【作者】 姚珍松；

【导师】 樊粤光；

【作者基本信息】 广州中医药大学 ， 中医骨伤科学， 2007， 博士

【摘要】 颈椎病(Cervical spondylosis)是由于颈椎间盘组织的退行性改变及其继发性病理改变累及其周围组织结构(神经根、脊髓、椎动脉、交感神经等)而出现的系列临床综合征。颈椎病的发病率约为7.3％-13.7％，50岁以上人群的颈椎病发病率逐渐增高。分析结果显示，颈椎的退变、劳损、外伤、姿势不正、炎症、颈椎管狭窄、颈椎畸形、颈部肌肉病变等多种因素共同导致颈椎病，颈椎间盘的退变则是颈椎发病的基本因素。椎间盘退变后引起颈椎节段间的松动和反应性的骨质增生、椎间关节退变等一系列继发性改变，这些改变引起了脊髓、神经根、血管等组织的压迫或刺激，出现临床症状。颈椎的退变包括了颈椎间盘(髓核、纤维环、软骨终板)的退变、椎间盘边缘的变性、椎间韧带和椎间关节的变性增生等多个方面的变化。在颈椎退变及其他病因的共同作用下，颈椎可能通过对脊髓、神经或血管的静态或动态机械压迫、或颈椎不稳活动范围过大造成的脊髓神经侵犯、或退变组织损害脊髓神经血循环、以及受损组织的炎症反应与免疫损伤等多种机制，造成脊髓、神经、血管或其他组织的压迫，产生症状。“颈椎病”这个概念包含了三个方面的基本内容：(1)颈椎间盘退变或椎间关节退变，(2)累及其周围组织，(3)出现相应的临床表现。颈椎病的诊断必须同时具备三个条件：(1)具备颈椎病的临床症状，(2)影像学检查显示颈椎间盘或椎间关节退行性改变，(3)影像学征象与临床表现相对应。颈椎病的发生发展是人体的一个生理过程，其演变过程可分成三个阶段：(1)功能失常期，表现为颈椎活动幅度增大或减小，易疲劳，影像学检查无明显特殊改变；(2)退变失稳期，表现为项肌痉挛、颈痛、头晕等神经症状，颈椎功能位照片有水平及角度位移；(3)增生稳定期，表现为颈椎僵硬，可因增生组织压迫神经根、脊髓、血管等，出现相应症状。对颈椎病的诊断必须结合病史、临床表现、影像学检查综合考虑。临床上根据颈椎病的主要临床表现特点和病理生理特征进行分类，具体的分类有不同的观点。多数临床医生所接受的主要类型有颈型颈椎病、神经根型颈椎病、脊髓型颈椎病、椎动脉型颈椎病。对于颈椎病的治疗，目前认为，除脊髓型颈椎病外，其余类型的颈椎病多数采用非手术治疗是有效的，只有少数病例需要手术治疗。对于脊髓型颈椎病而言，它的发生主要是由于脊髓的压迫与损伤，其自然史是一个持续加重的病理演变过程，一般认为，在脊髓型颈椎病早期和病情较轻可非手术治疗，病情持续发展则应尽早手术治疗。西医认为颈椎病非手术治疗有效的措施主要有休息、药物、颈椎牵引、理疗、家庭疗法、功能锻炼、疾病教育、局部封闭等。药物主要有麻醉止痛剂、抗炎剂、抗抑郁剂和肌肉松驰剂等。每一种疗法都有一定的适应症和禁忌症。颈椎病非手术治疗必须达到三个方面的目标：缓解疼痛、改善功能、防止复发。虽然每一种非手术治疗方法都是有效的，但一般只有综合的非手术治疗才能达到全部三个目标。对于非手术治疗无效的颈椎病患者，尤其是脊髓型颈椎病患者，应考虑手术治疗。颈椎病的手术入路主要有前路手术和后路手术。主要的手术方式有前路椎间盘切除加椎体间植骨(或Cage)融合术、前路椎体开槽减压或椎体次全切除植骨或钛网植骨融合内固定术，后路椎板扩大成形术或椎板切除减压术等。前路手术的主要指征是以颈椎间盘突出或椎体后缘骨赘压迫为主，病变节段在3个以内且椎管矢状径在10mm以上的椎管轻度狭窄者，无后纵韧带骨化。后路手术的主要指征是广泛椎管狭窄、多节段病变、脊髓后侧压迫为主。一般认为，单节段或短节段颈椎病宜行前路手术。多节段颈椎病，有人主张前路手术，也有人主张后路手术，尚存在争论。对于颈椎后凸畸形合并进展的椎管狭窄或后方压迫，可能需要前后路联合的手术治疗。合适的内固定材料的选择与应用，有助于颈椎稳定性的重建，也有利于病情康复。无论前路还是后路手术，术后良好的骨融合是最主要的，而内固定的合理应用能促进骨融合。中医认为颈椎病属“痹证”、“痿证”等范畴，有药物内服外用、牵引、推拿按摩、针灸等多种治疗方法，其中药物治疗是最主要的，一般认为颈椎病的基本病机特点是正气不足，感受风寒湿邪或瘀阻痰凝的本虚标实证，中医辨证论治多强调攻补兼施，根据病机特点辨证论治。对于脊髓型颈椎病，多属中医“痿证”范畴，认为其主要的病机特点是肝肾不足，经络不通，中医辨证多主张温阳补气，活血通络的治法。在临床治疗颈椎病的过程中，充分考虑颈椎病的病理特点，中西医结合治疗也是广为采用的。第二部分临床研究目的：探讨中药制剂参附注射液、川芎嗪注射液和西药前列地尔注射液的联合应用在治疗脊髓型颈椎病中的作用，为临床探讨提供资料。方法：临床通过对118例脊髓型颈椎病患者进行对照研究，探讨手术治疗或非手术治疗配合中药参附注射液、川芎嗪注射液和西药前列地尔注射液等药物在脊髓型颈椎病治疗中的作用。118例诊断明确的脊髓型颈椎病患者，按病情轻重和病程长短，分成手术治疗和非手术治疗2个大组。手术治疗41例，又分成手术配合中西药治疗组(1组)共29例和单纯手术治疗组(2组)12例；非手术治疗组共77例，又分成非手术配合中西药治疗组(3组)33例、非手术配合中药治疗组(4组)25例和非手术配合西药治疗组(5组)19例。经过2周治疗，行治疗结束时及6个月随访JOA评分改善率测定及改善率评级2项指标测定。结果：在手术治疗病例中，手术配合中西药治疗组的病人治疗后JOA评分改善率为81.4％，优良率为96.5％，6个月的JOA评分改善率为87.1％，优良率为96.5％，单纯手术治疗组治疗后JOA评分改善率为75.0％，优良率为91.7％，6个月随访JOA评分改善率为78.1％，优良率为91.7％，手术配合中西药治疗组6个月JOA评分改善率优于单纯手术治疗组(P＜0.05)。非手术治疗的病例，非手术配合中西药治疗组治疗后JOA改善率为77.1％，优良率为93.9％，6个月随访JOA改善率为74.4％，优良率为87.9％；非手术配合中药治疗组治疗后JOA改善率为70.6％，优良率为76.0％，6个月随访JOA改善率为52.9％，优良率为64.0％；非手术配合西药治疗组治疗后JOA改善率为68.9％，优良率为73.7％，6个月随访JOA改善率为58.6％，优良率为57.9％。在JOA改善率及评级方面，非手术配合中西药治疗组与非手术配合中药或非手术配合西药治疗组之间有显著性差异(P＜0.05)，非手术配合中药治疗组与非手术配合西药治疗组之间疗效相当(P＞0.05)。结论：参附注射液、川芎嗪注射液、前列地尔注射液等的联合应用，辅助手术治疗效果优于不辅助用药，在非手术治疗病例中，中西药联合使用效果优于单用中药或单用西药。认为非手术配合参附、川芎嗪及前列地尔，治疗病情较轻、病程较短的脊髓型颈椎病患者，手术配合参附、川芎嗪及前列地尔，治疗病情较重、病程较长的脊髓型颈椎病患者，疗效满意，且较安全，有临床探讨应用价值。中西药配合使用治疗脊髓型颈椎病，取得满意疗效的原因，可能与综合治疗改善或重建脊髓的血液循环，药效协同，改善脊髓神经组织的血供有关。更多还原

【Abstract】 Part One ReviewCervical spondylosis is a clinical syndrome of spinal cord, nerves or blood vessel induced by degeneration of cervical intervertebral disc and its secondary affection. Cervical spondylosis is a common disease of spinal or nerve dysfunction in patients older than 50 years. Now cervical spondylosis sick rate of Chinese is about 7.3%-13.7% and it keeps rising.The degeneration of cervical disc is the most important and basic reason of cervical spondylosis. The secondary affections of cervical disc degeneration include protrusion of cervical disc, instability of cervical joint, and hyperosteogeny of vetrtebra body and joint. The degeneration of these tissues can compress or hurt spinal cord, nerves or blood vessels and then produce clinical symptoms.There are a lot sorts of reasons of cervical spondylosis such as cervical spine degeneration (including cervical disc and bone degeneration), cervical strain, trauma to cervical spine, bad body posture, inflammation in neck, deformity of cervical vertebra, cervical spinal canal stenosis and neck muscle diseases and so on. Degeneration changes in the spinal column result in facet arthrosis, decreased intervertebral disc height, narrowing of the neuroforamina and osteophyte formation. These changes of disc and other tissues do harm to spinal cord, nerves or blood vessels by the mechanism of dynamic or statical compression, dynamic disequilibrium of cervical vertebrae, blood circulation disturbance and immune hurt. The degeneration of cervical vertebrae includes degeneration of cervical intervertebral discs, degeneration and hyperplasia of ligaments and degeneration and hyperosteogeny of cervical joints. As degeneration changes occur, there is oncroachment on the space available for the cord, which could lead to myelopathy from extrinsic compression of alteration in cord blood supply As a clinical conception, the term "Cervical Spondylosis" has three meanings: (1) degeneration of cervical disc or cervical joint; (2) hurting of other tissues such as spinal cord, nerve and blood vessel, and (3) producing a series of secondary clinical symptoms. To constitute a diagnosis of cervical spondylosis must meet three conditions at the same time: (1) positive clinical symptoms of cervical spondylosis, (2) positive radiological signs showing the degeneration of cervical intervertebral disc or of cervical joint, and (3) the radiological signs can explain all clinical symptoms. From degeneration of cervical spine to the clinical complains may last a long time of progress. This progress has endured three phages: (1) Dysfunction phase. At this phase patients may feel exhausted easily. Some patients’ cervical spine may have too big or too little a movement range. There are no positive radiological signs. (2) Degeneration and dysfunction phase. The patients may feel pain in neck, dizziness or cervical muscle spasm. The radiological check of cervical spine’ s flexion or extension position may show the cervical vertebrae body move further than normal levelly or in angle. (3) Hyperosteogeny and stable phase. At this phase patients may complain stiff in neck, or other symptoms coming from spinal cord injury, nerve or blood vessels compression. According to its clinical symptoms and pathogenesy cervical spondylosis can be divided into several types. Cervical spondylotic radiculopathy (CSR), cervical spondylotic myelopathy (CSM), vertebral artery type of cervical spondylosis, and neck type of cervical spondylosis, are the commonly accepted types of cervical spondylosis.The treatment for cervical spondylosis includes surgical treatment or nonsurgical treatment. The common opinion about cervical spondylosis treatment agrees that most part of cervical spondylosis can be treated well by nonsurgical treatment. The nonsurgical treatment for cervical spondylosis includes physical therapy and rehabilitation: rest, modalities, islmetrics, aerobic conditioning, flexibility exercises, progressive resistive exercises, disease education and home program. Other treatment includes injection therapy, medication (has four classes of medication: narcotics, anti-inflammatories, antidepressants and muscle relaxants), manipulation. A successful program for nonsurgical treatment of cervical spondylosis must achieve all three goals: pain relief, improved function, and prevention of recurrence. Although many modes of treatment are available, only a comprehensive rehabilitation program of reconditioning meets all three goals. Its effectiveness in helping to prevent recurrence has been established. Functional improvement may also be maintained through such a program, and functional disability may be minimizedCervical spondylotic myelopathy is the worst type of cervical spondylosis. All pathogenesis feature of cervical spondylotic myelopathy is the compression of spinal cord. The natural history cervical spondylotic myelopathy is typically one of insidious onset, long periods of static disability, and episodic worsening. This leads to stepwise degeneration over time. The symptoms of cervical spondylotic myelopathy include motor weakness, radiculopathy, spasticity, neck pain, hand dysfunction, gait abnormalities, proprioceptive loss, and bowel and bladder dysfunction. Cervical spondylotic myelopathy keeps improving and the symptoms of patients may deteriorate gradually. Cervical spondylotic is a graded process with variable clinical manifestations. Anatomic location of compression, ischemia, and dynamic factors also contribute to its spectrum. Perhaps the most important issue in myelopathy is that it is treatable, and its early diagnosis enhances the pool of good results. Emphasis should be placed on obtaining histories of numbness and clumsiness in the hands, decreased fine motor movement, and subtle gait disorders. Suspicion of its clinical existence remains the single greatest element in the identification of early cervical spondylotic myelopathy.Early cervical spondylotic myelopathy could be treated by nonsurgical treatment. Most cervical spondylotic myelopathy patients ask for surgical treatment. Surgical treatment involves a wide decompression of the spinal cord by a posterior or anterior approach. The anterior approach may be the ideal choice for decompression in patients with up to three-level stenosis and in those with primarily anterior pathology (osteophytes, spondylosis, disc herniation, and so forth). And anterior approach is the only recommended approach for patients with cervical kyphosis who need decompressive surgery. The anterior approach for surgical treatment of CSM includes ACDF (anterior cervical discectomy and fusion) or anterior corpectomy and strut grafting. Advanced age, long duration of symptoms, and increased severity of stenosis may be associated with poorer clinical outcome. Advanced age or severe presenting functional disability should not be contraindications to surgical treatment. The posterior approach may be considered in patients with stenosis at three or more levels, segmental OPLL, previous failed surgery, and posterior impingement due to buckling or infolding of the ligamentum flavum of facet arhtropathy. The posterior approach for surgical treatment of cervical spondylotic myelopathy includes laminectomy or laminoplasty. Kyphosis associated with developmentally narrow canal or posterior compression may require combined anterior posterior approaches. Disagreement on which approach is the best choice for long-level cervical spondylotic myelopathy remains. Cervical spine fixation is continually evolving, and better and more stable constructs are becoming available. Proper instrumentation may enhance patients’ rehabilitation. In stabilizing the cervical spine, the proper fusion remains the most important procedure, and spinal fixation devices can be used to augment the stability of the construct and enhance fusion rated.Cervical spondylosis belongs to bi-syndrome or flaccidity-syndrome in Traditional Chinese Medicine field. The major pathogenesis of Cervical spondylosis is deficiency of Qi, wind-cold-wetness evil and meridian obstacle by blood stasis or phlegm. The principal of therapy for Cervical spondylosis aims at both the restoration of healthy energy and elimination of evils. The available Traditional Chinese Medicine treatment method for Cervical spondylosis involves Chinese traditional herbs, acupuncture, massage, neck traction and so on. CSM belongs to flaccidity-syndrome in Traditional Chinese Medicine field and can be treated with Traditional Chinese Medicine. The main feature of Cervical spondylotic myelopathy pathogenesis is deficiency in origin and excess in superficiality. The deficiency syndrome complicates with excess symptoms. Deficiency of the kidney is the basic pathogenesis characteristic. Invigorating qi and yang, promoting blood circulation and dredging channel is now considered the good principal for working out a therapy for CSM. Now surgical or conservative combination treatment of Chinese traditional and Western medicine on cervical spondylotic myelopathy is used by a lot of doctors and has got good results.Part Two Clinical StudyObjective: To study the effects of Shenfu injection, tetramethylpyazine injection, Alprostadil injection on cervical spondylotic myelopathy (CSM) and to find some effective method or medicine for treatment of CSM.Methods: In this clinical comparative study 118 patients with CSM were treated after being divided onto two big groups: 41 patients with more sever illness in group A and 77 with slighter illness in group B. Surgical operation were the basic treatment for those in group A and cervical traction as basic treatment for those in group B. Surgical operation or cervical traction, Shenfu injection, tetramethylpyazine injection, Alprostadil injection, and Chinese herbs Buyang Huanwu Tang were used to treat the patients. 29 patients from group A were treated with surgical and combination of Chinese traditional and Western medicine (Group 1) and the other 12 patients were treated with simple surgical operation (Group 2). All patients in Group 1 were treated with surgical operation and Shenfu injection, tetramethylpyazine injection, alprostadil injection and Chinese herbs Buyang Huanwu Tang. The patients in Groups 2 were treated with simple surgical operation. There were three groups in group B, 33 patients in Group 3, 25 in Group 4 and 19 in Group 5. All patients in Group3 were treated with cervical traction, Shenfu injection, tetramethylpyazine injection, alprostadil injection and Chinese herbs Buyang Huanwu Tang. The patients in Group 4 were treated cervical traction, Shenfu injection, tetramethylpyazine injection and Chinese herbs Buyang Huanwu Tang. The patients in Group 5 were treated with cervical traction, alprostadil injection and vitamin B complex. According to evaluation of severity of myelopathy using Japanese Orthopedics Association (JOA) scores we assessed all patients before the treatment and after 2weeks, 6 months.Results: The patients in Group 1 had equal JOA recovering ratio after 2 weeks as those in Group 2. After 6 months patients in Group 1 had better JOA recovering ratio than those in Group 2 (P<0.05). The patients in Group 3 had better JOA recovering ratio and total good ratio than those in Group 4 and Group 5. The results of Group 4 and Group 5 were equal. Patients in Group 1 had an average recovering ratio 81.4% and a total good ratio 96.5% after treatment for 2 weeks. Patients in Group 2 had an average recovering ratio 75.0% and a total good ratio91.7% after 2 weeks. All patients in Group 1 had an average recovering ratio 87.1% and a total good ratio 96.5% after 6 months. All patients in Group 2 had an average recovering ratio 78.1% and a total good ratio 91.7% after 6 months. Patients in Group 3 had an average recovering ratio 77.1% and a total good ratio 93.9% after treatment for 2 weeks. Patients in Group 4 had an average recovering ratio 70.6% and a total good ratio 76.0% after 2 weeks. All patients in Group 5 had an average recovering ratio 68.9% and a total good ratio 73.7% after 2 weeks. Patients in Group 3 had an average recovering ratio 74.4% and a tetal good ratio 87.9% after treatment for 6 months Patients in Group 4 had an average recovering ratio 52.9% and a total good ratio 64.0% after 6months. All patients in Group 5 had an average recovering ratio 58.6% and an total good ratio 57.9% after 6 months. Results of statistical analysis showed that significant difference existed between Group 1 and Group 2 at 6-month follow-up (P<0.05). The average JOA recovering ratio and total good ratio of Group 3 were better than those in Group4 and Group 5 after both 2-week and 6-month follow-up check, control group (P<0.05).Conclusion: Treatments for CSM by the method of surgical operation combined with Shenfu injection, tetramethylpyazine injection, alprostadil injection and Chinese herbs Buyang Huanwu Tang could treat patients better than treatments of single surgical. Treatments of non-surgical operation combined with Shenfu injection, tetramethylpyazine injection, alprostadil injection and Chinese herbs Buyang Huanwu Tang could treat patients better than treatments of single non-surgical operation combined just Shenfu injection, tetramethylpyazine injection and Chinese herbs Buyang Huanwu Tang or just with alprostadil injection. The results of non-surgical treatments with Shenfu injection, tetramethylpyazine injection and Chinese herbs Buyang Huanwu Tang and the results of those with non-surgical treatment combined with alprostadil injection showed no distinct side effect nor harm to patients’ body and so it was considered a safe treatment method for cervical spondylotic myelopathy. The reasons of the good results might relate to that the combination therapy improve or reconstruct blood circulation for spinal cord and then nourish spinal cord better.更多还原