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颈椎融合及融合后邻近节段的退行性变 被引量:6

Cervical vertebral fusion and degeneration of adjacent seg-ments after fusion
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摘要 目的:回顾分析不同植骨材料、植骨部位等生物学因素对颈椎融合的影响;融合临近节段退行性变的发生率、发生的可能危险因素以及临床处理等,为更合理的选择和应用颈椎融合技术,从而进一步提高颈椎融合的远期效果提供依据和研究方向。资料来源:应用计算机检索Pubmed数据库1980-01/2005-09有关颈椎植骨融合以及融合后临近节段的文章,检索词“cervicalspine,fusion,bonegraft,spinefusion,adjacentsegmentdegeration”,限定文章语言种类为English。同时计算机检索中国期刊全文数据库、万方数据1980-01/2005-09的相关文章,相应检索词分别为“颈椎,融合,植骨,脊柱融合,临近节段退变”,限定文章语言种类为中文。资料选择:纳入标准:①有关颈椎各种类型植骨融合以及脊柱融合生物学过程的研究。②有关脊柱融合后临近节段退行性变的研究。排除标准:重复或类似以及陈旧的研究。资料提炼:共收集到187篇有关颈椎植骨融合以及融合后临近节段退行性变的文章,排除重复或类似以及陈旧的研究,24篇符合研究要求。资料综合:①颈椎融合骨移植材料:颈椎融合术中,自体或异体骨移植存在一些难以克服的缺陷;单独或与骨形态发生蛋白结合应用,具有更好的生物力学性能。②颈椎融合部位的选择:颈椎前路椎间融合效果优于后路融合。③颈椎融合术后临近节段退行性变的发生及发生率:椎间盘退行性变是融合临近节段最常见的退变表现;融合临近节段退变的发生率在术后10年随访可高达25%,而有症状的患者相对较少;颈椎前路融合后临近节段退变的发生率要明显高于后路融合。应用坚强内固定、术后颈椎曲度异常、融合节段过长、融合术中小关节损伤以及术前临近节段存在退行性变迹象的患者容易出现融合临近节段退行性变。结论:颈椎前路融合中,合理选择生物合成材料,以及应用骨形态发生蛋白等骨生长因子不仅可获得良好的融合,而且可避免骨移植并发症的发生。生物力学异常是导致临近节段退行性变的重要因素;导致临近节段退行性变的可控危险因素包括不使用或选用动力性内固定、保护融合临近节段的小关节、融合长度和矢状面平衡;无症状的临近节段退行性变虽常见但与临床症状并不具有相关性;临近节段退行性变的外科治疗包括神经减压和延长融合范围。 OBJECTIVE: To review the effects of biologic factors such as different types of bone graft materials and graft sites on the cervical spinal fusion and to review the etiology, incidence, risk factors associated with as well as treatment options for degeneration of adjacent segments to fused segments so as to provide further evidence and research direction for better longterm outcomes of cervical spinal fusion. DATA SOURCES: We searched the Pubmed database for literatures on cervical spinal fusion and degeneration of segments adjacent to fusion segments published from January 1980 to September 2005 with the key words “cervical spine, fusion, bone graft,spine fusion, adjacent segment degeneration” in English. Meanwhile, we searched the China Journal Full-text Database (CJFD) and Wanfang database for related articles published from January 1980 to September 2005 with the same key words in Chinese. STUDY SELECTION: Inclusion criteria included ① articles about cervical spinal fusion using any type of bone graft material and biologic process of spinal fusion and ② papers about adjac ;nt segment degeneration after spinal fusion. Exclusion criteria: Repetitive or similar and old research was excluded. DATA EXTRACTION: Totally 187 articles on cervical bone graft fusion and adjacent segment degeneration after spinal fusion were included. Repetitive or similar and old research articles were excluded. Twenty-four literatures were accorded with the above criteria. DATA SYNTHESIS: ① Bone grafting material of cerbical vertebral fusion: In cervical spinal fusion, autograft or allograft had some unavoidable drawbacks. Using alone or in combination with bone morphogenesis protein (BMP) had better biomechanical advantages. ② Choice of cervical vertebral fusion part: Anterior cervical fusion had a higher fusion rate than posterior fusion. ③ Occurrence and incidence of degeneration of adjacent segment after cervical spinal fusion: The most common abnormal finding in adjacent segment was disc degeneration. The incidence degeneration of adjacent segment could be as high as 25% at 10-year postoperative follow-up, but symptomatic patients was less; anterior fusion had a higher rate of adjacent segment degeneration than posterior fusion. Potential risk factors included rigid instrumentation, postoperative sagittal malalignmeat of cervical spine, fusion length, facet injury and pre-existing dedenerative changes. CONCLUSION: Anterior cervical spinal fusion with appropriate selection of ceramic synthetics and BMP can not only produce a better outcome, but also avoid those complications associated with bone grafts. Biomechanical alteration likely plays a primary role in the development of adjacent segment degeneration. Potentially modifiable risk factors for the development of adjacent segment degeneration includes fusion without or with dynamic instrumentation, protecting the facet joint of adjacent segment, fusion length and sagittal balance of cervical spine. Asymptomatic adjacent segment degeneration is common, but does not correlate with functional outcomes. Surgical management, when indicated, consists of neural elements decompression and extension of fusion.
作者 夏磊 李军伟
出处 《中国临床康复》 CAS CSCD 北大核心 2005年第46期122-124,共3页 Chinese Journal of Clinical Rehabilitation
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