单节段颈椎间盘突出症前路减压术后上肢近端麻痹的研究

Pathogenesis of postoperative proximal upper limb paralysis following anterior decompression for treating single-level cervical disc herniation

目的探讨单节段颈椎间盘突出症(cervical disc herniation,CDH)行前路减压术后继发上肢近端麻痹(proximal upper limb palsy,PULP)的发作特征及危险因素。方法回顾性分析颈椎管前路减压分别联合融合或非融合固定术,治疗235例单节段CDH患者资料,术后随访时间均在12个月以上。术前PULP组和非PULP组一般资料比较,差异均无统计学意义。按照术前临床表现,分为以脊髓型和神经根型损害两组。减压节段包括C_(3/4)、C_(4/5)、C_(5/6)和C_(6/7)椎间隙。分别比较不同手术节段或术前定位体征亚组间术后PULP发生率。以C_(5)椎体为界,比较其上(下)椎间水平减压术后总体PULP发生率。结果术后26例PULP患者均接受非手术治疗,末次随访均获得基本缓解。除C_(4/5)椎间隙和C_(5)髓节外,其余节段减压术后亦可继发PULP。C_(5)椎体上(下)各两个椎间减压术后PULP发生率和中下水平4个颈椎间隙减压术后PULP发生率比较,差异均无统计学意义。术前脊髓型表现者,术后PULP发生率高于神经根型表现者,差异有统计学意义。结论术前为上运动神经元通路损害为主要表现者,CDH前路减压术后更易继发PULP。PULP发作应与固有束神经元体系的早期、可逆和暂时损害密切相关。

Objective To investigate the characteristics and risk factors of secondarily proximal upper limb paralysis(PULP)after anterior decompression of single-segment cervical disc herniation(CDH).Methods The clinical data on 235 patients with single segmental CDH treated with anterior cervical decompression combined with fusion or non-fusion fixation was analyzed retrospectively.The follow-up lasted more than 12 months.There were no significant differences in demographic data between the postoperative PULP group and non-PULP group.According to preoperative clinical manifestations,the patients were divided into two groups:the spinal cord injury group and the nerve root injury group.The decompression segments included C3/4,C4/5,C5/6 and C6/7 intervertebral spaces.The postoperative PULP incidence rates were compared between subgroups of different surgical segments or preoperative localized signs.The overall incidence of PULP after upper(lower)intervertebral horizontal decompression with the C5 vertebral body as the boundary was compared.Results All the 26 patients with PULP received non-surgical treatment after operation and achieved basic remission during the last follow-up.In addition to C4/5 intervertebral space and C5 myelomere,PULP could also be secondary to other segmental decompression.There was no significant difference in the incidence of PULP between superior(inferior)two intervertebral spaces with C5 vertebrae as the benchmark or four subaxial intervertebral spaces at the middle and lower level,respectively.The incidence of postoperative PULP among patients concomitant with preoperative myelopathy phenotype was higher than among those with nerve root phenotype,and the difference was of statistical significance.Conclusions Patients who present with predominantly upper motor neuron pathway damage before operation are more vulnerable to PULP after anterior decompression targeted at CDH.The onset of PULP is closely related to the early,reversible and temporary impairment of the system of propriospinal tracts and neurons.