颈长肌血管来源与分布及临床意义

【摘要】 目的：分析颈长肌（longus colli,LCo）血管的来源及其在肌肉中的分布并探讨其临床意义。方法：成人防腐尸体标本12具（8男,4女）,在标本上进行解剖学研究。通过乳胶灌注显影血管,记录LCo血管来源,各分支血管在LCo的入肌点、走行、终点。分别测量入肌点、终点距离同侧同水平LCo内侧缘的直线长度,并记录相对应的椎体或者椎间盘节段,分析其临床意义。结果：根据血管与LCo的解剖位置关系,分为：（1）LCo上表面血管（上、中、下支）,主要来源于甲状腺下动脉、甲状颈干等血管。上支入肌点分布在C6~C7椎体距离LCo内侧缘16.80±9.87mm处,斜向内上方走行,止于C5~C6距离LCo内侧缘11.75±8.93mm处。中支入肌点分布在C6~T1距离LCo内侧缘16.62±5.96mm处,斜向内上方走行,偶有分叉,在C4~C7椎体,66.7%止于LCo内侧缘,33.3%止于距离LCo内侧缘7.87±4.27mm处。下支入肌点分布在C6~T2,距离LCo内侧缘15.65±4.47mm处。发出1~4个分支,成网状结构止于C6~T3的LCo内侧或向下进入心包外脂肪组织形成血管网;（2）LCo肌肉内走行血管,为上表面血管入肌后的延续,属肌肉营养血管,或向下穿行肌肉深部,进入椎体;（3）LCo下表面血管,分布于肌肉下表面与椎体之间。C5、C6的血管来源于椎动脉和甲状腺下动脉,C7和T1来源于颈深动脉。血管扭曲走行,形成血管簇进入椎体,从C3~T1不同椎体平面到LCo内侧缘距离分别为：1.85~4.60mm、1.89~2.61mm、2.60~7.27mm、1.19~7.95mm、2.06~8.61mm及2.47~8.08mm。结论：LCo血管分布具有规律性,表面血管形成上、中、下三支,深部血管多止于椎体上1/3两侧滋养孔。颈椎前路手术中,避免剥离椎体上部或上终板下方的LCo,可减少出血和术后颈部血肿的发生概率。     

Esophagus perforation complicating anterior cervical spine surgery

Purpose  

To study the diagnosis and treatment strategy of esophagus perforation complicating anterior cervical spine surgery.     

早期手术治疗急性颈脊髓损伤

目的 探讨早期手术治疗急性严重颈脊髓损伤的临床效果。方法 自1999～2002年对24例急性颈脊髓损伤的患者进行早期手术治疗，受伤到手术的平均时间为67h，手术方式包括颈椎前路手术、后路手术及前后路联合手术，对损伤的颈椎节段实施复位、减压、固定和融合。结果 22例获得12．38个月(平均18个月)的随访，除11例全瘫者中的2例无恢复外，其他病例均有不同程度的恢复，ASIA分级平均提高1．8个等级，无并发症发生。结论 对急性严重颈脊髓损伤，早期实施手术治疗可取得满意的治疗效果。     

Postoperative spinal cord herniation with pseudomeningocele in the cervical spine: a case report

Background context

Postoperative spinal cord herniation with pseudomeningocele is a rare disease, with only five cases reported before the present study.

Purpose

To describe the clinical features and radiologic findings of postoperative spinal cord herniation with pseudomeningocele.

Study design

Case report.

Methods

A case of a 51-year-old man who suffered from postoperative spinal cord herniation with pseudomeningocele was reported, and previous reports on this subject are reviewed.

Results

He had undergone excision of a spinal cord tumor in the cervical spine 10 years previously. He had progressive paraparesis and urinary disturbance 10 years later. The Computed Tomography Multi Planner Reconstruction myelogram showed dilation of the ventral subarachnoid space with left deviation of the spinal cord into the pseudomeningocele at C7. On observation at surgery, the spinal cord appeared displaced dorsally and herniated through the defect of the dorsal dura mater. The spinal cord was tightly adhesive around the dural defect. We released the adhesion of the spinal cord and the dural defect under the spinal cord, and the dural defect was repaired using an artificial dura mater.

Conclusions

The release of adhesion around dural defect and repair of dural defect under spinal cord monitoring resulted in a satisfactory neurologic recovery. Surgical repair of the dural defect with a dural substitute was necessary.     

无骨折脱位型颈髓损伤的临床研究进展

无骨折脱位型颈髓损伤是指没有骨折或脱位的颈部创伤所导致的急性颈脊髓损伤。通常多见于儿童,具体损伤机制至今仍不明了。X线、CT检查提示颈椎无骨折脱位,MRI检查有脊髓损伤的表现。临床表现多种多样,以脊髓中央型损伤综合征常见。临床治疗可分为保守治疗和手术治疗,如何选择合适的治疗方法仍存在争议。本文就无骨折脱位型颈髓损伤的病因、损伤机制、临床治疗等方面的研究进展作一综述。     

陈旧性颈髓损伤的外科治疗

目的：观察颈椎减压融合手术对陈旧性颈椎骨折脱位引起的颈脊髓或神经根损伤的治疗效果。方法：1999年1月～2003年12月手术治疗因颈椎骨折脱位合并不同程度颈脊髓损伤后1个月以上的患者58例，总结临床资料，比较手术前后感觉运动功能的改善程度。结果：平均随访27个月。术前ASIA分级A级的7例患者术后上肢有1～2个神经根功能改善者3例，下肢出现肌肉活动功能改善者2例：术前B级的11例患者术后8例上肢活动有改善，6例出现下肢功能改善；术前C级6例患者术后达D级3例，E级3例：术前D级34例患者术后达到E级24例，10例仍为D级。所有患者术后ASIA的感觉及运动评分较术前明显提高（P〈0．05）。结论：减压融合手术对陈旧性颈椎骨折脱位引起的颈脊髓损伤或神经根损伤仍是有效的治疗方法，脊髓功能的恢复与脊髓损伤程度有关。     

下颈椎骨折脱位并脊髓损伤的前路手术治疗

目的:探讨颈椎前路手术在治疗下颈椎骨折脱位并脊髓损伤中的复位率及临床疗效.方法:2006年1月～2011年1月,我院采用前路手术治疗下颈椎骨折脱位伴脊髓损伤患者196例,168例患者资料完整并获得随访,男123例,女45例,年龄18～71岁,平均38.7岁.ASIA分级A级21例,B级46例,C级60例,D级41例;按脱位程度Ⅰ度79例,Ⅱ度42例,Ⅲ度31例,Ⅳ度16例.所有患者术前先行小重量颅骨牵引(2～4kg),随后在全麻下行颈椎前路手术进一步复位,先行损伤节段椎间盘切除,以Caspar撑开器撑开复位;不能复位者,行脱位椎体次全切除,再次复位;仍不能复位者,则一期行后路松解,再行前路手术.结果:168例中经颈前路手术复位者为88.1％(148/168),其余11.9％(20/168)则通过前路-后路-前路手术获得复位.89.9％(151/168)获得了完全复位,10.1％(17/168)获得了90％以上的复位.平均随访30.7个月,死亡19例,失访9例,140例仍在随访中.术后6个月均获得骨性融合,颈椎椎间高度和生理曲度维持良好,无钢板螺钉并发症.术后发生声音嘶哑4例,咽喉疼痛17例,髂骨取骨区麻木18例,给予对症治疗后均好转.术后153例脊髓损伤者神经功能获得改善.结论:下颈椎骨折脱位并脊髓损伤,可通过前路手术治疗使颈椎获得即刻的稳定,防止继发性脊髓损伤,改善脊髓的功能状况.     

下颈椎骨折脱位并脊髓损伤的前路手术治疗

目的：探讨颈椎前路手术在治疗下颈椎骨折脱位并脊髓损伤中的复位率及临床疗效。方法：2006年1月～2011年1月,我院前路手术下颈椎骨折脱位伴脊髓损伤196例,168例患者资料完整,并得以随访,男123例,女45例,年龄18。71岁,平均38．7岁。所有患者术前先行小重量颅骨牵引（1．5～4．5kg）,随后在全麻下行颈椎前路手术进一步复位,先行损伤节段椎间盘切除,以Caspar撑开器撑开复位;不能复位者,行脱位椎体次全切除,再次复位;仍不能复位者,则一期行后路松解,再行前路手术。结果：168例中经颈前路手术复位者88．1％（148／168）,其余19．9％（20／168）则通过前路一后路一前路手术获得复位。89．9％（151／168）获得了完全复位,10．1％（17／168）获得了90％以上的复位。平均随访30．7,术后6个月均获得骨性融合,颈椎椎间高度和生理曲度维持良好,无钢板螺钉并发症。术后153例脊髓损伤者神经功能获得改善。结论：下颈椎骨折脱位并脊髓损伤,多可通过前路手术治疗,该入路可使颈椎获得即刻的稳定,防止继发性脊髓损伤,改善脊髓的功能状况。     

颈椎管扩大成形术在治疗无骨折脱位型颈脊髓损伤中的作用

目的:探讨颈椎管扩大成形术治疗无骨折脱位型颈脊髓损伤的临床疗效。方法:对24例无骨折脱位型颈脊髓损伤患者行颈椎管扩大成形术,早期进行康复训练,比较患者在治疗前后ASIA评分及改善率,并与10例保守治疗者进行对比。结果:两组在治疗后感觉及运动功能较治疗前有明显提高(P<0.05)。但手术组疗效明显优于保守治疗组(P<0.01)。结:论对无骨折脱位型颈脊髓损伤患者早期施行减压及稳定手术可取得比保守治疗更好的效果。线锯法颈椎管扩大成形术结合早期康复训练为无骨折脱位型颈脊髓损伤的治疗与功能恢复提供了新的思路。     

Adult spinal cord injury with no radiographic bone lesion: analysis of nine consecutive patients

Background

Spinal cord injury with no radiographic bone lesion described as spinal cord injury without radiographic abnormality (SCIWORA) in childhood is less often reported in adults than in children. This study was undertaken to report our experience in the management of nine cases over 25 years.

Patients and methods

This was a retrospective study from 1985 to 2009 concerning nine adult patients who sustained spinal cord injury with no radiographic abnormality. The ratio among all cervical spine traumas for the same period was 2.21%. Magnetic resonance imaging (MRI) was performed in all the patients. The patients’ clinical status at the time of admission and discharge was evaluated using the Frankel's grading system. We report the results based on the clinical, epidemiologic and radiological findings and outcomes.

Results

The mean age of our population was 37.43 years, ranging from 18 to 60 years. All the patients were men. The main etiology was falls (5/9) followed by road traffic accidents (4/9). According to the Frankel's grading system, four patients (44.45%) were grade A, four were grade B (44.45%), and one was grade C (11.11%). On MRI, medullar lesions were: contusion, non-compressive cervical disc herniation, cervical spine stenosis, and two cases of normal cervical spine. Four patients were operated on via the posterior cervical spine approach (laminectomy, C3-C7 in three cases and C1-C3 in one case). The other five patients were treated orthopaedically for 6 to 8 weeks. Three patients (3/9), who were Frankel's grade B and C with no demonstrable injury on MRI, improved to Frankel a useful neurological grade (Frankel's grades D or E) at the time of discharge. One patient evaluated as Frankel's grade A died from cardiovascular disturbance.

Conclusion

Spinal cord injury with no radiographic abnormality accounted for 2.21% of cases of spinal cord injury in our series. MRI is the investigation of choice, having diagnostic and prognostic value because it demonstrates neural and extraneural injuries and helps to identify surgically correctable abnormalities.     

无骨折脱位型颈髓损伤的临床研究

目的：探讨颈椎在无骨折脱位情况下出现颈髓损伤的临床机制。方法：观察２４例无骨折脱位型颈髓损伤，重点分析其影像学检查特点。结果：２７％病例合并椎管狭窄，８３％的病例存在椎间盘突出，不同程度压迫脊髓。结论：无骨折脱位型颈脊髓损伤机制中，存在外伤致颈椎间盘损伤，突出的间盘向后压迫损伤颈髓。颈椎间盘损伤受力机制为屈曲→压缩→过伸。颈椎管狭窄、椎间盘退变等是此类脊髓损伤的病理解剖基础     

Bilateral vocal cord paralysis after anterior cervical discoidectomy and fusion in a case of whiplash cervical spine injury: a case report

BACKGROUND

Bilateral vocal cord paralysis is a risk of anterior cervical discoidectomy and fusion. We discuss the mechanism of vocal cord paralysis and the precautions necessary to avoid this catastrophic complication. A rare case of bilateral vocal cord paralysis after anterior cervical discoidectomy and fusion (ACD/F) is reported.

CASE DESCRIPTION

The patient, a 37-year-old male, was paraplegic, had bilateral intrinsic hand muscle weakness and sphincter involvement following a whiplash cervical spinal injury. A C5-C6 ACD/F for traumatic C5-C6 disc prolapse was performed. On the third postoperative day, he developed difficulty in coughing and a husky voice. Otolaryngological evaluation revealed bilateral vocal cord paralysis. He later required a tracheostomy that partially alleviated his major symptoms.

CONCLUSION

In patients undergoing ACD/F, a mandatory preoperative evaluation of the vocal cords should be performed. An appropriate modification in surgical planning should be made if vocal cord palsy is diagnosed preoperatively to prevent bilateral vocal cord paralysis. Proper and judicious use of Cloward retractors is advocated.     

Smart flap of sternocleidomastoid muscle in anterior cervical spine surgery: Surgical anatomical dissection technique

The use of sternocleidomastoid muscle flap has firstly been described in 1909. In spine surgery, it is usually reserved in the cases of revision after anterior cervical spine procedures. The aim of this article is to introduce its usage as prophylactic measure in cases at high risk of iatrogenic fistula formation. The procedure consists of three main steps: sternocleidomastoid isolation, flap design and harvesting, and flap fixation. The use of a surgical anchor allows a better adherence to the plate preventing hematoma formation. The use of SCM smart flap in primary anterior cervical spine surgery as a prophylactic method could be considered a safe and feasible procedure in patients with a high risk of iatrogenic fistulas.     

无脊髓损伤颈椎骨折脱位的治疗分析

目的 探讨无脊髓损伤颈椎骨折脱位的治疗方法选择。方法 28例无脊髓损伤的颈椎骨折或骨折脱位，新鲜损伤26例，陈旧性损伤2例；其中23例手术治疗；5例保守治疗。结果 全部病例随访观察，症状均获得改善，17例完全恢复，7例残留手指麻木，4例颈椎旋转受限，颈椎椎间高度、生理曲度维持良好。结论 对于无脊髓损伤的稳定性上颈椎骨折脱位行牵引、制动、复位和固定，而不稳定性上颈椎骨折脱位应手术治疗；对于无脊髓损伤的下颈椎骨折脱位宜首选经前路手术治疗，前路手术除可达到减压、恢复颈椎椎间高度和生理曲度外，更重要的是可重建颈椎即刻稳定性，对防止继发性脊髓损伤有极其重要的作用。     

老年人颈椎过伸性损伤致颈髓损伤的治疗策略

目的探讨颈椎过伸性损伤致颈髓损伤手术治疗效果。方法对23例合并颈脊髓损伤的颈椎过伸性损伤老年患者行减压后植骨融合内固定术,其中前路手术18例,后路手术5例。结果23例均获随访,时间8～36个月。末次随访时脊髓功能Frankel分级：A级1例恢复至B级;B级7例恢复至c级2例、D级4例、E级1例;C级10例恢复至D级5例、E级5例;D级5例均恢复至E级。结论对颈椎过伸性损伤致颈髓损伤的老年患者,早期行手术减压、植骨融合内固定,疗效满意。     

无骨折脱位型颈脊髓损伤外科治疗随诊观察

目的 :探讨脊髓损伤程度、治疗方法及手术时机对无骨折脱位型颈脊髓损伤疗效的影响。方法 :对 118例手术治疗的无骨折脱位型颈脊髓损伤患者平均随访 30 3个月 (1～ 16 3个月 ) ,74例随访 1年以上 (平均 4 6 3个月 )。观察 :(1)伤后 3种不同脊髓功能状况的治疗效果 (A组 :受伤时呈完全性瘫痪 ,70例 ;B组 :不完全性瘫痪 ,4 2例 ;C组 :上肢部分瘫痪、下肢完全性瘫痪 ,6例 )。 (2 )保守治疗与手术治疗的效果。 (3)手术时机 (伤后 <12个月、>12个月 )对疗效的影响。并做统计学分析。结果 :(1) 3组之间在保守治疗效果、术后近期效果和后期随访结果上无显著性差异。 (2 ) 3组均经保守治疗 ,平均为 2 1 3个月。保守治疗的效果与术后近期、尤其与后期随访结果相比 ,JOA评分较低 ,存在统计学上的差异。 (3)伤后 <12个月和 >12个月手术的患者后期随访结果具有统计学上的差异。前者术后近期和后期脊髓功能恢复都较满意 ;后者术后近期恢复较明显 ,但后期脊髓功能却出现倒退现象。结论 :无骨折脱位型脊髓损伤患者不同的脊髓功能状况对脊髓功能恢复程度无影响 ;手术治疗效果明显优于保守治疗 ;手术时机对后期脊髓功能恢复有重要影响。最迟不应超过伤后 12个月     

颈椎骨折合并急性颈髓损伤的手术时机探讨

目的：探讨颈椎骨折合并急性颈髓损伤的手术时机。 方法：回顾性分析2000年1月~2011年1月我科治疗的颈髓损伤患者42例,其中急诊手术组（≤24h）18例,延期手术组（>24h）24例,对比分析手术前后神经功能变化、术后并发症和住院时间等临床资料,并进行统计学分析。 结果：急诊手术组感觉和运动功能改善明显,并发症发生率、重症监护时间和住院时间均低于延期手术组。 结论：颈椎骨折合并急性颈髓损伤的急诊手术减压是可行的,对神经功能的恢复有积极作用,并减少围手术期并发症。     

The impact of spine stability on cervical spinal cord injury with respect to demographics,management, and outcome: a prospective cohort from a national spinal cord injury registry

Background Context

Emergent surgery for patients with a traumatic spinal cord injury (SCI) is seen as the gold standard in acute management. However, optimal treatment for those with the clinical diagnosis of central cord syndrome (CCS) is less clear, and classic definitions of CCS do not identify a unique population of patients.

80例成人无骨折脱位型颈脊髓损伤不同疗法效果分析

[目的]探讨成人颈椎无骨折脱位型脊髓损伤(spinal cord injury without radiographic abnormality,SCIWO-RA)的手术和保守治疗与神经功能变化的关系。[方法]回顾性分析2005年以来收治的该类患者80例的临床资料,其中男72例,女8例,年龄52.7岁(34～74)岁。平均随访时间53周(48～60)周。按治疗措施不同分为前路手术、后路手术和保守治疗三组。提取入院及末次随访时应用ASIA(American Spinal Injury Association,ASIA)脊髓损伤神经学分类国际标准进行的运动、感觉评分和残损分级,进行组内和组间对比。[结果]入院8例A级、20例B级和26例C级患者中,治疗后分别有2、8例和4例提高1～2级。各组内末次随访与入院时对比,运动评分均增加2～5分(P0.01)。组间对比,前、后路手术两组间在入院及末次随访时的感觉和运动评分都没有明显区别。手术两组与保守治疗组对比,在入院和末次随访时,后者运动评分和针刺觉评分都明显高于前两者。但在改善程度上,三组间不存在统计学差异。[结论]对于成人颈SCIWORA患者,神经功能评价宜采用AISA标准,手术与保守治疗都能带来有限的神经功能改善,无优劣之分。决定预后的是外伤时脊髓损害的程度而不是治疗方法。     

Transient anisocoria after a traumatic cervical spinal cord injury: A case report

Context: Autonomic dysreflexia and dysautonomia can be a common complication following spinal cord injury, especially at levels of T6 and above and can lead to complications associated with the pupil. In this case report, we review autonomic dysreflexia, the anatomy and physiology of the sympathetic nervous system of the eye, as well as review the clinical relevance in understanding autonomic and pupillary changes in response to autonomic dysfunction.

Findings: We present a patient with an incomplete C4 level injury who was found to have isolated anisocoria on two separate occasions during his acute inpatient rehabilitation stay.

Conclusion/Clinical Relevance: Anisocoria associated with abnormal sympathetic activation may be a clinical sign of dysautonomia.