脊髓型颈椎病病人经颅磁电刺激运动诱发电位的对比研究

目的探讨磁电刺激运动诱发电位（ＭＥＰ）在脊髓型颈椎病（ＣＳＭ）的应用价值，并对其临床相关性进行分析。方法采用经颅磁、电刺激对３０例脊髓型颈椎病病人以及年龄性别等相配匹的３０名健康成人分别于外展小指肌、肱二头肌及下肢展短肌表面进行ＭＥＰ的检测。结果全部病人的ＭＥＰ都出现异常，表现为潜伏期、中枢传导时间（ＣＭＣＴ）延长，时限增宽，波辐降低或不能引出。磁刺激ＭＥＰ的ＣＭＣＴ和皮层刺激潜伏期与脊髓型颈椎病临床日本整形外科协会（ＪＯＡ）评分间有密切相关性，能较好地反映ＣＳＭ病人的病情。结论ＭＥＰ在检测ＣＳＭ病人运动功能方面具有定量评价作用。与电刺激相比，磁刺激ＭＥＰ能更好地反映ＣＳＭ病人的病情。     

21例脊髓型颈椎病电刺激运动诱发电位的临床研究

对２１例脊髓型颈椎病进行了电刺激运动诱发电位测试。ＭＥＰ异常率９０．５％，以运动中枢传导时间延迟为主，部分见双侧差值增大，皮层刺激ＭＥＰ波降低及波形消失。ＭＥＰ变化与肌力明显相关，手术后可见异常ＭＥＰ改善。结果表明，ＭＥＰ检查可作为检测本病患者运动功能状态的客观定量指标，对评价手术效果及预测运动功能的恢复有意义。     

颈前入路手术治疗脊髓型颈椎病疗效分析

目的 探讨脊髓型颈椎病（CSM）早期诊断、手术指征、手术技巧等对颈前人路手术效果的影响。方法 对75例CSM病人行颈前人路手术脊髓减压及椎间植骨融合术，所有病人都经静态及动态Hoffmann征或（和）Lhermitte征检查。结果 所有病人都经随访，手术优良率87．7％，其中静态Hoffmann征阳性者手术优良率为81．1％，早期仅为动态Hoffmann征或（和）Lhermitte征阳性者手术优良率为93．1％。结论 早期诊断、早期前路手术治疗CSM，特别是在仅为动态Hoffmann征或（和）Lhermitte征阳性时，彻底去除致压物能显著提高手术效果。     

65例颈椎型脊髓病体感诱发电位分析

目的 研究颈椎型脊髓病皮质体感诱发电位（ＳＥＰ）变化。方法 对６５例颈椎型脊髓病患者和２６例正常人进行正中神经和胫后神经刺激的ＳＥＰ对照研究，并对１０例患者作治疗前后对照观察。结果 本组异常率为４５％，主要表现为各波潜伏期和波间期（Ｎ２０－Ｐ２５，Ｐ２５－Ｎ３５，Ｐ４０－Ｎ４５）延长，且下肢的延长更加明显，部分患者出现波形分化不良。经保守治疗后６例正常，２例好转，且ＳＥＰ的好转先于临床的改善。结论     

颈前路手术治疗脊髓型颈椎病的护理体会

目的探讨颈椎前路手术治疗脊髓型颈椎病的护理效果。方法对颈椎前路手术治疗脊髓型颈椎病患者给予完善的围手术准备及护理。结果45例手术患者效果良好,术后骨性融合达到80％～90％。结论前路减压植骨融合钛板内固定术是目前治疗脊髓型颈椎病可靠而有效的方法之一,做好充分的术前准备,制定完善的护理计划是预防并发症最有效的方法。     

脊髓型颈椎病椎间盘白细胞介素1水平与颈脊髓功能的相关性

背景：白细胞介素1自身及其产生的级联反应在椎间盘退变及周围组织如脊髓的功能障碍中起着重要作用。 目的：分析脊髓型颈椎病患者颈椎间盘白细胞介素1α、白细胞介素1β水平及其与颈脊髓功能的相关性，探讨白细胞介素1在脊髓型颈椎病发病机制中可能起到的作用。 设计、时间及地点：实验采用对比观察，于2008-01/11在安徽医科大学第一附属医院骨科及安徽医科大学寄生虫学实验室完成。 对象：实验组收集安徽医科大学第一附属医院2008-01/10骨科住院的25例脊髓型颈椎病患者48个椎间盘组织，因颈椎创伤的10例患者20个椎间盘组织作为对照。标本均为颈椎前路手术摘取且患者自愿捐献。 方法：应用酶联免疫吸附(ELISA)法测量两组颈椎间盘白细胞介素1α、白细胞介素1β的水平；采用日本骨科协会颈脊髓功能评分(JOA评分17分法)对实验组病例进行术前颈脊髓功能评分。 主要观察指标：①两组椎间盘组织中的白细胞介素1α、白细胞介素1β水平。②实验组椎间盘组织中的白细胞介素1α、白细胞介素1β质量浓度与JOA评分相关性分析。 结果：所收集的病例全部纳入结果分析。脊髓型颈椎病患者椎间盘组织白细胞介素1α、白细胞介素1β质量浓度水平明显高于对照组(P < 0.01)。脊髓型颈椎病患者椎间盘组织中的白细胞介素1α、白细胞介素1β质量浓度与JOA评分间呈负相关(ra =-0.860；rb =-0.669，P < 0.01)。 结论：脊髓型颈椎病患者颈椎间盘组织的白细胞介素1α、白细胞介素1β水平明显增高，且与颈脊髓功能成负相关。     

Bryan人工颈椎间盘置换治疗脊髓型颈椎病8例

回顾性分析2007-05/2008-07南通大学第二附属医院脊柱外科和上海长征医院骨科收治的脊髓型颈椎病患者8例,男2例,女6例;年龄36~58岁,病程8~24个月;病变节段：均为单节段,C4~5 5例,C5~6 3例。全部患者均采用Bryan人工颈椎间盘置换,置换后3个月行JOA评分,摄置换节段前屈后伸位、左右侧屈位X射线平片,观察假体置入后的稳定性及置换颈椎节段的活动度。结果显示置换过程中和置换后未出现神经和血管损伤的并发症,平均置换时间135 min。8例患者均进行门诊随访,随访时间3~13个月,所有患者置换后症状明显缓解。JOA评分由置换前平均8.9分(6~12分)增加到置换后第3个月平均15.2分(12~17分)。置换后3个月置换节段前屈后伸活动范围平均5.3°(4.3°~6.1°);左右侧屈活动范围分别为平均3.4°(2.8°~4.3°)和3.5°(2.9°~4.3°)。假体无偏移或下沉。末次随访未发现置换节段异位骨化、假体松动、下沉或颈椎生理曲度的改变。提示Bryan人工椎间盘置换治疗脊髓型颈椎病近期临床效果良好,能维持颈椎正常的活动范围和生理曲度。     

电刺激运动诱发电位监护在脊柱脊髓手术中的应用

目的观察运动诱发电位在脊柱脊髓手术监护中的应用效果。方法对30例脊柱脊髓手术患者采用经颅电刺激-四肢肌记录肌活动电位，行术中脊髓机能监测，其中对采用经颅电刺激-四肢肌记录无效者，配合经脊髓硬膜外刺激-四肢肌记录肌活动电位。结果30例采用经颅电刺激-四肢肌记录方法，其中26例于术中和术后都记录到了正常的运动诱发电位波形。其余4例改为使用经脊髓硬膜外刺激-四肢肌记录方法后，共29例患者的运动诱发电位获得记录。结论采用经颅电刺激，并配合经脊髓硬膜外刺激-四肢肌记录肌活动电位，使术中对脊髓内部运动传导通路机能监测的有效率得到了提高。     

Functional evaluation using several evoked spinal cord potentials in elderly patients with cervical spondylotic myelopathy

INTRODUCTION In elderly patients who have cervical spondylotic myelopathy (CSM), magnetic resonance imaging (MRI) frequently demonstrates multiple intervertebral level compressions of the cervical spinal cord. However, it should be taken into account that…     

Spinal cord findings in cervical spondylotic myelopathy: A morphometric analysis

Morphometric analyses and pathological studies were carried out on spinal cords from seven cases (aged 71–88 years) with cervical spondylotic myelopathy (CSM), which were taken from cadaver specimens for anatomical dissection. The transverse sections of spinal cord specimens embedded in celloidin were stained with the luxol fast blue-periodic acid-Schiff-hematoxylin or the Klüver-Barrera methods. The measured items were flatness ration, and areas of cross-section, gray matter, and posterior funiculus at C2 to T1, and L1 levels. The measurements were carried out with the use of a combination of an electronic optical planimeter and a computer. The results showed that: (i) the most vulnerable segments in the cases of compression myelopathy were at C4-C6; (ii) the cross-sectional areas of the spinal cord with CSM were significantly smaller at C4-C6 levels compared with a normal group; (iii) the flatness ratio in CSM was obviously reduced at C4-C6 levels; (iv) the shape of the gray matter in CSM became severely flat, and the areas were significantly smaller at C4-C8, and L1 levels. The following findings were also observed: neuronal loss in the anterior horn; the formation of slit-like cavities in the gray matter (lateral part of the intermediate substance) at the compressed levels; and many amyloid bodies deposited in the posterior funiculus, and/or lateral funiculus. This finding had never been noted before in relation to CSM. There are three types of compression of the cervical spinal cord: whole ventral, ventromedian, and ventrolateral.     

Motor evoked potentials in the post-surgical follow-up of cervical spondylotic myelopathy

Eighteen patients (6 female, 12 male; average age 51 years, range 37–79) with clinical and radiological evidence (MRI) of cervical spondylotic myelopathy (CSM) were examined. The subjects were divided into two groups depending on whether radiology indicated single level (9 patients) or multilevel (9 patients) compression of the cervical cord. All of the patients underwent surgical decompression. Seriate exam with trans-cranial magnetic stimulation was performed in double session before surgery, and 3 and 12 months after surgery. The follow-up study of these patients revealed a statistically significant neurophysiological improvement only in those patients with single-level compression. In these cases, the cervical cord pathology revealed by MRI signal hyperintensity in T2 may at least partially consist of an edematous component and/or an initial demyelinization that has still a chance of recovery. In patients with multilevel damage, the compression may cause irreversible lesions.

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Sommario Sono stati esaminati 18 pazienti (6 femmine, 12 maschi), età media 51 anni (range 37–79), con evidenza clinica e radiologica (RMN) di mielopatia spondilosica cervicale (CSM). Essi sono stati suddivisi in due gruppi in base al dato radiologico di compressione midollare monofocale (9 pazienti) o multifocale (9 soggetti). Tutti i pazienti sono stati sottoposti ad intervento chirurgico decompressivo. È stato effettuato esame seriato con stimolazione magnetica a livello cranico nel preoperatorio in due distinte sedute (al fine di valutare l'effetto sui dati della variabilità legata alla metodica), a 3 e 12 mesi dopo l'intervento. I risultati ottenuti sono stati paragonati con i valori normali relativi a 20 soggetti normali.Le alterazioni dei parametri neurofisiologici considerati (Tempo di conduzione centrale, ampiezza delle risposte evocate), più evidenti a carico delle vie destinate agli arti inferiori, non sono risultate di entità statisticamente differente nel gruppo dei soggetti con lesione mono e multifocale. Lo studio del follow up di questi pazienti ha rivelato un miglioramento statisticamente significativo sul piano neurofisiologico solo nei pazienti con compressione monofocale. Si può ipotizzare che in caso di compressione monofocale, la sofferenza midollare evidenziata alla NMR come iperintensità di segnale in T2, possa essere costituita, almeno in parte, da una componente edematosa e/o una iniziale demielinizzazione, ancora suscettibile di miglioramento. Nei pazienti con danno di tipo multifocale invece la compressione a più livelli più frequentemente dà luogo ad un danno di tipo ischemico che rende impossibile il recupero.

     

Microscopic morphometry of the spinal cord with cervical spondylotic myelopathy

Quantitative studies with morphometric assessments were carried out on the slpinal cord of four cases (aged 71–88 years) with cervical spondylotic myelopathy (CSM), and compared with four normal spinal cords from age-matched cadaver specimens (aged 76–84 years). The histological preparation of the slpinal cord was made after embedding in celloidin and staining with luxol fast blue-periodic acid-Schiff-hematoxylin and Klüver-Barrera methods. the number, average transverse area and perimeter of the anterior horn cells (AHC) in the Rexed's lamina IX at C3, C5, C6 and L1 levels were counted and measured; the number, average transverse area and perimeter of axon in the posterior funiculus at C3 level and in the lateral corticospinal tracts at L1 level were also counted and measured under high magnification with oil immersion (1340 times), using a combination of an electronic optical planimeter, a microscope with a drawing tube, and a personal computer. The results can be summarized as: (i) The numbers of AHC in CSM at C5, C6 and L1 levels were significantly decreased compared with normal controls, and the average transverse area of AHC at C6 and L1 levels showed a decrease in varying degrees (p<0.05 or P<0.01, respectively). However, the number and average area of AHC in CSM at C3 level did not show any difference. (ii) The number and average transverse area of axons in the posterior funiculus with CSM at C3 level showed a significant reduction compared with normal controls (P<0.01 and P<0.05, respectively). (iii) There was an obvious decrease in the number of axons in the lateral corticospinal tracts of CSM at L1 level (P<0.01), but the average area of axons showed no statistical reduction. It can be deduced from these results that there were ascending degeneration of the posterior funciculus and descending degeneration of the lateral corticospinal tracts above and below the segments of comparession caused by CSM. The loss in number and reduction in transverse area of AHC mainly occurred in those segments involved with compression. However, the result of AHC at L1 level revealed that CSM may have a distal influence on AHC below thesegments of compression.     

Spinal cord tau pathology in cervical spondylotic myelopathy

We conducted an immunohistochemical and ultrastructural examination of the spinal cords from 11 cases of cervical spondylotic myelopathy (CSM), together with those from 11 age- and sex-matched control subjects. Immunostaining with AT8 antibody revealed various numbers of tau-positive neuropil thread-like structures (NTSs), often demonstrating a conspicuous astrocytic foot-like perivascular or subpial arrangement, and glial cells with short and thick processes, so-called thorn-shaped astrocytes (TSAs), in the affected cervical cords in 8 of the 11 CSM cases (73%). A number of tau-positive neuronal cytoplasmic pretangles/tangles were also found in the gray matter in all the CSM cases (100%). No such astrocytic or neuronal tau lesions were found in the control subjects. The tau deposited in the NTSs and TSAs was predominantly 4-repeat tau, whereas the neuronal cytoplasmic pretangles/tangles contained both 3-repeat and 4-repeat tau. Ultrastructurally, paired helical filaments about 20 nm wide, together with glial filaments, were detected occasionally in the astrocytic processes. In conclusion, the present findings indicate that astrocytic and neuronal tau lesions appear in the affected cervical cord during the disease process of CSM.     

Prolonged length of stay after posterior surgery for cervical spondylotic myelopathy in patients over 65 years of age

Prolonged length of stay (PLOS) has been associated with increased hospital resource utilization and worsened patient outcomes in multiple studies. In this study, we defined and identified factors associated with PLOS after posterior surgery for cervical spondylotic myelopathy in patients over the age of 65. PLOS was defined as length of stay beyond the “prolongation point” (that is, the day after which discharge rates begin to decline). Using the United States Nationwide Inpatient Sample database, 2742 patients met inclusion criteria, out of whom 16.5% experienced PLOS (stay beyond 6 days). After multivariate analysis, increasing age was independently associated with PLOS (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.02–1.06). Multiple comorbid conditions were associated with PLOS, including alcohol abuse (OR 3.85, 95% CI 1.87–7.94), congestive heart failure (OR 1.72, 95% CI 1.11–2.64), obesity (OR 1.70, 95% CI 1.14–2.55), and deficiency anemia (OR 1.44, 95% CI 1.01–2.05); the strongest associated operative parameter was blood transfusion (OR 2.39, 95% CI 1.75–3.28). Major complications independently associated with PLOS were deep vein thrombosis (OR 18.32, 95% CI 6.50–51.61), myocardial infarction (OR 8.98, 95% CI 2.92–27.56), pneumonia (OR 6.67, 95% CI 3.17–14.05), acute respiratory failure (OR 6.27, 95% CI 3.43–11.45), hemorrhage/hematoma (OR 5.04, 95% CI 2.69–9.44), and implant-related complications (OR 2.49, 95% CI 1.24–4.98). Average total hospital charges for patients who experienced PLOS were $122,965 US dollars, compared to $76,870 for the control group (p < 0.001). Mortality for patients who experienced PLOS was 2.7% versus 0.5% for patients who did not epxerience PLOS (p < 0.001). In conclusion, patients over the age of 65 who underwent posterior surgery for cervical myelopathy and stayed over 6 days in hospital were defined as having PLOS. Hospital charges and mortality rates were significantly higher for patients who experienced PLOS. Potentially modifiable and/or preventable risk factors were also identified.     

Trans-synaptic degeneration of motoneurons distal to chronic cervical spinal cord compression in cervical spondylotic myelopathy

Objective: To assess the effect of chronic cervical spinal cord compression upon remote motor unit function in patients with cervical spondylotic myelopathy (CSM). Methods: Fifty-three CSM patients and 47 healthy subjects were included. Bilateral motor unit number estimations (MUNEs) were recorded from both abductor digiti minimi and abductor pollicis brevis, and bilateral flexor carpi radialis (FCR) H-reflexes were examined in all subjects along with the nine-hole peg test (NHPT). The main outcome measures included the number of motor units, the average single motor unit potential (SMUP) area, the FCR Hmax/Mmax ratios and the NHPT time. Results: Statistically significant results compared to healthy controls included increased average SMUP area, increased FCR Hmax/Mmax ratio and increased NHPT time (p < 0.05). Abnormal SMUP was observed in 10/53 (18.9%) CSM patients along with reduced motor units in 3 of these 10 patients, while the FCR Hmax/Mmax ratios in the CSM patients with abnormal MUNE were higher than those in others (p < 0.05). There was a positive correlation between the NHPT time and the average SMUP area, and a negative correlation was noted between the NHPT time and the number of motor units (p < 0.05). Conclusion: In CSM patients, the motor units below the level of compression may exhibit dysfunction, which is likely a result of trans-synaptic degeneration. Both cervical spinal cord compressive injury and this trans-synaptic degeneration contribute to the impairment of fine motor ability in CSM patients. Therefore, treatment and rehabilitation efforts should account for these two dysfunctions.     

Descending spinal cord evoked potentials in cervical spondylotic myelopathy: Characteristic waveform changes seen at the lesion site

ObjectivesTo characterize waveform changes of descending spinal cord evoked potentials (D-SCEPs) seen in cervical spondylotic myelopathy (CSM).MethodsIntraoperative D-SCEP recording from serial intervertebral discs after transcranial electrical stimulation in 19 CSM patients with cord compression at a single level.ResultsCompared to the baseline (100%) obtained one level rostrally, the D-SCEP recorded at the compression site showed a significantly (p < 0.001) decreased amplitude (48%) and area (48%) of negative peak and increased amplitude (171%) and area (279%) of initial-positive peak. The degree in reduction of negative peak remained the same irrespective of the cord level involved, whereas enhancement of the positive peak tended to diminish with a more caudal compression.ConclusionsIn intraoperative electrophysiological studies of CSM with D-SCEP, an abrupt reduction of the negative peak accompanied by an enhancement of the initial-positive peak helps identify the site of conduction block. We speculate that progressive loss of the descending motor volleys at the synapses in the cervical enlargement may account for limited or absent enhancement of positive peak seen caudally.SignificanceThe current finding helps us understand the pros and cons of various electrophysiologic techniques for intraoperative localization of maximal cord involvement in CSM.     

Reversible pseudoathetosis and sensory ataxic gait caused by cervical spondylotic myelopathy

Proprioceptive deafferentation of spinal cord origin can cause pseudoathetosis, sensory ataxic gait, or both. The co-existence of pseudoathetosis and sensory ataxic gait caused by a surgically treatable condition of the spinal cord has been rarely reported. An 80-year-old man with cervical spondylotic myelopathy presented with severe sensory ataxic gait which confined him to a wheelchair. He also had poor control of his hands due to the pseudoathetoid movements of the fingers, which prevented him from sustaining constant muscle contraction. He underwent C3-4 and C4-5 anterior discectomies and anterior fusion. His neurological deficits gradually improved after the decompressive surgery. About 7 months postoperatively, he was totally independent in activities of daily living and needed no mobility aid. This case highlights the clinical importance of recognizing a surgically treatable and reversible condition of the spinal cord that causes pseudoathetosis and sensory ataxic gait.