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Chinese Journal of Reparative and Reconstructive Surgery logoLink to Chinese Journal of Reparative and Reconstructive Surgery
. 2024 May;38(5):542–549. [Article in Chinese] doi: 10.7507/1002-1892.202402018

伴颈椎后凸畸形的脊髓型颈椎病影像学特征与手术疗效分析

Analysis of imaging characteristics and effectiveness of cervical spondylotic myelopathy with cervical kyphosis

Haitao LU 1, Haiyang YU 1,*, Wei ZHANG 1, Zihao CHAI 1, Xiubo GE 1, Rui ZHAO 1, Haoran ZHANG 1, Xiaoming HU 1
PMCID: PMC11096889  PMID: 38752239

Abstract

Objective

To investigate the imaging characteristics of cervical kyphosis and spinal cord compression in cervical spondylotic myelopathy (CSM) with cervical kyphosis and the influence on effectiveness.

Methods

The clinical data of 36 patients with single-segment CSM with cervical kyphosis who were admitted between January 2020 and December 2022 and met the selection criteria were retrospectively analyzed. The patients were divided into 3 groups according to the positional relationship between the kyphosis focal on cervical spine X-ray film and the spinal cord compression point on MRI: the same group (group A, 20 cases, both points were in the same position), the adjacent group (group B, 10 cases, both points were located adjacent to each other), and the separated group (group C, 6 cases, both points were located >1 vertebra away from each other). There was no significant difference between groups (P>0.05) in baseline data such as gender, age, body mass index, lesion segment, disease duration, and preoperative C2-7 angle, C2-7 sagittal vertical axis (C2-7 SVA), C7 slope (C7S), kyphotic Cobb angle, fusion segment height, and Japanese Orthopedic Association (JOA) score. The patients underwent single-segment anterior cervical discectomy with fusion (ACDF). The occurrence of postoperative complications was recorded; preoperatively and at last follow-up, the patients’ neurological function was evaluated using the JOA score, and the sagittal parameters (C2-7 angle, C2-7 SVA, C7S, kyphotic Cobb angle, and height of the fused segments) were measured on cervical spine X-ray films and MRI and the correction rate of the cervical kyphosis was calculated; the correlation between changes in cervical sagittal parameters before and after operation and the JOA score improvement rate was analyzed using Pearson correlation analysis.

Results

In 36 patients, only 1 case of dysphagia occurred in group A, and the dysphagia symptoms disappeared at 3 days after operation, and the remaining patients had no surgery-related complications during the hospitalization. All patients were followed up 12-42 months, with a mean of 20.1 months; the difference in follow-up time between the groups was not significant (P>0.05). At last follow-up, all the imaging indicators and JOA scores of patients in the 3 groups were significantly improved when compared with preoperative ones (P<0.05). The correction rate of cervical kyphosis in group A was significantly better than that in group C, and the improvement rate of JOA score was significantly better than that in groups B and C, all showing significant differences (P<0.05), and there was no significant difference between the other groups (P>0.05). The correlation analysis showed that the improvement rate of JOA score was negatively correlated with C2-7 angle and kyphotic Cobb angle at last follow-up (r=−0.424, P=0.010; r=−0.573, P<0.001), and positively correlated with the C7S and correction rate of cervical kyphosis at last follow-up (r=0.336, P=0.045; r=0.587, P<0.001), and no correlation with the remaining indicators (P>0.05).

Conclusion

There are three main positional relationships between the cervical kyphosis focal and the spinal cord compression point on imaging, and they have different impacts on the effectiveness and sagittal parameters after ACDF, and those with the same position cervical kyphosis focal and spinal cord compression point have the best improvement in effectiveness and sagittal parameters.

Keywords: Cervical spondylotic myelopathy, cervical kyphosis, imaging characteristic, sagittal parameter

脊髓型颈椎病（cervical spondylotic myelopathy，CSM）主要表现为四肢功能障碍、感觉异常，部分患者甚至出现大、小便功能受累等，常需手术治疗[1-2]。颈前路椎间盘切除融合术（anterior cervical discectomy with fusion，ACDF）是治疗CSM的经典术式[3-5]，疗效肯定。但随着社会发展，CSM的治疗面临新的挑战，CSM伴颈椎后凸畸形逐渐增多并成为常见类型[6]，其治疗需统筹考虑脊髓减压和矢状面曲度重建，手术方式选择尚存在争议，且术后邻椎病、后凸进行性加重等相关并发症常见报道[7-9]。研究发现颈椎生理曲度不良是术后颈部疼痛、预后不良的重要原因[10-11]。

目前，对CSM伴颈椎后凸畸形的研究多集中于多节段压迫患者的治疗及手术方式对比[3，12]，研究对象多为中老年人群，然而颈椎后凸畸形发生趋于年轻化[13]，合并单节段脊髓压迫患者逐渐增多，对此类患者的研究应受到重视。我们在临床中发现，伴颈椎后凸畸形的CSM其后凸顶点（颈椎X线片上后凸范围内凸侧最远点椎体/椎间盘）与脊髓压迫点（颈椎MRI上对脊髓造成压迫的椎间盘）可存在多种位置关系，单纯针对压迫区进行ACDF的最终疗效尚无明确报道。本研究通过回顾分析我院2020年1月—2022年12月收治的单节段CSM伴颈椎后凸畸形患者临床资料，探究颈椎后凸顶点和压迫点不同位置关系，以及ACDF手术前后颈椎矢状面参数变化与临床疗效的关系。报告如下。

1. 临床资料

1.1. 一般资料

患者纳入标准：① 单节段单纯型CSM合并颈椎后凸畸形，且后凸Cobb角>5°；② 脊髓受压症状进行性加重，颈椎MRI示脊髓受压节段与查体症状相符，保守治疗3个月无效；③ 颈椎侧位X线片及颈椎MRI上C7椎体完全显露；④ 颈椎后凸畸形在颈椎过伸位X线片上可自发纠正，为可复性后凸畸形；⑤ 临床及影像学资料完整。

排除标准：① 既往有颈椎手术史；② 颈椎后凸畸形为先天性、特发性、创伤性或炎性病变等导致；③ 有强直性脊柱炎、类风湿性关节炎、弥漫性特发性颅骨肥厚等疾病；④ 存在感染、结核、肿瘤等疾病；⑤ 颈椎侧位X线片或颈椎MRI上重要骨性标志显示不清。

2020年1月—2022年12月共36例患者符合选择标准纳入研究。根据颈椎后凸顶点与脊髓压迫点的位置关系分为3组：相同组（A组，20例，两点处于相同位置）、相邻组（B组，10例，两点位置相邻）、相隔组（C组，6例，两点位置相隔>1个椎体）。3组患者性别、年龄、身体质量指数、病变节段、病程及术前C2～7角、C2～7矢状位轴向距离（C2-7 sagittal vertical axis，C2-7 SVA）、C7倾斜角（C7 slope，C7S）、后凸Cobb角、融合节段高度、日本骨科协会（JOA）评分等基线资料比较差异均无统计学意义（P>0.05），具有可比性。见表1。

表 1.

Comparison of baseline data between groups

3组患者基线资料比较

基线资料
Baseline data		 A组（n=20）
Group A (n=20)		 B组（n=10）
Group B (n=10)		 C组（n=6）
Group C (n=6)		 统计量
Statistical value		 P值
P value
年龄（x±s，岁） 52.90±7.56 44.60±12.33 55.00±18.59 F=2.279 0.118
性别（男/女，例） 7/13 7/3 4/2 χ2=4.153 0.125
身体质量指数（x±s，kg/m2） 24.99±2.65 23.02±2.13 24.18±3.96 F=1.698 0.199
病变节段（C3、4/C4、5/C5、6/C6、7，例） 2/3/10/5 0/2/5/3 3/0/2/1 χ2=8.896 0.179
病程（x±s，月） 20.85±8.58 20.20±5.84 17.50±3.93 F=0.480 0.623
术前影像学指标（x±s）
　C2～7角（°） −3.35±5.94 2.95±7.94 −4.03±10.49 F=2.480 0.099
　C2-7 SVA（mm） 25.97±10.93 19.12±9.29 31.83±23.10 F=1.859 0.172
　C7S（°） 16.63±4.87 12.89±7.37 19.47±10.01 F=2.021 0.149
　后凸Cobb角（°） 11.35±3.96 13.86±4.90 12.61±9.13 F=0.759 0.476
　融合节段高度（mm） 33.08±3.42 32.37±2.54 34.42±3.81 F=0.739 0.486
术前JOA评分（x±s，分） 11.2±1.9 11.1±0.8 11.2±0.8 F=0.190 0.982
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1.2. 手术方法

患者于全身麻醉下取仰卧位，术区消毒、铺巾。取颈部右侧横切口或斜切口入路，显露责任节段；纵行切开椎前筋膜，撑开器撑开后摘除椎间盘组织，刮除椎间隙上、下软骨终板和骨赘，蚕食咬除后纵韧带，向四周潜行减压；探及硬脊膜膨隆无受压，参照邻近椎间隙高度选择合适大小的Cage，将骨赘及碎骨填充其中后植入椎间隙；选择合适长度的钛板及螺钉固定，C臂X线机透视证实Cage及钛板位置良好，局部后凸改善满意。冲洗切口，放置引流管，逐层闭合切口，无菌敷料包扎。

1.3. 疗效评价指标

记录患者术后并发症发生情况，如吞咽困难、声音嘶哑、脑脊液漏、医源性神经或血管损伤、切口感染等。采用JOA评分评价患者神经功能，按照以下公式计算JOA评分改善率[14]，公式：（末次随访JOA评分−术前JOA评分）/（17−术前JOA评分）×100%。

术前及末次随访时行颈椎X线片和MRI检查，测量以下矢状位参数：① C2～7角[15]：C2与C7椎体后缘平行线之间的夹角；② C2-7 SVA：C2椎体的几何中心铅垂线至C7终板上后角的水平距离（C2椎体几何中心位于C7椎体后方时该距离记录为负值）；③ C7S：C7上终板延长线与水平线之间的夹角；④ 后凸Cobb角：标准侧位X线片后凸范围内上端椎上终板与下端椎下终板连线的垂直线间夹角，并计算后凸矫正率[16]，公式：（末次随访后凸Cobb角−术前后凸Cobb角）/（0−术前后凸Cobb角）×100%；⑤ 融合节段高度：融合节段上位椎体上终板中点至融合节段下位椎体下终板中点的距离。所有参数均由1名脊柱外科医生和1名放射科医生（医生对研究内容不知情），通过院内影像与信息传输系统（PACS）进行测量，长度精确至0.01 cm，角度精确至0.01°。

1.4. 统计学方法

采用SPSS26.0统计软件进行分析。计量资料经Shapiro-Wilk正态性检验，均符合正态分布，数据以均数±标准差表示，组间比较采用单因素方差分析，两两比较采用LSD检验。计数资料组间比较采用四格表卡方检验或列联表卡方检验。采用Pearson相关分析末次随访时颈椎矢状位参数及其手术前后差值与JOA评分改善率之间的相关性。检验水准 α=0.05。

2. 结果

36例患者中，仅A组发生1例吞咽困难，术后3 d吞咽困难症状消失，余患者未发生手术相关并发症。所有患者均获随访，随访时间12～42个月，平均20.1个月；3组随访时间比较差异无统计学意义（P>0.05）。末次随访时3组患者各影像学指标及JOA评分均较术前显著改善，差异有统计学意义（P<0.05）。A组后凸矫正率显著优于C组，JOA评分改善率显著优于B、C组，差异均有统计学意义（P<0.05）；其余组间比较差异无统计学意义（P>0.05）。相关性分析示，JOA评分改善率与末次随访时C2～7角、后凸Cobb角成负相关（r=−0.424，P=0.010；r=−0.573，P<0.001），与末次随访时C7S及后凸矫正率成正相关（r=0.336，P=0.045；r=0.587，P<0.001），与其余指标无相关性（P>0.05）。见表2～4，图1～3。

表 2.

Comparison of the outcome indicators between groups (x±s)

3组患者结局指标比较（x±s）

结局指标
Outcome indicator		 A组（n=20）
Group A (n=20)		 B组（n=10）
Group B (n=10)		 C组（n=6）
Group C (n=6)		 P值
P value
随访时间（月） 20.85±8.58 20.20±5.84 17.50±3.93 0.623
C2～7角手术前后差值（°） −10.11±4.79 −11.58±5.68 −8.85±6.29 0.593
C2-7 SVA手术前后差值（mm） −8.44±6.77 −4.00±9.34 −8.58±10.51 0.350
C7S手术前后差值（°） 5.89±3.49 5.65±5.00 3.04±6.31 0.389
后凸矫正率（%） 140.20±43.53 107.41±42.14 69.02±41.53 0.003
融合节段高度手术前后差值（mm） 2.75±0.85 3.07±0.77 3.14±0.67 0.448
JOA评分改善率（%） 65.00±11.01 55.89±12.81 51.30±10.88 0.023
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表 4.

Correlation analysis between JOA improvement rate and cervical sagittal parameters at last follow-up

JOA评分改善率与手术前后颈椎矢状位参数变化值的相关性分析

JOA评分
改善率
Improvement rate
of JOA score		 末次随访
Last follow-up		 手术前后差值
Changes before and after operation		 后凸矫正率
Correction rate of
kyphosis
C2～7角
C2-7 angle		 后凸Cobb角
Kyphotic Cobb
angle		 C2-7 SVA C7S 融合节段高度
Height of fused
segments		 C2～7角
C2-7 angle		 C2-7 SVA C7S 融合节段高度
Height of fused
segments
r值 −0.424 −0.573 −0.073 0.336 0.033 −0.228 −0.218 0.259 0.278 0.587
P值 0.010 <0.001 0.674 0.045 0.848 0.181 0.202 0.128 0.100 <0.001
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图 1.

A 40-year-old male patient with C5, 6 CSM with cervical kyphosis in group A

A组患者，男，40岁，C5、6 CSM伴颈椎后凸畸形

a～e. 术前X线片（箭头示后凸顶点）、MRI（箭头示脊髓压迫点）及CT；f. 术后即刻X线片示颈椎曲度恢复良好；g. 术后30个月X线片示颈椎曲度恢复良好，Cage无脱出、移位，钉棒无断裂

a-e. Preoperative X-ray film (arrow showed kyphosis focal), MRI (arrow showed spinal cord compression point), and CT; f. Immediate postoperative X-ray film showed good recovery of cervical curvature; g. X-ray film at 30 months after operation showed good recovery of cervical curvature, with no subluxation or displacement of the Cage, and no breakage of the nail rods

图 1

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图 3.

A 46-year-old male patient with C3, 4 CSM with cervical kyphosis in group C

C组患者，男，46岁，C3、4 CSM伴颈椎后凸畸形

a～e. 术前X线片（箭头示后凸顶点）、MRI（箭头示脊髓压迫点）及CT；f. 术后即刻X线片示颈椎曲度恢复良好；g. 术后27个月X线片示颈椎曲度恢复良好，Cage无脱出、移位，钉棒无断裂

a-e. Preoperative X-ray film (arrow showed kyphosis focal), MRI (arrow showed spinal cord compression point), and CT; f. Immediate postoperative X-ray film showed good recovery of cervical curvature; g. X-ray film at 27 months after operation showed good recovery of cervical curvature, with no subluxation or displacement of the Cage, and no breakage of the nail rods

图 3

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表 3.

Pairwise comparison of outcome indicators between groups

3组患者结局指标两两比较

结局指标
Outcome indicator		 A组 vs B组
Group A vs group B		 B组 vs C组
Group B vs group C		 A组 vs C组
Group A vs group C
效应值（95%CI）
Effect value (95%CI)		 P值
P value		 效应值（95%CI）
Effect value (95%CI)		 P值
P value		 效应值（95%CI）
Effect value (95%CI)		 P值
P value
后凸矫正率（%） MD=0.33（−0.01，0.66） 0.057 MD=0.38（−0.06，0.83） 0.092 MD=0.71（0.30，1.11） 0.001
JOA评分改善率（%） MD=0.09（0.00，0.18） 0.049 MD=0.05（−0.75，0.16） 0.446 MD=0.13（0.03，0.24） 0.015
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图 2.

A 44-year-old male patient with C5, 6 CSM with cervical kyphosis in group B

B组患者，男，44岁，C5、6 CSM伴颈椎后凸畸形

a～e. 术前X线片（箭头示后凸顶点）、MRI（箭头示脊髓压迫点）及CT；f. 术后即刻X线片示颈椎曲度恢复良好；g. 术后29个月X线片示颈椎曲度恢复良好，Cage无脱出、移位，钉棒无断裂

a-e. Preoperative X-ray film (arrow showed kyphosis focal), MRI (arrow showed spinal cord compression point), and CT; f. Immediate postoperative X-ray film showed good recovery of cervical curvature; g. X-ray film at 29 months after operation showed good recovery of cervical curvature, with no subluxation or displacement of the Cage, and no breakage of the nail rods

图 2

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3. 讨论

CSM是一种慢性退行性疾病，常伴有脊髓受压或缺血，导致神经功能障碍，患者生活质量下降。当颈椎椎间高度降低、生理性前凸角度丢失、椎间盘和小关节退变时，常发生退行性颈椎后凸畸形[6]，使得脊髓和神经周围空间进一步缩小，造成静力性压迫和神经损伤。当CSM与颈椎后凸畸形复合共存时，其主要责任节段位置可能不同，颈椎后凸顶点与脊髓压迫点的不同位置关系是否会影响术后疗效及术后颈椎矢状位平衡，目前仍缺乏相关研究。非手术治疗可在一定程度上改善神经功能，纠正颈椎矢状面失衡。然而，随着神经功能恶化，手术仍是治疗CSM伴颈椎后凸畸形的最有效策略[3]。临床上常采用ACDF治疗CSM伴颈椎后凸畸形患者，其优势在于可有效缓解神经受压状况、矫正颈椎后凸畸形[17]。

目前，临床工作中对CSM常用的术前影像学检查包括MRI、颈椎X线片和CT，明确其影像学特点对患者的诊断、治疗计划及预测术后疗效至关重要[18]。其中MRI是评估椎管狭窄和脊髓压迫程度的首选成像方式；颈椎X线片是评估颈椎曲度变化、测量颈椎矢状位参数常用的影像学检查[19]。但CT在术前评估颈椎矢状面失衡及脊髓病变的严重程度方面应用不佳[20]。本研究通过对患者颈椎X线片及MRI分析，发现单节段脊髓受压的CSM伴颈椎后凸畸形患者的脊髓压迫点与后凸顶点存在3种位置关系，即相同、相邻、相隔。探明不同位置关系之间的疗效及并发症有无差异，有利于针对患者影像学特征提供更加合适的诊疗计划，为伴颈椎后凸畸形的CSM治疗提供新思路，为制定系统性整体诊疗方案奠定基础。

3.1. 不同位置关系与神经功能恢复的关系

本研究结果显示3组患者末次随访时JOA评分均较术前改善，其中A组JOA评分改善率显著优于B、C组。有研究表明[21]颈椎后凸畸形存在时，脊髓内压呈增大趋势，同时颈后侧肌韧带复合体呈现持续性紧张状态，这可能与颈痛及脊髓神经症状密切相关，A组患者融合节段为后凸顶点节段，椎间Cage的植入使后凸顶点椎间隙高度恢复，更能缓解颈后侧肌韧带复合体的紧张状态，达到良好术后效果。伴颈椎后凸畸形的患者其颈椎椎体运动是以后凸顶点为中心，在颈椎矢状面上旋转和位移，后凸顶点处应力最大，同时顶点对应的椎间盘拉伸与关节突关节咬合运动构成的轴向负荷也增大[22]。A组患者矫正后凸顶点处的异常结构，能够最大程度地减小后凸顶点处轴向负荷，有利于促进术后神经功能恢复。

目前颈椎后凸畸形对术后疗效的影响仍存在争议，有研究认为对于≤3个脊髓压迫节段的CSM伴颈椎后凸畸形患者，ACDF均可达到良好临床效果[3]。Wang等[5]也认为CSM患者的主要症状是由于脊髓受压引起，充分的脊髓减压即可获得满意疗效，他们认为CSM仅对脊髓压迫进行充分减压即可，对颈椎后凸畸形无需额外处理。但Wu等[9]表示颈椎后凸畸形也可能导致脊髓受压，加重脊髓病症状，在进行充分脊髓减压的同时应进行后凸矫正。关晓明等[16]认为CSM伴颈椎后凸畸形患者的术后疗效与颈椎后凸畸形程度有关，对于重度颈椎后凸畸形患者应兼顾减压与矫形。我们研究发现，单节段脊髓压迫的CSM伴颈椎后凸畸形患者后凸顶点与脊髓压迫点之间存在3种位置关系，不同位置时术后疗效存在差异。故对于CSM伴颈椎后凸畸形患者选择手术方案时，不仅要考虑脊髓充分减压，还要兼顾后凸畸形的影响，应结合患者后凸顶点与脊髓压迫点的位置关系，制定更加合理的手术方式。

3.2. 颈椎矢状位参数与神经功能恢复的关系

随着国内外学者对颈椎矢状位平衡的深入研究，颈椎矢状位参数在预测颈椎术后疗效和神经功能恢复中的作用已成为研究热点，在手术计划和决策中，利用颈椎矢状位参数可以使外科医生优化CSM的临床结局[9]。Acharya等[23]认为CSM患者行减压手术时，必须考虑到颈椎矢状面失衡。我们的研究结果显示ACDF术后各组患者的颈椎矢状位参数、颈椎曲度以及后凸Cobb角都得到了改善，其中末次随访时C2～7角、后凸Cobb角与JOA评分改善率成负相关，C7S、后凸矫正率与JOA评分改善率成正相关，这可能与术中应用 Caspar 撑开器、椎间Cage植入提升手术节段椎间隙高度，增加了前柱高度有关，椎间隙高度的增加间接扩大了椎管和椎间孔容积，能够进一步解除相应节段脊髓、神经根所受压迫，同时椎体撑开后小关节压力得到缓解，可降低术后颈部疼痛[24]。

本研究发现患者术后颈椎前凸角度越小或颈椎后凸畸形角度越大，术后疗效越不佳，可能是因为机体依然要利用不当的肌肉模式和身体姿势，以补偿颈椎前凸丢失带来的头颈部重心失衡[25]。颈椎后凸畸形角度增大会伴随着颅骨前移以及C2-7 SVA前向增加，颈部肌肉会承受更大负荷，从而导致颈部轴性症状发生[26]。颈椎后凸畸形患者C2-7 SVA增加与脊髓信号强度升高相关，随着C2-7 SVA增加，颈椎后凸畸形患者表现出更明显的脊髓病变症状[27]。因此，术后C2-7 SVA降低，能够使头部重心后移，进而改善颈椎矢状位失衡，缓解颈肩部疼痛[28]。末次随访时C7S的增大与患者疗效成正相关，可能是由于融合节段的椎间Cage植入及钛板内固定，颈椎曲度恢复，矫正颈椎后凸畸形，同时C7S代偿性增大，能够有效维持颈椎矢状位平衡及头颈部重心稳定[29]。我们研究发现颈椎后凸矫正率与术后JOA评分改善率成正相关。颈椎后凸畸形的矫正恢复了椎间盘和小关节的生物力学分布，降低了颈部肌肉紧张和韧带应力，减少了无菌性炎症的发生[30]，有助于缓解术后颈部疼痛。有学者则认为术后神经功能恢复主要与脊髓充分减压有关，术后颈椎曲度减少对恢复无显著影响[31]。本研究发现3组患者颈椎后凸矫正率不同，是因为当后凸顶点与压迫点处于相同位置时，ACDF可对颈椎后凸顶椎进行纠正，涉及后凸范围较大；相邻位置时仅涉及后凸范围的颅侧或尾侧，复位作用有限；同样，处于相隔位置时，对颈椎后凸的矫形作用则更加有限。本研究结果发现，末次随访时残留的后凸Cobb角越大，患者JOA评分改善率越差，提示我们应在充分脊髓减压基础上，尽可能地矫正后凸畸形，临床上可采用大角度Cage重建颈椎前凸[32]。

综上述，本研究发现颈椎后凸顶点与脊髓压迫点在影像学上存在不同位置关系，且对ACDF术后疗效和颈椎矢状位参数改善产生影响，其中颈椎后凸顶点与脊髓压迫点相同者临床疗效和颈椎矢状位参数改善最佳。但本研究尚存在不足之处，第一，纳入病例数较少，术后随访时间较短，后续将增加病例数并延长随访时间，探究颈椎后凸顶点和脊髓压迫点不同位置关系对ACDF术后疗效的影响。第二，仅采用JOA评分及改善率对术后神经功能恢复进行评价，可能导致术后疗效评价不确切。第三，未考虑颈椎后凸矢状位参数改变与胸腰椎及脊柱骨盆参数之间的关系，后续应进一步研究伴有颈椎后凸畸形的CSM患者其胸腰椎曲度对颈椎曲度的影响。

利益冲突　在课题研究和文章撰写过程中不存在利益冲突；课题经费支持没有影响文章观点和对研究数据客观结果的统计分析及其报道

伦理声明　研究方案经蚌埠医科大学附属阜阳医院（阜阳市人民医院）医学伦理委员会批准（［2022］6号）

作者贡献声明　陆海涛、张伟、柴子豪：参与研究设计及实施、数据收集整理及统计分析；陆海涛：文章撰写；张浩然、赵锐、胡晓明、葛修博：参与数据收集整理及统计分析；于海洋：负责研究设计及实施，并对文章的知识性内容作批评性审阅

Funding Statement

国家骨科与运动康复临床医学研究中心创新基金资助项目（2021-NCRC-CXJJ-PY-35）；阜阳市自筹经费科技计划项目（FK202081021）

Innovation Funds of National Orthopaedic and Sports Rehabilitation Clinical Medical Research Center (2021-NCRC-CXJJ-PY-35); Fuyang Self-funded Science and Technology Program (FK202081021)

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Articles from Chinese Journal of Reparative and Reconstructive Surgery are provided here courtesy of Sichuan University

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