椎板切除术后颈椎后凸畸形

颈椎后凸畸形在临床上十分常见 ,椎板切除术后引起的医源性后凸畸形 ,是最常见的类型。引起医源性颈椎后凸畸形的主要原因有 :(1)对术前已存在的颈椎的生理弧度改变未引起重视 ;(2 )术中对颈椎后结构的切除 ,破坏其拴系能力 ;(3)颈部肿瘤在放疗时对局部拴系结构的破坏[1] 。出现畸形后 ,由于软组织损伤和神经组织损害所引起的局部疼痛症状以及相应的脊髓症状 ,是临床治疗需要解决的二个重要方面。现就椎板切除术后颈椎后凸畸形的病因、发病机制、预防和治疗作一综述。1　发病机理正常颈椎的生理前凸平均为 14.4°[2 ] ,其矢状位上的承重轴位…     

椎板切除术后颈椎畸形的手术治疗

目的:探讨椎板切除术后颈椎后凸畸形的手术方法和疗效。方法:对17例椎板切除术后颈椎后凸畸形患者采用颈椎前路减压矫形、植骨内固定的方法进行手术治疗。结果:17例患者中,颈椎畸形得到不同程度矫正,其中9例变为直立型,5例变为前凸型;脊髓功能评分平均提高5.9分,平均改善率为48.6％。结论:椎板切除术后颈椎后凸畸形的持续发展严重影响患者的脊髓功能;前路手术可同时解决畸形矫正和脊髓减压,是较为理想的手术方法;椎体牵开器及内固定器材的正确使用,是手术操作的要点。     

颈椎椎板切除术后神经根病

目的　报道一组多节段颈椎椎板切除术后神经根病并探讨其机理。　方法　２８７ 例颈椎椎板切除术患者中３７ 例（１２．９％ ） 出现手术后神经根病。其中男２７ 例,女１０ 例,平均年龄５６ 岁。其中颈椎病２５ 例, 后纵韧带骨化１２ 例。发病时间为手术后４ 小时～６ 天,最常见类型为颈５（Ｃ５） 、颈６（Ｃ６） 神经根,以运动障碍为主。　结果　完全缓解时间平均为５ ．４ 个月（２ 周～３ 年）。完全缓解时间与脊髓运动功能恢复率呈负相关（ｒ＝ －０ ．８３２, Ｐ＜ ０．０１）,颈椎病患者预后优于后纵韧带骨化（ｔ＝２ ．９６０, Ｐ＜ ０．０１）。　结论　手术后神经根病可能因颈椎后路减压后神经根栓系引起;前路减压及融合手术既可直接切除致压物,又能稳定脊柱,因而可有效预防手术后神经根病     

青少年颈椎椎板切除术后后凸畸形防治的研究进展

青少年患者因肿瘤或其它原凶行颈椎椎板广泛切除术后容易发生颈椎后凸畸形（postlaminectomy kyphosis），据报道其发生率可高达38％～100％.颈椎后凸畸形可导致颈椎局部受力异常，加速邻近节段颈椎的退行性改变，并可能形成恶性循环，逐渐加重对脊髓的压迫和刺激。轻者表现为颈部疼痛不适．重者导致脊髓受压。青少年由于正处在发育阶段，其病情发展更为迅速、严重,所以应早期行手术治疗，尽可能恢复颈椎的正常生理曲度，解除脊髓受压。笔者就相关问题综述如下。     

单开门椎板成形术起始节段对术后颈椎后凸的影响

目的:分析颈椎后路单开门椎板成形术中,是否保留C_2附着的肌肉韧带复合体,术后对颈椎后凸畸形的影响。方法:对2011年2月至2014年6月因脊髓型颈椎病接受颈后路单开门椎板成形术中选择病例进行回顾性分析,其中采用C_3-C_6单开门的患者40例(A组),男28例,女12例,年龄(68.4±9.3)岁;采用C_4-C_6单开门+C_3椎板减压患者40例(B组),从而保护C_2附着的肌肉韧带复合体,男26例,女14例,年龄(66.8±8.4)岁。术前及末次随访时观察颈痛VAS评分、JOA评分、颈椎Cobb角、颈椎活动度。结果:所有患者获得随访,时间24~31(26.5±3.4)个月。两组患者术前的VAS、JOA评分及颈椎活动度差异无统计学意义(P0.05),末次随访均得到改善(P0.05),组间比较差异无统计学意义;两组患者的颈椎Cobb角术前差异无统计学意义,术后也都有明显改善,但B组的改善优于A组。结论:从C_4开始单开门,保留C_2附着的肌肉韧带复合体,能明显减少颈椎的后凸畸形。     

椎板切除术术后硬膜外纤维化预防的研究进展

正椎板切除术术后硬膜外过度的纤维增生会造成椎管狭窄,压迫硬膜囊及神经根,或与其粘连,限制神经根活动,引起术后疼痛复发,即腰椎手术失败综合征(FBSS),而这种疼痛难以通过药物等非手术治疗途径得到缓解[1]。由于纤维组织与硬膜粘连,二次手术时很难将硬膜与硬膜外组织分离,甚至会造成硬膜囊的撕裂,增加了二次手术的难度,延长了手术时间,二次手术后FBSS依然可能发生。有研究发现,随着手术次数增加,第二、三次手术的成功率     

单侧与双侧引流对颈椎后路全椎板切除侧块螺钉内固定术后主要并发症的影响

目的 比较放置单侧与双侧引流管对颈椎后路全椎板切除侧块螺钉内固定术后主要并发症的影响,为引流方案的选择提供依据.方法 回顾性分析2015年1月—2017年12月在本院接受颈椎后路全椎板切除侧块螺钉内固定术治疗的75例患者资料.根据引流管放置数量分为单侧组(n=45)和双侧组(n=30).统计并比较2组患者年龄、性别、疾...     

应用椎板开窗法置入胸椎椎弓根螺钉的精确性和安全性评估

目的 分析应用椎板开窗法行胸椎椎弓根螺钉置入治疗重度脊柱侧后凸患者的精确性和安全性. 方法 1996年6月至2007年12月,应用椎板开窗法行胸椎椎弓根螺钉置入治疗23例重度脊柱侧后凸患者(A组),其中男性9例,女性14例;年龄13～23岁,平均17.8岁;术前主胸弯冠状面Cobb角平均97.3°,平均后凸角67.4°.作为对照,同期应用非开放法置钉治疗重度脊柱侧后凸患者22例(B组),其中男性7例,女性15例;年龄14～21岁,平均17.2岁;术前主胸弯冠状面Cobb角平均为96.6°,平均后凸角62.1°.两组患者术后均行CT扫描,统计螺钉置入并发症,对螺钉穿透椎弓根皮质骨的CT扫描图像进行联机测量并统计分析.结果 A组和B组各置入胸椎椎弓根螺钉209和201枚,术中发生椎弓根骨折5例和16例,发生硬膜撕裂4例和7例,螺钉错置18枚和45枚.B组螺钉错置率高于A组,差异具有统计学意义(P<0.05).A组上、中胸椎与下胸椎之间、凸侧与凹侧之间,螺钉错置率差异均具有统计学意义(P<0.05).两组均无脊髓及大血管损伤. A和B组经平均3.2年、3.4年随访,术后冠状面和矢状面平均矫正度未见明显丢失.结论 重度脊柱侧后凸胸椎椎弓根螺钉置入技术难度较高,应用椎板开窗法可有效增加螺钉置入精确性和安全性.     

椎板后路阻滞对腹腔镜肾切除术患者术后镇痛的影响

目的观察椎板后路阻滞(retrolaminar block, RLB)对腹腔镜肾切除术患者术后镇痛效果及术后早期恢复的影响。方法腹腔镜肾切除术患者60例,男31例,女29例,年龄18～65岁,ASAⅠ或Ⅱ级,采用随机数字表法分为两组,每组30例:RLB组(R组)与局部浸润组(L组)。R组于全麻诱导后在超声引导下于术侧行RLB,L组于手术结束时行局部浸润麻醉,两组局麻药皆采用0.4%罗哌卡因30 ml。两组术中均行静-吸复合麻醉,术后行舒芬太尼PCIA。记录术后拔管时间、PACU停留时间、镇痛泵有效按压次数和首次下床活动时间。结果 L组拔管时间、PACU停留时间明显长于R组(P0.05),术后24、48 h L组镇痛泵有效按压次数明显多于R组(P0.05),首次下床活动时间明显长于R组(P0.05)。结论与局部浸润比较,椎板后路阻滞可为腹腔镜肾切除术患者提供有效术后镇痛,并有利于术后恢复。     

Cervical laminoplasty vs cervical laminectomy with fusion

Cervical spinal stenosis is a commonly encountered condition. Symptoms of radiculopathy are ameliorable to conservative measures. However, central canal stenosis in the setting of myelopathy is a disease warranting surgical intervention. To decompress the spinal cord, the canal needs to be expanded. Traditionally this can be accomplished via a laminectomy. The occurrence of postoperative deformity has led to the advent of other surgical techniques to address spinal stenosis. Both cervical laminoplasty and laminectomy with posterior fusion are available options that may prevent the progression of cervical instability or deformity or both. This article discusses the treatments available and outlines the benefits of each.     

Selective blocking laminoplasty in cervical laminectomy and fusion to prevent postoperative C5 palsy

BACKGROUND CONTEXT

Cervical laminectomy and fusion (CLF) is a common surgical option for multilevel cord compression. Postoperative C5 palsy occurrence after CLF has been a vexing problem for spine physicians. The posterior shift of the cord following laminectomy has been implicated as a major factor for postoperative C5 palsy, but attempts by spine surgeons to mitigate excessive shift while providing sufficient decompression have not been well reported.

Effectiveness of multiple-level decompression in laminoplasty and simultaneous C1 laminectomy for patients with cervical myelopathy

A retrospective study to investigate the relationship between the surgical levels and decompression effects was performed in patients with cervical myelopathy who had undergone Tension-band laminoplasty (TBL) with/without simultaneous C1 laminectomy. One hundred and sixty-eight patients (115 males, 53 females; age: 31–80 years, average 58.9 years; follow-up period: 12–120 months, average 20 months) were divided into three groups according to the range of the surgical levels: seventy-two patients in group A underwent TBL at the C2–C7 levels with C1 laminectomy; 60 patients in group B underwent TBL at the C2–C7 levels; 36 patients in group C underwent TBL at the C3–C7 levels. Neurological evaluation was performed by using the Japanese Orthopedic Association (JOA) scoring system. The alignment changes of the spinal column and the spinal cord were analyzed using pre- and post-operative roentgenograms and MRIs. The differences in the pre- and post-operative anterior subarachnoid spaces (D-ASAS), the spinal cord diameters (D-CORD), and the dural sleeve diameters (D-DURA) at the C1–C7 levels were also analyzed by using MRIs. The JOA scores improved in all groups. As for the spinal alignment, neither significant changes between pre- and post-operation in any group nor significant differences among the three groups were found. The lordosis of the cervical spinal cord was decreased in all groups. D-ASAS of group A was larger than that of group B at the C1–C5 levels (P<0.05), as were those of D-CORD and D-DURA at the C1–C2 and C4–C5 levels (P<0.05). D-ASAS of group A was larger than that of group C at the C1–C4 levels (P<0.05), as were those of D-CORD and D-DURA at the C1–C5 levels (P<0.05). In conclusion, laminoplasty including the C2–C7 levels with simultaneous C1 laminectomy was proven to allow the most posterior shift of the spinal cord within the widened dural sleeve at C5 or higher levels without significantly changing the spinal alignment.     

Analysis of the cervical spine alignment following laminoplasty and laminectomy

Very little detailed biomechanical examination of the alignment of the cervical spine following laminoplasty has been reported. We performed a comparative study regarding the buckling-type alignment that follows laminoplasty and laminectomy to know the mechanical changes in the alignment of the cervical spine. Lateral images of plain roentgenograms of the cervical spine were put into a computer and examined using a program we developed for analysis of the buckling-type alignment. Sixty-four patients who underwent laminoplasty and 37 patients who underwent laminectomy were reviewed retrospectively. The subjects comprised patients with cervical spondylotic myelopathy (CSM) and those with ossification of the posterior longitudinal ligament (OPLL). The postoperative observation period was 6 years and 7 months on average after laminectomy, and 5 years and 6 months on average following laminoplasty. Development of the buckling-type alignment was found in 33% of patients following laminectomy and only 6% after laminoplasty. Development of buckling-type alignment following laminoplasty appeared markedly less than following laminectomy in both CSM and OPLL patients. These results favor laminoplasty over laminectomy from the aspect of mechanics.     

颈3椎板切除单开门成形术对颈椎轴性症状的影响

目的对传统C3～7椎板成形术进行改良,探讨C3切除、C4～7成形的改良椎板成形术是否相对于传统的椎板成形术能有效降低术后颈椎轴性症状的发生。方法2002年3月至2005年3月,接受C3椎板切除的椎板成形术并获得完整随访的44例颈椎病患者作为试验组(A组),平均随访时间为18个月(12～27个月);同期接受传统椎板成形术并获得完整随访的50例患者作为对照组(B组),平均随访时间为27个月(12～40个月)。对两组患者手术前后的JOA评分、颈椎曲度指数、颈椎活动度及轴性症状严重程度进行比较评估。结果JOA评分恢复率,A组患者为59.2%±11.3%,B组患者为60.1%±19.5%,两组差异无统计学意义。A组术后有明显轴性症状患者的比例为22.7%,B组为54.0%,两组比较差异有统计学意义(P<0.05)。A组患者术后颈椎曲度指数丢失2.1%±1.6%,B组患者术后颈椎曲度指数丢失6.4%±3.2%,两组患者手术前后颈椎曲度的变化差异有统计学意义(P<0.01)。A组患者术后颈椎活动度丢失4.6°±4.0°,B组患者术后颈椎活动度丢失11.6°±7.8°,两组差异有统计学意义(P<0.01)。结论C3椎板切除的椎板成形术在获得良好神经减压效果的同时,可以维持颈半棘肌结构和功能的完整性,减少对颈椎后伸机制的破坏,从而降低术后颈椎轴性症状的发生率。     

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.     

Effect of multilevel open-door laminoplasty and laminectomy on flexibility of the cervical spine: an experimental investigation

STUDY DESIGN.: A biomechanical comparison of 2 commonly used posterior surgical procedures for spinal cord decompression in the cervical spine: laminoplasty (open door) and laminectomy. OBJECTIVE.: To delineate differences in cervical motion after laminoplasty (2-level and multilevel) and laminectomy. SUMMARY OF BACKGROUND DATA.: Cervical spondylotic myelopathy is a common spinal cord disorder in persons aged 55 years or older. Laminectomy and laminoplasty are the 2 common posterior-based techniques used for decompression of spinal cord. There is lack of adequate literature data on the intersegmental rotations at the operated and adjacent levels. METHODS.: Five human cadaveric specimens were tested sequentially as follows: (1) intact, (2) laminoplasty at C5-C6, (3) laminoplasty at C3-C6, and (4) laminectomy at C3-C6, each subjected to 2 N·m moments in flexion/extension, right/left lateral bending, and right/left axial rotation. For laminoplasty, the laminae of the involved vertebrae were stabilized with standard 10-mm plates and screws. The total and segmental motions of the specimens were measured before and after the surgical procedures. Statistical analysis was performed using repeated measures analysis of variance, with P < 0.05 as the level of significance. RESULTS.: Two-level laminoplasty led to minimal decrease (<7% in the 3 loading modes) in C2-T1 motion. Multilevel laminoplasty resulted in a minimal increase during lateral bending (4%) and axial rotation (6%). During flexion/extension, both C4-C5 and C2-C3 showed a decrease of 20% (P > 0.05) and 17% (P > 0.05) after 2-level and multilevel laminoplasty, respectively. Laminectomy resulted in a statistically significant (P < 0.05) increase in the C2-T1 range of motion compared with the intact condition during the 3 loading modes (21% in flexion/extension, 8% in lateral bending, and 15% in axial rotation). CONCLUSION.: Both 2-level and multilevel laminoplasty preserved the C2-T1 range of motion. Laminectomy resulted in a significant increase in C2-T1 motion due to the loss of the posterior structures.     

Follow-up after cervical laminectomy, with special reference to instability and deformity

Misalignment and instability after cervical laminectomy, performed to treat spondylotic myelopathy, has been described as possible adverse effects. Forty-six consecutively patients on whom laminectomy had been performed in a 4-year period were identified; 7.7 +/- 0.6 years after operation, 11 patients had died and 27 patients were available for follow-up. Postoperative static subluxation was observed in 26% of the patients with an average slip of 3.7 +/- 3.1 mm; 7% had abnormal intervertebral movement displaying 1-2 mm movement from full flexion to full extension. Seventy-four per cent of the patients showed abnormal spinal curvature as judged from radiographs. However, no correlation with outcome was observed. Seventy-four per cent of the patients thought of the result of the operation as either good or fair; objectively, the best long-term effect of the operation was upon arm function. Although some patients develop postural anomaly, laminectomy remains, in terms of instability, a justifiable procedure in the elderly patient with spondylosis.     

Usefulness of QuickDASH in patients with cervical laminoplasty

Purpose

Clumsiness and numbness of the upper extremity is one of the most common complaints of patients with cervical myelopathy. However, most previous evaluations after cervical laminoplasty have only been based on physicians’ points of view. We used Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) self-report questionnaire, which was designed to measure physical function and symptoms in people with upper-limb disorders to evaluate functional outcomes after laminoplasty.

Methods

Ninety-four patients who underwent laminoplasty for cervical myelopathy and replied to the questionnaire were included in this study. The average age was 62 years, and mean follow-up period was 61 months. The Japanese Orthopedic Association (JOA) score, Neck Disability Index (NDI), Short-Form Health Questionnaire of 36 questions (physical component score, PCS), upper-extremity pain (Numerical Rating Scale), and QuickDASH (0–100, 0 being least severe) were used to evaluate surgical outcomes. Satisfaction with treatment was also investigated, and internal consistency and criterion-related validity were evaluated. The QuickDASH cutoff value for patient satisfaction was determined by receiver operating characteristic curve (ROC) analysis.

Results

The mean total JOA scores were 10 before and 13 after surgery, and average postoperative QuickDASH score was 30. Cronbach α of the QuickDASH was 0.94. QuickDASH was significantly correlated with JOA score for upper-extremity motor and sensation, NDI, PCS, and pain. Cutoff value of the QuickDASH was 34.0 by ROC analysis. Significantly better QuickDASH scores were found for patients who were satisfied with treatment than for those who were not, whereas JOA score for upper-extremity motor function did not show a significant difference.

Discussion

QuickDASH had significant correlations with disease-specific JOA scores and other generic outcome measures. Moreover, QuickDASH significantly reflected patients’ satisfaction with treatment, whereas the JOA score for upper-extremity motor function did not.

Conclusion

QuickDASH was useful in evaluating upper-extremity functional outcomes after cervical laminoplasty.