摘要
目的:提出一种新的下颈椎损伤评分系统,即后方骨-韧带复合体损伤分级和严重程度评分(posterior ligament-bone injury classification and severity, PLICS),并评估其指导下颈椎骨折脱位手术入路选择的价值。方法:回顾性分析2002年1月至2015年12月期间收治394例下颈椎骨折脱位(subaxial cervical fracture dislocations, SCFDs)且行单纯前路手术复位固定患者的病历资料,按照纳入及排除标准,最终354例纳入研究。PLICS评分由左、右侧柱及后柱三方面评分组成。后柱的损伤分为轻度、中度和重度,分别赋予1~3分。侧柱损伤的评估包括韧带结构及骨结构,韧带损伤评估即侧块关节半脱位计1分,完全脱位或关节突绞锁时计2分;侧柱的骨折分为轻、中、重三度,分别赋予1~3分。对于侧柱的评估取韧带结构或骨结构损伤的最高得分,与后柱损伤的得分一并纳入PLICS总分的计算。将随访期间出现螺钉松动、钢板移位、颈椎后凸畸形或棘突间隙张开的患者归为失败组,其余患者归为成功组。比较两组患者术前PLICS评分,手术前后的颈部疼痛视觉模拟评分(visual analogue scale,VAS)、颈部功能障碍指数(neck disability index,NDI)及美国脊髓损伤协会(American Spinal Injury Sssociation,ASIA)分级。结果:354例患者均获得随访,随访时间为(18.0±4.0)个月。成功组339例,失败组15例。术后12个月随访时,失败组患者VAS评分由术前(6.9±0.6)分降至(1.9±0.6)分,差异有统计学意义( t=22.481, P<0.0001);成功组患者由术前(5.6±1.0)分降至(1.1±0.3)分,差异有统计学意义( t=77.252, P<0.0001);两组患者术前( t=-4.948, P<0.0001)及术后12个月随访时( t=-9.076, P<0.0001)VAS评分的差异均有统计学意义。成功组患者的NDI明显低于失败组(7.1%±1.2% vs 15.7%±2.7%, t=24.993, P<0.0001)。两组患者术前PLICS评分的差异有统计学意义( t=8.777, P<0.0001)。根据PLICS评分绘制单纯前路术后内固定失败的ROC工作曲线,曲线下面积为0.981,95%可信区间为0.943,1.000,当PLICS评分为6.5分时,约登指数最大为0.927,敏感度0.994,特异度0.067。综合考虑PLICS评分的临床实用性及PLICS评分为7分时亚分类不同的临床结局,最终将阈值定为PLICS评分为7分且合并单侧重度侧块骨折。 结论:PLICS评分系统的建立基于下颈椎后方三柱结构的解剖学基础,既兼顾了双侧侧块、棘突及椎板等骨性结构及侧块关节囊等韧带结构,又依据对每柱骨-韧带结构损伤特点赋值,量化地反映下颈椎后方三柱结构的总体损伤程度。通过两组患者术前PLICS评分与临床疗效的比较观察,最终确定PLICS评分≥7分且同时伴有单侧重度侧块骨折,单纯前路手术后内固定失败的风险较高,可考虑行前后联合入路手术。
Objective To propose a new grading system-the posterior ligament-bone injury classification and severity(PLICS)score for subaxial cervical spine injury,and evaluate its value in guiding the approach selection for subaxial cervical fracture and dislocation.Methods All of 394 cases of subaxial cervical fracture and dislocation who received single anterior reduction and fixation in our hospital from January 2002 to December 2015 were retrospectively analyzed.According to the inclusion and exclusion criteria,354 cases were finally included in this study.The Patients experienced internal fixation failure,postoperative kyphosis or interspinal process space dilation during follow-up were included into the failure group.Other patients were included into the successful group.The difference of visual analogue scale(VAS),neck disability index(NDI),ASIA score and PLICS score before and after surgery between the two groups was compared respectively.The PLICS score is composed of left,right and posterior columns.The injury of the posterior column was classified into mild,moderate and severe degrees,with 1-3 points respectively.The evaluation of lateral column injury included ligament and bone structure.The evaluation of ligament injury included:1 point for the subluxation of the facet joint,2 points for the dislocation or the facet joint;Fractures of the lateral column was classified into mild,moderate and severe degrees,with 1-3 points respectively.For the evaluation of the lateral column,the highest score of ligament or bone structure injury was reflected as the score of posterior column injury and was taken into the calculation of the final PLICS score.Results All 354 patients had complete follow-up data,and the average follow-up time was 18.0±4.0 months,including 339 patients of successful group and 15 patients of failure group.At the 12 month follow-up,the average VAS score of the patients in the successful group decreased from 6.9±0.6 before the operation to 1.9±0.6(t=22.481,P<0.0001),and the average VAS score of the patients in the failure group decreased from 5.6±1.0 to 1.1±0.3(t=77.252,P<0.0001).The difference between the two groups was statistically significant.The NDI score of the successful group was significantly lower than that of the failure group(7.1%±1.2%vs 15.7%±2.7%,t=24.993,P<0.0001).PLICS score in two groups of patients were analyzed.There was a significant difference in PLICS scores between the two groups(t=8.777,P<0.0001).According to the PLICS score,the ROC operating curve of the failure of internal fixation after anterior-only surgery was determined.The area under the curve was 0.981,and the 95%confidence interval was 0.943,1.000.When the PLICS score was 6.5,the maximum value of the Jordan index was 0.927,the sensitivity was 0.994,and the specificity was 0.067.Considering the clinical practicality of PLICS score and the different clinical outcomes of the sub-classification groups of the PLICS score=7,we finally set the threshold as PLICS score=7 with the unilateral severe lateral mass fracture.Conclusion The PLICS score is based on the anatomy of the posterior three-column structure of the subaxial cervical spine.It gives consideration to the bony structures,including bilateral lateral mass,spinous process,lamina,and the ligament structures.What's more,the overall damage severity of the posterior three columns of the subaxial cervical spine was quantified according to the evaluation of the injury characteristics of each column of ligament-bone structure.In this study,PLICS score and clinical efficacy were compared between two groups of patients,and it was finally determined that when PLICS score≥7 with the unilateral severe lateral mass fracture,the risk of internal fixation failure is higher for anterior-only approach surgery alone.For these patients,anterior and posterior approach surgery may be considered.
作者
杨俊松
刘鹏
刘团江
闫亮
张正平
张海平
赵元廷
赵勤鹏
邹鹏
陈浩
拓源
贺宝荣
郝定均
Yang Junsong;Liu Peng;Liu Tuanjiang;Yan Liang;Zhang Zhengping;Zhang Haiping;Zhao Yuantin;Zhao Qinpeng;Zou Peng;Chen Hao;Tuo Yuan;He Baorong;Hao Dingjun(Department of Spinal Surgery,Honghui Hospital,Xi'an Jiaotong University,Xi'an 710054,China)
出处
《中华骨科杂志》
CAS
CSCD
北大核心
2020年第22期1503-1512,共10页
Chinese Journal of Orthopaedics
基金
国家自然科学基金重点项目(81830077)。
关键词
颈椎
脊柱骨折
脱位
脊柱融合术
Cervical vertebrae
Spinal fractures
Dislocations
Spinal fusion
