甲基强的松龙在脊髓型颈椎病围手术期的应用

目的观察脊髓型颈椎病患者围手术期应用甲基强的松龙（methyloprednisonlone,MP）预防脊髓神经功能损害的效果,探讨最佳用药方案。方法 2009年3月至2012年3月,36例确认为脊髓型颈椎病的患者随机分为A、B两组。采用颈前路减压植骨融合内固定或一期后、前路椎管减压内固定治疗,手术由同组医师完成。A组20例,减压前30min给予MP 1 000mg冲击,术后第1天起MP按照200mg、200mg、80mg、80mg逐日减量,共应用5d。B组16例,减压前不予冲击,减压即刻80mg及术后80mg/日静推共5d。如果减压后8h内出现脊髓损害加重的情况,立即按第三次全美急性脊髓损伤研究冲击方案执行,并排除血肿压迫等原因。两组手术开始后均给予20%甘露醇125mL静滴,术后按125mL/8h静滴,共4d。对两组术前、术后1周、术后3个月及术后6个月进行脊髓型颈椎病JOA评分。结果 A组有1例,B组有2例减压后8h内出现神经症状加重,按第三次全美急性脊髓损伤研究方案冲击后缓解;两组术前JOA评分比较,差异无统计学意义（P〉0.05）;术后1周、3个月、6个月两组JOA评分与术前比较均明显提高（P〈0.05）;术后1周JOA评分A组优于B组（P〈0.05）;术后3个月、6个月两组间比较,差异无统计学意义（P〉0.05）。结论脊髓型颈椎病围手术期应用MP可预防脊髓神经功能损害,促进近期神经功能恢复。术前宜权衡利弊,术中、术后仔细观察神经功能变化并及时处理,MP冲击应用并无必要。     

Cervical foraminal stenosis as a risk factor for cervical kyphosis following cervical laminoplasty

BACKGROUND CONTEXTCervical laminoplasty (CLP) is an effective spinal cord decompression method for patients with cervical myelopathy. However, cervical kyphosis after CLP may cause insufficient decompression of the spinal cord. Thus, prevention of cervical kyphosis after CLP and identification of its risk factors are essential.PURPOSEThis study aimed to investigate the relationship between preoperative cervical foraminal stenosis and kyphotic changes after CLP.STUDY DESIGNA retrospective study.PATIENT SAMPLEWe reviewed 108 patients who underwent CLP for cervical myelopathy between May 2014 and May 2019 and who were followed up for at least 24 months.OUTCOME MEASURESFor clinical assessments, neck pain, arm pain, neck disability index, Japanese Orthopedic Association scores, EuroQol 5-Dimension, and subjective improvement rate reported by the patients were evaluated. For radiologic parameters, C2-7 Cobb lordotic angle (CLA), C2-7 sagittal vertical axis, T1 slope (TS), TS minus CLA (TS-CLA), and cervical range of motion were assessed preoperatively and postoperatively for 24 months. Cervical foraminal stenosis was evaluated by magnetic resonance imaging and computed tomography.METHODSThe study population was divided into the kyphosis group (n = 25 patients) and the lordosis group (n = 83 patients) according to the CLA at 24 months postoperatively. Preoperative risk factors related to postoperative kyphosis were analyzed. Statistical analyses were performed using independent two-sample t test, Chi-square test, logistic regression analysis, and linear mixed model.RESULTSPreoperative foraminal stenosis, CLA, TS, and TS-CLA were significantly different between the kyphosis and lordosis groups. In multivariate logistic regression analysis, foraminal stenosis (odds ratio [OR], 4.471; p = .0242) significantly increased the risk of kyphosis. The probability of developing kyphosis decreased with an increase in the CLA (OR, 0.840; p = .0001), while the probability of developing kyphosis increased with an increase in the TS-CLA (OR, 1.104; p = .0044).CONCLUSIONSPreoperative cervical foraminal stenosis is an independent risk factor for cervical kyphosis following CLP. Thus, CLP may not be a suitable surgical option for cervical myelopathy combined with foraminal stenosis.     

脊髓型颈椎病脊髓受压征象的MRI分级及其临床意义

目的:建立脊髓型颈椎病(cervical spondylotic myelopathy,CSM)脊髓受压征象的MRI分级系统,探讨其可靠性及其与年龄、病程和JOA评分的相关性。方法:收集2010年1月～2011年9月就诊的78例多节段CSM患者的颈椎MRI资料,男51例,女27例;年龄42～77岁,平均55.1岁;病程0.25～276个月,平均48.8个月。以颈椎MRI中脊髓形态、脊髓信号、脊髓与硬膜囊关系作为分级依据征象,将每个征象按照其严重程度分为3个等级,相应赋予0～2分,按3个征象总分划分为四级:0级,0分;Ⅰ级,1～2分;Ⅱ级,3～4分;Ⅲ级,5～6分。由3位初、中、高级职称医师对78例患者的颈椎MRI从C2/3～C6/7进行2次独立分级和1次共同分级,Kappa分析评价每位医师前后2次之间及3位医师之间分级结果的一致性。将3位医师对三个征象共同分级的结果进行Spearman相关分析,同时将患者年龄、病程、术前JOA评分与分级结果进行Spearman相关分析。结果:3位医师分别2次对78例患者的390个节段进行分级,0级82～94个(21.03%～24.10%),Ⅰ级112～126个(28.72%～32.31%),Ⅱ级111～137个(28.46%～35.13%),Ⅲ级47～70个(12.05%～17.95%)。同一医师前后2次分级一致的节段占74.6%～78.5%,Kappa值为0.657～0.706;不同级别医师分级一致的节段占71.5%～76.7%,Kappa值为0.614～0.683。三个征象分级的结果之间相关系数分别为0.552、0.603、0.577,呈显著性正相关(P<0.05)。患者年龄、病程与3位医师共同分级结果的相关系数分别为0.372～0.511、0.388～0.498,呈显著性正相关(P<0.05);术前JOA评分与3位医师共同分级结果的相关系数为-0.409～-0.546,呈显著性负相关(P<0.05)。结论:依据脊髓形态、脊髓信号、脊髓与硬膜囊关系建立的脊髓型颈椎病脊髓受压征象的MRI分级系统具有良好的一致性,其与患者年龄、病程呈正性相关,而与术前JOA评分呈负性相关,对脊髓受压后病变的严重程度评估和研究有指导意义。     

扩大半椎板减压内固定治疗无骨折脱位型颈脊髓损伤

目的探讨后路扩大半椎板减压内固定术治疗无骨折脱位型颈髓损伤的疗效。方法回顾性分析2001年6月-2008年6月本院采用后路扩大半椎板减压植骨内固定术治疗的47例无骨折脱位型颈髓损伤患者的临床资料,通过随访比较术前、术后的JOA评分并结合影像学检查进行疗效评价。结果所有患者随访10—60个月,平均24h个月,术后脊髓功能均有不同程度改善,JOA评分由术前平均7．6分上升至平均14．9分,植骨均获融合,无血管、神经及内固定相关并发症发生。结论颈椎后路扩大半椎板减压内固定术是治疗无骨折脱位型颈髓损伤的安全有效的方法,但需合理掌握手术适应证。     

Spinal cord injury in cervical spinal stenosis by minor trauma

BackgroundThe size of the spinal canal is a factor that contributes to the neurologic deficits associated with cervical OPLL and CSM. We investigate the development of neurologic deterioration after minor trauma and the clinical results of decompressive surgery in cervical spinal stenosis retrospectively.MethodWe treated 200 cases (98 cervical OPLLs and 102 CSMs) of cervical spinal stenosis for 8 years. There were 63 (33.5%) minor trauma cases to the cervical spine in 200 patients. Of these 63 patients, 18 developed myelopathy, 13 showed deterioration of preexisting myelopathy, and no neurologic change was observed in 32 patients. The neurologic status was assessed by the JOA score. The patients were divided into 2 groups according to the residual cervical spinal canal diameter: group I (<10 mm cervical spinal canal) and group II (≥10 mm cervical spinal canal).ResultsNeurologic outcome depended on the diameter of the residual spinal canal; 22 of the 25 patients in group I developed neurologic deterioration, whereas that occurred in 8 of the 38 patients in group II (P < .05). After surgical decompression, 8 patients in group I and 30 patients in group II came out with an improved JOA score of more than 50% (P < .05).ConclusionEven indirect minor trauma to the neck can cause irreversible changes in the spinal cord if there is marked stenosis of the cervical spinal canal. It may be beneficial to check lateral radiograph of the cervical spine as a screening tool for early detection of cervical spinal stenosis especially in Asian people older than 40 years.     

"跳跃型"多节段脊髓型颈椎病16例治疗

目的探讨"跳跃型"多节段脊髓型颈椎病的病情特点与治疗方法.方法 16例"跳跃型"多节段脊髓型颈椎病患者,男性11例,女性5例,平均年龄53.4岁,平均病程14个月,病变累及跳跃的2个功能节段者11例,累及跳跃的3个功能节段者5例,术前JOA评分为8.1分.对于跳跃一个节段累及2个功能节段的病例采用受累节段减压融合+跳跃节段融合+内固定,对于累及2个节段以上或跳跃间隙大于2个节段者采用受累节段减压融合+头颈胸石膏外固定.结果 16例获平均18个月随访,手术有效率93.8%,优良率68.7%,术后JOA评分平均为14.5分,所有病例均获骨性融合,无假关节形成.结论跳跃型多节段脊髓型颈椎病病情复杂,采用多节段减压融合+内固定或可靠的外固定,可获良好治疗效果.     

Spinal posterior movement after posterior cervical decompression surgery: clinical findings and factors affecting postoperative functional recovery

This study investigated the posterior movement of the spinal cord after posterior decompression surgery and evaluated factors affecting postoperative functional recovery in patients with cervical spondylotic myelopathy (CSM). Thirty-two patients with CSM underwent posterior decompression from C3 to C7 through laminectomy (n=12) and single, open-door laminoplasty (n=20). There were no significant differences between laminectomy and laminoplasty in degree of spinal posterior movement, recovery rate, and curvature index. Japanese Orthopedic Association (JOA) scores improved from preoperative (10.63±1.77; range, 7-14) to 3-months postoperative (13.57±1.50; range, 11-16) (n=32, P<.05) and from preoperative (10.24±1.87; range, 7-14) to 6-months postoperative (14.16±1.54; range, 12-16) (n=21) (P<.05). C5 palsy was observed in 1 (3.1%) patient. The vertebral body-to-spinal cord distances significantly increased after operations, with the greatest posterior movement at C5 and the least posterior movement at C3 and C7. However, the difference in the degree of the spinal movement of C3 to C7 was not statistically significant (P>.05). Furthermore, no correlation was found between the magnitude of spinal posterior movement and the curvature index. In addition, the magnitude of posterior movement and age were not correlated with the postoperative JOA improvement, but the preoperative JOA scores were. Our study shows that both laminectomy and laminoplasty can produce a similar degree of posterior movement of the spinal cord. Cervical lordosis is not associated with the posterior movement of the cord. The preoperative JOA scores, but not posterior movement of the cord and age, are important determinants for postoperative outcome.     

ARCH钛板联合单开门椎管扩大成形术治疗脊髓型颈椎病的近期疗效观察

目的:探讨ARCH钛板联合单开门椎管扩大成形术(expansive single open door-laminoplasty,EOLP)治疗脊髓型颈椎病(cervical spondylotic myelopathy,CSM)的近期临床疗效。方法:2016年1月至2016年12月将ARCH钛板做内固定材料的EOLP应用于32例CSM患者的治疗中,男23例,女9例;年龄39～82岁,平均64.5岁;病程6～24个月,平均13.1个月。临床疗效评定采用日本骨科协会(JOA)评分法,评分内容包括上下肢运动功能、肢体感觉功能、膀胱功能。通过影像学资料测量术前和术后6个月最狭窄节段的椎管矢状径,计算其改善率以明确减压效果。结果:所有患者获得随访,时间6～20个月,平均12.2个月。32例患者的术前症状均有不同程度好转,JOA评分由术前的9.78±1.34提高至术后6个月的12.94±1.16,JOA改善率为(44.09±11.06)%(P0.01)。椎管扩大明显,最狭窄处椎管矢状径由术前的(8.47±0.60)mm扩大至术后6个月的(12.51±0.78)mm,改善率为(48.27±11.81)%(P0.01)。随访期间未见内固定物松动、移位、断裂及"再关门"现象。结论:ARCH钛板联合EOLP治疗CSM可明显减少出现"再关门"及其他相关术后并发症的可能,近期临床疗效满意。     

前后路手术治疗脊髓型颈椎病的分析

目的分析脊髓型颈椎病（CSM）前后路手术的疗效和特点。方法对105例CSM术后患者，按JOA评分系统行术前和术后的神经功能分析：结果随访时间平均为36个月（20～80个月），术后54例前路减压植骨内固定患者48例明显改善，而后路椎管成型术51例患者中42例症状改善明显。结论前后路手术对早期CSM的治疗均取得良好的治疗效果，但随时间的延长（即晚期）其手术治疗效果也下降。晚期患者脊髓损害时间愈长手术治疗效果愈差。术前症状持续的时间与术后恢复程度有明显的相关性。     

皮层体感诱发电位与脊髓型颈椎病患者脊髓功能相关性

目的研究皮层体感诱发电位(cortical somatosensory evoked potentials,CSEP)与脊髓型颈椎病(cervical spondylitic myelopathy,CSM)患者脊髓功能的相关性。方法 2008年7月—2012年5月在本院诊断为CSM的患者67例。记录CSM患者CSEP与颈段脊髓传导功能的相关指标,包括N13、N20潜伏期,N9~N20、N9~N13峰间潜伏期(interpeak latency,IPL),P13~N13、P20~N20峰-峰值(peak-peak amplitude,PPA)。记录患者日本骨科学会(Japanese Orthopaedic Association,JOA)评分。将CSEP记录值与JOA评分关系绘制成散点图,当观察到点分布有直线趋势,进行直线相关分析。结果 N9~N13 IPL与JOA评分呈显著负相关。N13潜伏期和N9~N20 IPL与JOA评分呈负相关。结论 N9~N13 IPL与CSM患者脊髓功能障碍程度显著相关,可作为CSM患者脊髓功能评估的电生理指标。     

开放性椎体成形术治疗胸腰椎转移性肿瘤的临床探讨

目的:探讨开放性椎体成形术在胸腰椎转移性肿瘤治疗中的临床应用和治疗效果。方法:自2003年9月至2009年12月,对21例胸腰椎转移性肿瘤患者施行了后路椎管减压、开放式骨水泥椎体成形联合短节段椎弓根钉固定的手术治疗,其中男14例,女7例;年龄48～73岁,平均59.5岁;病程1～4个月,平均2.5个月。原发病灶:肺癌8例,乳腺癌4例,前列腺癌4例,肝癌2例,甲状腺癌1例,原发病灶不明2例。脊髓神经功能按Frankel分级:B级4例,C级6例,D级5例,E级6例。通过比较手术前后腰背部疼痛VAS评分、病椎前后缘高度、Cobb角及脊髓神经功能恢复程度来分析临床结果。结果:21例患者手术顺利,无严重并发症发生,无脊髓、神经功能加重。术后1周VAS评分由术前的(8.78±0.45)分减少至(2.25±0.36)分。16例合并病理性骨折者,病椎前缘高度由术前(12.7±2.1)mm增加到术后的(19.5±3.9)mm,病椎后缘高度由术前(14.1±1.8)mm增加到术后的(20.3±2.3)mm,Cobb角由术前(26.0±8.9)°减少到术后的(6.0±0.9)°。各项指标与术前相比,差异均有统计学意义(P0.05)。术后脊髓神经功能按Frankel分级:C级2例,D级4例,E级15例。21例均获得随访,时间5～28个月,平均14个月,未发生内固定松动及断裂。15例随访期间死亡。结论:在椎管后路减压内固定的同时,行开放性椎体成形术,手术创伤小、安全性高,能有效重建脊柱稳定性,减轻疼痛,提高患者的生活质量,对于身体状况较差、预期寿命较短的脊柱转移性肿瘤患者提供了一种可选择的手术方式。     

The increase in dural sac area is maintained at 2 years after X-stop implantation for the treatment of spinal stenosis with no significant alteration in lumbar spine range of movement

Background contextThe X-stop interspinous process decompression (IPD) device has been used effectively in the management of symptomatic spinal stenosis. This study examines the radiological outcomes at 2 years postoperatively after X-stop implantation.PurposeTo measure the effect of X-stop IPD device on the dural sac and foraminal areas at 24 months postoperatively at instrumented level in symptomatic lumbar canal stenosis. We also aimed to assess its effect on change in lumbar spine movement.Study designProspective observational study.Patient sampleForty-eight patients treated with X-stop had preoperative positional magnetic resonance imaging (MRI) scans, 40 of whom had 2 years postoperative positional MRI scans. Complete scans were available for 39 of these patients.Outcome measuresPositional MRI scans were performed pre- and postoperatively. Measurements were done on these scans and are presented as the outcome measures.MethodsAll patients had a multipositional MRI scan preoperatively and at 6 and 24 months postoperatively. Foraminal area was measured in flexion and extension. Dural cross-sectional area was measured in standing erect and in sitting neutral, flexion, and extension (sitting) positions. The total range of movement (ROM) of the lumbar spine and individual segments was also measured.ResultsComplete scan data for 39 patients' scans were available. An increase in mean dural sac area was found in all positions. At 24 months after surgery, the mean dural sac area increased significantly in all four postures mentioned above. A small increase in mean foraminal area was noted, but this was not statistically significant. Mean anterior disc height reduced from 5.9 to 4.1 mm (p=.006) at 24 months at the instrumented level in single-level cases, from 7.7 to 6.1 mm (p=.032) in double-level cases caudally, and from 8.54 to 7.91 (p=.106) mm cranially. We hypothesize that the reduction in anterior disc heights could be a result of the natural progression of spinal stenosis with aging. There was no significant change in posterior disc heights at instrumented level or adjacent levels. The mean lumbar spine motion was 21.7° preoperatively and 23° at 24 months (p=.584) in single-level cases. This was 32.1° to 31.1° (p=.637) in double-level cases. There was no significant change in the individual segmental range of motion at instrumented and adjacent levels.ConclusionX-stop interspinous device remains effective in decompressing the stenosed spinal segment by increasing the anatomic dural cross-sectional area and foraminal area of spinal canal. It does not significantly alter the ROM of lumbar spine at instrumented and adjacent levels at 24 months postoperatively.     

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.     

Retrospective cohort study between selective and standard C3-7 laminoplasty. Minimum 2-year follow-up study

A total of 64 patients with cervical spondylotic myelopathy (CSM) were assessed in this study. Forty-two patients underwent selective expansive open-door laminoplasty (ELAP). Twenty-two patients who underwent conventional C3-7 ELAP served as controls. There were no significant differences in recovery rate of JOA scores, C2–C7 angle or cervical range of motion between two groups. Incidence of axial symptoms and segmental motor paralysis in selective ELAP was significantly lower than those in the C3-7 ELAP. Size of anterior compression mass, postoperative spinal cord positions and decompression conditions were evaluated using preoperative or postoperative MRI in 50 of 64 patients. There was a positive correlation between number of expanded laminae and maximum anterior spaces of spinal cord. Incomplete decompression was developed in three of 37 patients in selective ELAP and in two of 13 patients in C3-7ELAP. Mean size of anterior compression mass at incomplete decompression levels was significantly greater than that at complete decompression levels. Since, there was less posterior movement of the spinal cord in selective ELAP than that in C3-7ELAP, minute concerns about size of anterior compression mass is necessary to decide the number of expanded laminae. Overall, selective ELAP was less invasive and useful in reducing axial symptoms and segmental motor paralysis. This new surgical strategy was effective in improving the surgical outcomes of CSM, and short-term results were satisfactory.     

颈前路分节段减压融合治疗多节段颈椎病

目的评价颈前路分节段减压植骨融合术治疗多节段颈椎病的临床疗效。方法对24例连续3或4个节段病变的颈椎病患者采用分节段减压融合术治疗。均行术前X线、MR I和术后X线片检查。均于术前及术后3个月进行JOA评分。结果 24例均获随访,时间3~48（28±20）个月。患者功能均有不同程度的改善。无植骨块不愈合、内置物下沉等并发症发生。JOA评分术前平均为（8.20±2.26）分,术后3个月平均为（13.50±1.28）,改善率为60.2%,植骨融合率100%。结论颈椎前路分节段减压融合术具有减压彻底、术后神经功能恢复好、恢复颈椎曲度、融合率高、并发症少等优点。     

Expansive open‐door laminoplasty and selective anterior cervical decompression and fusion for treatment of multilevel cervical spondylotic myelopathy

Objective: To evaluate the clinical results of combined expansive open‐door laminoplasty by splitting of spinous processes and selective anterior cervical decompression and fusion in treatment of multilevel severe cervical spondylotic myelopathy (CSM). Methods: Twenty‐eight patients (16 men and 12 women) underwent one‐stage combined expansive open‐door laminoplasty and selective anterior decompression and fusion for severe CSM; the average patient age was 51.3 years (range, 32–63 years). Clinical results were assessed by Japanese Orthopaedic Association (JOA) scores, number of finger grip and releases (G and R) in ten seconds, hand‐grip strength, visual analog scale (VAS) of axial pain, and C2‐C7 angle. Results: There was no worsening of neurological symptoms due to cord injury, cerebrospinal fluid leakage, or wound infection. All cases completed one‐year follow‐up. The JOA scores, number of G and R in ten seconds, and hand‐grip strength were all significantly improved (P < 0.05). Satisfactory decompression was shown by MRI or CT to have been achieved in all cases. The C2‐C7 angle did not differ significantly from that found pre‐operatively. The axial neck pain score was 2.0 ± 0.1 on VAS. Conclusion: Combined expansive open‐door laminoplasty by splitting of spinous processes and selective anterior decompression and fusion achieves complete spinal canal decompression with minimal morbidity; this strategy is effective in improving the surgical outcomes of CSM in one‐year follow‐up.     

A radical procedure of circumferential spinal cord decompression through a modified posterior approach for thoracic myelopathy caused by severely impinging anterior ossification

Background contextThoracic myelopathy caused by an anterior, massive ossified plaque is often progressive and responds poorly to conservative treatment. Direct removal of the compressing ossification is the optimal procedure for a spinal cord that is severely impinged anteriorly. However, both anterior and posterior decompressive manipulations have caused catastrophic iatrogenic spinal cord injuries. A comprehensive treatment method for severe thoracic myelopathy that enables a sufficient and safe decompression of the spinal cord is needed.PurposeThe purpose of this study is to demonstrate the efficacy, safety, and results of a one-stage circumferential decompressive procedure using a modified posterior approach in patients with severe thoracic myelopathy resulting from anterior spinal compression.Study designA modified procedure of circumferential spinal cord decompression for thoracic myelopathy is described. A retrospective study was conducted to investigate the clinical outcomes of 23 sequentially treated patients.Patient sampleTwenty-three patients were treated sequentially with a modified procedure for circumferential spinal cord decompression for thoracic myelopathy.Outcome measuresOutcomes were assessed using the Japanese Orthopedic Association (JOA) score, modified Frankel classification, Hirabayashi recovery rate, and a general assessment of complications.MethodsTwenty-three patients with thoracic myelopathy caused by a massive, anterior ossified structure were treated with an extensive posterior laminectomy, anterior removal of the ossification, and interbody fusion with kyphosis-reversing stabilization through a modified posterolateral approach. The neurologic outcomes are evaluated according to the JOA and the modified Frankel classification before surgery, 2 weeks after surgery, 1 year after surgery, and at the final follow-up visit. The surgical outcomes are also described using the Hirabayashi recovery rate. Radiographs, computed tomography (CT), and magnetic resonance imaging were performed before and after surgery. A postoperative CT scan was obtained to determine the efficacy of the decompression. Operative time, intraoperative blood loss, and complications were reviewed from the medical records. In addition, a 48-year-old man who presented with severe thoracic myelopathy resulting from anterior impingement with multiple osteophytes is described as an illustrative patient.ResultsThe sites of ossification in this series were distributed widely, from T4–T12. The anterior ossified plaques of all patients were resected completely. Five patients who had intraoperative evidence of dural ossification required resection of the ossified dura matter. The average operating time was 276 minutes. Mean intraoperative blood loss was 1,350 mL. The postoperative follow-up ranged from 2.5 to 6 years, with an average of 4.6 years. The average preoperative JOA score was 4.3±1.5 points, and it improved to 6.1±1.9 points 2 weeks postoperatively, to 8.1±1.8 points 1 year postoperatively, and to 8.5±1.9 points at the most recent follow-up. The overall Hirabayashi recovery rate at the final examination averaged 63.6±22.4%. Eight patients were graded as excellent, 10 as good, 4 as fair, and 1 as unchanged. No patient was graded as deteriorated. The paralysis improved by at least 1 grade in 22 patients (95.7%). Transient deterioration of thoracic myelopathy occurred immediately after surgery in three patients (13%). Cerebrospinal fluid leakage occurred in six patients (26.1%). One patient sustained severe bilateral groin pain, three had unilateral intercostal neuralgia, and pleura tear occurred in one patient.ConclusionOne-stage posterior decompression, anterior extirpation of the ossification, and interbody fusion with instrumentation via a modified posterior approach is a safe and effective treatment for severe thoracic myelopathy resulting from prominent anterior impingement. This procedure is technically demanding, and the indications are limited to thoracic myelopathy caused by severe anterior impingement of various etiologies from T4–T12.     

Skip laminectomy--a new treatment for cervical spondylotic myelopathy, preserving bilateral muscular attachments to the spinous processes: a preliminary report.

BACKGROUND CONTEXT: Techniques in current use for expansive laminoplasty operations (ELAP) on the cervical spine damage the extensor mechanisms, resulting in restriction of neck motion, loss of lordosis and persistent axial pains. PURPOSE: This article introduces a new surgical technique called skip laminectomy, which reduces morbidity after decompression of the cervical spinal canal. STUDY DESIGN/SETTING: A prospective study is presented of all patients with multilevel cervical spondylotic myelopathy (CSM), treated by this new procedure between December 1998 and March 2000. PATIENT SAMPLE: Since December 1998, 61 patients with CSM have undergone the procedure, of whom 24 (13 men and 11 women) were selected for this study. Follow-up periods ranged from 12 to 25 months, with an average of 18 months. Average age at operation was 69 years (range, 50 to 82 years). Eighteen patients with CSM on whom C3-C7 open-door laminoplasties had been performed by the author before 1998 were selected as controls for study of postoperative atrophy of the deep extensor cervical muscles. There were 11 men and 7 women, average age 67 years (range, 45 to 81). OUTCOME MEASURES: Axial symptoms and Japanese Orthopaedic Association (JOA) scores were recorded. Pre- and postoperative ranges of neck motion were measured on lateral flexion and extension radiographs. Pre- and postoperative cervical curvature indexes were calculated according to Ishihara's method. For quantitative analysis of damage to the posterior cervical muscles, atrophy rates were calculated from cross-sectional areas of the deep extensor muscles on the pre- and postoperative axial magnetic resonance imaging. METHODS: In skip laminectomy, standard laminectomies are performed at selected levels, combined with partial laminectomies of the cephalad halves of laminae at other selected levels, where the muscular attachments to the spinous processes are left undisturbed. Instead of a standard laminectomy, an interlaminar decompression can be performed at levels where the anterior spinal cord compression is insignificant. It is accomplished by simply removing the cephalad half of the inferior lamina and ligamentum flavum without detaching the semispinalis cervicis and multifidus muscles from the adjacent spinous processes. RESULTS: Using JOA scores, the average recovery rate was 61.0%. None of the patients complained of persistent axial symptoms. The postoperative range of flexion-extension motion averaged 97% of the preoperative measures. The cervical curvature index was reduced in 1 of the 24 patients. The atrophy rate of the deep extensor muscles after skip laminectomy was 20% of that seen after open-door laminoplasty. CONCLUSIONS: Skip laminectomy for cervical spinal canal decompression is less invasive than conventional laminectomy and ELAP. It is effective in preventing postoperative problems, such as persistent axial symptoms, restriction of neck motion and loss of cervical lordosis.     

一期前后路手术C7棘突骨椎间植骨融合治疗脊髓型颈椎病

目的:总结前后路一期手术时应用自体C7棘突骨行椎间植骨融合治疗脊髓型颈椎病(CSM)的临床疗效。方法:2004年2月至2008年12月,对30例脊髓前后方均有压迫的CSM患者采用一期前后路手术,其中男21例,女9例,年龄39～70岁,平均54.5岁;术前JOA评分4～13分,平均7.6±2.5分。后路手术时切取C7棘突骨作为前路椎间植骨融合的材料。观察患者术后神经功能改善和椎间植骨融合情况。结果:手术时间3.0～5.0h,平均3.5h;术中出血量270～600ml,平均380ml。未发生脊髓神经症状加重、感染、脑脊液漏等并发症。随访6～50个月,平均24.2个月,末次随访时JOA评分9～15分,平均13.7±1.8分,平均改善率为72%,其中优7例,良18例,好转5例。椎间植骨全部获得融合,未见植骨块塌陷和移位,内固定无松动和断裂。结论:对脊髓前后方均有压迫的CSM患者采用一期前后路手术减压可取得良好的效果,将后路手术时切取的自体C7棘突骨用于前路椎间植骨具有取骨简便、融合率高及相对节省治疗费用的优点。     

颈脊髓MRI信号增强与脊髓型颈椎病手术指征

目的：探讨脊髓MRI信号增强能否作为脊髓型颈椎病（CSM）脊髓减压的指征。方法：总结87例轻型CSM病人保守治疗随访结果与颈脊髓T2加权信号增强（ISI）的关系。结果：有ISI组与无ISI组、ISI减少组与ISI无变化组治疗前、后JOA评分无明显差异;ISI减少、无变化或无ISI均不影响保守治疗满意率。结论：对轻型CSM、ISI不能作为常规脊髓减压手术的指征。