神经根型颈椎病术前选择性神经根阻滞精准定位的进展

Preoperative precise location of responsible segment of cervical radiculopathy: the development of selective nerve root block

神经根性颈椎病是较为常见的脊柱外科疾病,对诊断明确、定位明确的神经根型颈椎病,积极的手术干预可有效缓解症状。随着微创技术的广泛应用,对术前病灶节段的精确定位的要求也随之提高,而由于皮区痛觉分布存在不典型的情况,导致磁共振结果、神经学查体的神经根定位效果不够可靠,继而直接影响手术效果。因此,近年来,术前选择性神经根阻滞(selective nerve root block,SNRB)在神经根型颈椎病中用于术前责任神经根定位逐渐增多。但由于此技术最初多为麻醉或放射科领域应用,目前国内外尚无对神经根型颈椎病术前SNRB不同穿刺技术、并发症相关风险因素、与穿刺安全性相关局部精细解剖等方面的内容梳理。我们将这一系列要点与微创脊柱外科临床应用相结合,与神经根型颈椎病责任节段术前精准定位目相联系,对颈椎SNRB的发展历史,不同穿刺入路的发展及差异(包括前外侧入路、外侧入路、后外侧入路、背侧“直接”入路和背侧“间接”入路),与颈椎SNRB灾难性并发症相关的因素(血管因素、固醇类激素种类选择等)以及能够提高颈椎SNRB安全性的要点(穿刺局部血管精细解剖及分布与进针角度影响等)及争议点(造影剂使用与否、颈椎侧位的重要性等),SNRB应用发展(背侧入路、超声引导下的颈椎SNRB应用效果等)进行了整理,作此综述。根据对研究结果的整理,总结术者在不同情况下对不同穿刺入路的选择参考,以期辅助脊柱外科医生更安全地应用SNRB进行术前定位。

Cervical spondylotic radiculopathy is one of the commonly seen spinal surgery diseases. For well-diagnosed and well-located cervical spondylotic radiculopathy, surgical intervention can effectively alleviate symptoms. With the wide application of minimally invasive surgical techniques, the requirements for precise preoperative orientation of responsible segments have increased, especially in multisegmental cervical spondylotic radiculopathy cases. However, due to the cutaneous pain distribution is often atypical, magnetic resonance imaging and neurological examinations may be not reliable enough for accurate location preoperatively which may fail to get a satisfactory surgical outcome. Selective nerve root block (SNRB) in preoperative localization of responsible nerve roots in cervical spondylotic radiculopathy has gradually increased. Yet this technology has been mostly used by anesthesiologists or radiologists, this field in minimally invasive spinal surgery is relatively blank. As we know, there is no previous review summarized the commonly used approaches of SNRB, the risk factors relating to complications, and the local precise blood vessels anatomy. In summary, we believe that combination these series of points with the necessity of preoperative precise location in cervical spondylotic radiculopathy may increase the safety of cervical SNRB. The keywords about "cervical" and "selective nerve root block" have been used in English and Chinese literature databases. The articles were filtrated by title, abstract and full text. There were 21 articles taken in the review. We summarized the history and distinction of different approaches including anterior lateral approach, lateral approach, posterior lateral approach, dorsal "direct" approach and dorsal 'indirect' approach, and described the indication of each approach. As well as the factors associating with catastrophic complications in cervical SNRB, for instance, the vascular distribution relating to vascular mistaken injection, steroid kind selection because large steroid particle may block some thin but vital arteries. In addition to cervical local blood vessels distribution and variation, the needle trajectory also played a key role in the complications of SNRB. Besides, other controversy points, such as whether use contrast media or not, the importance of the lateral position of the cervical spine, etc., were discussed in this review based on clinical researches. The purpose of the present study is hoping to provide some references for spine surgeons to apply SNRB technology more safely.