[摘要] 目的:研究前路颈椎体次全切除减压、植骨融合、内固定术治疗脊髓型颈椎疾病的疗效。 方法:对2006年12月至2009年12月共32例脊髓型颈椎病行前路1-2节椎体次全切除减压、自体髂骨或钛网植骨融合、颈前路钛板螺钉内固定术的疗效进行回顾性分析。术前及术后6-12月对脊髓功能行JOA评分,SPSS 16.0软件统计分析2次评分差别是否有显著性;并通过颈椎过伸过屈位X片观察植骨融合率。结果:脊髓功能多数得到明显改善,术后12月JOA评分平均高于术前3.1分,两次评分差别有显著性,P=0.01;JOA评分平均改善率为57.8%;全部病例植骨均融合成功,融合率为100%。结论:前路颈椎体次全切除减压融合内固定术是治疗脊髓型颈椎疾病的有效方法,它能恢复脊髓神经功能,植骨融合可靠,能重建颈椎稳定性。
[关键词] 椎体次全切除;植骨融合;脊髓型颈椎病;疗效
[Abstract] Object:To explore the clinical outcome of anterior decompression of the cervical spondylotic myelopathy by subtotal vertebrectomy, titanium mesh fusion or autogenous iliac bone graft combined with internal titanium plate fixation. Methods: A retrospective review was performed on 32 cases with cervical spondylotic mydopathy of 1-2 segments who were treated by ACCF from Sep. 2006 to Apr. 2009. The group was consisted of 20 males and 12 females, with an average age of 51 years （ranged from 37 to 65 years）.The 37 surgical segments ranged from C3 to C7:2 in C3, 5 in C4, 8 in C5 , 10 in C6 ,4 in C7 , 2 in C4-5 , 2 in C 5-6 in 3. They were all treated by anterior subtotal vertebrectomy of 1 or 2 segments according to the responsible segments and titanium mesh fusion or autogenous iliac bone graft combined with internal titanium plate fixation, and were followed up for 6-12months. Japanese Orthopaedic Association （JOA） score was used for an objective assessment of the patients" preoperative and postoperative clinical status, and the differences of mean JOA scores was analyzed with SPSS v.16.0.The flexion-extension lateral radiographs of cervical spine were observed to assess bone fusion rate. Results :The mean JOA scores of all patients were increased of 3.1（ranged from 2-6） after operations, there were significantly differences between preoperative and postoperative mean JOA scores（P=0.01）; The average recovery ratio was 57.8% （range 33 to 100%）; and all of the bone plants got fused, bone fusion rate was 100%. Conclusion :The treatment outcome of anterior decompression of the cervical spondylotic myelopathy by subtotal vertebrectomy, titanium mesh fusion or autogenous iliac bone graft combined with internal titanium plate fixation is satisfactory; it can restore the nerve function and reconstruct the stability of the cervical spine.
[Key Words] spinal cord compression;cervical vertebrae decompression;spinal fusion; treatment outcome
脊髓型颈椎病是常见的颈椎退变性疾病,可对患者的行走、持物等重要的脊髓功能造成损害。目前多数学者主张早期手术治疗,手术方式可分为前路椎体次全切除减压融合内固定术及后路椎板开门等成形术及前后路联合手术。对于仅涉及3个椎节段以下压迫的颈椎病多主张前路手术。我科自2006年12月至2009年12月对32例涉及1-2节颈椎节段的脊髓型颈椎病行前路颈椎体次全切除减压、自体髂骨块或者颈椎钛网植骨融合、前路钛板螺钉内固定术,取得了良好的效果。
1 资料与方法
1.1一般资料 本组病例男20例,女12例,年龄37-65岁,平均年龄51.4岁;病程3-31月。脊髓压迫涉及1-2椎节段,分布于C3-7范围,共37个节段,详见表1。影像学检查见这些节段病理改变为椎间盘突出、椎体后缘骨赘增生、椎间隙狭窄或不稳定,并排除发育性颈椎管狭窄或者后纵韧带骨化及肿瘤结核等其他性质的病变。术前脊髓功能按照JOA评分为9-14分,平均11.5分。
1.2术前准备 术前行颈椎正侧位和动力位X片、MRI检查,必要时加做CT平扫,以明确诊断和排除肿瘤、结核、后纵韧带骨化等其他性质的病变;根据脊髓神经损害的定位症状体征结合影像学检查结果作为确定引起脊髓功能损害的“责任节段”,确定减压范围。术前禁烟,做气管推移训练,控制好合并的内科疾病,需取髂骨者局部备皮。
1.3手术方法 气管内全麻,气管插管过程中防止过度后伸,以免加重脊髓损伤;术中头颈轻度过伸后仰位,自左侧胸锁乳突肌内侧缘做斜行切口入路,自内脏鞘与血管鞘之间钝性分离达椎体前方,防止过度用力或过久牵拉食管和气管。C臂X光机定位后切开椎前筋膜及前纵韧带,骨膜下剥离至双侧颈长肌内缘偏外2mm处。先部分切除病变节段上下位椎间盘,安装使用Caspar椎体撑开器,适度撑开椎体间隙,再于病变节段椎体上纵形开宽约1.5cm骨槽减压,彻底切除残余的椎间盘,抵达椎体后纵韧带,切除后纵韧带并摘除脱出到后纵韧带后方的髓核组织,潜行减压,将增生骨赘切除,扩大椎管。取合适大小的自体髂骨块或者充填满松质骨的颈椎钛网植入减压后的骨槽安放前路适当长度的4孔或6孔颈椎前路钛板螺钉固定。术后1-2天拔出引流管,拔管后就开始功能锻炼;戴分体式颈围2-3月;每3月来院随访一次。
2 结果
手术时间50-120分钟,平均78分钟;出血100-350ml,平均173ml。32例患者颈脊髓功能均有不同程度改善,无加重病例;术后6-12月JOA评分13-17分,平均14.6分;术后比术前评分平均增加3.1分;两次JOA评分做成对资料的t检验显示二者有显著差异性,P=0.01;术后评分平均改善率为57.8%（注:平均改善率=提高分/损失分×100%,其中提高分=术后平均分-术前平均分,损失分=17-术前平均分）。术后6-12月颈椎动力位X片检查见各植骨节段均获骨性融合,融合率为100%;无内固定物移位、下沉等;颈椎稳定性获得恢复。无严重并发症发生,最常见者为咽喉不适、异物感,共19例,经对症治疗3-7天后消失;吞咽困难1例,该患者为颈4-6椎间盘突出,术前即有吞咽困难且精神紧张,经流质饮食、理疗等治疗一月后恢复;切口迟发性血肿一例,经引流换药等保守治疗痊愈。无深部感染或血肿,脊髓损害无加重,无呼吸衰竭、神经根损伤或麻痹、喉返神经损伤、食管气管漏、脑脊液漏、内固定位置不良或松动拔出等并发症。
图-1 术前MRI显示C5-6、6-7椎间盘突出
图-2 术后X片显示内固定物位置良好
3 讨论
随着老年社会临近以及长期坐位低头姿势办公等生活习惯变化等因素,颈椎病患者日益增多,其中脊髓型患者比例较高,患者表现为四肢麻木乏力,行走踩棉花感及不稳,躯干束带感,双手完成系扣端碗等日常动作困难,逐渐加重,重者大小便障碍;体查可见受损节段及以下的肢体触痛觉减退、肌力下降,肌腱反射亢进,Hoffmann征、巴氏征等病理征阳性,部分患者还有肌张力增高,脊髓损害明显。X平片、MRI、CT检查可见颈椎某处或多处椎间盘突出,可伴椎间隙狭窄,椎体后缘骨赘增生,脊髓受压。此类患者保守治疗难以恢复脊髓功能,多主张早期手术治疗[1]。颈椎前路椎体次全切除减压、植骨内固定手术是目前治疗此类疾病的一项有效的技术[2]。此术式相对后路单开门椎板成型或者椎板切除等手术而言有很多的优势,其切口小,剥离范围小,组织损伤少,出血少,解除来自前方的椎间盘髓核突出或游离物、骨赘、增厚的后纵韧带,减压彻底、充分、直接而有效,更好地重建颈椎生理曲度[3],且没有后路手术易出现的顽固性的术后长期轴性痛、颈五神经根麻痹等并发症,是解除脊髓前方局限性受压迫的理想术式。一般认为,颈椎“责任节段”在3节以内者适合行颈椎前路椎体次全切除减压、植骨、内固定术,尤其以1-2节段为佳,而1-2节段的减压融合结果无显著区别[4][5]。如果手术范围超过3节,植骨融合难度大,固定容易失败[6][7],颈椎活动范围损失太多等因素,而宜行后路椎板成形或者椎板切除术,必要时可加做前路局限性减压而组成前后联合手术的术式。故术前决定手术入路和方案时,如影像学检查见多个颈椎节段有退变,需要根据症状体征表现出来的神经损害的定位,并结合既往经验来判断真正引起颈椎病的节段,即“责任节段”,如其在3节以内即可行前路手术,尤其1-2节段内更为合适。盲目扩大手术范围不仅增加了手术难度和并发症发生率,对于治疗效果也无益处。因为前路手术可能会误伤喉返神经、气管、食道,或者因为显露范围过大、牵拉力度过大和持续时间过长,气管插管时间过长,均易造成气管和食道水肿、血肿、缺血,而容易形成气管食管漏,很难处理;如果节段太长会明显增加此并发症的发生率[8]。本组病例选择谨慎,均为涉及3个或以下的连续病变的椎间盘或者2节病椎以下的椎体,固定的节段短,融合过程中的骨再生距离短,颈椎活动度损失不大,并排除椎管狭窄、后纵韧带骨化等影响疗效的因素,可能是本组病例疗效好、并发症少的重要原因。此外,熟练的手术操作技术和恰当的围术期处理也很重要。
4.结论颈椎前路椎体次全切除减压、植骨融合内固定术是治疗1-2节段脊髓型颈椎病的成熟可靠的方法,疗效优良,并发症少,值得在有脊柱外科基础的基层医院推广应用。
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