重症脊髓型颈椎病前、后路联合手术治疗次序的选择

目的：探讨前、后路联合手术治疗重症脊髓型颈椎病手术次序选择的原则.方法：回顾性分析45例重症脊髓型颈椎病患者,男27例,女18例,先行颈椎前路减压再行后路椎管扩大成形手术19例（A组）,先行颈椎后路椎管扩大成形再行前路减压融合手术26例（B组）.术前、术后均采用JOA评分法进行评分,根据JOA评分改善率评价两组治疗效果的优良率.结果：术中A组1例因前路手术使椎管前方骨化组织进一步挤压脊髓组织致患者截瘫;2例因前路手术致压物切除不彻底,术后患者症状无明显改善.B组1例术后出现C5脊神经根麻痹,颈椎前路减压后逐渐恢复.术后随访9～38个月,平均20.4个月.两组优良率分别为69.23%（B组）、42.10%（A组）,B组患者手术治疗效果明显优于A组.结论：前后路联合手术治疗重症脊髓型颈椎病应先行后路椎管扩大成形再行前路减压融合,手术效果较好,并发症少,安全性高.     

前或后路手术治疗颈椎退变性疾病的远期疗效分析

目的：探讨前路或后路手术治疗颈椎退变性疾病的远期疗效.方法：回顾分析前或后路手术治疗的462例颈椎退行性疾病患者.采用环锯法颈椎前路扩大脊髓减压并椎体间自体髂骨移植346例;颈椎后路手术116例,其中,中野术式56例,改良中野术式60例.采用40分法评定疗效.结果：颈椎前路手术后随访4.1～18年,平均13.5年,优185例（53.5%）,良126例（36.4%）,有效13例（3.7%）,差22例（6.4%）,优良率为89.9%.颈椎后路手术后随访4.2～16年,平均12.8年,优63例（54.3%）,良41例（35.3%）,有效3例（2.6%）,差9例（7.8%）,优良率为89.6%,且以改良中野术式的效果最佳,优良率为95%,无1例再关门.结论：前路或后路手术治疗颈椎退变性疾病均可获得较满意的远期疗效.远期效果与正确选择手术入路、有效减压、稳定颈椎有关.     

多节段颈椎管狭窄症手术治疗方法的比较

目的比较颈椎后路扩大成形术、前路减压术、前后路联合入路手术治疗颈椎管狭窄症的临床效果。方法 36例患者分3组随访,分别为单纯颈后路单开门椎管扩大成形术(12例);单纯前路减压内固定术(14例);颈椎前后路手术(10例)。比较三种不同术式方法治疗的疗效差异。结果 3组获得随访平均19.8个月,症状明显改善。结论对于多节段颈椎管狭窄症采用颈椎前后路减压手术的效果优于单纯后路手术减压,术后脊髓减压更充分。     

术中超声检查在颈、胸部椎管减压术中的应用

术中准确判断受压脊髓和神经根的减压情况是保证椎管减压手术成功的关键。作者应用７．５ｍＨｚ探头对行颈、胸部椎管减压术的２６例患者（单纯颈椎管前路减压９例，后路颈、胸部椎管减压６例，颈椎后路单开门椎管扩大１１例）在术中和术终时通过椎管减压窗进行横、纵和任意方向的超声扫描，观察硬膜囊、脊髓和神经根与周围组织的关系。作者体会，术中超声检查可以在手术中了解脊髓与神经根的受压情况和判定减压效果，客观地反映手术彻底程度。     

单开门并神经根管扩大术治疗脊髓型颈椎病

目的：探讨应用单开门并神经根管扩大术治疗多节段脊髓型颈椎病的手术方法与效果。方法：采用后路单开门椎管扩大成形与神经根管扩大术治疗多节段脊髓型颈椎病27例。结果：全组经3-75个月，平均26个月的随访。疗效按（JOA）17分评分标准评定：优（术后改善率＞75％）16例，良（50％-74％）6例，中（25％-49％）4例，差（≤24％）1例，平均优良率81.4％。结论：后路单开门椎管扩大成形与神经根管扩大术，在脊髓得到充分减压的同时也解除了神经根的压迫，可以提高椎管扩大成形术的手术疗效。     

颈椎后路加前路巨大骨化物切除减压术

目的探讨颈椎后路加前路手术在巨大骨性致压物切除中的应用价值和注意事项。方法对12例先经后路扩大椎管再经前路直接切除巨大骨化物患者的临床资料及手术治疗结果，进行了回顾性分析。结果术后随访3．4年(3个月～10年)，JOA评分提高5分(1～7分)，优6例，良5例，差1例，疗效持久。结论局限性巨大骨化物单纯行后路减压疗效不持久；先行后路椎管扩大为前路手术提供了安全余地，使前路直接切除骨化物成为可能；术中应扩大显露，仔细操作。     

颈椎病伴椎管狭窄手术入路的选择

[目的]探讨颈椎病伴椎管狭窄时的治疗策略及手术入路选择，为颈椎病手术治疗提供有益的经验。[方法]通过收集2002年7月～2003年12月间颈椎病伴椎管狭窄经前路减压术后疗效不佳或症状复发的病例，经分析后再次行后路减压手术治疗并观察其近期疗效；同时随机抽取1985年4月～1992年5月间病情相似而行后路减压的一组病例进行远期疗效随访，对比两组术后疗效。[结果]经前路减压术后脊髓功能（JOA）改善率仅为11．7％，但经后路者为70．3％；而前者经后路减压再手术后脊髓功能改善率可提高至52．8％。[结论]颈椎病伴颈椎管狭窄病例经前路减压术后疗效不佳或症状复发的主要原因在于椎管狭窄因素仍然存在，对上述病例行后路减压再手术治疗后，仍可取得一定的疗效；而最初便经后路减压治疗的此类患者则可取得较显著的远期疗效，提示经后路多节段减压可一期有效地扩大颈椎椎管，从而提高手术治疗颈椎病的疗效。     

后前路联合手术治疗严重颈椎退行性疾病

目的探讨后前路联合手术治疗严重颈椎退行性疾病的疗效和手术适应证。方法施行后前路联合手术治疗严重颈椎退行性疾病17例,其中男11例,女6例;年龄46-72岁,平均56.3岁。3例分期后前路手术,14例一期后前路手术。手术步骤为先行后路单开门椎管扩大成形术,然后一期或分期（6个月后）行前路椎管前方减压、植骨融合内固定术。结果无围手术期死亡及神经功能加重病例,术后发生脑脊液漏2例,轴性疼痛2例。术后随访13例,JOA评分由术前平均（8.3±2.28）分增至术后平均（13.1±1.27）分,手术前后评分差异显著（t=11.5,P〈0.01）,脊髓功能改善率为66.5%。结论一期后前路联合手术疗效满意。该手术方式减压充分,可降低单纯前路手术脊髓损伤的风险和减少单纯后路手术后C5神经根麻痹的发生率,适用于全身情况较好、多节段颈椎病变伴脊髓前方局部受压严重的患者。     

颈椎翻修手术的原因及对策

目的 探讨颈椎翻修术的适应证、手术方式及其临床疗效.方法 自1998年4月～2007年12月,对21例颈椎手术后患者进行了翻修手术.翻修手术距离首次手术的时间2～42个月,平均15.3个月.所有病例均出现临床症状,其中表现为放射性颈肩痛16例、颈部活动受限5例,原有的脊髓受压表现加重8例,再次出现新的脊髓压迫症状7例.首次手术的术前诊断包括:下颈椎骨折脱位6例,神经根型颈椎病2例,脊髓型颈椎病9例,颈椎不稳4例.手术方式包括:单纯前路减压加自体髂骨植骨4例,前路减压加颈椎前路钢板固定8例,前路减压加Cage融合2例,前路椎体次全或全切除加内固定3例,后路CerviFix单纯内固定3例,后路双开门减压1例.结果 本组术后疗效优良13例(61.9%),好转6例(28.6%),无效及加重各1例(9.5%).21例术前评分2～14(8.65±0.37)分,术后8～16(14.27±0.69)分,差异有显著性(P<0.01).植骨于术后3～6个月融合.未出现喉上、喉返神经损伤、气管食管漏、脑脊液漏以及呼吸系统并发症.结论 颈椎翻修术式视具体情况而定,术前宜详细制定手术方案,彻底减压与正确的固定是手术成败的关键.     

颈椎后纵韧带骨化症的诊疗对策

目的：探讨不同手术入路治疗颈椎后纵韧带骨化症的效果。方法：回顾性分析87例颈椎后纵韧带骨化症患者的临床表现、影像学检查、各种手术途径、术式及其效果。结果：前路手术35例,其中骨化灶直接切除19例、骨化灶漂浮法13例和不用减压的前路椎间融合3例。后路手术21例,其中单开门椎管成形6例,全椎板切除减压15例,前后联合手术31例。患者术前JOA评分平均为8．9（4～17）分。本组患者随访3个月～10年,平均3．8年,术后JOA评分,前路手术平均14．1分,甲均改善率68_3％,后路手术平均11.9分,平均改善率51．2％,后前路手术平均13．4分,平均改善率65．4％。后路手术并发节段性神经根麻痹3例,肌肉不全瘫痪者1例,并发术后血肿压迫脊髓致神经症状急性加重2例。结论：明确手术指征要综合考虑患者的年龄、病程、骨化程度、椎管狭窄率,以及脊髓功能损害情况,应根据颈椎后纵韧带骨化的具体部位、范围、椎管矢状面狭窄率选择相应的手术入路和术式。应用内固定有利于植骨融合和保持颈椎的稳定。     

Expansive laminoplasty for myelopathy in ossification of the longitudinal ligament

Laminectomy, which had long been used for treatment of cervical spondylotic myelopathy, including ossification of the longitudinal ligament in the cervical spine, had numerous complications such as postoperative malalignment of the cervical spine and vulnerability of the spinal cord caused by total removal of the posterior structures. In 1977 Hirabayashi devised an open door expansive laminoplasty, which is a relatively easier and safer procedure than laminectomy, that eliminated such problems by preserving the posterior elements. The decompression effect of the expansive laminoplasty against a compressed spinal cord is comparable with that of laminectomy and anterior decompression followed by fusion, whereas the expansive laminoplasty has no structural problems and adverse effects on adjacent disc levels that often are associated with anterior decompression followed by fusion. Average recovery rate of expansive laminoplasty for cervical spondylotic myelopathy has been reported to be approximately 60% (Japanese Orthopaedic Association score) and with long term stability. At present, authors consider all patients with cervical spondylotic myelopathy candidates for expansive laminoplasty except for those having preoperative kyphosis and single level lesion without canal stenosis. Two remaining problems of expansive laminoplasty to be solved are prevention of C5,C6 radicular pain and/or paresis, the most frequent complication that occurs in approximately 5% to 10% of the patients, although most complications resolve spontaneously within 2 years, and correction of nonlordotic alignment to lordosis which are essential for posterior decompression effect of expansive laminoplasty by allowing the spinal cord to shift dorsally.     

颈椎后纵韧带骨化的治疗方法

从１９８３年８月至１９９１年３月，手术治疗６３例颈韧后纵韧带骨化（ＯＰＬＬ）的患者。手术方法包括前路椎间减压融合，椎体次全切除植骨融合、后路全椎板切除。单开门椎板成形椎管扩大手术、双开门椎板成形椎管扩大手术，及前后路两次手术。随诊６到９６个月，疗效为３９例代。１６例良，优良率８７．２％。本文讨论了前路椎间减压、椎体次全切除及后路椎板成形椎管扩大手术的方法。作者认为对ＯＰＬＬ伴广泛性椎管狭窄者以后路双开门椎板成形椎管扩大手术较为合理。     

Surgical outcome of ossification of the posterior longitudinal ligament (OPLL) of the thoracic spine: implication of the type of ossification and surgical options

OBJECTIVE: Ossification of the posterior longitudinal ligament (OPLL) in the thoracic spine produces myelopathy through anterior spinal cord compression that is usually progressive and unaffected by conservative treatment. Therefore, early decompressive surgery is imperative. However, decompression surgery of thoracic myelopathy is difficult, and the outcome is often poor. A retrospective study was conducted to investigate the surgical outcome of 21 patients with thoracic OPLL to evaluate which type of surgical approach is better and which type of thoracic OPLL results in a better surgical outcome. METHODS: A total of 21 patients with thoracic OPLL (10 men and 11 women; mean age 54 years), who underwent surgical treatment at our department from March 1985 to October 2000, were included in the study. Seven patients exhibited the flat-type OPLL and underwent either anterior decompression and fusion (one patient), anterior decompression via a posterior approach (three patients), or expansive laminoplasty (three patients). Fourteen patients exhibited the beak-type OPLL and also underwent either anterior decompression and fusion (two patients), anterior decompression via a posterior approach (six patients), or expansive laminoplasty (six patients). RESULTS: Regarding of operative time and blood loss, there were no marked differences between the two types of OPLL, regardless of the type of surgical procedure; anterior decompression and fusion and anterior decompression via a posterior approach yielded longer operative times and larger blood loss volumes than expansive laminoplasty. Concerning clinical outcome, there were five cases of neurologic deterioration. All of the five deteriorated cases were of the beak-type OPLL treated by a posterior approach. Two of these patients were treated with expansive laminoplasty. CONCLUSIONS: There were five instances of neurologic deterioration in our thoracic OPLL series, and all of them exhibited beak-type OPLL. In the beak-type OPLL, a subtle alteration in the spinal alignment during posterior decompression procedures may increase spinal cord compression, leading to the deterioration of symptoms. A potential increase in kyphosis following laminectomy should be avoided by fixation with a temporary rod. If intraoperative monitoring suggests spinal cord dysfunction, an anterior decompression procedure should be attempted as soon as possible.     

前后路联合颈椎管扩大成形术治疗严重脊髓型颈椎病

目的评价前后路联合颈椎管扩大成形术治疗脊髓型颈椎病伴发育性颈椎管狭窄的临床效果。方法我科于2007年3月～2010年12月间应用该手术方式治疗22例严重脊髓型颈椎病患者。其中,发育性颈椎管狭窄合并颈椎间盘退行变突出17例,发育性颈椎管狭窄发育合并后纵韧带钙化5例。手术前后通过神经功能JOA评分、颈部轴性症状评估和颈椎动态侧位片、颈椎MRI进行临床疗效比较。结果 22例患者均获随访,平均随访时间24（3～36）个月。根据JOA评分,术后优良率为81.8%（18/22）,颈部轴性症状减轻,X线检查未见颈椎不稳,MRI示颈髓压迫解除。结论前后路联合颈椎管扩大成形术治疗脊髓型颈椎病合并发育性颈椎管狭窄是一种疗效好且效果稳定的手术方法。     

Cervical laminoplasty to enlarge the spinal canal in multilevel ossification of the posterior longitudinal ligament with myelopathy

We studied 23 patients with severe myeloradiculopathy involving multiple (more than three) levels of ossification of the posterior longitudinal ligament (OPLL) of the cervical spine, who were treated with laminoplasty to enlarge the spinal canal. The resected spinous processes were used as bone grafts to support the opened laminae. These patients were analyzed pre- and postoperatively with a neurological evaluation according to the Japanese Orthopedic Association (JOA) score system for cervical myelopathy. Follow-up was from 2.0 to 5.3 years with an average of 31.5 months. The results were compared with those in 31 patients with the same degree (multilevel) of OPLL who had been operated upon previously by laminectomy (14 cases) or anterior resection (17 cases). Postoperative neurological recovery by improvement ratio of the JOA score was observed in 81.2% of those who had undergone expansive laminoplasty, in 72.4% of those with laminectomy, and in 63.6% of those with anterior decompression. We concluded that expansive laminoplasty is a safer procedure with fewer complications. Stability is achieved by fixing the expanded laminae permanently with a bone graft. The neurological recovery following our technique of laminoplasty and fusion appears to be superior to that with laminectomy or anterior decompression.     

脊髓型颈椎病手术治疗53例临床总结

１９９２年１１月～１９９６年８月手术治疗脊髓型颈椎病５３例。优良率９２４％。手术方法包括颈前、后方减压及椎板成形术。前路手术适于Ｃ３,４以下１～２个椎间病变的减压。广泛椎板切除可致鹅颈畸形及晚期脊髓损害。改良单开门棘突骨支撑植骨椎管扩大成形术及植骨的双开门椎管扩大成形术较为合理     

前后路一期手术治疗复杂下颈椎损伤

目的 探讨前后路一期减压内固定手术治疗复杂下颈椎损伤的临床效果和价值。方法 22例复杂下颈椎损伤在全麻下行前后路一期手术，先后路减压复位侧块钢板内固定，再前路减压植骨；或者先后路单开门减压，再前路椎体次全切除，植骨前路钢板内固定。结果 平均随访18个月，8例脱位者达完全复位，受压脊髓得到有效减压。内置物无松动，无断裂，植骨后4个月均骨性融合，无血管、神经、食道、气管损伤并发症。脊髓功能均有不同程度恢复，发生2例消化道应激性溃疡。结论 只要掌握好适应证，前后路一期手术治疗复杂下颈椎损伤是-积极有效的方法。     

应用单开门椎板成形术治疗颈椎后纵韧带骨化症

目的 探讨颈椎后纵韧带骨化症的适宜手术入路及方式。方法 观察及分析应用单开门椎板成形术治疗颈椎后纵韧带骨化症３０２例的近期与１－９年远期临床疗效并将手术前、后Ｘ线片、ＣＴ及ＭＲＩ等影像学资料进行对比。结果 ３０２例后纵韧带骨化症手术近期及远期神经功能评分显著提高,平均改善率分别为４６％和６８％,后Ｘ线片显示颈椎管矢以显著增加,ＣＴ示椎管截面积显著扩大,而ＭＲＩ则显示脊髓向后移行,前后方压迫均解除。     

单开门与胶原酶溶盘联合治疗颈髓损伤的临床研究

目的探讨颈后路单开门椎管扩大成形术与胶原酶直视下溶盘术联合治疗外伤性无骨折脱位型颈脊髓损伤的疗效。方法对11例外伤性无骨折脱位型颈脊髓损伤患者行颈后路单开门椎管扩大成形术，然后在直视下将胶原酶注入突出的颈椎间盘，术后平均随访时间为24个月，结合症状、体征、影像学资料，观察手术效果。结果联合治疗有效地缓解了患者的症状、体征。影像学资料显示椎管容积明显增加，突出的间盘缩小。术后6个月平均JOA改善率63．7％。结论联合治疗不仅通过后路单开门扩大了椎管的容积，而且通过溶盘术缓解了颈髓前面突出髓核的压迫，从而取得了较好的治疗效果。单开门椎管扩大成形术和胶原酶溶盘术联合治疗Ⅲ型无骨折脱位型颈脊髓损伤是一种可行的手术方法。     

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.