discectomy and fusion

Shipeng Xiao1, Shuai Xu2,†(), Shichun Li1, Cai Yun1   

  1. 1. Department of Orthopedics, Shijingshan Teaching Hospital, Capital Medical University, Beijing 100043, China
    2. Department of Spinal Surgery, Peking University People's Hospital, Beijijng 100043，China
  • Received:2022-04-08 Published:2022-06-15
  • Corresponding author: Shuai Xu
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引用本文：

肖士鹏, 徐帅, 李士春, 云才. T1倾斜角-颈椎前凸角（T1S-CL）在三节段颈椎前路椎间盘切除融合术中的意义[J]. 中华临床医师杂志(电子版), 2022, 16(06): 558-565.

Shipeng Xiao, Shuai Xu, Shichun Li, Cai Yun. The significance of T1 slope minus cervical lordosis in consecutive three-level anterior cervical discectomy and fusion[J]. Chinese Journal of Clinicians(Electronic Edition), 2022, 16(06): 558-565.

目的

本研究目的在于探究连续性3节段颈椎前路椎间盘切除融合术（ACDF）手术前后颈椎序列和平衡状态的变化情况，并进一步探究该术式下T1倾斜角减去C2-C7颈椎前凸角（T1S-CL）的合理阈值。

方法

本研究为单中心回顾性研究。收集2011年1月至2015年12月北京大学人民医院脊柱外科73例脊髓型颈椎病（CSM）患者接受连续性3节段ACDF，其中45例患者使用零切迹独立自锁系统，28例使用椎间融合器-前方钛板内固定系统，平均随访周期为73.8±8.6（m）。颈椎矢状位参数包括CL、C2-C7矢状位垂直距离（C2-C7 SVA）、T1S和T1S-CL，T1S-CL用于评估颈椎平衡状态，所有参数在术前和末次于颈椎X线上测得。生活质量由颈椎功能障碍指数（NDI）和日本矫形外科协会（JOA）评分评估，NDI=20分定义为生活质量评分阈值。T1S-CL阈值的确定基于影像学参数和临床指标，通过线性回归和Logistic回归模型进行双重判定。

结果

CL和T1S在末次较术前相比均有提高（P＜0.05）而T1SCL平均减低4.5±9.7°（P=0.008），C2-C7 SVA对比基线差异无统计学意义（P=0.253）。临床疗效方面，NDI和JOA在末次较术前相比显著改善（P＜0.001）。相关性分析显示，末次随访C2-C7 SVA与T1S-CL存在相关性，T1S与T1S-CL存在相关性（P＜0.05），末次随访NDI与矢状位参数之间存在相关性。C2-C7 SVA为NDI的独立危险因素（χ2=34.02，P=0.001，比值比=1.51，ROC-AUC=0.955），而T1S-CL为C2-C7 SVA的独立影响因素（χ2=12.26，P=0.001，比值比=1.24，ROC-AUC=0.878）。当NDI=20分时，线性回归和Logistic回归分析预测C2-C7 SVA的临界值为29.2 mm，此时对应T1S-CL的阈值为20.7°。

结论

3节段ACDF能够重建CSM患者颈椎矢状位序列并改善颈椎平衡状态。对于该人群，C2-C7 SVA的临界值为29.2 mm，此时对应颈椎平衡参数T1S-CL的阈值为20.7°。

关键词: 脊髓型颈椎病, 多节段颈椎前路椎间盘切除融合术, T1倾斜角减C2-C7颈椎前凸角, 临床结局
Objective

This study was to indentify the change of sagittal cervical alignment and balance after 3-level anterior cervical discectomy and fusion (ACDF) and to determine the threshold of T1 slope minus C2-C7 cervical lordosis (T1S-CL) in 3-level ACDF.

Methods

A single-center, retrospective, case-series study was conducted. A total of 73 cases with cervical spondylotic myelopathy (CSM) were collected from deportment of spinal surgery, Peking University People's Hospital including with a mean follow-up of 73.8±8.6 (m), where 45 patients was performed 3-level ACDF with stand-alone self-locked cage system and 28 cases with anterior cage-with-plate system. The cervical sagittal alignment paramters included CL, C2-C7 sagittal vertical axis (C2-C7 SVA), T1S and T1S-CL (the measurement for evaluating cervical balance), which were measured on cervical X-ray at baseline and final follow-up. The quality-of-life scale was evaluated by Neck disability index (NDI) and Japanese Orthopedic Association (JOA) score, where NDI with 20 was defined as the threshold of quality-of-life scale. The threshold of T1S-CL was determined according to radiological and clinical outcomes by both linear and logistic regression model.

Results

The CL and T1S improved (P＜0.05) and T1S-CL decreased by 4.5±9.7 (P=0.008) at last while C2-C7 SVA was of no significance compared to baseline (P=0.253). For clinical outcomes, all cases acquired inprovement on NDI and JOA (P＜0.001). At last, C2-C7 SVA was correlated to T1S-CL and T1S-CL was correlated to T1S. There were close correlation between cervical radiological parameters and NDI. C2-C7 SVA was independent risk factor for NDI (χ2=34.02, P=0.001, odd ratio=1.51, ROC-AUC=0.955) and T1S-CL was independent influencing factor for C2-C7 SVA (χ2=12.26, P=0.001, odd ratio=1.24, ROC-AUC=0.878). The two regression models predicted C2-C7 SVA with a cutoff of 29.2 mm when NDI was 20, corresponded to the threshold on T1S-CL of 20.7°.

Conclusion

Consective 3-level ACDF was able to rebuilting cervical alignment and balance status. The cutoff on C2-C7 SVA with 29.2 mm corresponds to a thershold of T1S-CL with 20.7° in multilevel ACDF.

Key words: Cervical spondylotic myelopathy, Multilevel anterior cervical discectomy and fusion, T1 slope minus C2-C7 cervical lordosis, Clinical outcomes
图1 颈椎侧位X线矢状位参数的测量。图a为CL和T1S的定义示意图；图b为C2-C7 SVA的定义示意图注：CL为C2-C7颈椎前凸角；T1S为T1倾斜角；SVA为矢状位垂直距离
表1 颈椎矢状位参数及临床疗效在末次与术前的对比
参数Parameters 术前Baseline 末次Last follow-up P值P value
CL（°） 9.6±12.9 14.9±8.6 0.002
C2-C7 SVA（mm） 19.9±9.6 18.7±9.1 0.253
T1S（°） 23.7±7.3 26.2±6.8 0.015
T1S-CL（°） 15.8±9.8 11.7±8.4 0.008
NDI 38.3±3.8 12.3±6.7 ＜0.001
JOA 11.1±2.3 16.6±2.4 ＜0.001
表2 术前和末次随访影像学参数的相关性分析
参数Parameters CLa（°） C2-C7 SVAa（mm） T1Sa（°）
r值 P值 r值 P值 r值 P值
C2-C7 SVA1（mm） -0.386 0.001
T1S1（°） 0.607 ＜0.001 0.090 0.450
T1S-CL1（°） -0.783 ＜0.001 0.557 ＜0.001 0.019 0.876
C2-C7 SVA2（mm） -0.409 ＜0.001
T1S2（°） 0.363 0.002 0.434 ＜0.001
T1S-CL2（°） -0.673 ＜0.001 0.735 ＜0.001 0.445 ＜0.001
ΔC2-C7 SVA（mm） -0.357 ＜0.001
ΔT1S（°） 0.378 0.001 0.287 0.014
ΔT1S-CL（°） -0.753 ＜0.001 0.565 ＜0.001 0.324 0.005
图2 颈椎序列参数相互作用示意图。图a为CL减低时T1S和C2-C7 SVA的变化示意图；图b为正常CL下T1S和C2-C7 SVA示意图；图c为CL增大时T1S和C2-C7 SVA的变化示意图注：CL为C2-C7颈椎前凸角；T1S为T1倾斜角；SVA为矢状位垂直距离
表3 临床疗效指标与影像学参数间的相关性分析
CLa（°） C2-C7 SVAa（mm） T1Sa（°） T1S-CLa（°）
r值 P值 r值 P值 r值 P值 r值 P值
NDI1 -0.176 0.137 0.239 0.042 -0.004 0.970 0.218 0.064
JOA1 -0.051 0.667 -0.240 0.041 -0.065 0.587 0.014 0.908
NDI2 -0.411 ＜0.001 0.723 ＜0.001 0.199 0.092 0.550 ＜0.001
JOA2 0.184 0.136 -0.307 0.011 -0.073 0.556 -0.226 0.066
表4 末次随访关于NDI和C2-C7 SVA多元线性回归分析
因变量 变量Coefficient 非标准化系数Unstandardized 标准化系数Standardized t值 P值
B值 SE值 Beta
NDI 常数（constant） 2.851 2.41 2.579 0.012
CL（°） -2.404 3.386 -2.745 -0.71 0.480
C2-C7 SVA（mm） 0.487 0.085 0.489 5.713 ＜0.001
T1S（°） 2.248 3.400 2.114 0.661 0.511
T1S-CL（°） -2.332 3.385 -2.761 -0.689 0.493
C2-C7 SVA（mm） 常数（constant） 8.488 3.409 2.135 0.026
T1S-CL（°） 0.834 0.110 0.911 7.574 ＜0.001
T1S（°） 0.207 0.139 0.133 1.494 0.140
图3 C2-C7 SVA和T1-CL的阈值判定。图a为NDI基于C2-C7 SVA的线性回归分析散点图；图b为NDI基于C2-C7 SVA 的Logistic回归分析的ROC曲线；图c为C2-C7 SVA基于T1S-CL的线性回归分析散点图；图d为C2-C7 SVA基于T1S-CL的Logistic回归分析的ROC曲线注：NDI为颈椎功能障碍指数；SVA为矢状位垂直距离；ROC曲线为接受者操作特征曲线；CL为C2-C7颈椎前凸角；T1S为T1倾斜角
图4 末次随访颈椎平衡与失平衡的病例。图a为行C4-C7的ACDF使用SLC内固定术后颈椎平衡病例；图b为行C4-C7的ACDF使用SLC内固定术后颈椎失平衡病例；图c为行C3-C6的ACDF使用ACP内固定术后颈椎平衡病例；图d为行C3-C6的ACDF使用ACP内固定颈椎失平衡病例注：ACDF为颈前路椎间盘切除融合术；SLC为独立自锁内固定系统；CL为C2-C7颈椎前凸角；T1S为T1倾斜角；SVA为矢状位垂直距离；NDI为颈椎功能障碍指数；ACP为颈前融合器-钛板系统
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