颈椎椎管容积的动态CT测量及其临床意义

[目的]通过三种体位下的动态CT测量，观察正常人和脊髓型颈椎病（CSM）患者的颈椎椎管占位率的动态变化，并探讨其临床意义。[方法]对10例正常人和20例CSM患者分别行中立位、过屈位和过伸位螺旋CT扫描（C4-6），将数据传至工作站，进行容积再现（volume Rendering，VR）等后处理成像，测量每一截面骨性椎管和纤维性椎管的面积及椎管椎体的矢状径线，利用MATLAB求出三种体位下颈椎的椎管占位率，经统计学处理后分析其动态变化。[结果]在中立位下，正常人和CSM患者的颈椎椎管占位率差异有显著性意义（P〈0．01），CSM〉正常人。对于CSM患者，其中立位下颈椎管率与JOA评分不相关，Pearson相关系数为0．183（P〉0．05）；继发性椎管矢状径、有效椎管率和椎管占位率与JOA评分密切相关，Pearson相关系数分别为0．445（P〈0．05），0．496（P〈0．05），-0．611（P〈0．01）。在不同体位下，正常人和CSM患者的颈椎椎管占位率的动态变化相一致，均为：过伸位〉中立位〉过屈位，且差异有显著性意义（P〈0．01）。[结论]（1）颈椎管占位率可以客观反映颈椎屈伸运动中颈脊髓受压程度的动态变化，对预测CSM的发病、判断脊髓的受压程度、合理选择手术方式均具有重要意义。（2）过伸位时椎管占位率增大，是过伸性颈椎损伤发生的机制所在；过屈位时颈椎管占位率减小，可能是颈椎生理曲度变直或反曲的机体代偿机制之一。     

术中颈椎持续牵引的有限元分析

目的分析在颈椎术中持续牵引的安全性。方法采集志愿者颈椎薄层CT扫描数据,以DICOM格式保存,使用医学三维重建软件进行全颈椎三维有限元模型建立,应用模型优化软件对模型进行优化,以STL格式文件导入到有限元分析软件进行有限元分析,对模型施加10Nm纯扭矩模拟颈椎中立位、前屈位及过伸位,再施加50~300N的牵引力,测量不同三维运动状态下颈椎管长度、椎管横径及矢状径的变化。结果在颈椎中立、前屈及后伸三种不同运动状态下,随着牵引重量的增加,颈椎后伸位椎管长度的增量最大,中立位增量最小;所有体位各节段颈椎椎管横径、矢状径均减小,中立位下颈椎椎管横径、矢状径下降幅度最小,后伸位下降幅度最大。在中立位50N牵引力作用下,与前屈、后伸位无牵引状态相比,其椎管长度增加1.76%;各节段椎管横径小于前屈位,基本大于后伸位;椎管矢状径略小于上述两种体位,但是横矢状径增(减)量均小于1 mm。结论小重量牵引对于颈椎手术而言并无因颈脊髓牵拉及椎管狭窄加重而出现颈脊髓损伤的风险,是安全可行的。     

脊髓型颈椎病患者颈脊髓与椎管匹配关系和脊髓致压因素的动态变化分析

【摘要】 目的：观察脊髓型颈椎病（cervical spondylotic myelopathy,CSM）患者颈脊髓与颈椎管匹配关系的动态变化,分析脊髓椎管匹配关系及脊髓致压因素与脊髓受压风险的关系。方法：收集2018年1月~2021年7月在我院行颈椎动态磁共振成像（dynamic magnetic resonance imaging,DMRI）检查的CSM患者的影像学资料,排除图像不清晰、屈伸角度不理想者,共纳入63例患者,其中男37例,女26例;年龄50~67岁（56.6±4.9岁）。在DMRI横断面T2像上测量颈椎前屈、中立、后伸体位下C3~C7椎间盘水平脊髓面积及硬膜囊面积,计算脊髓与硬膜囊面积的比值（即椎管占有率）;横断面T2像上测量椎间盘突出程度,矢状面T2像上测量黄韧带厚度;横断面T2像上观察脊髓的受压程度,采用改良Muhle分级标准进行脊髓受压分级;观察椎间盘的退变程度,应用Pfirrmann分级标准进行评估。将所有观察节段分为椎间盘突出组及椎间盘非突出组进行比较,分析椎间盘突出是否影响脊髓椎管的匹配关系及黄韧带厚度变化。结果：共测量252个颈椎节段,其中C3/4椎间盘非突出节段33个,突出节段30个;C4/5非突出节段21个,突出节段42个;C5/6非突出节段17个,突出节段46个;C6/7非突出节段27个, 突出节段36个。椎间盘非突出组与突出组都满足脊髓横断面积后伸位>中立位>前屈位,硬膜囊面积前屈位>中立位>后伸位,椎管占有率后伸位>中立位>前屈位,差异均有统计学意义（P＜0.05）。椎间盘突出组中立位与非突出组前屈位、中立位C5/6椎管占有率在C3～C7四个节段中最高,差异均有统计学意义（P＜0.05）。椎间盘突出程度后伸位>中立位>前屈位,脊髓受压分级后伸位>中立位>前屈位,黄韧带的厚度后伸位>中立位>前屈位,差异有统计学意义（P＜0.05）;椎间盘突出组的椎间盘退变等级高于非突出组,差异有统计学意义（P＜0.05）。椎间盘突出组黄韧带较厚,与非突出组比较差异有统计学意义（P＜0.05）。结论：DMRI可显示CSM患者颈脊髓与椎管匹配关系的动态变化,颈椎由前屈位向后伸位运动时椎管占有率增高,脊髓受压风险增大,其中C5/6节段所受影响最明显。     

颈椎间盘突出的动态MRI测量及意义

目的：通过对颈椎间盘突出的动态ＭＲＩ测量,了解突出椎间盘及椎管内软组织在颈椎过伸、中立、过屈三位置下的变化,并探讨其临床意义。方法：对３１例中立位ＭＲＩ扫描发现颈椎间盘突出者,行过屈、过伸位扫描。测量三位置下硬膜囊前间隙、脊髓中矢径、硬膜囊中矢径、突出椎间盘大小及椎管／椎体矢径,分析其动态变化。结果：１４例椎管、椎体比值小于０．７５,占４５．２％。３１例颈椎间盘突出的硬膜囊、脊髓中矢径及突出的椎间盘大小在三位置变化中有显著性差异（Ｐ＜０．０５或Ｐ＜０．０１）,而硬膜囊前间隙大小变化无显著性差异（Ｐ＞０．０５）。结论：发育性颈椎管狭窄者易患颈椎间盘突出,且好发于Ｃ４～Ｃ７节段,动态ＭＲＩ可为治疗颈椎多节段椎间盘突出前路非广泛减压植骨术提供帮助。     

颈椎动力位MRI在无骨折脱位型脊髓损伤治疗方案选择中的价值

目的探讨应用颈椎动力位MRI在无骨折脱位型脊髓损伤治疗方案选择中的价值。方法自2014年6月至2015年12月,11例颈椎外伤后出现肢体麻木无力的患者,通过X线及CT未发现明显骨折脱位,中立位MRI发现可疑损伤节段20个,再次行过屈位及过伸位MRI,判断椎管狭窄程度变化以及脊髓高信号损伤出现的情况,从而辅助制定治疗策略。结果中立位MRI上20个可疑损伤节段中,90%(18/20)节段颈椎过伸位MRI上椎管狭窄程度加重,55%(11/20)节段在颈椎过伸位MRI上椎管狭窄程度加重1级,35%(7/20)节段加重2级,10%(2/20)节段无变化(但其中包含一个在中立位即表现为3级椎管狭窄的);过屈位上,25%(5/20)节段椎管狭窄程度减轻1级,75%(15/20)节段无变化。70%(14/20)可疑损伤节段在任何体位均未出现T2像上颈脊髓高信号,10%(2/20)可疑损伤节段仅在过伸位上出现T2像上颈脊髓高信号,20%(4/20)可疑损伤节段在任何体位均出现T2像上颈脊髓高信号。根据中立位MRI,30%(6/20)节段明确脊髓受压具有手术指证,且均考虑行颈椎前路手术;根据过伸位MRI,60%(12/20)可疑损伤节段因明确脊髓受压具有手术指证,且有3个患者共因出现多节段椎管狭窄由原计划的前路手术改为后路手术。结论颈椎动力位MRI可以进一步揭示颈脊髓的动态压迫,是对常规中立位MRI的重要补充,对颈椎无骨折脱位型颈脊髓损伤患者治疗方案的制定具有重要意义,对于手术方法及手术节段的选择具有重要的辅助参考价值。     

下颌角不能准确定位颈椎节段：影像学研究

目的依据颈椎侧位数字摄影(DR)资料,探讨下颌角(MDA)是否可作为颈椎节段体表定位的恒定参考。方法选取57例男性和66例女性的颈椎闭口标准侧位(中立位)及过伸过屈位的DR资料(照射野含下颌骨全部),半定量测量不同体位下MDA与颈椎节段的对应关系。设定C_2/C_3水平为0,每上升半个椎体或一个椎间隙,数字减1,反之加1。定量测量不同体位下上颈椎角(AUCS)与全颈椎角(ACS)及其变化,并进行统计学分析。结果同性别比较,各体位下MDA对应的颈椎节段差异均有统计学意义(P0.05);不同性别间比较,过屈位及中立位MDA对应的颈椎节段差异无统计学意义(P0.05);过伸位时女性MDA对应的颈椎节段高于男性,差异有统计学意义(P0.05)。不同性别间比较,各体位下AUCS及ACS差异均无统计学意义(P0.05)。同性别比较,各体位下AUCS及ACS差异均有统计学意义(P0.05)。过屈位向中立位及过伸位变换过程中,AUCS和ACS逐渐增大,过屈位到中立位的角度变化均小于中立位到过伸位的角度变化。结论中立位时MDA并非恒定对应于C_2/C_3水平,颈椎屈伸时MDA与颈椎节段的对应关系发生变化,且不局限于1个椎体高度,MDA不能作为颈椎体表定位的恒定参考。     

屈伸位颈椎MR扫描对颈椎管狭窄程度的研究

目的：研究颈椎管狭窄者在颈椎屈伸位下椎管狭窄程度的变化。方法：30例颈椎管狭窄,男13例,女17例;年龄28～66岁,平均39岁。颈椎椎管矢状径10mm以下即绝对狭窄者12例,颈椎椎管矢状径10～12mm即相对狭窄者18例．均行中立、前屈、后伸位MR扫描,获取MR图像后评价颈椎管的狭窄程度和颈髓受压情况的变化,结果：颈椎管狭窄者在后伸位上出现颈椎管狭窄加重19例,较前屈位8例明显多（P〈0．05）。结论：对于颈椎管狭窄的影像学诊断,屈伸位颈椎MR扫描可较好地补充常规中立位MR检查,而且后伸位MR较中立位和前屈位更具敏感性     

颈椎动力位MRI在脊髓型颈椎病诊治中的作用

目的探讨颈椎动力位MRI在脊髓型颈椎病诊治中的作用。方法分别测量42例患者共59节病变节段在颈椎过屈、中立、过伸位时的硬膜囊中矢径与脊髓中矢径,对比两者在不同体位下的变化。结果 59节病变节段,在过屈、中立、过伸位时,测出平均硬膜囊中矢径分别是:(7.63±0.90)mm,(6.48±0.82)mm,(5.85±0.89)mm;平均脊髓中矢径分别是:(6.44±0.80)mm,(5.81±0.82)mm,(5.56±0.82)mm。在过伸位时,硬膜囊中矢径与脊髓中矢径之间差值最小(0.29±0.60)mm(P0.01),脊髓代偿空间最小。结论在脊髓型患者中,颈椎病动力位MRI可以显示脊髓在不同体位下动态受压变化,对其治疗方式的选择有极大帮助。     

34例合并颈椎管狭窄的颈髓低能量损伤病例分析

目的探讨颈椎管狭窄合并低能量颈髓损伤的特点。方法回顾性分析34例颈椎管狭窄合并低能量颈髓损伤病例的临床资料。通过MRI矢状位T1、T2图像记录椎管狭窄的长度、所有狭窄节段的纤维矢状径、狭窄的原因、脊髓损伤的位置、最窄节段的位置,同时记录患者的年龄和性别。根据脊髓损伤处椎管纤维矢状径、最窄节段椎管纤维矢状径与所有狭窄节段的椎管纤维矢状径分三组,作LSD-t检验,对三组变量进行两两分析。结果 34例中,脊髓损伤位置与最窄节段的位置分布相吻合。损伤节段的椎管纤维矢状径与最窄节段椎管纤维矢状径均值均小于所有狭窄节段的椎管纤维矢状径均值,差异有统计学意义(P0.05)。结论低能量颈髓损伤的位置分布与颈椎管狭窄的最窄节段位置关系密切,低能量颈髓损伤的发生与颈椎管纤维矢状径相关。     

颈椎管容积与颈脊髓体积比值与脊髓型颈椎病病变程度的相关性分析

背景：直接测量颈椎管容积和颈脊髓体积可以较全面、立体地反映颈椎管对颈段脊髓的包容情况,尸体标本石蜡灌注法、树脂灌注法和有限元模型法均具参考价值,但操作繁复,且较难应用于临床,目前尚缺乏能够准确测量颈脊髓体积和颈椎管容积的简便测量方法。目的：探讨颈椎管容积与颈脊髓体积比值与脊髓型颈椎病（CSM）临床症状的相关性。方法：根据JOA评分将CSM患者分为A组（轻度）31例及B组（中重度）27例,所有患者均接受颈椎MRI扫描并计算颈椎管容积与颈脊髓体积比值,对两组患者的颈椎管容积与颈脊髓体积比值进行独立样本t检验,对两组患者的颈椎管容积与颈脊髓体积比值和JOA评分进行相关性分析。结果：A组患者的颈椎管容积与颈脊髓体积比值明显大于B组（t=15.094,P=0.001）;B组患者的颈椎管容积与颈脊髓体积比值与JOA评分的决定系数（r2=0.738）高于A组（r2=0.563）;颈椎管容积与颈脊髓体积比值与JOA评分的线性回归趋势提示A、B两组患者的颈椎管容积与颈脊髓体积比值均与JOA评分呈正相关。结论：颈椎管容积与颈脊髓体积比值可以反映颈椎管对颈脊髓的包容状态,利用MRI测量颈椎管容积与颈脊髓体积比值可以定量反映脊髓的损害程度。     

Measurement of the cervical spinal cord volume on MRI

BACKGROUND: There are some reports about the relationships between the clinical manifestations and the spine morphology or spinal cord morphology in patients with myelopathy. It has also been reported that there are interindividual variations in the cross-sectional area of the spinal cord. In most of these reports, the cross-sectional area, compression ratio, and anteroposterior diameter were used as morphologic parameters of the spinal cord, but no reports have been published on the use of spinal cord volume. OBJECTIVES: To measure the cervical spinal cord volume of healthy people and to evaluate the relationships between this volume and each of height, body weight, age, and gender, in a morphologic study of cervical spinal cord on magnetic resonance imaging (MRI). METHODS: The cervical spinal cord volume of 90 healthy people (47 males, 43 females) was measured on MRI, and the relationships between this volume and each of gender, height, body weight, and age were evaluated. In addition, the cervical spinal cord volume ratio was evaluated. RESULTS: Our study showed that in healthy people, the cervical spinal cord volume depended on the gender, age, height, and body weight and that the cervical spinal cord volume was larger in the males than in the females, decreased with age, and increased with height and body weight. However, the cervical spinal cord volume ratio was not affected by gender, age, height, or body weight. CONCLUSIONS: We consider that the cervical spinal cord volume ratio can be used to evaluate cervical spinal cord atrophy in patients with cervical myelopathy and can be important information in looking for clinically critical points. The cervical spinal cord volume was larger in males than in the females, decreased with age, and increased with height and body weight. The cervical spinal cord volume ratio was not affected by gender, age, height, or body weight.     

Changes of cervical spinal cord and cervical spinal canal with age in asymptomatic subjects

STUDY DESIGN: Prospective study on magnetic resonance imaging (MRI) and radiographic findings of the cervical spine. OBJECTIVE: To elucidate the age-related changes of the cervical spinal cord and the cervical spinal canal and the relationship between the spinal cord and the spinal canal in asymptomatic subjects using MRI and radiography. SETTING: Tokyo, Japan. METHODS: The transverse area of the cervical spinal cord and the ratio of the anteroposterior diameter to the transverse diameter (RAPT) were investigated, using MRI in 229 asymptomatic subjects. The sagittal spinal canal diameter and anteroposterior diameter of the cervical vertebral body were also measured on plain lateral radiographs. The canal body ratio (CBR), which was defined as the diameter of the spinal canal divided by that of the vertebral body, was calculated. RESULTS: The transverse spinal cord area correlated negatively with age. RAPT did not correlate with age. The CBR correlated negatively with age. The correlation between spinal cord area and CBR was significant but weak and the correlation between RAPT and CBR was not significant. CONCLUSION: The transverse area of the cervical spinal cord measured by MRI decreased with age, while RAPT remained unchanged. The bony spinal canal became narrower with age. The spinal cord area and the shapes of the spinal cord were independent from the spinal canal diameter in asymptomatic subjects. These facts should be considered when evaluating radiological findings in patients with cervical spinal disorders.     

一次性颈椎后路椎管扩大成形术加经硬脊膜入路髓核摘除术治疗脊髓钳夹型颈椎病

目的 探讨采用一次性颈椎后路单开门椎管成形术加经硬脊膜入路椎间盘髓核摘除术治疗脊髓钳夹型颈椎病的手术方法及观察其近期手术疗效.方法 本组6例脊髓钳夹型颈椎病患者术前均行X线片、CT和MRI检查确诊.手术方法均采用颈后路单开门椎管扩大成形术,然后在颈椎间盘突出相应的硬脊膜的位置上纵行切开硬脊膜,显露颈髓和上、下神经根及齿状韧带,切开纤维环取出髓核组织.结果 本组6例均获随访,按JOA评分标准平均提高3-6分,肌力平均提高2-3级,术前症状基本消失或缓解.术后予以X线片及MRI复查,无明显并发症,钳夹节段的颈髓均显示压迫解除.结论 一次性颈椎后路单开门椎管扩大成形术加经硬脊膜入路椎间盘髓核摘除术是治疗脊髓钳夹型颈椎病的一种可行有效的手术方法.它可避免多次手术的痛苦.     

The relationship between the cervical spinal canal diameter and the pathological changes in the cervical spine

A congenitally narrow cervical spinal canal has been established as an important risk factor for the development of cervical spondylotic myelopathy. However, few reports have described the mechanism underlying this risk. In this study, we investigate the relationship between cervical spinal canal narrowing and pathological changes in the cervical spine using positional magnetic resonance imaging (MRI). Two hundred and ninety-five symptomatic patients underwent cervical MRI in the weight-bearing position with dynamic motion (flexion, neutral, and extension) of the cervical spine. The sagittal cervical spinal canal diameter and cervical segmental angular motion were measured and calculated. Each segment was assessed for the extent of intervertebral disc degeneration and cervical cord compression. Based on the sagittal canal diameter, the subjects were classified into three groups: A, subjects with a congenitally narrow canal, diameter of less than 13 mm; B, subjects with a normal canal, diameter of 13–15 mm; C, subjects with a wide canal, diameter of more than 15 mm. When compared with Groups A and B, the disc degeneration grades at the C3-4, C5-6, and C6-7 segments and the cervical cord compression scores at the C3-4 and C5-6 segments showed significant differences. Additionally, when compare with Groups A and C, the disc degeneration grades at all segments, except C2-3, and the cervical cord compression scores at all segments, except C2-3, showed significant differences. With respect to the cervical kinematics, few differences in the kinematics were observed between Groups B and C, however, the kinematics in Group A was different with other two groups. In Group A, the segmental mobility at the C4-5 and C6-7 segments were significantly higher than those observed in Group B, and the segmental mobility at the C3-4 segment was significantly lower than that observed in Groups B or C. We demonstrated the unique pathological and kinematic traits of cervical spine that exist in a congenitally narrow canal. We hypothesize that kinematic trait associated with a congenitally narrow canal may greatly contribute to pathological changes in the cervical spine. Our results suggest that cervical spinal canal diameter of less than 13 mm may be associated with an increased risk for development of pathological changes in cervical intervertebral discs. Subsequently, the presence of a congenitally narrow canal can expose individuals to a greater risk of developing cervical spinal stenosis.     

无骨折脱位型颈脊髓损伤的病因与手术疗效观察

目的探讨无骨折脱位型颈脊髓损伤的病理基础，评价不同手术方法的治疗效果。方法回顾22例分别采用了前路减压、植骨、内固定或后路单开门椎管扩大成形术的无骨折脱位型颈脊髓损伤病例，分析其术前影像学资料，探讨病理实质；根据术前、术后Frankel分级情况及影像学的变化，判断手术疗效。结果22例无骨折脱位型颈髓损伤病例中，过伸型损伤16例(62．7％)，退变性椎管狭窄15例(68．2％)，先天性椎管狭窄4例(18．2％)。前路手术患者随访见内置物无松动、脱落或断裂，固定节段均获得骨性融合；后路手术患者术后X线正位片显示无再关门现象。14例患者术后MRI检查显示，椎管容积扩大，颈髓受压缓解。3例术后脊髓功能无改善，其余病例均有不同程度恢复。结论颈椎椎管狭窄是无骨折脱位型颈脊髓损伤的重要病理基础，颈髓过伸性损伤是发生四肢瘫的直接原因。只要术式选择合理、手术操作正确，前、后路手术均能获得较理想脊髓神经功能恢复。     

颈椎脊髓脑脊液柱椎管面积的MRI测量及其意义

目的探讨颈椎脊髓、脑脊液柱、椎管MR I横断面面积的相互比值与脊髓型颈椎病发病的关系。方法于颈椎MR I T2轴位像测量70例脊髓型颈椎病(CSM)患者及80例正常成人的脊髓横断面、脑脊液柱、椎管面积,每例共测量C4、C5、C6、C74个节段。每节段于椎体后高中点处、与脊髓纵轴垂直、终板平行作扫描,分别计算各节段脊髓/脑脊液柱、脊髓/椎管、脑脊液柱/椎管面积的比值。结果脊髓/椎管面积比值,CSM组4个节段均明显高于正常成人组;脊髓/脑脊液柱面积比值,CSM组C4、C5节段明显高于正常成人组;脑脊液柱/椎管面积比值于两组中无显著差异。结论椎体后高中点水平脊髓横断面面积与相应水平椎管横断面面积比值的增高是脊髓型颈椎病的发育性致病因素。     

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。     

无颈椎骨折脱位的急性颈髓损伤

目的探讨无颈椎骨折脱位的急性颈髓损伤的特征和机制.方法对33例无颈椎骨折脱位的急性颈髓损伤病例进行回顾性研究,分析其神经学、X线和MRI检查结果.结果颈髓完全性损伤者8例,不完全性损伤者25例;21例患者有颈椎变性改变(椎间盘间隙狭窄伴有骨赘形成者15例,后纵韧带骨化者6例),3例C5颈椎管Pavlov率小于0.8;30例可见颈髓受压,25例表现为椎旁软组织损伤.结论无颈椎骨折脱位的急性颈髓损伤的重要诱因为颈椎变性改变和发育性颈椎管狭窄,致病原因主要为颈髓受压;MRI检查有利于查明脊髓损伤的部位和机制.