椎体次全切除术与椎管扩大椎板成形术术后颈椎矢状位平衡的对比研究

目的对比分析椎体次全切除植骨融合术与椎管扩大椎板成形术术后颈椎矢状位平衡的变化。方法收集2010年2月—2013年1月本院收治的100例因脊髓性颈椎病伴椎管狭窄症并接受颈椎椎体次全切除植骨融合术(前路组,n=53)或颈椎椎管扩大椎板成形术(后路组,n=47)患者的临床及影像学资料,通过对比术前及末次随访时日本骨科学会(JOA)评分、C_(2~7) Cobb角、矢状面轴向垂直距离(SVA)、T_1倾斜角(T_1-slope)的变化,分析不同术式术后患者矢状位平衡的变化。结果所有手术均顺利完成,随访(25.5±3.2)个月。2组患者术前JOA评分、C_(2~7) Cobb角、SVA、T_1-slope差异无统计学意义(P0.05)。末次随访时JOA评分、C_(2~7) Cobb角、SVA均较术前明显改善,且组间差异有统计学意义(P0.05);前路组中,术前高T_1-slope患者与低T_1-slope患者术后颈椎后凸发生率差异无统计学意义(P0.05);后路组中,高T_1-slope患者颈椎后凸发生率显著高于低T_1-slope患者,差异有统计学意义(P0.05)。结论颈椎前路椎体次全切除术对术后颈椎矢状位平衡的影响优于颈椎后路椎管扩大椎板成形术;当术前患者T1-slope较高时,为减少术后矢状位平衡失代偿,可尽量选择前路手术。     

术前颈椎曲度与椎管扩大成形术后脊髓后移程度及疗效的相关性

目的:观察术前不同颈椎曲度的慢性压迫性颈脊髓病患者行单开门椎管扩大成形术后脊髓后移的距离及临床疗效,探讨颈椎曲度与椎管扩大成形术后脊髓后移程度及临床疗效的相关性.方法:选取我院2005年1月～2011年12月采用传统棘突、小关节囊悬吊法单开门椎管扩大成形术治疗并获得完整随访资料的慢性压迫性颈脊髓病患者共63例,包括脊髓型颈椎病26例,颈椎后纵韧带骨化症(OPLL)20例,发育性颈椎管狭窄合并颈脊髓病17例,均因多节段颈椎间盘退变突出、后纵韧带骨化导致多节段颈脊髓受压或合并发育性颈椎管狭窄而采用单开门椎管扩大成形术治疗.根据术前X线片上颈椎曲度将患者分为后凸畸形组(n=16)、曲度变直组(n=18)和曲度正常组(n=29),在术前、术后颈椎MRI T2加权像中心矢状位片上测量并计算C3～C7各节段脊髓后移距离(posterior shift of center of spinal cord,PCS),比较三组患者C3～C7各节段PCS的差异;评价术前和末次随访时神经功能(JOA评分),计算并比较三组患者末次随访时JOA评分改善率及差异.结果:三组患者的年龄、性别比、病程、随访时间、病种构成和术前JOA评分等无统计学差异(P＞0.05).术后各节段脊髓均有明显后移,三组患者C3～C7五个节段的PCS均无统计学差异(P＞0.05).随访时间15～90个月,平均47±24个月,三组患者末次随访时平均JOA改善率分别为59.81％、69.25％、54.44％,差异无统计学意义(P＞0.05).C5水平脊髓后移距离与末次随访时JOA改善率无线性相关关系(r=0.110,P=0.390).结论:术前不同颈椎曲度的慢性压迫性颈脊髓病患者椎管扩大成形术后脊髓均能后移,并可取得较好的临床疗效;椎管扩大成形术后脊髓后移程度、神经功能改善率与术前颈椎曲度无明显相关性.     

前路或后路手术治疗颈椎后纵韧带骨化症的中期疗效观察

目的:观察颈椎前路椎体次全切减压融合术(ACCF)和颈椎后路单开门椎管扩大成形术在治疗颈椎后纵韧带骨化症(OPLL)的中期临床疗效和影像学改善情况。方法:2010年1月~2012年12月我院收治33例颈椎OPLL患者,男17例,女16例;年龄41~78岁(58.6±8.8岁)。其中16例骨化块累及2个节段及以内者通过ACCF切除骨化块减压(A组);17例骨化块累及2个节段以上、前路切除有困难者采用后路单开门椎管扩大成形术(B组)。所有患者术前、术后3个月、1年、2年、3年和末次随访时进行JOA评分。通过配对样本t检验分析两组患者术前、术后和末次时的JOA评分、颈椎曲度及椎管狭窄率的变化情况。结果:A组1例术后发生吞咽困难;B组1例发生脑脊液漏,1例发生切口感染。均经对症处理后痊愈。A组随访48.56±8.02个月,B组随访52.59±8.88个月。两组患者术后JOA评分均较术前有显著性改善(P0.05);术后和末次随访时颈椎曲度较术前无明显差异(P0.05);A组末次随访骨化块面积明显大于术后(P0.05),B组末次随访骨化块面积较术后无明显差异(P0.05)。结论:对于颈椎OPLL,ACCF和后路单开门椎管成形术均为有效且安全的术式,中期随访疗效满意。前者通过切除或"漂浮"骨化块达到有效减压;后者能够扩大椎管缓解脊髓压迫,中期随访椎管狭窄率维持稳定。     

颈椎前路减压分段融合术和后路椎管扩大成形术治疗多节段脊髓型颈椎病的病例对照研究

目的 :比较颈椎前路减压分段融合术和后路椎管扩大成形术治疗多节段脊髓型颈椎病的临床疗效。方法:对2009年7月至2012年6月收治的56例多节段脊髓型颈椎病病例进行回顾性分析,男32例,女24例;年龄42~79岁,平均(56.9±12.8)岁,病程2个月~16年,平均(10.6±3.2)年。所有患者术前经影像学检查显示有多节段颈椎间盘突出,并具有脊髓型颈椎病的临床表现。其中34例采用颈椎前路减压分段融合术(前路组),22例采用后路椎管扩大成形术(后路组)。通过影像学资料对两组患者手术前后的病变节段前柱高度和颈椎前曲度进行比较,并采用JOA评分评价手术效果。结果:两组患者无神经血管并发症发生,并获得24~36个月的随访(平均28.6个月)。前路组,术后2周时颈椎病变节段前柱高度较术前明显增高(P0.05),颈椎前曲度较术前明显降低(P0.05)。后路组,术后2周及末次随访时,病变节段前柱高度和颈椎前曲度较术前差异均无统计学意义(P0.05)。两组间在术后2周及末次随访时颈椎前曲度差异有统计学意义(P0.05)。术后两组JOA评分均出现了明显恢复,术后3个月及末次随访时,前路组明显高于后路组(P0.05),且JOA评分改善率前路组也优于后路组(P0.05)。结论:这种分段式前路融合手术可以有效地恢复颈椎前柱高度,并且与颈椎后路椎管扩大成形术相比,可以显著地改善脊髓功能,是治疗多节段脊髓型颈椎病的有效方案。     

颈前路椎间盘切除椎间融合器融合术加颈后路单开门术治疗脊髓型颈椎病

[目的]探讨颈椎前路椎间盘切除椎间融合器融合术加颈椎后路单开门椎管扩大成形术治疗脊髓型颈椎病在临床上的应用价值。[方法]应用Cervical Cage行颈椎前路椎间盘切除椎间融合术，同时，颈椎后路行单开门椎管扩大成形术11例，平均随访6个月。按40分法和JOA评分对手术前后脊髓功能进行评分，并测量颈椎术前术后前柱高度及椎管宽度和进行相关性分析．[结果]颈椎前路椎间盘切除椎间融合器融合术加颈椎后路单开门椎管扩大成形术，明显改善脊髓型颈椎病的脊髓功能。40分法平均37分，改善率83％；JOA评分16．5分，改善率91％；前柱高度平均增加1．28mm；椎管宽度平均增加2．22mm。[结论]颈椎前路椎间盘切除椎间融合器融合术加颈椎后路单开门椎管扩大成形术，有效恢复了颈椎前柱高度、增加椎管宽度，明显改善了脊髓型颈椎病的脊髓功能。     

严重颈椎后纵韧带骨化症椎管占位率与术后C5神经根麻痹的关系

目的探讨严重颈椎后纵韧带骨化症(OPLL)患者颈椎后路双开门椎管扩大椎板成形术后C_5神经根麻痹的发生率与椎管占位率的关系。方法回顾性分析本院2014年1月—2017年1月采用颈椎后路双开门椎管扩大椎板成形术治疗的44例严重OPLL患者(椎管占位率50%)的临床资料。以术后是否发生C_5神经根麻痹将患者分为麻痹组(11例)和非麻痹组(33例)。所有患者进行影像学检查,测量并记录患者椎管占位率,累及椎体数量,OPLL分型,术前、术后Cobb角和神经功能日本骨科学会(JOA)评分,并计算Cobb角和JOA评分改善率。采用t检验分析以上因素组间差异是否有统计学意义,对差异有统计学意义的因素采用Spearman相关分析和Logistic回归分析评价其与C_5神经根麻痹的相关性。结果 t检验结果显示2组间椎管占位率、术前JOA评分、术后JOA评分及JOA评分改善率差异有统计学意义(P0.05),纳入相关分析。Spearman相关分析结果显示椎管占位率与术后C_5神经根麻痹呈正相关;术前、术后JOA评分及JOA评分改善率与术后C_5神经根麻痹呈负相关。Logistic回归分析只有椎管占位率进入方程,椎管占位率与术后C_5神经根麻痹具有相关性。结论严重颈椎OPLL患者术后C_5神经根麻痹发生率较高。椎管占位率与术后C_5神经根麻痹呈正相关,椎管占位率越高,C_5神经根麻痹发生率越高。     

不同手术方案对脊髓型颈椎病合并椎管狭窄症患者术后疗效及颈椎矢状位参数的影响

目的探讨前路椎体次全切除术和后路椎管扩大椎板成形术对脊髓型颈椎病(CSM)合并椎管狭窄症患者术后疗效及颈椎矢状位参数的影响。方法回顾性分析2010年3月—2015年8月收治的147例CSM合并椎管狭窄症患者的临床资料,其中80例行前路椎体次全切除术治疗(A组),67例行后路椎管扩大椎板成形术治疗(B组)。比较2种手术方法治疗前后日本骨科学会(JOA)评分、Cobb角及矢状位垂直距离(SVA)。将2组患者根据T_1倾斜角分别分为高T_1倾斜角(≥25°)亚组和低T_1倾斜角( 25°)亚组,对不同亚组之间的疗效及手术安全性进行比较。结果 2组术后JOA评分和Cobb角均高于术前,差异有统计学意义(P 0.05)。A组术后SVA低于术前,差异有统计学意义(P 0.05),B组术后SVA与术前相比差异无统计学意义(P 0.05)。A组术后JOA评分和Cobb角均高于B组,SVA低于B组,差异均有统计学意义(P 0.05)。A组中,高T_1倾斜角亚组和低T_1倾斜角亚组JOA评分改善效果和后凸畸形发生率比较差异无统计学意义(P 0.05);B组中,低T_1倾斜角亚组JOA评分改善效果和后凸畸形发生率优于高T_1倾斜角亚组,差异均有统计学意义(P 0.05)。结论相较于后路椎管扩大椎板成形术,前路椎体次全切除术治疗CSM合并椎管狭窄症临床疗效更佳,且有助于改善颈椎矢状位平衡;在高T_1倾斜角水平下,应尽可能选择前路椎体次全切除术。     

短节段侧块螺钉内固定结合"锚定法"后路单开门椎管扩大椎板成形术治疗不稳定性多节段脊髓型颈椎病

目的探讨短节段侧块螺钉内固定联合“锚定法”后路单开门椎管扩大椎板成形术治疗不稳定性多节段脊髓型颈椎病(MCSM)的疗效。方法回顾性分析2015年1月—2016年6月接受短节段侧块螺钉内固定联合“锚定法”后路单开门椎管扩大椎板成形术治疗的35例不稳定性MCSM患者临床资料,记录手术时间、术中出血量、术后引流量、住院时间及并发症发生情况,在手术前后影像学图像上测量C2~7 Cobb角、颈椎活动度(ROM)、椎管矢状径及椎管横截面积,并计算椎管扩大率。采用日本骨科学会(JOA)评分及其改善率评价术后神经功能改善情况,采用疼痛视觉模拟量表(VAS)评分及颈椎功能障碍指数(NDI)评价患者疼痛及功能改善情况。结果所有手术均顺利完成。患者随访18个月;手术时间(93.0±21.5)min,术中出血量(189.5±35.1)mL,术后引流量(169.4±15.6)mL,住院时间(8.5±0.8)d。术后C2~7 Cobb角、椎管矢状径、椎管横截面积、JOA评分、VAS评分及NDI较术前明显改善,差异均有统计学意义(P<0.05);椎管扩大率为(72.6±11.5)%,JOA评分改善率为(81.5±5.3)%。术后颈椎ROM与术前相比差异无统计学意义(P>0.05)。术后发生颈部轴性疼痛6例,C5神经根麻痹1例。所有患者未发生螺钉及铆钉松动、脱落,扩大的椎管再关闭现象或其他并发症。术后影像学资料显示骨融合良好。结论短节段侧块螺钉内固定联合“锚定法”后路单开门椎管扩大椎板成形术治疗MCSM能明显改善患者脊髓功能,维持颈椎曲度及稳定性,疗效确切。     

纳米人工椎板在颈椎后路减压椎管重建手术中的临床应用研究

[目的]评估颈椎后路减压手术中应用纳米人工骨重建椎管后临床症状的改善和影像学变化。[方法]观察组30例多节段脊髓型颈椎病行颈椎后路减压人工椎板椎管重建术,对照组38例多节段脊髓型颈椎病行颈椎后路双开门椎管扩大成形术。两组术后平均随访25个月。比较两组的手术时间、术中出血量、术前术后JOA(日本矫形外科学会)评分,轴性症状及C5神经根麻痹的发生情况,颈椎X线片及CT了解椎管矢状径扩大情况及人工椎板融合情况。[结果]观察组手术时间平均92 min,术中出血量平均316 ml,低于对照组,有1例发生C5神经根麻痹。两组在手术时间、出血量及C5神经根麻痹的发生方面比较差异有统计学意义(P<0.05)。观察组术后JOA评分改善率为74.3%,3例出现轴性症状,理疗治疗后好转。术后各节段椎管矢状径皆超过14 mm,术后1年和2年人工骨骨性融合率分别为43.3%和71.1%。两组在JOA评分改善率、轴性症状发生率、椎管矢状径扩大及植骨融合方面比较差异无统计学意义(P>0.05)。[结论]在颈椎后路全椎板切除减压手术中应用纳米人工椎板重建颈椎管效果良好,获得与颈椎后路双开门椎管扩大成形术相同的治疗效果,而且具有手术时间短、术中出血少及并发症较少的优点。     

两种术式治疗颈椎后纵韧带骨化伴发育性椎管狭窄的比较

[目的]比较一期前后路与单纯后路治疗颈椎后纵韧带骨化伴发育性椎管狭窄的临床疗效差异。[方法]回顾性分析本院2013年4月~2016年7月收治的颈椎后纵韧带骨化伴发育性椎管狭窄患者31例,根据手术方式不同为分2组,其中前后联合组16例采用一期后路单开门椎管扩大成型术联合前路椎体次全切植骨内固定术治疗,单纯后路组15例采用后路单开门椎管扩大成型术治疗。采用日本矫形外科学会(JOA)颈椎评分系统评估患者神经功能改善情况。行影像检查,测量Pavlov比值、脊髓缓冲空间、K-line阳性率。[结果] 31例患者均顺利完成手术。两组患者手术并发症发生率差异无统计学意义(P>0.05)。前后联合组手术时间显著长于单纯后路组(P<0.05);前后联合组术中平均出血量略多于单纯后路组,但差异无统计学意义(P>0.05)。随访(18.48±4.69)个月,两组患者的JOA评分均随时间推移而显著增加(P<0.05)。虽然术前两组间JOA评分的差异无统计学意义(P>0.05),但术后6个月及末次随访时,前后联合组的JOA评分显著高于单纯后路组(P<0.05)。影像方面,两组患者末次随访时各节段(C_(3~7)) Pavlov比值和脊髓缓冲空间均显著高于术前(P<0.05);但相应时间点两组间各节段(C_(3~7))的Pavlov比值的差异均无统计学意义(P>0.05),而末次随访前后联合组患者各节段(C_(3~7))脊髓缓冲空间均显著大于单纯后路组(P<0.05)。末次随访时两组患者K-line阳性率均较术前显著增加(P<0.05)。末次随访时前后联合组的K-line阳性率显著高于单纯后路组(P<0.05)。[结论]采用一期前后路手术较单纯后路手术治疗颈椎后纵韧带骨化伴发育性椎管狭窄能够获得更大减压效果,提高临床疗效。     

脊髓线预测颈椎后路开门术后脊髓减压效果的临床研究

目的 探讨颈椎后路开门手术后脊髓减压程度的预测及方法.方法 收集2008年3月至2009年8月25例行颈椎单开门椎管成形术患者术前、术后的MRI图像.根据脊髓前方的压迫程度可分为0～4分;其中＞3分(3和4分)表明有脊髓压迫,＜3分表明脊髓无压迫.在开门节段上位椎体下终板做一水平线与脊髓前方成一交点,在开门节段下位椎体...     

多节段脊髓型颈椎病术前颈椎曲度对椎管扩大椎板成形术术后神经功能恢复影响

目的探讨多节段脊髓型颈椎病患者术前颈椎曲度与椎管扩大椎板成形术术后神经功能之间的相关性。方法选取2013年1月—2015年12月在第二军医大学附属长征医院实施椎管扩大椎板成形术的70例多节段脊髓型颈椎病患者作为研究对象进行回顾性分析。按照患者术前X线片中的颈椎曲度将患者分为曲度正常组(A组)、曲度变直组(B组)、轻度曲度后凸组(C组),比较3组患者术后各节段脊髓后移距离、神经功能恢复率,并探讨术前颈椎曲度、术后脊髓后移距离与神经功能恢复率之间的相关性。结果 3组患者术后各节段脊髓后移距离组间差异无统计学意义(P0.05)。3组患者术前、术后的组间日本骨科学会(JOA)评分、神经功能恢复率差异均无统计学意义(P0.05);与术前相比,术后3组患者的JOA评分均明显增高,差异具有统计学意义(P0.05)。颈椎曲度与神经功能恢复率、脊髓后移距离之间无相关性。结论术前颈椎曲度变直及轻度后凸的多节段脊髓型颈椎病患者在实施椎管扩大椎板成形术后脊髓神经功能均可改善,曲度变直及轻度后凸可能不再是多节段脊髓型颈椎病行椎管扩大椎板成形术的禁忌证。     

颈椎后路减压术后脊髓后移的临床意义

 目的 探讨颈椎后路全椎板减压和椎管成形术后脊髓后移对多节段脊髓型颈椎病的临床 意义。方法 回顾性分析 2004年 6月至 2007年 9月 65例多节段脊髓型颈椎病患者的病例资料, 男 41例, 女 24例;年龄 39~75岁, 平均 56.3岁。 33例采用颈后路选择性椎板切除术(切除组), 32例采用 颈后路单开门椎管成形术(开门组)。两组患者术前日本矫形骨科学会(Japanese Orthopaedics Associa tion, JOA)评分、颈椎曲度指数的差异无统计学意义。术后 1年, 评估两组的脊髓后移距离、神经功能 (JOA评分)改善率、颈椎曲度指数丢失及轴性症状评分。结果 全部病例均获得 26~47个月的随访, 平均 34个月。切除组术后 1年脊髓后移距离(1.4±0.6) mm, 开门组(3.3±1.2) mm,差异有统计学意义;切除组 JOA评分改善率 60.5%±21.3%, 开门组 61.1%±17.9%,差异无统计学意义;切除组颈椎曲度指数丢失 3.3%±1.7%, 开门组 3.1%±2.4%, 差异无统计学意义;切除组 18.2%(6/33)的患者术后有明显轴性症状, 开门组为 33.3%(10/30), 两组轴性症状临床评分的差异有统计学意义。结论 选择性椎板切除术后脊髓后移距离小于单开门椎管成形术。脊髓后移程度与术后功能恢复程度及颈椎曲度无关, 而与轴性症 状有关。     

Place de la laminoplastie dans le traitement de la myélopathie cervicale d’origine arthrosique

Cervical spondylotic myelopathy (CSM) is a common condition. Uninstrumented laminectomy may be complicated by postoperative instability, whereas anterior or posterior decompression with fusion may be associated with stiffness and adjacent segment disease. Cervical laminoplasty, initially oriented towards pediatric patients and ossification of the posterior longitudinal ligament, becomes an interesting surgical alternative to decompress and reconstruct cervical anatomy without fusion. Eighteen patients (12 men, 6 women), mean age 64.2 who presented with CSM were treated surgically using multilevel laminoplasty, and reviewed after 1 month, 6 months, 1 year and 2 years. Clinical evaluation was performed based on the Benzel-JOA and Nurick scores. The preoperative mean Benzel-JOA score was 13.55; Preoperative mean Nurick score was 1.88. Preoperative MRI was carried-out in 16/18 patients. Intramedullary hyperintensity in T2 was observed in 6 patients. The operation was performed on 2 levels (4 patients) 3 levels (11 patients) and 4 levels (3 patients). We used the open-door hinged laminoplasty technique, using metallic implants, without bone graft. At one month FU, mean JOA score was 15.44, and Nurick dropped to 1.05. At 6 months, mean JOA was 16.28 and Nurick was 0.71. At one year, the mean JOA score was 16.16, and Nurick was 0.83. At 2 years, mean JOA was 17.5, and Nurick was 0.25. One infection, one dural tear and one transient episode of C5 paresthesia were observed. We conclude that spinal cord decompression by open-door laminoplasty for CSM allows significant clinical improvement observed progressively in the two years following surgery.     

Clinicoradiologic study of cervical laminoplasty with posterolateral fusion or bone graft

STUDY DESIGN: A retrospective study of cervical expansive laminoplasty for cervical myelopathy from a clinicoradiologic perspective. OBJECTIVE: To clarify the correlation among sagittal curvature of the cervical spine, cervical range of motion, sagittal plane translation, spinal cord atrophy, and myelopathic symptoms in patients who have undergone laminoplasty. SUMMARY OF BACKGROUND DATA: Laminoplasties were developed to diminish the undesirable effects of laminectomy, which include postoperative kyphotic changes and instability. However, the superiority of laminoplasty over laminectomy remains controversial. METHODS: Fifty-one patients with cervical spondylotic myelopathy or ossification of the cervical posterior longitudinal ligament who underwent laminoplasty were radiologically assessed before and after surgery. The index of the sagittal curvature, intervertebral range of motion, listhesis, and the transverse area of the spinal cord at the site of maximal compression were measured to evaluate interrelations among those parameters and myelopathic symptoms. RESULTS: There were no patients with kyphotic curvature before surgery. The postoperative curvature tended to be less lordotic. This tendency did not adversely affect postoperative symptoms. The intervertebral range of motion was significantly decreased except at C1-C2. The final C4-C5 range of motion and the postoperative myelopathic symptoms were negatively correlated. A significant correlation was observed between the postoperative spinal cord atrophy and the final myelopathic symptoms. CONCLUSIONS: The decrease in the lordotic curvature index and the decrease in the intervertebral range of motion after laminoplasty did not cause neurologic deterioration. In the C4-C5 intervertebral segment with a high incidence of listhesis, the restriction of the C4-C5 range of motion improved the clinical myelopathic symptoms. The radiologic prognostic factors were the postoperative restriction of intervertebral range of motion in preoperatively unstable segments and the anatomic reversibility of spinal cord insult.     

选择性融合联合单开门椎管扩大椎板成形术治疗局部不稳的颈椎后纵韧带骨化症的疗效

目的:比较三种颈椎后路术式治疗存在局部不稳的颈椎后纵韧带骨化症(ossification of the posterior longitudinal ligament,OPLL)患者的临床疗效,探讨选择性融合联合单开门椎管扩大椎板成形术的临床应用价值。方法:回顾分析我院2014年6月~2017年6月收治的存在局部不稳的颈椎OPLL患者107例,其中男性61例,女性46例;年龄68.1±10.2岁(33~84岁),随访时间2.1±1.3年(0.5~3.5年)。所有患者证实存在OPLL及颈椎局部不稳,且存在颈脊髓压迫相关症状体征,其中38例行单纯颈后路单开门椎管扩大椎板成形术(A组),35例行选择性融合联合单开门椎管扩大椎板成形术(B组),34例行传统颈后路椎板切除固定术式(C组)。分别于术前、术后2d及末次随访时采用日本矫形外科学会(Japanese Orthopaedic Association,JOA)评分并计算Hirabayashi改善率,对患者的神经功能情况进行评估;拍摄颈椎正侧位及过屈过伸位X线片测量颈椎的曲度(C2-7 Cobb角)、颈椎整体活动度(C2-7 range of motion,C2-7 ROM)和颈椎不稳节段的活动度,统计内固定相关并发症。通过颈椎MRI评估患者颈髓高信号的情况并计算高信号强度比值(high signal intensity ratio,HSIR)。比较三组患者颈椎整体活动度和不稳节段的活动度,比较存在颈髓高信号患者的术前、术后HSIR及三组之间的差异。结果:三组患者均取得了满意的神经功能改善,末次随访时JOA评分分别为14.93±3.18分、15.22±2.79分和14.72±3.02分,Hirabayashi改善率分别为(66.35±13.48)%、(70.06±14.14)%和(64.14±18.05)%。三组患者术前颈椎曲度分别为7.43°±3.69°、7.66°±2.99°、6.96°±4.38°,组间比较无统计学差异(F=13.19,P=0.071),末次随访时颈椎曲度与术前相比基本一致(5.58°±4.26°、5.73°±3.81°、5.49°±4.33°),随访期间未发现颈椎曲度明显改变、后凸等情况。随访期间未出现内固定相关并发症。末次随访时A、B两组患者颈椎整体活动度(C2-7 ROM)无统计学差异(17.63°±8.31°和18.72°±9.52°,P=0.089),C组患者末次随访颈椎整体活动度明显差于A、B两组患者(3.90°±7.74°vs 17.6°±8.3°,P=0.012;3.90°±7.74°和18.72°±9.52°,P=0.003);B组、C组患者术后颈椎不稳节段活动度明显降低,末次随访时已完全融合。共有71例(71.03%)患者出现颈椎MRI T2加权高信号表现,存在高信号的节段与存在不稳的节段一致。三组患者HSIR值末次随访时均较术前明显降低(1.33±0.18 vs 1.68±0.11,1.12±0.12 vs 1.71±0.14和1.20±0.33 vs 1.65±0.18,P=0.001),但与A组患者相比,B组和C组患者的降低程度均较显著,差异存在统计学意义(P<0.05)。结论:选择性融合联合单开门椎管扩大椎板成形术是治疗存在局部不稳的颈椎OPLL患者的有效方法,可以在广泛减压颈脊髓压迫的同时增加颈椎的节段稳定性,同时保留颈椎一定的活动度、减少术后轴性症状发生。     

颈椎椎板成形术后脊髓后移的相关因素分析

 目的 探讨颈后路单开门椎板成形术后脊髓后移的影响因素及其规律。方法 2008年2月至2010年10月收治的压迫性颈脊髓病患者经筛选后43例纳入本研究,均接受C₃～C₇后路单开门椎板成形术,男32例,女11例;年龄33～78岁,平均57.9岁。脊髓型颈椎病伴发育性颈椎管狭窄30例,颈椎后纵韧带骨化症13例。门轴侧关节突螺钉锚定法21例,保留门轴侧肌肉韧带复合体的钛缆悬吊法22例。术前、术后3个月颈椎中立位MRI正中矢状面测量各节段代表脊髓及硬膜囊后移的参数：脊髓前缘后移,脊髓后缘后移,硬膜囊前缘后移,硬膜囊后缘后移;将齿突与T₁椎体后下角的连线定义为E线,其长度为E值,从每个基准点向E线作垂线,每个垂线段的长度为Px(x=1~6),得到代表每个节段局部曲度的参数(100×Px/E);以颈椎曲度指数 (curvature index, CI) 表示颈椎整体曲度。对以上参数进行线性相关分析。结果 硬膜囊前缘后移在不同水平无明显变化,脊髓前缘后移、脊髓后缘后移与硬膜囊后缘后移则随所处节段不同而相应发生变化,且三者的变化具有一致性。脊髓后缘后移最大值位于C_5,6水平,但C_5,6水平脊髓后缘后移与CI无相关性。相关分析表明脊髓后缘后移与硬膜囊后缘后移呈高度线性相关,与(100×Px/D)具有较低的相关性 。结论 颈椎单开门椎管扩大成形术后脊髓的后移程度与同水平硬膜囊的后移程度高度相关,与局部曲度相关性较弱,与颈椎整体曲度无相关性。     

颈椎椎弓根钉固定结合单开门椎管扩大成形治疗颈椎管狭窄伴无骨折脱位型颈脊髓损伤的临床研究

目的探讨颈椎椎弓根钉固定结合单开门椎管扩大成形治疗颈脊髓前方无局限性压迫、颈椎不稳定的颈椎管狭窄伴无骨折脱位型颈脊髓损伤的临床疗效。方法自2006-06--2011-03纳入颈椎管狭窄伴无骨折脱位型颈脊髓损伤44例。包括脊髓中央综合征26例,前脊髓损伤综合征12例,Brown-Sequard综合征4例,其他2例。结果所有患者均顺利完成手术。获12—60个月随访40例,平均（25．2±17．6）个月,末次随访时JOA脊髓功能评分改善率为68．5％;但双上肢功能恢复较差,出现双手不同程度肌肉萎缩5例;X线片检查显示颈椎生理曲度良好,无断钉、断棒及颈椎失稳;CT检查显示螺钉位置良好,椎管扩大成形满意,无门轴断裂及再关门。结论颈椎椎弓根钉固定结合单开门椎管扩大成形治疗颈脊髓前方无局限性压迫、颈椎不稳定的颈椎管狭窄伴无骨折脱位型颈脊髓损伤可取得较满意疗效。     

Postoperative changes of spinal curvature and range of motion in adult patients with cervical spinal cord tumors: analysis of 51 cases and review of the literature

OBJECTIVE: We sought to determine factors likely to influence postoperative changes in cervical spinal curvature and range of motion (ROM) in patients with cervical spinal cord tumors. METHODS: Fifty-one patients who underwent tumor excision via a single posterior approach were examined. Surgical methods were classified as follows: group A, expansive open-door laminoplasty (ELAP); group B, conventional laminectomy; and group C, hemilaminectomy (HL). Pre- and postoperative cervical spinal curvature, cervical curvature type, and ROM were evaluated using lateral radiographs. RESULTS: Worsening of cervical curvature type was statistically less frequent in group C than in group A or B (P < 0.05), although no significant difference was evident overall between pre- and postoperative cervical curvature indexes or ROM in any group. Cases of C2 surgery showed more frequent curvature worsening (80%) in group A than in other groups (P < 0.05). Postoperative changes of the cervical curvature in patients with cervical spinal cord tumors were greatly influenced by the surgical method; the cervical curvature was particularly unfavorable when patients had C2 decompression. CONCLUSIONS: Careful attention to postoperative changes in the spinal curvature is needed when ELAP is performed, especially if surgery involves C2. HL is the best posterior approach for resection of cervical spinal cord tumors from the viewpoint of postoperative spinal curvature and ROM.     

Investigation of motor dominant C5 paralysis after laminoplasty from the results of evoked spinal cord responses

BACKGROUND: Postoperative motor dominant C5 paralysis was known as one of several complications after laminoplasty. Several theories have been proposed for postoperative segmental paralysis after laminoplasty, but its etiology remains unclear. OBJECTIVE: To investigate the possible mechanism for postoperative motor dominant C5 paralysis from intraoperative electrophysiological studies using evoked spinal cord potentials (ESCPs). METHODS: A total of 66 patients who had undergone laminoplasty due to compressive cervical myelopathy were studied retrospectively. In all patients, the symptomatic intervertebral levels of cervical myelopathy were identified by several types of the ESCPs. Motor dominant C5 paralysis was determined as at least 1 level down compared with pre-operative shoulder abduction according to the manual muscle testing. RESULTS: Five patients (7.6%) showed postoperative motor dominant C5 paralysis. C5 paralysis occurred from 1 to 3 days after surgery and compromised unilaterally in all 5 patients. The causes of cervical myelopathy were cervical spondylosis in 3 patients and ossification of the posterior longitudinal ligament in 2 patients. One patient with severe impairment (2 in manual muscle-testing [MMT] scale) did not show clinical recovery. The other 4 patients recovered to 4 or 5 on the MMT score from 3 to 6 months after the onset. Based on the findings of ESCPs, the C4-5 level was affected by cervical myelopathy in all 5 patients with postoperative motor dominant C5 paralysis (C4-5 level in 3 patients, both C4-5 and C5-6 levels in 2 patients). A high signal intensity area on T2-weighted magnetic resonance imaging (MRI) was observed in all patients who showed apparent motor dominant C5 paralysis in this study. CONCLUSIONS: Cervical myelopathy at the C4-5 level is a potential risk for motor dominant C5 paralysis. Although it is merely a speculation, when C5 radiculopathy occurs after laminoplasty, C5 paralysis becomes clinically apparent because the deltoid muscle gets predominantly innervated by C5 root due to intramedullary spinal cord damage on the C6 segment in C4-5 myelopathy before surgery. It may represent the high signal intensity area on T2-weighted MRI at the C4-5 level.