改良颈椎后路单开门椎管扩大成形术治疗多节段脊髓型颈椎病

Modified open-door laminoplasty for multiple-segment cervical spondylotic myelopathy

目的:总结保留颈半棘肌肌止、C3椎板切除、C4-C7"锚定"单开门椎管扩大成形术治疗多节段脊髓型颈椎病的临床效果。方法:2009年1月～2011年10月,共对74例多节段脊髓型颈椎病患者采用保留颈半棘肌肌止、C3椎板切除、"锚定法"固定悬吊C4-C7椎板的单开门椎管扩大成形术治疗,其中57例患者获得随访,男31例,女26例,年龄50-71岁,平均63岁。术前JOA评分4-11分,平均8.5±2.0分,颈椎活动度23°-49°,平均37.4°±10.3°,颈椎曲度指数6.0%-22.0%,平均(13.9±7.4)%。观察患者术中和术后并发症发生情况;术后6个月复查颈椎X线片,测量颈椎曲度指数和颈椎活动度,观察颈椎曲度指数和颈椎活动度变化情况;末次随访时对患者神经功能进行JOA评分,计算神经功能改善率。结果:手术均顺利完成,手术时间50-110min,平均70min。术中出血150-600ml,平均230ml。术中无脊髓损伤、脑脊液漏等并发症发生。术后早期41例患者有颈痛,给予消炎镇痛治疗,术后3周内疼痛消失或明显缓解。2例出现切口感染,经抗感染治疗并再次清创后切口延时愈合。9例有明显轴性症状,发生率为15.8%;6例出现C5神经根麻痹,给予甲基强的松龙、营养神经药物等治疗后症状明显缓解。随访6-32个月,平均13个月,术后6个月颈椎曲度指数为4.2%-21.1%,平均(11.3±8.1)%,较术前丢失(2.9±2.4)%;颈椎活动度为18°-46°,平均28.2°±10.8°,平均丢失8.2°±5.1°。患者神经功能均不同程度得到改善,末次随访时JOA评分为10-17分,平均13.8±2.3分,较术前明显提高(P<0.05),神经功能改善率为29.0%-77.3%,平均(57.0±19.7)%。末次随访均未发现"再关门"现象。结论:保留颈半棘肌肌止、C3椎板切除、"锚定法"固定悬吊C4-C7椎板的单开门椎管扩大成形术可明显改善多节段脊髓型颈椎病患者的神经功能,手术操作简单,临床疗效满意。

Objectives： To discuss the clinical effect of C3 laminectomy and C4-C7 open-door laminoplasty for cervical spondylotic myelopathy（CSM）. Methods： From January 2009 to October 2011, 74 patients under- went extensive open-door laminoplasty, detailed as C3 laminectomy reserving attachment of musculus semi- spinalis cervicis and C4-C7 modified open-door laminoplasty. 57 patients got follow-up. Among them, there were 31 males and 26 females. The ages ranged from 50 to 71 years with a mean age of 63 years. The JOA scores were 4-11 points, with a mean of 8.5±2.0 before the operation. The range of motion was 23°-49° with a mean of 37.4°±10.3°. The cervical curvature index was 6.0%-22.0%, with a mean of （13.9±7.4）%. The preoperative and postoperative JOA scores were recorded. The JOA score and the incidence of axial symptom were reviewed. At six months after the operation, the change of ROM and cervical curvature index was noted. Results： The mean operative time was 70min ranging from 50 to 110min. The mean volume of blood loss was 230ml ranging from 150ml to 600ml. No complication such as spinal cord injury or eerebrospinal fluid leakage was noted. 41 patients had early postoperative neck pain, which resolved after corresponsive manage- ment. The rate of evident axial symptom was 15.8%. Two patients developed wound infection. Six patients were complicated with C5 nerve root palsy, which alleviated after symptomatic treatment. The patients with postoperative neurological deficit improved to different degrees. The postoperative JOA scores were 10-17points, with a mean of 13.8±2.3 points, which showed significant difference （P〈0.05）. The JOA improvement rate was 29.0%-77.3%, with a mean of （57.0±19.7）%. Loss of cervical curvature index was （2.9±2.4）%. The range of motion was 18°-46° with a mean of 28.2°±10.8°, and the loss of ROM was 8.2°±5.1°. No door-re- close was noted during follow-up. Conclusions： C3 laminectomy reserving attachment of musculus semi- spinalis cervicis and C4-C7 open-door laminoplasty for cervical spondylotic myelopathy is reliable and simple.