颈椎病伴椎管狭窄患者再手术问题探讨

目的：探讨颈椎病伴椎管狭窄患者再手术的原因、手术方式及其相关问题。方法：我院2002年7月～2003年12月对40例颈椎病伴椎管狭窄术后疗效不佳或症状复发的患者进行了后路多节段（5个或以上）减压手术。根据其手术治疗方式及影像学资料分析再手术原因，并进行术后疗效评价。结果：经前路手术者再手术的主要原因为：（1）伴有多节段颈椎管狭窄因素时，只选择部分压迫重的节段行减压融合15例；（2）经前路多节段（≥3个节段）减压融合后，相邻节段继续退变，出现新的脊髓压迫表现及椎间不稳定9例；（3）伴有OPLL时，行部分节段前路减压融合后，病变呈进展表现，产生或加重对脊髓的压迫8例。经后路手术者再手术的原因为：（1）后路减压节段不够5例（包括1例前后路联合手术者）；（2）后路减压不充分3例。再手术后随访1．3～2．7年，平均2．1年，所有患者脊髓功能获得一定的提高，JOA评分改善率为51．3％。结论：颈椎病伴椎管狭窄病例再手术的主要原因为椎管狭窄因素仍然存在，经后路多节段（5个或以上）减压手术治疗可彻底去除颈椎管狭窄因素，有效解除脊髓前、后方所受的压迫，可获得较满意的临床疗效。

The evaluation and analysis to the problems of reoperation in cervical spondylotic myelopathy with spinal stenosis

Objective:To evaluate the causes of reoperation,surgical patterns,and correlated problems in treatment of cervical spondylotic myelopathy with spinal stenosis.Method:40 cases of cervical spondylotic myelopathy with spinal stenosis who underwent decompression but with poor outcomes,or recurrence,had revision through secondary posterior decompression of several segments(5 or more) during the period of July 2002 to December 2003.According to surgical patterns and presentation in image examination,the causes of reoperation were analyzed,with assessment of outcome.Result:The main causes of reoperation in patients who underwent anterior decompression were:(1)When long segment or multiple segment cervical spinal stenosis,certain segments with severe compression were chosen,decompressed and fused through anterior approach(15 cases);(2)After anterior decompression and fusion of several segments(3 or more),adjacent segment degeneration continued,new spinal cord compression and instability appeared(9 cases);(3) With OPLL,certain cervical segments decompressed and fused by the anterior approach,but pathological changes advanced,developing spinal cord compression with aggravation(8 cases).The main causes of reoperation in posterior decompression were:(1)Insufficient decompression segments(5 cases,including 1 case decompressed by anterior and posterior approach);(2)Insufficient decompression range(3 cases).At follow-up,1.3~2.7y (mean 2.1y),spinal cord function of all patients improved,and the mean JOA recovery rate was 51.3%.Conclusion:The main cause of reoperation in patients of cervical spondylotic myelopathy with spinal stenosis lies in existing spinal stenosis.Secondary posterior decompression at several segments(5 or more) radically removes the stenosis,which can relieve spinal cord compression at anterior and posterior side of spinal cord,and lead to satisfied outcome.