颈前路分段减压植骨融合术治疗多节段脊髓型颈椎病

TREATMENT OF MULTI-LEVEL CERVICAL SPONDYLOTIC MYELOPATHY BY ANTERIOR SEGMENTAL DECOMPRESSION AND AUTOGRAFT FUSION

目的探讨颈前路分段减压植骨融合术治疗多节段脊髓型颈椎病的方法和疗效。方法 2007年1月-2009年5月,采用颈前路分段减压植骨融合术治疗23例多节段脊髓型颈椎病。男16例,女7例;年龄49～70岁,平均58岁。均为连续3个节段病变,其中C3、4、C4、5、C5、615例,C4、5、C5、6、C6、78例。23例均有不同程度四肢与躯干感觉减退,双手握力减弱,双下肢行走不稳及腱反射亢进。颈椎MRI示均有3个节段椎间盘退变、突出,相应节段脊髓受压。病程6～28个月,平均12.5个月。将日本骨科协会(JOA)评分系统作为疗效评价标准,记录患者术前及术后1周,3、12个月JOA评分并计算改善率。结果 1例术中硬膜囊撕裂,以明胶海绵填塞,术后未见脑脊液漏。术后切口均Ⅰ期愈合。无椎动脉损伤及喉返神经损伤发生。23例均获随访,随访时间12～24个月,平均15.1个月。术后2周内患者神经症状明显好转,下肢肌力增加,肢体活动较术前明显改善,且双上肢感觉异常基本消失。1例术后1周钛网向上终板塌陷约2mm,随访期内未见加重;余内固定物位置良好。23例术后12个月颈椎正侧位X线片均可见椎间隙融合,椎间高度及生理弧度维持良好。JOA评分由术前(9.1±0.3)分提高至术后12个月(14.3±0.4)分,比较差异有统计学意义(P<0.01);术后12个月时改善率为65.8%±0.2%。按照Odom临床效果分级标准评价:获优10例,良8例,可4例,差1例。结论颈前路分段减压植骨融合术可达到充分减压,即刻重建颈椎稳定性,植骨融合率高,是治疗多节段脊髓型颈椎病的有效方法之一。

Objective To evaluate the clinical effects of anterior segmental decompression and autograft fusion in treating multi-level cervical spondylotic myelopathy （CSM）. Methods Between January 2007 and May 2009, 23 patients with multi-level CSM were treated with anterior segmental decompression, autograft fusion, and internal fixation. There were 16 males and 7 females with an average age of 58 years （range, 49-70 years）. Consecutive 3 segments of C3,4, C4, 5, and C5, 6 involved in 15 cases and C4, 5, C5, 6, and C6, 7 in 8 cases. All patients suffered sensory dysfunction in limbs and trunk, hyperactivity of tendon reflexes of both lower extremities, walking with limp, and weakening of hand grip. Cervical MRI showed degeneration and protrusion of intervertebral disc and compression of cervical cord. The disease duration was 6 to 28 months （12.5 months on average）. Japanese Orthopaedic Association （JOA） score system was adopted for therapeutic efficacy evaluation. JOA scores were recorded preoperatively, 1 week, 3 months, and 12 months postoperatively. Results Dura tear occurred in 1 case and was treated by filling with gelatinsponge during operation; no cerebrospinal fluid leakage was observed after operation. All the incisions healed by first intention. All cases were followed up 12 to 24 months （15.1 months on average）, and no vertebral artery injury or recurrent laryngeal nerve injury occurred. The nervous symptoms in all cases were improved significantly within 1 week after operation. Lower limb muscle strength increased, upper limb abnormal sensation disappeared, and limb moved more agile. A 2-mm collapses of titanium mesh into upper terminal plate were found in 1 case and did not aggravated during follow-up. The other internal fixator was in appropriate situation, and the fusion rate was 100%. The JOA score increased from 9.1 ± 0.3 preoperatively to 14.3 ± 0.4 at 12 months postoperatively with an improvement rate of 65.8% ± 0.2%, showing significant difference （P 0.01）. According to Odom evaluation scale, the results were excellent in 10 cases, good in 8 cases, fair in 4 cases, and poor in 1 case. Conclusion Anterior segmental decompression and autograft fusion is a recommendable technique for multi-level CSM, which can make full decompression, conserve the stability of cervical cord, and has high fusion rate.