内镜下颈椎管成形术治疗脊髓型颈椎病

Minimally invasive laminoplasty for cervical spondylotic myelopathy using microendoscopy

目的探讨内镜下微创颈椎管成形术治疗脊髓型颈椎病的可行性及适应证，并分析其临床疗效。方法收集2011年1月至2013年12月我院51例采用内镜下微创颈椎管成形术治疗并随访〉9个月的脊髓型颈椎病患者的临床资料，其中男28例，女23例，年龄41-76岁，平均（58．2±7．9）岁。病程0．5-15年，平均5．5年。所有患者影像学检查均发现颈椎间盘突出伴脊髓压迫，其中两节段者5例（C5-6）；三节段者7例（C3-5和C4-6分别为3例和4例）；四节段者22例（C3-6）；五节段者17例（C3-7）。依据日本矫形外科协会（Japanese Orthopaedic Association，JOA）评分和疼痛视觉模拟量表测定的评分（visual analog scales，VAS），分别评估疗效及轴性症状；摄颈椎正侧位X线片评估颈椎曲率和活动度；采用cT扫描测量手术前后颈椎管矢状径，比较颈椎管大小变化并观察椎板切开减压槽处骨愈合情况；MRI评估脊髓内信号强度变化及脊髓减压状况；应用配对设计资料t检验对JOA评分、VAS评分、颈椎曲率和活动度进行统计学分析。结果51例的手术时间58～139min，平均（115．3±21．9）min，术中出血量110-380ml，平均（228．1±73．2）ml；术后随访9-36个月，平均（20．2±5．9）个月。JOA评分从术前（8．02±1．69）分增加至术后1年（13．02±1．48）分，差异有统计学意义（t=22．846，P=O．000），疗效评估：优17例，良28例，可4例。轴性疼痛VAS评分术后1年为（2．22±0．90）分，与术前（4．96±1．39）分比较，差异有统计学意义（t=23．205，P=O．000），轴性症状评估：优18例，良21例，可12例。术前颈曲指数（cervical curvature index，CCI）为15．40％±4．50％与术后颈曲指数15．09％±4．87％的差异无统计学意义，颈椎活动度术前为40．98°±8．27°，术后38．88°±9．53°，两者差异无统计学意义。术后椎管矢状径增加1．3-3．2mm，平均（2．32±0．42）mm。共204个椎板行双侧开槽微型钛板固定，末次随访共146个椎板双侧减压槽处发生骨愈合，愈合率为71．6％。本组术后发生一侧上肢轻度活动障碍1例，给予甲泼尼龙琥珀酸钠治疗后肌力逐渐恢复。出现l枚小螺钉轻微松动1例，未给予处理。结论内镜下微创颈椎管成形术是一种可减少棘突一韧带复合体和深部肌肉损伤的新手术方式，能安全有效治疗脊髓型颈椎病。

Objective To explore the indications, feasibility and clinical outcome of minimally invasive laminoplasty for cervical spondylotic myelopathy （CSM） using microendoscopic technique. Methods From January 2011 to December 2013, 51 patients with CSM treated by this technique in our hospital were reviewed in this study. All these patients were followed up at least 9 months. There were 28 males and 23 females with a mean age of 58 years （range 41-76 years）. All patients were found to have cervical disc herniation with spinal cord compression. Among these patients, 2 segments （C5-6）, 3 segments （C3-5/C4-6）, 4 segments （C3-6） and 5 segments （C3-7） laminoplasty performed in 5, 7, 22 and 17 cases respectively. Therapy effect and axial symptom were evalu- ated according to Japanese Orthopedic Association （JOA） scores and visual analogue scales （VAS） respectively. Cervical curvature index （CCI） and range of motion （ROM） were judged by X-ray. The sagittal diameter of cervical spine,canal enlargement and bony healing were judged by CT scans. Spinal cord signal intensity changes and spinal cord decompression status judged by MRI. Statis- tical analysis of JOA score, VAS score, CCI and ROM were performed by paired design t test. Results The mean operative time was （115＋21.9） min, ranging 58-139 rain. The mean blood loss was （227.8＋73.2） ml, ranging 110-380 ml. The followe-up time ranged 9-36 months with an average of （20-＋5.9） months.. The mean JOA scores had improved from 8.02± 1.69 pre-operatively to 13.02-＋1.48 post-operatively. The results were excellent in 17 cases, good in 28 and fair in 4. The VAS scores of axial pain signifi- cantly improved to 2.22±0.90 at the final follow-up compared with 4.96± 1.39 preoperatively. Axial symptom were excellent in 18 cases, good in 21 and fair in 12. Pre-operative was 15.40%±4.50% and postoperative was 15.09%±4.87%, there was no significant difference. ROM of pre-operative was 40.98°±8.27°and postoperative was 38.88°±9.53°, and there was no significant difference. The sagittal diameter of the spinal canal increased 1.3-3.2 mm postoperatively with an average of （2.32±0.42） mm. A total of 204 vertebral lamina were bilaterally slotted and fixed. 146 lamina were observed bone healing at the last follow-up. The bone healing rate was 71.6%. Complications such as upper limb motion dysfunction occurred in 1 case muscle strength restored after treatment of methylprednisolone sodium succinate, and little screw looseness in occurred 1 case, and non special treatment was given.. Con- clusion CMEL is a newsurgical approache which causes less damage to the spinous process-ligament complex and the deep ex- tensor muscles, and the procedure can be used for CSM effectively and safely.