【作者】 林颖；

【导师】 陈博来；

【作者基本信息】 广州中医药大学 ， 中医骨伤科临床， 2011， 硕士

【摘要】 背景脊髓型颈椎病(Cervical Spondylotic myelopathy, CSM)是颈椎退行性疾病的一种,是以椎间盘退行性变为基本病理基础,相邻椎体节段的椎体后缘骨赘形成,以此构成对脊髓和／或支配脊髓血管的压迫因素,导致不同程度的脊髓功能障碍的疾病,是成人脊髓病里最常见的类型。选择合适的入路对CSM的治疗尤其重要,对于以1-2个节段椎间盘突出为主要致病因素的CSM,在手术入路选择上并无太大分歧,而对于3个节段及以上的多节段椎间盘突出,尤其是伴有发育性椎管狭窄的CSM,采取何种入路一直是临床争论不休的问题。然而无论采取何种术式,其目的都是一致的,都是为了解除脊髓和神经根的压迫。大部分后路手术的支持者,将脊髓向后漂移作为脊髓减压、手术成功的标志。长久以来,“弓弦原理”用作脊髓漂移的解释为大家广泛接受。根据“弓弦原理”,脊髓的移动在颈椎前凸的情况下应该是最大的,因为一旦后方椎管被手术扩大,脊髓向背侧移动,硬膜囊行走曲线由“弓背”转向“弓弦”,正常的前凸可为脊髓移动提供较大的空间。因此,有研究者将术前颈椎生理曲度变直或后凸视为后路减压手术的禁忌症,并指导临床手术入路的选择。然而也有研究指出,明显的脊髓移动可在颈椎生理曲度变直或者后凸的情况下被观察到。随着脊柱外科学的发展,人们对本病的疾病病理学认识水平提高,检测手段的进步,目前急需对CSM后路术后的脊髓漂移进行进一步的研究。本文通过对多节段脊髓型颈椎病行后路手术治疗的病例进行回顾性分析,对其手术前后的颈椎核磁共振(MRI)资料进行测量,将脊髓漂移、颈椎曲度与临床疗效的关系进行深入研究,探讨三者之间的关系,为多节段脊髓型颈椎病后路手术的选择提供一定临床依据。目的观察颈椎后路手术治疗脊髓型颈椎病后路术后脊髓漂移情况,并通过随访评价,分析后路术后脊髓漂移与术前颈椎生理曲度、手术节段及术后疗效之间的关系。方法对45例采用颈椎后路手术治疗且手术前后均行MRI检查、资料结果齐全的脊髓型颈椎病患者进行回顾性分析：1)进行随访,通过日本骨科学会脊髓型颈椎病JOA评分(17分法)、SF-36生活质量评分、颈部VAS评分评估临床疗效；2)测量术前术后MRI影像的T2加权像的中央矢状面,记录脊髓漂移情况(术后与术前手术节段椎体后缘至脊髓中点的距离之差),以及术后颈椎曲度；3)对测量结果进行统计学分析：所有数据应用医学统计软件SPSS 13.0进行处理,采用t检验和Spearman相关性检验。P<0.05时有统计学意义。结果共40例获得随访,随访时间6-48个月,平均17.2个月。随访时JOA分值为10.87±3.16,SF-36分值为101.20±20.93,颈部VAS分值为0.25±0.00,脊髓漂移距离(mm)为1.39±0.88,手术前颈椎曲度分别为19.98±14.98。应用Spearman相关性分析,脊髓漂移与JOA改善率(N=0.10,P=0.54>0.05)；与颈部VAS(N=0.11,P=0.47>0.05)；与随访SF-36(N=0.24,P=0.14>0.05),显示脊髓漂移和术后疗效之间无任何统计学相关性；同时按脊髓漂移值小于或大于等于2mm分为漂移A组、B组,其术后JOA改善率(%)、术后随访SF-36评分、术后颈部VAS评分分别为30.44±78.67、102.30±19.29、0.32±0.98与-37.96±1.43、97.44±26.83、0.00±0.00,应用独立样本T检验分析,两组间的术后改善率、8F-36评分、颈部VAS差异无统计学意义(P值分别为p=0.547、p=0.201、p=0.334>0.05)。为探讨脊髓漂移和颈椎曲度、术后疗效的关系,按颈椎曲度分为前凸组和非前凸组,两组的术后JOA改善率、随访SF-36评分、VAS评分、脊髓漂移值分别为32.21±74.07、99.25±19.12、0.36±1.03、1.34±0.68和-42.74±144.15、103.5±26.89、0.00±0.00、1.49±1.25,两组间采用独立样本T检验分析,前凸组和非前凸组的术后JOA改善率、末次随访时的SF-36评分、颈部VAS进行比较分析,P值分别为p=0.092、P=0.588、P=0.283>0.05,差异没有统计学意义。按手术节段分为常规长节段组和选择性短节段组,两组的术后JOA改善率、术后随访SF-36评分、术后颈部VAS评分、术后脊髓漂移值(%)分别为8.67%±105.64%、101.96±20.40、0.29±0.973、1.55±0.91和37.04%±72.66%、98.61±23.79、0.11±0.33、0.82±0.47。采用独立样本T检验分析,两组间的脊髓漂移值差异P=0.027<0.05有统计学意义,而长节段组和选择性短节段组的术后改善率、SF-36评分、颈部VAS差异无统计学意义(P值分别为p=0.457、p=0.678、p=0.593>0.05)结论颈椎后路手术治疗脊髓型颈椎病术后脊髓漂移情况与术后疗效无统计学相关性；与术前颈椎生理曲度无相关性。术前颈椎后凸的患者也可获得良好术后疗效。手术节段的多少与脊髓漂移程度有相关性,但与术后疗效无统计学相关,因此,对于多节段的脊髓型颈椎病患者,常规广泛、连续的后路长节段减压手术未必是必须的,选择性短节段减压术也可考虑。更多还原

【Abstract】 BackgroundCervical spondylosis is part of the aging process and affects most people if they live long enough. Degenerative changes affecting the intervertebral disks, vertebrae, facet joints, and ligamentous structures encroach on the cervical spinal canal and damage the spinal cord, especially in patients with a congenitally small cervical canal. Cervical spondylotic myelopathy (CSM) is the most common cause of myelopathy in adults. It’s important to choose a suitable procedure, and there are widespread controversies about surgical approach nowadays, especially for the multilevel CSM. However, the surgery is generally performed to decompress the spinal cord and nerve root, no matter which approach it. Most of surgeons take spinal cord drift as a sign of succession decompression. "Bowstring principle", which used to explain the spinal cord drift for a long time, means that spinal cord is capable to get a biggest movement in cervical lord sis. According to this idea, most surgeons consider cervical hypnosis as the contraindication of posterior cervical spondylotic surgery. As the development of spinal surgery and MRI technology, this opinion is now being questioned by more and more experts.ObjectiveTo investigate the relationship among post decompressive migration of the spinal cord, clinical outcomes and preoperative cervical spine curvature.MethodsPreoperative and postoperative cervical spine MRIs of 45 patients who underwent cervical laminoplasty with/without fusion for the treatment of CSM were reviewed. Radiographic parameters including preoperative cervical spine curvature, spinal cord drift to the midpoint of the spinal cord were measured for statistical correlation. The recovery rate were based on the mJOA score, SF-36, VAS of the neck. ResultsFollow-up visit lasted from 6-48 months, with average of17.2 months. Statistical data were calculated as below:mJOA score was 10.87±3.16, SF-36 was 101.20±20.93, VAS of the neck was0.25±0.00, spinal cord drift (mm) was 1.39±0.88, postoperative cervical spine curvature were 19.98±14.98.According to application of spearman correlation analysis, no statistical correlation was revealed between post-decompressive spinal cord drift and clinical outcomes (spinal cord drift (mm) to mJOA score:N=0.10, P=0.54>0.05, to VAS of the neck:N=0.11, P=0.47>0.05, to SF-36:N=0.24, P=0.14>0.05). Also patients were divided into two groups according to spinal cord drift. The difference betweent mJOA、VAS of the neck、spinal cord drift (mm) of two groups was not statistically significant (p=0.547、p=0.201、p=0.334>0.05). The data shows that the preoperative cervical spine curvature did not statistically correlate with postoperative spinal cord drift.To discuss the relationship of spinal cord drift、cervical curvature and clinical outcomes, patients were divided into Normal-cervical-curvature Group and Abnormal-cervical-curvature Group. Analysis of the data did not reveal any statistical correlation between spinal cord drift and clinical outcomes(p=0.092、P=0.588、P=0.283>0.05).Patients were separated to Long-level Group (patients who received extensive and consecutive posterior laminoplasty) and Short-level Group (patients who received selected posterior decompression surgery). There was no significant difference between the subjects in Long-level Group and Short-level Group with respect to the mJOA recovery rate, sf-36, VAS of the neck, but the migration of the postoperative posterior drift of the spinal cord was greater for those in Long-level Group than for those in Short-level Group. There was no correlation between clinical outcomes and the length of surgery section.ConclusionsThe postoperative spinal cord drift in patients undergoing multisegmental decompressive laminoplasty with/without fusion for CSM does not statistically correlate with neither clinical outcomes nor preoperative cervical spine curvature. And there is no statistical correlation between preoperative cervical spine curvature and clinical outcomes. Although traditional extensive and consecutive laminoplasty resulted in a greater degree of shifting than did selected segmental laminoplasty, there was no difference found in the clinical outcomes between the two procedures. For multisegmental cervical spondylotic myelopathy, the traditional extensive and consecutive laminoplasty is not always necessary.更多还原