【作者】 罗彬；

【导师】 王清；

【作者基本信息】 泸州医学院 ， 外科学， 2012， 硕士

【摘要】 目的：探讨颈椎椎弓根螺钉固定结合单开门椎管扩大成形治疗颈脊髓前方无局限性压迫、颈椎不稳定的颈椎管狭窄伴无骨折脱位型颈脊髓损伤的临床疗效。方法：2006年6月～2011年3月我院脊柱外科收治颈椎管狭窄伴无骨折脱位型颈脊髓损伤患者,采用颈椎椎弓根螺钉固定结合单开门椎管扩大成形治疗44例,纳入标准：①颈椎管狭窄(退变性或发育性狭窄)伴CSCIWFD:②影像学显示颈椎管前方无明显局限性颈脊髓受压；③颈椎管前方有明显压迫,尤其是多节段压迫,MRI显示硬膜囊前后受压呈“葫芦串”样改变；④椎动脉CTA显示椎动脉无明显畸形和损害；⑤无颈椎手术史。排除标准：①无颈椎管狭窄的CSCIWFD:②颈椎间盘损伤突出致颈脊髓损伤；③1-2个节段椎体后缘骨赘形成或韧带骨化致脊髓前方受压；④C7椎体后下缘显示不清；⑤颈椎结核、肿瘤及感染疾病；⑥颈椎前路手术后行后路椎管扩大成形翻修的病例。颈椎椎弓根螺钉固定节段范围选择：①MRI显示有颈脊髓损伤信号及临床诊断有颈脊髓损伤节段；②颅骨牵引有椎间隙增宽的节段；③MRI显示颈椎前后纵韧带和椎间盘(APLLD)有损伤的节段；④影像学检查和临床症状、体征不相符合的颈脊髓存在损伤的节段。该组病例男性28例,女性16例,年龄34-71岁,平均51.7±8.2岁,60岁以上患者25例。脊髓损伤类型：脊髓中央综合症26例,前脊髓损伤综合症12例,Brown-Sequard综合症4例,其它2例。入院时JOA脊髓功能评分4-13分,平均7.2±2.3分。致伤因素：车祸伤11例,跌倒伤7例,高处坠落伤9例,骑自行车摔伤9例,颈部重物砸伤2例,颈部按摩伤2例,游泳伤4例。术前、术后及随访时采用日本矫形外科学会脊髓功能评分系统(JOA评分)评分并计算改善率评估脊髓功能；X线片、CT及MRI评估颈椎曲度、稳定性、内固定位置及椎管扩大情况。结果：所有患者均顺利完成手术,手术时间100-180分钟,平均130±15.5分钟；失血150-600ml,平均250±48.5ml。44例患者共置入颈椎椎弓根螺钉186枚：C354枚,C472枚,C538枚,C618枚,C74枚；单节段固定38例：C3-422例,C4-510例,C5-65例,C6-71例。双节段固定5例：C3-52例,C4-62例,C5-71例。跳跃节段固定1例：C3-4、C5-61。术中行椎弓根穿刺置钉钉道出血8次,均为暗红色涌血,无喷射状出血,快速攻丝并拧入椎弓根螺钉出血停止。术后CT检查证实该组患者椎弓根螺钉穿破外侧骨皮质8枚,没有螺钉穿破椎弓根内侧骨皮质进入椎管。浅表切口感染2例、无椎动脉及脊髓损伤等并发症发生,术后第4天因肺栓塞死亡1例,失访3例,40例患者随访12-60个月,平均25.2±17.6个月,末次随访时JOA颈脊髓功能评分改善率为68.5%,双上肢功能恢复较差并双手不同程度肌肉萎缩5例,术后15月、19月因脊髓功能恢复不佳考虑颈脊髓前方局限性受压再次行颈前路脊髓减压植骨融合内固定2例,术后脊髓功能进一步改善。本组病例随访时存在轴性症状5例。X线片检查显示颈椎曲度良好,无断钉、断棒及颈椎不稳定；CT检查显示螺钉位置良好,椎管扩大成形满意,无门轴断裂及再关门。结论：颈椎椎弓根螺钉固定结合单开门椎管扩大成形治疗颈脊髓前方无局限性压迫、颈椎节段性不稳定的颈椎管狭窄伴无骨折脱位型颈脊髓损伤固定融合了不稳定节段,有利于颈椎曲度的恢复,减少轴性症状的发生,持续扩大的颈椎管解除了脊髓压迫,神经功能恢复满意。更多还原

【Abstract】 Abstract:objective:To investigate the clinical efficacy of posterior expansive open-door laminoplasty and pedicle screw fixation for spinal cord injury without fracture or dislocation in patients with cervical stenosis. Methods:Between June2006and March2011,44patients （28males and16females.） with cervical spinal cord injury with cervical stenosis but without fracture or dislocation in plain films were included to receive posterior C3to C7expansive open-door laminoplasty and pedicle screw fixation. Inclusion criteria:1.patients with cervical stenosis suffered from spinal cord injury without fracture and dislocation of the cervical spine.2. Absence of local anterior compression in radiographs.3. Multi-level anterior compressions, especially patients presented with due to multiple anterior and posterior compressions.4. Absence of vertebral artery deformity or encasement according to CT angiography.5. Absence of congenital cervical deformity or previous operations on cervical spine. Exclusion criteria:1. non-stenotic cervical spine injury.2. Spinal cord injury secondary to disc herniation.3. Single level of two-level compression by osteophyte or ossification of posterior longitudinal ligaments.4. unclear of posterior inferior part of C7vertebrae in radiographs.5. Tuberculosis, tumor or other infectious disease of cervical spine.6. Previous operation on cervical spine. The mean age was51.7±8.2years （range,34-71years）. The mechanism of injury included11motorcycle accidents,7falls from a stand-height,9falls from a height,9bicycle accidents,2crush injuries,2injuries from cervical massage and4diving injuries. All patients developed incomplete spinal cord injury, including central cord syndrome in26patients, anterior spinal cord syndrome in12, Brown-Sequard syndrome in4and mixed type in2. The mean preoperative JOA score was7.2±2.3（range,4to13）. Neurological functions were assessed in terms of improvement rate of JOA score. The cervical alignment, position of implants and status of the canal were evaluated by roentgenograms and computed tomography （CT）.Results:All patients were successfully managed with this technique. Operation time was mean of130±15.5min （range,100to180min） and blood loss was mean of250±48.5ml （range,150to600ml）. All patients have no other major complications occurred. Totally,180screws in44patients were implanted, including52in C3,68in C4,36in C5,18in C6,2in C7. the instrumented segments included4cases of two-segement fixation,2in C3-5,1in C3-4、C5-6,1in C4₆. Intraoperativ,8patients developed ecessive bleeding（non-pulsatile） from the screw tract, which subsided after screw insertion. Postoperativ CT demonstrated lateral cortical perforation in8cases and no spinal canal intrusion occured. The40patients were followed up for an average of25.2±17.8months （range,12to60months）. But for5patients who still sustained a poor functional improvement of upper extremities, the JOA improvement rate was68.5%at last follow-up. Two of them needed reoperations to decompress the residual anterior compression by anterior cervical decompression and fusion procedure. After that, satisfactory improvement of neurological function was documented. Postoperative radiography demonstrated that cervical alignment was maintained in all patients and no implant failure and spinal instability developed. CT scan showed screws were in place and the patency of spinal canal was maintained. No reclose of the canal and fracture of hinge occurred during follow-up. Conclusions:Posterior cervical laminoplasty combined with pedicle screw fixation is an effective procedure for patients with cervical stenosis after cervical spinal cord injury without fracture and dislocation. This procedure is highly practicable and useful in terms of stabilizing the instable segments, restoring cervical alignment, reducing postoperative axial symptoms and maintaining the position of the laminoplasty and thus promoting recovery of neurological functions.更多还原