颈椎节段性不稳定的分型诊断及标准初探

为探讨颈椎节段性不稳的类型并对临床治疗和预防提供依据，根据５６９例伴有节段性不稳的颈椎病患者的临床特点和影像学特征，将其分为前后滑移型（１９３例占３３．９％）轴向旋转型（１０８例占１９％）左右侧摆型（１７例占３％）环枢不稳型（６８例占１１．９％）混合型（１８３例占３２．２％）发现前后滑移和轴向旋转是颈椎节段必环稳定性的主要形式，纠正和预防颈椎的前后滑移和轴向旋转错位是防治此类颈椎病的重要措施。     

原位旋转植骨在颈椎前路减压融合术中的应用

目的：观察原位旋转植骨在颈椎前路减压融合术中植骨融合的效果及临床疗效。方法：应用Cloward法行颈椎前路减压＋原位旋转植骨融合主治疗216例颈椎病变患者，随访1－6年，影像观察骨融合情况及颈椎曲度的变化。按40分评分评定临床疗效。结果：疗效，优112例（51．9％），良76例（35．2％），有效21例（9．7％），无效6例（2．8％），加重1例（0．4％），优良率87．1％，影像表现：术后2－3个植骨块愈合，术后1年单节段植骨颈椎保持较好前凸，24例2－3节段植骨出现前凸消失，21例颈椎反曲，结论：原位旋转植骨简便，骨融合较快，临床疗效好，在2节段以内的颈椎前路减压融合术中具有明显的优势。     

颈椎病合并下颈椎不稳的外科治疗策略

目的 探讨颈椎病合并下颈椎不稳的临床诊断、术式选择及手术疗效。方法 对手术治疗的32例颈椎病合并下颈椎不稳,分别摄术前及术后随访之颈椎正侧位、伸屈侧位X线片及颈椎MR检查。32例均经前路行减压、植骨融合、内固定手术治疗。以颈椎不稳节段与颈椎主要退变节段重合,并行减压内固定患者为A组,共7例;对25例颈椎不稳与颈椎病节段不重合,以其中仅处理颈椎病节段9例为B组;在处理颈椎病节段同时处理颈椎不稳节段16例为C组。以“40分”评分法分别对患者术前、术后随访情况予以评价,对数据分别行组间均值t检验及组内配对t检验。结果 经12～36个月随访（平均25个月）,所有患者均获骨性融合,平均改善率61．2％。A、B、C组间均值t检验：术前差异无显著性（P〉0．05）、术后差异亦无显著性（P〉0．05）。各组内配对t检验,术前、术后随访差异均有显著性（P〈0．05）。结论 在颈椎病合并下颈椎不稳的患者中,不稳节段与主要退变节段关系密切但往往并不重合。通过颈前路手术,在处理颈椎病节段同时处理相邻颈椎不稳节段,临床疗效满意。     

高龄颈椎病患者前路减压手术的疗效

目的研究70岁以上颈椎病患者的临床特征和前路手术治疗效果。方法采用回顾性分析，将20例70岁以上颈椎病患者作为老年组，将31例年龄小于69岁的多节段颈椎病患者作为对照组。两组均行前路减压植骨融合手术，应用日本骨科协会JOA评分系统进行疗效评价，比较两组的手术疗效和并发症发生情况。结果围手术期死亡1例，余50例随访24-55个月，平均35个月。老年组术前JOA评分平均9．3分（3～14分），终末随访时JOA评分平均13．4分（8～17分），优良率为68％，改善率为58％；对照组术前JOA评分平均11．0分（6～13分），终末随访时JOA评分平均14．8分（10-17分），优良率和改善率分别为71％和67％。两组比较优良率与改善率差异均无统计学意义（x^2=0．04，P=0．85；t=1．12，P=0．138）。老年组有7例出现了手术相关并发症，并发症发生率为35％，高于对照组（3例，10％），但差异无统计学意义（x^2=3．47，P=0．06）。术前颈椎过伸过屈侧位X线片显示老年组只有1例（5％）存在颈椎不稳，而对照组有8例（26％）颈椎不稳。结论（1）颈椎不稳的“过度代偿”机制可能是多节段高龄颈椎病的发病原因。（2）前路减压手术可以改善高龄颈椎病患者的神经症状，提高生活质量，但手术并发症发生率相对较高。     

颈椎黄韧带退变和脊髓型颈椎病的相关性研究

目的：探讨颈椎黄韧带退变和脊髓型颈椎病的相关性。方法：收集10例脊髓型颈椎病和19例颈椎外伤患者的黄韧带标本，对其进行厚度测量及组织学检查；用Woessner法及盐析法测定黄韧带中Ⅰ型与Ⅱ型胶原含量的比值；对黄韧带厚度与Ⅰ、Ⅱ型胶原含量的比值进行相关性研究。结果：颈椎黄韧带退变后弹力纤维含量下降，排列紊乱，胶原纤维含量增加，颈椎病组黄韧带厚度和Ⅰ/Ⅱ型胶原含量的比值与对照组比较有显著性差异（P〈0.05）；颈椎不稳节段的黄韧带胶原含量较其它节段显著增加。结论：颈椎不稳与黄韧带退变密切相关，黄韧带中Ⅱ型胶原过度增加可能是脊髓型颈椎病发生的重要因素之一。     

钢板内固定在颈椎前路术中的应用

颈椎骨折、颈椎间盘突出症、颈椎节段性不稳、单节段或多节段脊髓型颈椎病等病症在临床中并不少见。随着MRI的普及和广泛应用,我们发现很多病例的脊髓压迫都来自前方。从治疗角度来说,以往的环锯法减压、单纯开槽式减压在维持减压节段椎节的高度和生理曲度以及颈椎稳定性方面均存在一定缺陷,远期随访效果并不理想。自2000年起,我们采用颈椎前路开槽式减压自体髂骨植骨加自锁钢板内固定治疗颈椎骨折、颈椎间盘突出症、颈椎节段性不稳、单节段或多节段脊髓型颈椎病、颈椎后纵韧带骨化病(OPLL)等病种患者38例,平均随访19个月,效果良好。本手…     

退行性颈椎不稳的手术治疗

目的 应用手术治疗退行性颈椎不稳．观察其疗效，并探讨手术适应证。方法 自1998年4月～2001年4月，对15例影像学上有颈椎不稳、伴体位性症状、经1年以上严格保守治疗无效的非脊髓型颈椎病患者施行手术治疗，男6例，女9例；年龄44～65岁．平均55．2岁。病程1．5～4年．平均28个月，体位性症状主要包括：随颈椎屈伸或旋转出现的神经根型、交感型以及椎动脉型颈椎病样症状，所有病例均采取前路颈椎不稳节段融合加铁板内固定术。自体髂骨植骨7例,其中单节段3例；双节段4例,双节段者行开槽植骨。应用椎间融合器(钛网)8例．其中单节段2例，植骨取自异体骨；双节段6例，行开槽植骨．植骨取自椎体切除部分，结果 随访时间8个月～4年，平均25个月。15例患者症状均获明显改善．12例症状完全消失，3例偶有颈背部酸胀感。融合节段均获得骨性愈合。结论 影像学上出现退行性颈椎不稳同时伴有颈椎体位性症状，且两者可相互解释者．通过行不稳节段的融合术可获得良好的治疗效果，退行性颈椎不稳有良性转归的可能，因此应严格掌握手术适应证。     

颈椎病发病学中的不稳定因素

[目的] 探讨退变性不稳在颈椎病发生中的意义。[方法] 随访216例颈肩痛和（或）神经根性痛患者，男143例，女73例。年龄29～4l岁，平均37．8岁。表现颈肩痛的患者173例，神经根征者28例，兼有神经根征、颈肩痛者15例。依据退变性颈椎不稳X线诊断标准：不稳定组82例，稳定组134例。全部患者采用物理疗法和（或）局部制动治疗。[结果] 随访2～7a，平均4．3a。不稳定组患者中4例出现不稳节段椎体后缘骨赘形成，3例出现椎间盘突出，6例出现椎体后缘骨赘形成伴椎间盘突出，3例出现不稳节段脊髓内T2高信号。稳定组中2例出现C4.5椎间盘突出，2例出现C5椎体后缘骨赘形成。不稳定组颈椎病发生率19．5l％明显高于稳定组2．99％，差异有统计学意义（P〈0．05）。[结论] 颈椎退变性不稳定在颈椎病的发生、发展中起着重要作用，是颈椎病形成的原因之一。     

Bryan人工椎间盘置换术治疗颈椎病的近期临床效果及出现的问题

目的：总结近3年应用Bryan人工椎间盘置换术治疗颈椎病的疗效，分析容易出现的问题，探讨其原因及相关对策。方法：回顾性分析121例应用Bryan人工椎间盘置换术治疗的颈椎病患者，共145个置换节段，其中单节段99例，双节段20例，三个节段2例。应用JOA 17分法评价术前和末次随访时的神经功能状况。观察末次随访时颈椎侧位X线片上假体的前后径与椎体前后径的差异，假体上下终板的相互位置关系．假体轴线与原来椎间隙轴线的对应关系。在颈椎过伸过屈侧位X线片上观察假体上下终板间的活动以及假体前后缘有无钙化或骨化。结果：随访12～24个月，平均18个月，脊髓型颈椎病患者的平均JOA评分由术前平均8．5分增加到术后平均15．5分，神经根型颈椎病患者的症状完全消失。未见假体松动、移位以及症状加重者。有42个假体（28．97％）的前后径小于椎体的前后径；颈椎中立位时有23个假体（15．86％）的上下终板的前缘或者后缘过于接近，影响置换节段的前屈或后伸；有32个假体（22．07％）的轴线与原有椎间隙的轴线不一致．向头侧或尾侧旋转。上述问题绝大部分出现在开展此手术早期的病例。3例共4个置换假体（2．76％）在术后1年内出现假体周围融合，2例在椎体的前缘，1例在椎体的后缘。结论：Bryan人工椎间盘置换术治疗颈椎病近期临床效果良好，但实施该手术需要经历一定的学习曲线，应当重视出现的相关问题,缩短学习曲线。     

颈椎弓根螺钉置入固定治疗颈椎不稳的疗效和安全性分析

目的分析颈椎弓根螺钉置入固定治疗颈椎不稳的临床结果，总结其临床疗效和安全性。方法颈椎弓根螺钉固定治疗颈椎不稳19例，平均随访时间为16．3个月。分析术前及术后6个月随访时JOA评分，采用颈椎残障功能量表（neck disability index，NDI）评价患者日常生活障碍程度变化。测量术后6个月及末次随访时颈椎屈伸侧位X线片，观察融合节段的稳定性。结果术后6个月随访时JOA评分较术前增加4．2±1．3（P〈0．05），平均改善率为61％。NDI评分术前为34．2±11．4，术后6个月为18．8±9．5（P〈0．01），随访时融合节段稳定。椎弓根螺钉骨皮质穿破率为7．6％，未出现神经、血管损伤。结论术前仔细研究影像学资料，颈椎弓根螺钉置入固定治疗颈椎不稳可以获得满意的临床疗效和安全性。     

无X线异常的颈脊髓损伤分类外科治疗探讨

目的 探讨无X线异常的颈脊髓损伤(spinal cord injury without radiographic abnormality,SCIWORA)的致伤特点、形成因素及经分类的外科治疗近、远期神经功能疗效.方法 回顾性分析2000年3月至2004年7月间81例经外科治疗的颈SCIWORA病例.男55例,女26例;年龄43～68岁,平均57.3岁.根据颈椎倾向损伤的运动形式和颈椎本身的病理基础将SCIWORA的形成因素归纳为三类,Ⅰ类:屈曲运动为主短节段(一或两个节段)致伤,具有节段性颈椎间盘退变性突出或脱出者19例;Ⅱ类:过伸运动为主多节段(≥三个节段)致伤,具有多节段(≥三个节段)颈椎管狭窄者41例;Ⅲ类:挥鞭样复合(过伸及屈曲并重)致伤,具有多节段椎管狭窄以及节段性椎间不稳定,或前方节段性椎间盘退变性突出或脱出者21例.在有效维持患者生命体征的前提下,针对不同形成因素分别采用前路减压融合、后路多节段椎管扩大成形及后路椎管扩大成形+不稳定节段内固定融合(或+前路减压融合)的手术方式进行早期治疗,观察近期神经功能改善情况并进行远期随访.结果 经术后1个月、3个月、1年及终末(54～118个月,平均78.5个月)随访,神经功能日本矫形外科协会(Japanese Orthopaedic Association,JOA)评分改善率分别为25.1%、41.3%、63.6%及60.9%;远期随访神经功能改善优良率为80.2%.结论 SCIWORA为一类急性、动态且有限的脊髓损伤,虽然有共性的临床表现,但其致伤特点及形成因素并非单一,故经归类并早期进行具有针对性外科治疗,仍可取得较明显的神经功能改善.     

Spinal deformity and instability after multilevel cervical laminectomy

Sixty-four patients who had undergone multilevel cervical laminectomy were studied for postoperative spinal deformity and instability. Special attention was given to patients with cervical spondylosis (CS), ossification of the posterior longitudinal ligament (OPLL), and spinal cord tumors. Twenty-three (36%) of 64 patients showed postoperative changes in curvature type and 9 (14%) had developed spinal deformity (kyphotic or meandering-type curvature). In two juvenile patients, the deformity developed soon after operation and spinal fusion was required to prevent neurologic complications. In the adult cases, contrary to the hitherto accepted concept, long-term follow-up revealed the tendency of the deformity to develop more frequently in OPLL cases than in CS cases. Mobility of the cervical spine was reduced considerably after laminectomy, both in CS and OPLL cases. There was no adult patient who required further operation for severe deformity or instability after laminectomy. Extensive laminectomy, even including the C2 lamina, seemed to have no adverse effect on the stability of the cervical spine.     

家族性颈椎后纵韧带骨化症的临床症状特点

目的通过对家族性颈椎后纵韧带骨化症(OPLL)的临床症状分析,揭示家族聚集性OPLL的临床症状特点与遗传模式。方法 2011年1月—2016年12月,通过询问OPLL患者的家族史筛选出6个明显表现为家族聚集性的OPLL家系。对患者和其家系中每位成员进行颈椎X线、CT检查,观察是否有颈椎OPLL表现,同时询问是否存在OPLL相关症状。结果共纳入研究对象53例,家族性OPLL发生率为24.5%(13/53);混合型∶连续型∶局灶型∶节段型=7∶4∶1∶1;患者年龄为(52.9±8.4)岁,发病年龄为(46.9±9.5)岁,最常累及节段为C_(3~6)。以颈痛为首发症状者9例,以脊髓压迫为首发症状者4例。统计全部症状的发生情况:上肢麻木疼痛10例,头晕头痛6例,颈肩痛5例,下肢麻木疼痛5例,胸腹束带感4例,踩棉花感3例,上肢肌力障碍3例,下肢肌力障碍2例,括约肌功能障碍2例。统计每个分型的患者出现症状数占各自类型全部症状数(例数×9)的比例,混合型49.2%(31/63),连续型41.7%(15/36),局灶型22.2%(2/9),节段型11.1%(1/9)。结论家族性颈椎OPLL临床症状的发生、发展特点与其影像学发生、发展、分型特点关系紧密。局灶型、节段型患者占全体比例较小,平均年龄较小,出现症状的数目较少,症状程度较轻;混合型、连续型患者占全体比例较大,平均年龄较大,出现症状的数目较多,症状程度较重。     

Segmental cervical instability does not drive the loss of cervical lordosis after laminoplasty in patients with cervical spondylotic myelopathy

BACKGROUND/CONTEXTKyphotic deformity after cervical laminoplasty (CLP) often leads to unfavorable neurological recovery due to insufficient indirect decompression of the spinal cord. Existing literature has described that segmental cervical instability is a contraindication for CLP because it is a potential risk factor for kyphotic changes after surgery; however, this has never been confirmed in any clinical studies.PURPOSETo confirm whether segmental cervical instability was an independent risk factor for postoperative kyphotic change and to examine whether segmental cervical instability led to poor neurological outcomes after CLP for cervical spondylotic myelopathy (CSM).STUDY DESIGN/SETTINGA retrospective studyPATIENT SAMPLEPatients who underwent CLP for CSM between January 2013 and January 2021 with a follow-up period of ≥1 year were enrolled.OUTCOME MEASURESCervical radiographic measurements including C2–C7 lordosis (C2–7 angle), cervical sagittal vertical axis, C7 slope, flexion range of motion (fROM) and extension ROM (eROM) were assessed using neutral and flexion-extension views. Segmental cervical instability was classified into anterolisthesis (AL) of ≥2 mm displacement, retrolisthesis (RL) of ≥2 mm displacement, and translational instability (TI) of ≥3 mm translational motion. The amount of C2–7 angle loss at the follow-up period compared to the preoperative measurements was defined as cervical lordosis loss (CLL). Neurological outcomes were assessed using the recovery rate of the Japanese Orthopedic Association score (JOA-RR).METHODSCLL was compared among patients with and without segmental cervical instability. Further, multiple linear regression model for CLL was built for the evaluation with adjustment of the reported risks, including cervical sagittal vertical axis, C7 slope, fROM, eROM, and patient age together with AL, RL, and TI, as independent variables. The JOA-RR was also compared between patients with and without segmental cervical instability.RESULTSA total of 138 patients (mean age, 68.7 years; 65.9% male) were included in the analysis. AL, RL, and TI were found in 12 (8.7%), 33 (23.9%), and 16 (11.6%) patients, respectively. Comparisons among the groups showed that AL led to greater CLL; however, RL and TI did not. Multiple linear regression analysis revealed that greater CLL is significantly associated with greater fROM and smaller eROM (regression coefficient [β]=0.328, 95% confidence interval: 0.178 to 0.478, p<.001; β=?0.372, 95% confidence interval: ?0.591 to ?0.153, p=.001, respectively). However, there were no significant statistical associations in the AL, RL, and TI. Whereas, patients with AL tended to exhibit lower JOA-RR than those without AL (37.8% vs. 52.0%, p=.108).CONCLUSIONSSegmental cervical instability is not the definitive driver for loss of cervical lordosis after CLP in patients with CSM; thus, is not a contraindication in and of itself. However, it is necessary to consider the indications for CLP, according to individual cases of patients with AL on baseline radiograph, which is a sign of poor neurological recovery.     

腰椎间盘突出症再手术原因分析和手术方式探讨

目的:探讨腰椎间盘突出症再手术的原因及手术方式。方法:对39例腰椎间盘突出症术后症状无改善或缓解一段时间后复发需再手术的患者进行分析和总结。再手术方式:椎板间开窗或经原椎板间扩大开窗、椎间盘切除8例;半椎板切除减压、椎间盘切除3例;全椎板切除减压、椎间盘切除27例(其中23例行后路椎弓根内固定加横突间植骨融合,2例同时行椎间cage置入融合);经左前外侧入路腹膜外椎间盘切除、椎间植骨融合1例。结果:再手术原因包括复发性腰椎间盘突出20例、相邻节段腰椎间盘突出7例、腰椎节段性不稳定8例和腰椎间盘未彻底去除4例,其中合并继发性腰椎管狭窄8例,硬膜外瘢痕形成4例。术中发生脑脊液漏4例,均行硬膜修补,术后恢复良好。随访1年6个月～5年7个月,其中31例患者症状明显改善,7例症状部分改善,1例无改善,优良率为79.5%。再手术前JOA评分平均11.8分,再手术后末次随访时平均25.6分,有显著性差异(P<0.05),恢复率为80.2%。23例行椎弓根内固定加横突间植骨融合患者末次随访时植骨融合率为70%,1例行椎间植骨融合患者末次随访时植骨融合。结论:腰椎间盘突出症再手术的主要原因为复发性腰椎间盘突出、相邻节段腰椎间盘突出、腰椎节段性不稳定和腰椎间盘未彻底去除等,正确分析再手术原因并选择合理的手术方式,仍可以取得较为满意的疗效。     

An analysis of heterotopic ossification in cervical disc arthroplasty: a novel morphologic classification of an ossified mass

Background contextAlthough the precise cause of heterotopic ossification (HO) remains unclear, it is certain that it increases with time. The reason why the reported occurrence rate has been given as a wider range is that there were no clinical reports that have addressed the occurrence rate based on the morphology and position.PurposeThe aim of this retrospective study was to determine whether radiological parameters had an influence on the formation of HO and to compare the results after cervical arthroplasty using Bryan (Medtronic Sofamor Danek, Memphis, TN, USA), PCM (Cervitech, Rockaway, NJ, USA), and Prestige LP (Medtronic Sofamor Danek) implants.Study design/settingA retrospective study.Patient sampleEighty-one patients were included.Outcome measurementThe occurrence of HO was determined at the four corners of the disc space according to the McAfee classification system. Heterotopic ossifications were classified into Type 1, Type 2, and Type 3 HOs (end plate, traction spur, and teardrop types) based on their morphologic features. The presence of preoperative ossifications, sex, type of device, operated level, hybrid implantation, depth behind the prosthesis, cervical lordotic angle, and segmental angle between the footplates of the prosthesis were assessed as predictors in terms of location and morphologic features.MethodsEighty-one patients after 95 cervical arthroplasties using the Bryan (35 segments), PCM (30 segments), and Prestige LP implants (30 segments) underwent postoperative radiographs or three-dimensional computed tomography with a mean follow-up period of 46, 39, and 30 months, respectively, after the operation.ResultsThe overall incidence of all cases and one-level subgroup were 64.2% and 60.3%, respectively. According to the types of device, the incidence of HO was 49% (Bryan), 80% (PCM), and 60% (Prestige). Type 1 HO (62.1%) was found only in the posterosuperior disc space. Type 2 HO (13.7%) was primarily detected in the anterosuperior disc space rather than the posterosuperior disc space (3.2%). Type 3 HO (4.2%) developed only in the anterior disc space. In the anterior disc space, the incidence of Type 2 and Type 3 HOs was highest in the PCM group. In the posterior disc space, the Bryan group showed a lower proportion in the high McAfee class than the other device groups. The occurrence of Type 1 HO in the posterosuperior disc space was significantly related with the presence of preoperative ossification (p=.030), ossification in the ligamentum nuchae (p=.027), male sex (p=.042), and PCM device (p=.012). A well-fitting (p<.002) and less lordotic segmental angle (p<.015) were correlated with Type 1 HO. Implantation in the upper cervical level (p=.016) and hybrid implantation with cage (p=.033) or artificial disc (p=.048) on the upper adjacent level were significant risk factors for anterior Type 2 HO. Cervical lordotic angle at 1 month after surgery had a significant connection with the occurrence of anterior Type 2 HO in both groups of all cases (p=.032) and one-level subgroup (p=.000).ConclusionsType 1 HO developed mostly in the posterior disc space. Type 2 HO was the dominant type in the anterior disc space. Type 3 HO developed only in the anterior disc space. It is certain that both Type 1 and Type 2 HOs are related to biomechanical stresses (compressive force for Type 1 HO and traction force for Type 2 HO). It is suggested that a cervical arthroplasty should be selected in terms of the implant level, hybrid conditions on the upper adjacent segment, disc design vulnerable to the pseudotranslation, the presence of preoperative ossification, and fitting implants to end plates to reduce the development of HO.     

颈椎单开门椎管扩大成形术铰链侧不同程度骨折后骨愈合的对比研究

 目的 观察颈椎单开门椎管扩大成形微型钢板固定术后椎板铰链侧不同程度骨折的断端骨愈合情况。方法 2009年9月至2011年12月采用颈椎单开门椎管扩大成形Centerpiece钢板固定术治疗的患者49例,男41例,女8例;年龄34~83岁,平均 61岁。根据术后CT扫描,将椎板铰链侧骨折分为不完全骨折和完全骨折。完全骨折分为四型：Ⅰ型,骨折断端无移位分离;Ⅱ型,骨折断端部分移位或分离;Ⅲ型,骨折断端完全移位分离;Ⅳ型,骨折断端向椎管内移位或塌陷。观察铰链侧骨折愈合情况并比较不同类型骨折愈合率的差异。结果 随访6~35个月,平均16个月。术后1周CT扫描243个节段,椎板铰链侧完全骨折占58.0%(141/243);其中Ⅰ型完全骨折占66.0%(93/141)、Ⅱ型25.5% (36/141)、Ⅲ型6.4%(9/141)、Ⅳ型2.1%(3/141)。术后6个月不完全骨折的愈合率97.7%,高于完全骨折愈合率89.7%,差异有统计学意义。术后3个月及6个月不同类型完全骨折愈合率的差异均有统计学意义,Ⅲ型骨折术后愈合率最低。结论 椎板铰链侧完全骨折以Ⅰ型骨折为主,完全骨折的骨愈合率低,Ⅲ型骨折最差。     

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。     

Multilevel oblique corpectomy for cervical spondylotic myelopathy preserves segmental motion

Purpose

To document the neurological outcome, spinal alignment and segmental range of movement after oblique cervical corpectomy (OCC) for cervical compressive myelopathy.

Methods

This retrospective study included 109 patients—93 with cervical spondylotic myelopathy and 16 with ossified posterior longitudinal ligament in whom spinal curvature and range of segmental movements were assessed on neutral and dynamic cervical radiographs. Neurological function was measured by Nurick’s grade and modified Japanese Orthopedic Association (JOA) scores. Eighty-eight patients (81%) underwent either a single- or two-level corpectomy; the remaining (19%) undergoing three- or four-level corpectomies. The average duration of follow-up was 30.52 months.

Results

The Nurick’s grade and the JOA scores showed statistically significant improvements after surgery (p < 0.001). The mean postoperative segmental angle in the neutral position straightened by 4.7 ± 6.5°. The residual segmental range of movement for a single-level corpectomy was 16.7° (59.7% of the preoperative value), for two-level corpectomy it was 20.0° (67.2%) and for three-level corpectomies it was 22.9° (74.3%). 63% of patients with lordotic spines continued to have lordosis postoperatively while only one became kyphotic without clinical worsening. Four patients with preoperative kyphotic spines showed no change in spine curvature. None developed spinal instability.

Conclusions

The OCC preserves segmental motion in the short-term, however, the tendency towards straightening of the spine, albeit without clinical worsening, warrants serial follow-up imaging to determine whether this motion preservation is long lasting.     

显微手术切除及椎管固定融合治疗高颈段椎管哑铃型肿瘤

目的探讨显微手术切除高颈段椎管哑铃型肿瘤及椎管固定融合的方法及效果。方法回顾性分析11例高颈段椎管哑铃型肿瘤患者的临床资料,其中ToyamaⅡ型6例,Ⅲ型4例,Ⅴ型1例。均行显微手术切除,其中远外侧入路3例,颈后正中入路8例。同时行椎管固定融合6例。结果本组全切10例,次全切除1例。术后病理学诊断为神经纤维瘤9例,脊膜瘤2例。术后症状明显改善9例,改善2例,无感染及死亡病例。随访10例,平均时间27个月（3个月～3年）,患者的症状和神经功能均有不同程度的改善,无颈椎不稳及后凸畸形。结论高颈段椎管哑铃型肿瘤显微手术切除并椎管固定融合能明显改善症状,安全性好,并发症少。