Posterior Surgical Treatment of Cervical Spondylotic Myelopathy: Review Article

Background

Cervical spondylosis is now recognised as the leading cause of myelopathy and spinal cord dysfunction worldwide. Chronic spinal cord compression results in chronic inflammation, cellular apoptosis, and microvacular insufficiency, which are thought to the biologic basis for cervical spondylotic myelopathy (CSM).

Questions/Purposes

Our purpose was to address the key principles of CSM, including natural history and presentation, pathogenesis, optimal surgical approach, results and complication rates of posterior surgical approaches for CSM so that the rationale for addressing CSM by a posterior approach can be fully understood.

Methods

We conducted a systematic search of PubMed/MEDLINE and the Cochrane Collaboration Library for literature published through February 2014 to identify articles that evaluated CSM and its management. Reasons for exclusion included patients with ossification of the posterior longitudinal ligament (OPLL), patients with degenerative disc disease without CSM, and patients with spine tumor, trauma and infection. Meeting abstracts/proceedings, white articles and editorials were additionally excluded.

Results

The search strategy yielded 1,292 articles, which was reduced to 52 articles, after our exclusion criteria were introduced. CSM is considered to be a surgical disorder due to its progressive nature. There is currently no consensus in the literature whether multilevel spondylotic compression is best treated via an anterior or posterior surgical approach.

Conclusion

Multilevel CSM may be safely and effectively treated using a posterior approach, either by laminoplasty or with a laminectomy and fusion technique.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-014-9425-5) contains supplementary material, which is available to authorized users.     

Pathogen Stimulation History Impacts Donor‐Specific CD8+ T Cell Susceptibility to Costimulation/Integrin Blockade–Based Therapy

Recent studies have shown that the quantity of donor‐reactive memory T cells is an important factor in determining the relative heterologous immunity barrier posed during transplantation. Here, we hypothesized that the quality of T cell memory also potently influences the response to costimulation blockade‐based immunosuppression. Using a murine skin graft model of CD8⁺ memory T cell–mediated costimulation blockade resistance, we elicited donor‐reactive memory T cells using three distinct types of pathogen infections. Strikingly, we observed differential efficacy of a costimulation and integrin blockade regimen based on the type of pathogen used to elicit the donor‐reactive memory T cell response. Intriguingly, the most immunosuppression‐sensitive memory T cell populations were composed primarily of central memory cells that possessed greater recall potential, exhibited a less differentiated phenotype, and contained more multi‐cytokine producers. These data, therefore, demonstrate that the memory T cell barrier is dependent on the specific type of pathogen infection via which the donor‐reactive memory T cells are elicited, and suggest that the immune stimulation history of a given transplant patient may profoundly influence the relative barrier posed by heterologous immunity during transplantation.     

患椎间短椎弓根螺钉在单节段腰骶椎结核稳定性重建中的临床研究

目的证明后路患椎间短椎弓根螺钉固定治疗单节段腰骶椎结核的可行性,并探讨其适应证及疗效。方法 204例诊断明确、脊柱后凸畸形35°,符合纳入标准的单节段腰、骶椎结核患者,随机分为2组,均先进行后路矫形、内固定手术,同期或二期进行前路彻底病灶清除、椎体间自体髂骨支撑植骨融合术。其中短钉组104例,选用长20~35 mm的短椎弓根钉置于患椎椎弓根。如1个患椎剩余骨质1/3,而另1个患椎剩余骨质1/3,则行短钉、常规螺钉固定。长钉组:常规椎弓根螺钉置于患椎相邻的正常椎骨中,固定范围跨越患椎上、下各1个正常间隙。所有患者均采用四联化疗方案。结果 2组患者平均随访62.1个月。术后均无严重并发症发生,末次随访时,所有患者均治愈,无内固定松动及断裂现象。植骨平均愈合时间,短钉组4.3个月,长钉组4.6个月,Cobb角矫正度及丢失率2组分别为13.26°±3.76°,6.22%和16.35°±2.63°,5.24%,2组比较差异无统计学意义(P0.05),组内术前术后比较差异有统计学意义(P0.05)。血沉与C反应蛋白的术前术后差异无统计学意义。2组患者术后2年生活、工作基本恢复正常。短钉组患者术后功能恢复较长钉组好。结论腰、骶椎结核后路患椎间短椎弓根钉固定、前路病灶彻底清除术具有仅融合、固定病变节段,保留相邻正常的脊柱运动单元功能,术后脊柱功能恢复好等优点,具有很高的临床应用价值。     

退变性腰椎侧凸的手术治疗及疗效

目的探讨退变性腰椎侧凸的后路手术方法和手术疗效。方法回顾性分析2007~2012年本院手术治疗并获得随访的32例退变性腰椎侧凸患者的手术方法及疗效。患者均接受腰椎后路减压椎间融合器植骨融合内固定术,术后随访6个月~6年。采用下腰痛Oswestry功能障碍指数(Oswestry disability index,ODI)对患者手术前后的临床症状进行评分和疗效评价;通过手术前后冠状位和矢状位Cobb角度的比较,了解患者手术治疗的侧凸矫正率和腰椎前凸的恢复情况。结果患者ODI术前(52.30±13.65)%、术后(9.62±6.41)%,术前术后比较差异有统计学意义(P0.05),术后疼痛改善率为81.6%。32例患者中,24例疗效为优,6例疗效为良,2例疗效为可,术后疗效评价的优良率为93.8%。患者冠状位Cobb角术前21.99°±8.97°、术后6.84°±5.32°,术前术后比较差异有统计学意义(P0.05),侧凸矫正率为69.0%。患者腰椎前凸Cobb角术前13.80°±15.99°、术后24.95°±12.86°,术前术后比较差异有统计学意义(P0.05)。结论退变性腰椎侧凸采用腰椎后路减压椎间融合器植骨融合椎弓根螺钉内固定术治疗效果较理想,术后疗效满意。手术的关键是彻底减压、正确选择融合节段、重建退变节段椎间高度、矫正前凸减少和后凸畸形、纠正椎体侧方移位和侧凸畸形以稳定椎体。     

显微镜辅助下颈前路椎间盘切除植骨融合术治疗多节段脊髓型颈椎病

目的探讨显微镜辅助下颈前路椎间盘切除植骨融合术(anterior cervical discectomy with fusion,ACDF)治疗多节段脊髓型颈椎病的疗效。方法回顾性分析2011年1月~2012年8月本院行颈前路手术治疗的60例脊髓型颈椎病患者的临床资料,根据手术方式分为常规ACDF组(A组,30例)和显微镜辅助ACDF组(B组,30例)。比较2组的手术时间、术中出血量、住院天数及并发症,以日本骨科学会(Japanese Orthopaedic Association,JOA)评分(17分法)及其改善率评价术后神经功能改善情况。结果 A组手术时间为(132.5±8.9)min,B组为(137.0±9.1)min,差异无统计学意义(P0.05)。A组术中出血量为(113.6±8.0)m L,B组为(93.7±5.3)m L,差异有统计学意义(P0.01)。A组住院(7.37±1.73)d,B组(6.63±1.13)d,差异无统计学意义(P0.05)。A组术前JOA评分为6.60±1.21,术后12个月为13.83±0.91,改善率为(69.72±7.66)%;B组术前JOA评分为6.87±1.46,术后12个月为14.23±1.17,改善率为(72.51±11.26)%。A组和B组改善率差异有统计学意义(P0.05)。结论显微镜辅助ACDF和常规ACDF是治疗多节段脊髓型颈椎病有效的方法,但显微镜辅助ACDF可减少术中出血量,是治疗多节段脊髓型颈椎病优先选择的手术方案。     

P物质、降钙素基因相关肽、白介素6与椎体骨折并发远隔部位疼痛的相关性研究

目的探讨胸腰段椎体压缩骨折出现远隔部位疼痛的病因。方法选取Denis分类屈曲型骨折的手术病例62例,腰痛伴远隔部位疼痛11例为实验组,腰痛不伴远隔部位疼痛51例为对照组。术中取多裂肌标本,制作冰冻切片,P物质(SP)、降钙素基因相关肽(CGRP)、白介素6(IL-6)抗体免疫组化染色;计算椎体前缘高度和后缘高度的比值来衡量伤椎的压缩程度;手术前及手术后2周分别行VAS、JOA、ODI评分。结果实验组:术前椎体压缩程度(68.73±11.91)%、VAS(8.09±1.51)分、ODI(40.45±3.48)%、JOA(14.00±3.80)分,术后椎体压缩程度(84.00±6.08)%、VAS(5.00±1.34)分、ODI(21.73±3.80)%、JOA(15.36±3.56)分;对照组:术前椎体压缩程度(75.27±14.14)%、VAS(7.65±1.43)分、ODI(39.24±4.64)%、JOA(11.90±3.59)分,术后椎体压缩程度(83.75±8.89)%、VAS(2.76±1.18)分、ODI(15.82±3.65)%、JOA(20.84±3.71)分。实验组与对照组术前椎体压缩程度比较,差异无统计学意义(P0.05),术后椎体压缩程度比较,差异无统计学意义(P0.05)。实验组与对照组术前VAS、ODI、JOA评分差异无统计学意义(P0.05),术后VAS、ODI、JOA评分对照组优于实验组(P0.05)。免疫组化:实验组11例标本SP、CGRP、IL-6染色结果均为阳性。对照组51例标本SP、CGRP、IL-6染色结果阴性。结论屈曲暴力造成脊柱后方组织损伤,SP、CGRP、IL-6介导的炎症反应刺激脊神经后支,是产生远隔部位疼痛的重要原因。     

脊伤颗粒对大鼠急性脊髓损伤后运动功能及Caspase-3表达的影响

目的 研究脊伤颗粒对大鼠脊髓损伤(spinal cord injury,SCI)后运动功能及半胱氨酸蛋白酶-3(Caspase-3)表达的影响.方法 随机抽取大鼠32只作为假手术组,其余118只大鼠采用改良Allen'S打击器制作大鼠SCI模型,将造模成功的96只大鼠随机分为模型组、甲基强的松龙组(下称甲强龙组)、脊伤颗粒组.分别给予假手术组、模型组生理盐水灌胃,甲强龙组尾静脉注射药物,脊伤颗粒组予以相应药物灌胃.在给药后1、3、7、14 d的4个不同时间点采用BBB行为学功能评分;再分批处死大鼠,取出SCI组织用HE染色观察其病理变化,用免疫组化染色检测Caspase-3表达阳性细胞,原位末端标记法(TUNEL法)标记凋亡细胞.结果 (1)BBB运动功能评分方面,与假手术组比较,模型组评分低(P＜0.01);与模型组比较,脊伤颗粒组、甲强龙组评分高(P＜0.05);与甲强龙组比较,SCI后1、3d,脊伤颗粒组评分偏低,(P＜0.05),SCI后7、14 d脊伤颗粒组评分偏高(P＜0.05).(2)在平均积分光密度值和细胞凋亡率方面,与假手术组比较,模型组数值偏高(P＜0.01);与模型组比较,甲强龙组、脊伤颗粒组平均数值低(P＜0.05);与甲强龙组比较,SCI后1、3d,脊伤颗粒组平均数值偏高(P＜0.05),SCI后7、14 d,脊伤颗粒组平均数值偏低(P＜0.05).结论 脊伤颗粒能部分恢复SCI后模型大鼠的运动功能并可明显抑制细胞Caspase-3表达和细胞凋亡.     

表达Ag85B与ESAT6融合蛋白的基因疫苗的免疫学特性

目的测定表达Ag85B与ESAT6融合蛋白的两种重组质粒AZ-pcDNA3-EF和EZ-pcDNA3-AF在小鼠体内诱导的免疫应答及保护力。方法50只BALB/c小鼠随机分为5组(每组10只),将表达Ag85B与ESAT6融合蛋白的两种重组质粒AZ-pcDNA3-EF和EZ-pcDNA3-AF分别免疫小鼠3次,每次间隔2周,同时设卡介苗(BCG)免疫组、空载体质粒免疫组和生理盐水对照组。最后一次免疫结束后,每组取5只小鼠血清,酶联免疫吸附测定(ELISA)法检测特异性抗体的滴度,并分离小鼠的脾淋巴细胞,并在体外用结核分枝杆菌(MTB)培养滤液蛋白(cu lture filtrate prote in,CFP)刺激,测定脾淋巴细胞增殖指数和γ干扰素(IFN-γ)水平。用1 m l含1×105克隆形成单位(CFU)的MTB毒株H37Rv经尾静脉感染其余每组5只BALB/c小鼠,4周后计数脾脏细菌负荷数。结果质粒AZ-pcDNA3-EF和EZ-pcDNA3-AF免疫小鼠血清的特异性抗体滴度分别为1∶1 000和1∶1 500。其脾淋巴细胞刺激指数分别为2.2和2.4,而生理盐水对照组和空载体质粒免疫组的刺激指数只有0.9和1.1;脾淋巴细胞悬液中诱发的IFN-γ分别为(5.48±0.38)ng/m l和(5.76±0.51)ng/m l,显著高于生理盐水对照组和空载体质粒免疫组(P<0.05),但与BCG免疫组的(5.55±0.31)ng/m l比较差异无统计学意义。结核毒株攻击后,与空载体质粒免疫组相比,质粒AZ-pcDNA3-EF和EZ-pcDNA3-AF免疫的BALB/c小鼠其抗MTB在脾脏中增殖有显著作用,3组脾脏细菌负荷对数值(lg,CFU/g)分别为6.08±0.25、4.63±0.11、4.50±0.32,但不及BCG免疫组的4.09±0.27。结论表达Ag85B与ESAT6融合蛋白的基因疫苗在小鼠体内诱导的IFN-γ水平与BCG相当,其保护力有待进一步提高。     

无骨折脱位型颈脊髓损伤患者颈髓的弥散张量成像

目的探讨应用磁共振弥散张量成像(DTI)定量分析无骨折脱位型颈脊髓损伤患者的可行性。方法对15例无骨折脱位型颈脊髓损伤患者(患者组)和20例健康志愿者(对照组)行常规MRI和DTI扫描,分别测量各向异性分数(FA)和表观弥散系数(ADC)。结果患者组FA为(0.475±0.109),ADC为(1.438±0.252)×10-3mm2/s。对照组FA为(0.604±0.096),ADC值为(1.371±0.280)×10-3mm2/s。与对照组相比,患者组FA降低(P0.05),ADC无显著性差异(P=0.267)。纤维束示踪成像(FT)显示,患者组颈髓白质纤维束不同程度受压凹陷、扭曲、减少、稀疏甚至断裂。结论 DTI能够敏感地发现无骨折脱位型颈脊髓损伤,FT能直观显示颈髓白质纤维束的细微损伤,为颈髓损伤程度的临床评估提供客观依据。