脊髓型颈椎病前路术后脊髓损伤的原因及防治对策

目的 探讨脊髓型颈椎病前路手术引起脊髓损伤的原因和防治策略.方法 分析2001年-2009年共749例实施前路减压融合手术的脊髓型颈椎病患者病历资料.共有5例患者在术后即刻或术后早期出现了脊髓功能下降.其中男3例,女2例;年龄48-62岁,平均52岁.2例合并有后纵韧带骨化.术前日本骨科学会(JOA)评分9-16分,平均12.4分.手术方式采用前路经颈椎间盘或椎体次全切除减压、自体髂骨或Cage融合、钛合金板内固定术.术中出血50～200 ml.2例患者术后即刻发现脊髓功能障碍加重,1例术后6 h出现下肢感觉运动消失,1例术后24 h出现一侧肢体瘫痪,1例术后5 d出现四肢麻木加重.4例患者早期给予大剂量甲基强的松龙冲击治疗.5例患者均再次行颈椎前路探查术,其中1例患者同时又行后路单开门椎管扩大成形术.结果 随访时间1～2年,平均16个月.4例患者脊髓功能(JOA评分)术后3个月均恢复或优于术前水平,术后1年均优于术前水平;1例患者术后1年神经功能仍无改善.分析脊髓损伤原因:术中减压和止血伤及脊髓2例,减压不彻底1例,血肿和止血纱布压迫各1例.结论 颈前路减压手术引起脊髓损伤的主要原因是术后延迟损伤,如果发现和处理及时,脊髓功能大多数可以恢复至术前水平.应尽量避免术中操作伤及脊髓,从而导致脊髓功能永久性障碍.

Abstract：

Objective To investigate the causes and prevention strategies of postoperative spinal cord injury after anterior approach surgery for cervical spondylotic myelopathy. Methods The clinical data of 749 patients with cervical spondylotic myelopathy treated with anterior approach surgery from 2001 to 2009 were retrospectively studied.There were five patients with spinal cord dysfunction instantly or early after operation,including three males and two females at average age of 52 years (range,48-62 years).Two patients were combined with ossification of the posterior longitudinal ligament.The Japanese Orthopaedic Association (JOA) score was average 12.4(9-16)preoperatively.The surgeries included anterior cervical diskectomy(or corpectomy)and interbody fusion(iliac bone graft or cage or titanium mesh)and locking plates fixation.The blood loss was 50-200 ml.The symptoms included instant spinal cord injury in two patients,loss of the motor and feeling of both legs at 6 h after surgery in one,paralysis of one side limbs at 24 h after surgery in one and numbness of limbs at 5 days after surgery in one.Four patients were treated by large dose of methylprednisolone.Five patients underwent anterior exploration surgery,of which one patient received posterior cervical one-door expansive laminoplasty. Results The patients were followed up for average 16 months(12-24 months).The JOA score of four patients was recovered at three months and WaS better than preoperation after surgery.The function of spinal cord of one patient showed no improvement at one year after surgery.The causes for spinal cord injury included inappropriate surgical manipulation in decompression and haemostasis in two patients,insufficient decompression in one,epidural hematoma in one and absorbable hemostatic gauze in one. Conclusions The major causes of postoperative spinal cord injury in anterior approach surgery for cervical spondylofic myelopathy are the delayed postoperative injury.The spinal cord can recover to normal and has satisfactory prognosis if discovered promptly.We must avoid the spinal cord injury by surgical Manipulation that may result in permanent neurological deficits.     

Anterior lumbar interbody fusion

A new technique for lumbar fusion surgery incorporates threaded interbody cages. In contrast to its posterior counterpart, the anterior approach to this surgery appears to result in better fusion, less morbidity and quicker operations. This article reviews spinal anatomy and fusion and discusses the indications for anterior lumbar interbody fusion. The radiographer's role in diagnostic imaging, surgery and post-operative routines is chronicled. Radiation dose considerations are addressed and suggestions for improving follow-up assessment are offered.     

上颈椎疾病手术方法选择

 目的 分析上颈椎疾病的病因、寰枢椎复位和脊髓受压情况,探讨上颈椎疾病的手术方法选择.方法 2003-01至2007-06收治169例上颈椎疾病,根据病因分为:上颈椎骨折74例,先天性上颈椎疾病65例,肿瘤21例,其他病因导致寰枢椎不稳9例.根据病因、寰枢椎复位情况和脊髓受压情况分别采用前路手术、后路手术或者前后路手术.结果 28例可复位齿状突骨折患者采用前路空心螺钉内固定.97例上颈椎可复位,脊髓前方无明显受压患者采用单纯后路复位内固定,取自体松质骨植骨融合.44例难复位或脊髓前方明显受压患者采用前路减压、复位,后路内固定、取自体松质骨植骨融合.结论 根据上颈椎疾病病因、复位和脊髓受压情况,应分别选择前路、后路或者前后路联合手术治疗.     

颈椎单侧关节突交锁的治疗选择

目的 探讨颈椎单侧关节突交锁的不同治疗方法选择.方法 32例颈椎单侧关节突交锁,行头颅牵引复位成功8例,其中3例维持牵引1个月后改行头颈胸石膏固定,余5例行前路减压植骨融合内固定术.23例牵引失败,其中14例行前路切开复位、椎间盘切除植骨融合内固定术;3例前路复位失败行椎间盘切除加椎体次全切除减压植骨内固定术,1例前路复位失败改行后路切开复位后再前方植骨内固定术;3例行后路切开复位侧块内固定植骨融合术,2例行后路切开复位减压、前路椎间盘切除减压植骨内固定术.1例由于漏诊,伤后8个月行前路减压植骨融合术.结果 平均随访18个月.发现颈椎不稳2例,均为仅行牵引复位,未做融合术者.颈前路手术者植骨块术后12周均获骨性融合.颈椎生理曲度及椎间隙高度恢复较好.无内固定并发症,亦无治疗中神经并发症.结论 下颈椎单侧关节突交锁的治疗需要综合考虑多方面的因素,包括是否伴有椎间盘损伤、是否合并后柱骨折、脊髓压迫及损伤情况.对伴有创伤性颈椎间盘突出的单侧关节突交锁者,前路减压复位稳定术是首选方法,对于不伴椎间盘突出者,可试行牵引复位或直接后路切开复位固定.     

Ⅰ期前路颈椎复位减压及椎间植骨融合内固定术治疗下颈椎AO C型F4亚型单节段损伤

目的探讨I期前路颈椎复位减压、椎间植骨融合内固定术治疗下颈椎AO C型F4亚型单节段损伤的疗效方法采用回顾性病例系列研究分析2012年1月至2019年12月郑州市骨科医院收治的45例下颈椎AO C型F4亚型单节段损伤患者临床资料,其中男31例,女14例;年龄23-78岁[(48.5±3.7)岁]。损伤节段:C4/5 11例,C5/6 19例,C6/7 15例。单侧16例,双侧29例。伤后24 h内,全身麻醉下行I期前路复位减压、椎间植骨融合内固定术。椎间融合方式:自体髂骨块28例,颈椎椎间融合器17例。观察手术时间、术中出血量、关节突复位时间及成功率、术后并发症及切口愈合情况。术前和术后3个月通过颈椎侧位X线片测量颈椎间隙高度及颈椎局部Cobh角,评估颈椎生理曲度。在CT冠矢状位图像上进行Lenke分级,了解椎间植骨融合率。MRI检查了解椎管内脊髓减压情况,并于术前及术后3个月应用美国脊髓损伤协会(ASIA)分级、日本骨科学会(JOA)评分和术后改善率进行神经功能评估。结果患者均获随访3~9个月[(6.1±3.6)个月]。手术时间为40-75 min[(55.1±8.2)min],术中出血量为40-80 ml[(45.2±5.3)ml],复位时间1.5-3.0 min[(2.I±0.5)min],复位成功率为100%。术后无脊髓损伤加重、大血管及食管损伤等并发症,切口均1/甲愈合。术后3个月椎间高度[(4.9±0.8)m m]较术前[(3.3±0.6)mm]提高(P<0.05)。术后3个月颈椎Cobb角[(6.5±2.1)°]较术前[(-4.6±3.6)°]增加(P<0.01)。按Lenke分级,术后3个月椎间融合程度A级41例,B级4例,融合良好。除6例术前ASIA分级A级患者术后无明显改善外.其余患者ASIA分级较术前均有不同程度恢复。术后3个月JOA评分[(15.0±3.2)分]较术前[(7.4±2.3)分]提高(P<0.05),术后改善率为(73.3±17.6)%。结论I期前路颈椎复位减压、椎间植骨融合内固定术治疗下颈椎AO C型F4亚型单节段损伤,可早期手术减压,能够使对顶/脱位的小关节突复位,有效改善颈脊髓功能。     

无脊髓损伤下颈椎脱位的手术治疗

目的 探讨无脊髓损伤下颈椎脱位的手术方法选择及疗效.方法 分析总结2004年1月-2009年6月手术治疗的无脊髓损伤下颈椎脱位患者11例.根据Allen分类均为牵开屈曲型损伤,其中Ⅰ度脱位7例,Ⅱ度脱位1例,Ⅲ度脱位3例.陈旧性脱位8例,新鲜脱位3例,均为单纯颈椎外伤,不合并其他脏器损伤.单纯前路复位内固定椎间植骨融合7例,前后路联合复位内固定植骨融合4例.术后随访观察临床疗效.结果 11例患者手术经过顺利,术前11例Frankel分级E级,术后11例Frankel分级E级.X线片示11例患者均恢复颈椎正常序列和曲度.随访3～31个月未出现脊髓损伤症状及再脱位.术后3.5～5.5个月(平均4.3个月)达植骨融合.结论 合并关节突交锁的下颈椎脱位宜Ⅰ期行前后路联合复位内固定,无关节突交锁者可单纯前路复位椎间植骨融合.复位及内固定植骨融合术是治疗无脊髓损伤型下颈椎脱位的有效方法.     

Klippel-Feil syndrome: patterns of bony fusion and wasp-waist sign

Cervical spine radiographs of 33 patients with Klippel-Feil syndrome were studied for patterns of bony fusion and presence of wasp-waist sign. Five patients were found to have the classic features of massive cervical fusion. Two patients with two adjacent levels of bony fusion showed a wasp-waist sign. Fusion at one level of the cervical spine accounted for 26 remaining cases. The wasp-waist sign was observed in 14 of the cases in which there was complete vertebral interbody fusion, making this finding a valuable radiologic sign. Partial anterior or posterior vertebral interbody fusion, or isolated fusion of the neural arch, however, may or may not be associated with the wasp-waist sign. Klippel-Feil syndrome, easy to recognize when presenting with classic features or when associated with the wasp-waist sign, may be confused with a variety of other entities.     

一期前路病灶清除钛网植骨后路内固定治疗胸腰椎结核并后凸畸形66例疗效观察

目的观察一期前路病灶清除钛网植骨后路内固定术治疗胸腰椎结核并后凸畸形的临床疗效。方法对66例胸腰椎结核并后凸畸形患者在术前进行至少3周正规抗结核药物治疗后行病灶清除、椎间植骨及后路内固定术,根据术后后凸畸形的矫正角度及Frankel分级评价效果。结果对66例患者随访9~18(12±2)个月,所有患者无局部复发及窦道形成,术前术后Cobb角差异有统计学意义(P<0.05),Frankel分级与术前比较均有1~3级恢复。结论一期前路病灶清除、钛网植骨、后路内固定手术具有病灶清除彻底,植骨融合内固定可靠,畸形矫正理想等优点。     

Degenerative diseases of the cervical spine: comparison of a multiecho data image combination sequence with a magnetisation transfer saturation pulse and cervical myelography and CT

Assessing degenerative disease in the cervical spine remains a challenge. There is much controversy about imaging the cervical spine using MRI. Our aim in this prospective study was to compare a T2*-weighted 2D spoiled gradient-echo multiecho sequence (MEDIC) with a magnetisation transfer saturation pulse with cervical myelography and postmyelographic CT. Using an assessment scale we looked at the vertebral bodies, intervertebral discs, neural foramina, anterior and posterior nerve roots, grey matter, ligamenta flava, oedema in the spinal cord and stenosis of the spinal canal. We also evaluated postmyelography CT and the MEDIC sequence for assessing narrowing of the neural foramina in a cadaver cervical spine. We examined 67 disc levels in 18 patients, showing 18 disc prolapses and 21 osteophytes narrowing the spinal canal or the neural foramina. All MRI studies showed these abnormalities findings equally well. Postmyelography CT was significantly better for showing the bony structures and the anterior and posterior nerve roots. The MEDIC sequence provided excellent demonstration of soft-tissue structures such as the intervertebral disc and ligamentum flavum. No statistical differences between the imaging modalities were found in the assessment of narrowing of the neural foramina or the extent of spinal stenosis. The cadaver measurements showed no overestimation of abnormalities using the MEDIC sequence.     

聚醚醚酮融合器及椎弓根固定系统治疗腰椎退行性病变疗效观察

目的探讨后路椎管减压,单枚聚醚醚酮融合器植入及椎弓根螺钉固定系统治疗腰椎退行性病变临床疗效。方法2006年1月～2009年1月采用单枚聚醚醚酮椎间融合器治疗54例腰椎退变患者,其中男35例,女19例,年龄42-70岁,平均年龄57．2岁;其中腰椎间盘突出症26例,腰椎管狭窄16例,腰椎滑脱8例,退变性侧凸4例。结果平均随访2年（1-4．5年）。采用Nakai及Suk评分标准判定结果,优32例,良14例,可8例,优良率85％,术后椎间融合率96．3％。结论腰椎退行性病变患者在行后路减压,单枚聚醚醚酮椎间融合器植入及椎弓根系统治疗后,疗效满意,融合率高,是治疗腰椎退行性病变的良好方法。     

Size-invariant descriptors for detecting regions of abnormal growth in cervical vertebrae.

Digitized spinal X-ray images exhibiting specific pathological conditions such as osteophytes can be retrieved from large databases using Content Based Image Retrieval (CBIR) techniques. For efficient image retrieval, it is important that the pathological features of interest be detected with high accuracy. In this study, new size-invariant features were investigated for the detection of anterior osteophytes, including claw and traction in cervical vertebrae. Using a K-means clustering and nearest neighbor classification approach, average correct classification rates of 85.80%, 86.04% and 84.44% were obtained for claw, traction and anterior osteophytes, respectively.     

Identifiable causes for poor outcome in surgery for cervical spondylosis

Summary Outcome from surgery for cervical spondylosis is often disappointing. To identify possible causes of poor outcome 56 such patients referred for post-operative computed myelography or MRI were evaluated, 22 of which eventually had further surgery. Alternative diagnoses to cervical spondylosis were eventually established in 14.3 %; 26.8% had spinal cord atrophy 15.6% of which also had myelomalacia; 28.6% had diffuse spinal canal stenosis; and in 57.1% surgery had failed to decompress the spinal canal. These findings can be partly explained by patient selection criteria; nevertheless they do serve to emphasises the point often ignored in discussions of the efficacy of surgery in cervical spondylosis, that operations significantly often fail to achieve adequate decompression. Furthermore there was no evidence in this material that osteophytes regress after spinal fusion.     

Ⅰ期前后路联合手术治疗颈髓前后方同时受压

目的 探讨颈髓前后方同时受压Ⅰ期前后路手术的方法。方法 总结1999年6月～2003年11月收治的25例颈髓前后方同时受压的临床资料。男18例，女7例；年龄28～56岁，平均36．4岁。交通伤致颈椎三柱骨折18例，嵌夹型颈椎病5例，椎体和附件、椎板恶性巨细胞瘤2例。结果 25例均行Ⅰ期前后路联合手术减压内固定，创伤患者术后l例死亡，17例有不同程度恢复；颈椎病患者症状和阳性体征基本消失；肿瘤患苫疼痛基本消失，其中1例出现肺转移。结论 对各种原因引起颈髓前后方同时受压的患者，Ⅰ期前后路联合手术是理想方法，可使严重颈椎骨折脱位患者彻底解除颈髓压迫，损伤节段获得早期稳定，方便护理和功能锻炼，有利于脊髓功能恢复。     

无骨折脱位型颈髓损伤的手术治疗

目的探讨无骨折脱位型颈髓损伤的病理基础、手术方法的选择和治疗效果。方法对20例采用手术治疗的无骨折脱位型颈髓损伤患者进行回顾分析，并根据不同的特点采用不同的手术方式，观察近期疗效。结果20例无骨折脱位型颈髓损伤患者中，退变性椎管狭窄13例(65％)，节段性不稳6例(30％)。以颈椎间盘脱出为主要表现7例(35％)；存在各种原因所致的椎管储备间隙明显减少或消失的病理基础7例(35％)；在椎管储备间隙明显减少或消失的病理基础上，伴有节段性椎间不稳或椎间盘脱出6例(30％)。20例术后随访9～84个月，平均36．5个月。前路手术固定节段均获骨性融合，内固定物无松动，断裂；后路手术无再关门现象。术后MRI检查显示椎管容积扩大，颈髓受压缓解。3例术后脊髓功能无改善，其余患者均有不同程度恢复。结论颈椎椎管狭窄是无骨折脱位型颈髓损伤的重要病理基础；合理选择术式，手术操作正确，前、后路手术均能获得较理想的脊髓功能恢复效果。     

+Gz associated stenosis of the cervical spinal canal in fighter pilots

Previous magnetic resonance imaging (MRI) studies have shown that repeated exposure to +Gz forces can cause premature degenerative changes of the cervical spine (i.e. a work-related disease). This paper reports on two clinical cases of +Gz-associated degenerative cervical spinal stenosis caused by dorsal osteophytes in fighter pilots. Conventional x-rays and MRI were used to demonstrate narrowing of the cervical spinal canal. The first case was complicated by a C6-7 intervertebral disk prolapse and a congenitally narrow spinal canal. The second case involved progressive degenerative spinal stenosis in the C5-6 disk space which required surgery. The findings in this case were confirmed by surgery which showed posterior osteophytes and thickened ligaments compressing the cervical medulla. These two cases suggest that +Gz forces can cause degenerative spinal stenosis of the cervical spine. Flight safety may be jeopardized if symptoms and signs of medullar compression occur during high +Gz stress. It is recommended that student fighter pilots undergo conventional x-rays and MRI studies in order to screen out and reject candidates with a congenitally narrow spinal canal. These examination methods might be useful in fighter pilots' periodic medical check-ups in order to reveal acquired degenerative spinal stenosis.     

复杂性枢椎骨折合并相邻节段不稳的外科治疗

目的 探讨复杂枢椎骨折合并相邻节段不稳的临床、影像学特点,提供合理的手术治疗策略.方法 回顾分析手术治疗且资料完整的21例枢椎骨折患者,男14例,女7例;平均年龄34岁.根据枢椎骨折的类型及其相邻寰枢关节、C2/3椎间的稳定情况,分别采用以下手术方式:(1)前路C2/3椎间盘切除及植骨、颈前路钢板固定;(2)齿状突螺钉固定;(3)后路C1～2椎弓根、颈椎侧块螺钉固定或联合前后路手术,稳定上颈椎.结果 21例全部获得6～36个月随访(平均12个月),术后佩戴颈围3个月,3个月均获得骨性融合,颈椎伸屈侧位片显示颈椎稳定,无内固定松动、脱出及断裂,无椎动脉损伤、神经损伤、脑脊液漏及切口感染等手术并发症.5例脊髓损伤神经功能恢复良好.结论 对于枢椎骨折,在确定骨折的类型及准确判断相邻寰枢关节、C2/3稳定性受破坏程度的基础上,通过手术治疗,可取得良好的疗效.     

复杂性枢椎骨折合并相邻节段不稳的外科治疗

目的 探讨复杂枢椎骨折合并相邻节段不稳的临床、影像学特点,提供合理的手术治疗策略.方法 回顾分析手术治疗且资料完整的21例枢椎骨折患者,男14例,女7例;平均年龄34岁.根据枢椎骨折的类型及其相邻寰枢关节、C2/3椎间的稳定情况,分别采用以下手术方式:(1)前路C2/3椎间盘切除及植骨、颈前路钢板固定;(2)齿状突螺钉固定;(3)后路C1～2椎弓根、颈椎侧块螺钉固定或联合前后路手术,稳定上颈椎.结果 21例全部获得6～36个月随访(平均12个月),术后佩戴颈围3个月,3个月均获得骨性融合,颈椎伸屈侧位片显示颈椎稳定,无内固定松动、脱出及断裂,无椎动脉损伤、神经损伤、脑脊液漏及切口感染等手术并发症.5例脊髓损伤神经功能恢复良好.结论 对于枢椎骨折,在确定骨折的类型及准确判断相邻寰枢关节、C2/3稳定性受破坏程度的基础上,通过手术治疗,可取得良好的疗效.     

复杂性枢椎骨折合并相邻节段不稳的外科治疗

目的 探讨复杂枢椎骨折合并相邻节段不稳的临床、影像学特点,提供合理的手术治疗策略.方法 回顾分析手术治疗且资料完整的21例枢椎骨折患者,男14例,女7例;平均年龄34岁.根据枢椎骨折的类型及其相邻寰枢关节、C2/3椎间的稳定情况,分别采用以下手术方式:(1)前路C2/3椎间盘切除及植骨、颈前路钢板固定;(2)齿状突螺钉固定;(3)后路C1～2椎弓根、颈椎侧块螺钉固定或联合前后路手术,稳定上颈椎.结果 21例全部获得6～36个月随访(平均12个月),术后佩戴颈围3个月,3个月均获得骨性融合,颈椎伸屈侧位片显示颈椎稳定,无内固定松动、脱出及断裂,无椎动脉损伤、神经损伤、脑脊液漏及切口感染等手术并发症.5例脊髓损伤神经功能恢复良好.结论 对于枢椎骨折,在确定骨折的类型及准确判断相邻寰枢关节、C2/3稳定性受破坏程度的基础上,通过手术治疗,可取得良好的疗效.     

颈后纵韧带骨化后脊髓损伤的手术入路选择

目的 探讨颈后纵韧带骨化后脊髓损伤的外科治疗手术入路选择. 方法 回顾性分析25例颈后纵韧带骨化后脊髓损伤患者手术治疗的临床资料.按照Frankel神经功能分类法分级:A级2例,B级3例,C级14例,D级6例.前路手术12例,后路手术8例,后前路联合手术5例. 结果 术中无大血管、气管、食管、脊髓损伤等严重并发症.所有患者均获随访,时间15～86个月,平均38.3个月,前路手术患者均获骨性融合,内固定无松动、断裂及脱出.后路手术患者术后X线及CT摄片显示无再次关门现象.21例患者脊髓功能获得不同程度改善,4例尤改善者上肢疼痛、麻木有不同程度的缓解. 结论 采用前路、后路或后前路联合入路治疗颈后纵韧带骨化后脊髓损伤均取得良好临床疗效,根据影像学表现结合患者全身情况合理选择手术入路是手术成功的关键.     

Expanding lesions of the cervical spinal canal.

Attention has recently been directed to decrease in size of the spinal canal, notably in relation to production of posterior osteophytes in spondylosis. Tumors of the cord, roots, or meninges, syringolmyelia and hydromyelia may enlarge sufficiently in size or be critically located so that expansile change of the cervical spinal canal may result.