颈椎病患者后纵韧带与硬脊膜粘连的判断

How to determine whether adhesion between posterior longitudinal ligament and spinal dura mater exists or not

目的回顾性评估经前路手术证实的脊髓型颈椎病后纵韧带与硬脊膜粘连特点。方法2005年12月至2007年1月，治疗18例脊髓型颈椎病患者，男11例，女7例；年龄55～72岁，平均65．4岁。术前行颈椎CT与MR检查，未发现有后纵韧带及硬脊膜骨化。二节段颈椎间盘突出12例（66．7％），三节段颈椎间盘突出6例（33.3％）。二节段手术方法为单椎节椎体次全切除＋钛网（或髂骨）＋颈前路钢板固定；三节段手术方法为单椎节椎体次全切除植骨内固定，另一病变节段用颈椎cage植入融合。手术中证实存在后纵韧带与硬脊膜粘连，术中以“漂浮”方法处理后纵韧带与硬脊膜粘连。应用配对计数资料Kappa系数检验两种影像学提示存在后纵韧带和硬脊膜粘连的吻合度。结果全部病例手术后神经功能均有不同程度改善，按JOA评分法，术前平均9．6分，术后平均12．1分。4例术中损伤硬脊膜未直接修补，术后发生脑脊液漏，经适当加压处理，伤口均获得愈合。颈后纵韧带与硬脊膜粘连的CT横断位扫描示椎间盘与硬脊膜接触不光滑，有毛刺现象；MRI示后纵韧带增厚，粘连处硬膜下间隙与邻近间隙不对称。统计分析结果Kappa系数=0．40，P〈0．05，表明CT与MRI显示后纵韧带和硬脊膜粘连情况时，两者比较差异有统计学意义。结论脊髓型颈椎病前路减压术前MR检查能判断后纵韧带与硬脊膜粘连，其准确率优于CT扫描。手术中采用“漂浮”方法能有效处理粘连病变。

Objective To evaluate retrospectively whether posterior longitudinal ligament（PLL） adhere to dura mater in the patients with cervical spondylotic myelopathy（CSM） or not before the anterior cervical operation. Methods From December 2005 to January 2007, of 18 patients with CSM the adhesion between PLL and dura mater was found in the anterior cervical operation. The patients included of 11 males and 7 females, with mean age of 65.4 years （range 55-72 years）. All the patients were measured by CT and MRI before operation. There were 12 cases of dual-segmental cervical intervertebral disc herniation, 6 of tri-segmental disc herniation. The former cases were treated with one level corpectomy and titanium mesh or iliac grafting and cervical anterior plate, and the latter with an additional cervical cage in the intervertebral space. The floatation method was used to deal with the adhesion. The fitness between the two radiological methods was analyzed by matched-pairs Kappa coefficient test. Results The nerve functions of all the patients were improved after anterior cervical decompression. The mean score of JOA was increased from 9.6 of pre-operation to 12.1 of post-operation. There were 4 cases with injury in dura mater, which healed after appropriate dealing with the leakage of cerebrospinal fluid. None of lacerated dura was directly repaired during the operation. The condition of the coarse touch and bur between intervertebral disc and dura mater were found in CT transverse scanning. The thickening of the PLL and the unsymmetrical space between inferior and superior subdural cavity was found in MRI. The coefficient test proved that the difference of the CT and MRI was significant in finding the adhesion. Conclusion MRI is better than CT in finding the adhesion between the PLL and dura mater in CSM before operation, besides the floatation method should be good to deal with the adhesion.