目的 观察颈后路有限椎板切除联合神经根管减压术在降低C5神经根麻痹及其促进神经功能改善的作用。方法 回顾性分析2014年3月至2016年5月69例在本院接受手术治疗的多节段脊髓型颈椎病患者,其中,38例采用有限椎板切除、神经根管减压内固定术治疗(A组),31例采用常规椎板切除内固定术治疗(B组)。术后观察患者神经功能恢复、颈椎曲度指数变化及C5神经根麻痹发生情况。结果 所有手术均顺利完成。A组患者椎板切除宽度(16.8±2.1) mm,显著小于B组(21.7±2.5) mm (t=8.849, P<0.001)。两组在手术时间、术中出血量上比较无显著性差异(t<0.439, P>0.05)。术后两组日本骨科协会(JOA)评分持续性升高(F>42.996, P<0.05),不同时间点组间比较无显著性差异(t<1.021, P>0.05);颈椎曲度指数较术前有改善,且维持至末次随访(F>86.379, P<0.05),不同时间点组间比较无显著性差异(t<0.943, P>0.05)。A组术后C5水平脊髓漂移距离(2.5±0.5) mm,显著小于B组(3.6±0.7) mm (t=7.602, P<0.001)。两组神经功能改善率无显著性差异(t=0.724, P=0.471)。A组C5神经根麻痹发生率5.2%(2/38),低于B组22.5%(7/31) (χ2=4.514, P=0.034)。结论 颈椎有限椎板切除联合神经根管减压术可解除脊髓压迫并限制脊髓过度向后漂移,促进神经功能恢复的同时降低C5神经根麻痹的发生。
Objective To observe the effect of limited laminectomy combined with foraminal stenosis decompression on preventing C5 nerve root palsy and improving neurological function. Methods From March, 2014 to May, 2016, 69 patients with multi-segment cervical spondylotic myelopathy underwent surgical treatment in our hospital were included. Thirty-eight patients (group A) were treated with limited laminectomy combined with foraminal stenosis decompression and internal fixation, and 31 patients (group B) underwent routine laminectomy and internal fixation. The postoperative neurological recovery rate, cervical curvature index (CCI) and C5 palsy rate were recorded and analyzed. Results No spinal cord and nerve injury occurred during the operation. The width of laminectomy was (16.8±2.1) mm in group A, and was significantly less than (21.7±2.5) mm in group B (t=8.849, P<0.001). There was no significant difference in operation time and intraoperative blood loss between two groups (t<0.439, P>0.05). The Japanese Orthopaedic Association (JOA) score increased continuously after surgery in both groups (F>42.996, P<0.05), and no significant difference was found between them at each time point (t<1.021, P>0.05). The cervical curvature index improved after surgery (F>86.379, P<0.05), and no significant difference was found between them at each time point (t<0.943, P>0.05). The spinal cord drift distance was (3.6±0.7) mm in group A, and ws significantly shorter than (2.5±0.5) mm in group B (t=7.602, P<0.001). There was no significantly difference in the neurological recovery rate between two groups (t=0.724, P=0.471). The C5 palsy rate was lower in group A (5.2%, 2/38) than in group B (22.5%, 7/31) (χ2=4.514, P=0.034). Conclusion Limited laminectomy combined with foraminal stenosis decompression could relieve the spinal cord compression and restrict the excessive back drift, promote the neurological function recovery and reduce the incidence of C5 palsy.
[1] 郝喜荣,赵轶波,陆向东,等. 颈椎后路单开门椎管扩大成形术中开门侧不同固定方式的疗效比较[J]. 中华骨科杂志, 2017, 37(8): 449-456.
[2] Du W, Zhang P, Shen Y, et al.Enlarged laminectomy and lateral mass screw fixation for multilevel cervical degenerative myelopathy associated with kyphosis[J]. Spine J, 2014, 14(1): 57-64.
[3] 李鹏飞,贾楠,王立红,等. 颈后路4种手术方式对颈椎曲度及轴性症状的研究[J]. 河北医科大学学报, 2017, 38(1): 24-28.
[4] Lee DH, Joo YS, Hwang CJ, et al.A novel technique to correct kyphosis in cervical myelopathy due to continuous-type ossification of the posterior longitudinal ligament[J]. J Neurosurg Spine, 2017, 26(3): 325-330.
[5] Harshavardhana NS, Dabke HV, Mehdian H.A new fixation technique for French-door cervical laminoplasty: surgical results with a minimum follow-up of 6 years[J]. Clin Spine Surg, 2017, 30(4): E331-E337.
[6] 廖邦强,付晓玲,邱睿韫,等. 钉棒系统在颈椎单开门椎管扩大成形术中的力学研究[J]. 中国现代医学杂志, 2015, 25(29): 55-58.
[7] Radcliff KE, Limthongkul W, Kepler CK, et al.Cervical laminectomy width and spinal cord drift are risk factors for postoperative C5 palsy[J]. J Spinal Disord Tech, 2014, 27(2): 86-92.
[8] Nori S, Aoyama R, Ninomiya K, et al.Cervical laminectomy of limited width prevents postoperative C5 palsy: a multivariate analysis of 263 muscle-preserving posterior decompression cases[J]. Eur Spine J, 2017, 26(9): 2393-2403.
[9] Pal D, Bayley E, Magaji SA, et al.Freehand determination of the trajectory angle for cervical lateral mass screws: how accurate is it?[J]. Eur Spine J, 2011, 20(6): 972-976.
[10] Abumi K, Itoh H, Taneichi H, et al.Transpedicular screw fixation for traumatic lesions of the middle and lower cervical spine: description of the techniques and preliminary report[J]. J Spinal Disord, 1994, 7(1): 19-28.
[11] 孟亚轲,周丽丽,郭永飞,等. 颈椎减压术后C5神经根麻痹的研究进展[J]. 中华骨与关节外科杂志, 2016, 9(4): 342-346.
[12] Abumi K.Cervical spondylotic myelopathy: posterior decompression and pedicle screw fixation[J]. Eur Spine J, 2015, 24(Suppl 2): 186-196.
[13] 成俊,谭均,赵耘,等. 椎板切除融合治疗多节段脊髓型颈椎病伴节段不稳[J]. 临床骨科杂志, 2017, 20(1): 1-4.
[14] Cherian J, Mayer RR, Haroun KB, et al.Contribution of lordotic correction on C5 following cervical laminectomy and fusion[J]. Neurosurgery, 2016, 79(6): 816-822.
[15] Blizzard DJ, Gallizzi MA, Sheets C, et al.The role of iatrogenic foraminal stenosis from lordotic correction in the development of C5 palsy after posterior laminectomy and fusion[J]. J Orthop Surg Res, 2015, 10: 160.
[16] 肖善富,张喜善,李平,等. 单开门椎管扩大成形术后颈椎曲度与C5神经根麻痹的关系[J]. 临床骨科杂志, 2016, 19(4): 395-399.
[17] Xia G, Tian R, Xu T, et al.Spinal posterior movement after posterior cervical decompression surgery: clinical findings and factors affecting postoperative functional recovery[J]. Orthopedics, 2011, 34(12): e911-e918.
[18] Morishita K, Kasai Y, Takegami K, et al.Disturbance of shoulder elevation after cervical laminoplasty[J]. [in Japanese]. Jpn Spine Res Soc, 2002, 13: 229.
[19] 胡炜,马信龙,曹胜,等. 椎间孔切开在预防椎板成形术后并发C5神经根麻痹中的作用[J]. 中华骨科杂志, 2015, 35(6): 617-623.
[20] Lubelski D, Derakhshan A, Nowacki AS, et al.Predicting C5 palsy via the use of preoperative anatomic measurements[J]. Spine J, 2014, 14(9): 1895-1901.
[21] Baba H, Uchida K, Maezawa Y, et al.Lordotic alignment and posterior migration of the spinal cord following en bloc open-door laminoplasty for cervical myelopathy: a magnetic resonance imaging study[J]. J Neurol, 1996, 243(9): 626-632.
[22] Suda K, Abumi K, Ito M, et al.Local kyphosis reduces surgical outcomes of expansive open-door laminoplasty for cervical spondylotic myelopathy[J]. Spine, 2003, 28(12): 1258-1262.
[23] 王伟,于海洋,梁成民,等. 后路椎板切除侧块螺钉固定治疗多节段颈椎病术后脊髓后移和膨胀变化及其与疗效的相关性[J]. 中国脊柱脊髓杂志, 2015, 25(4): 317-322.
[24] Klement MR, Kleeman LT, Blizzard DJ, et al.C5 palsy after cervical laminectomy and fusion: does width of laminectomy matter?[J] Spine J, 2016, 16(4): 462-467.
[25] Ko HY, Park JH, Shin YB, et al.Gross quantitative measurements of spinal cord segments in human[J]. Spinal Cord, 2004, 42(1): 35-40.
[26] Sherman JL, Nassaux PY, Citrin CM.Measurements of the normal cervical spinal cord on MR imaging[J]. AJNR Am J Neuroradiol, 1990, 11(2): 369-372.
[27] Radcliff K.C5 palsy and cervical laminectomy width: what is the right answer?[J]. Spine J, 2016, 16(4): 468-469.
[28] Bydon M, Macki M, Aygun N, et al.Development of postoperative C5 palsy is associated with wider posterior decompressions: an analysis of 41 patients[J]. Spine J, 2014, 14(12): 2861-2867.
