不伴随感觉障碍的慢性脊髓型颈椎病的治疗体会

The treatment experience of the chronic cervical spondylotic myelopathy without sensory disorders

目的:总结不伴随感觉障碍的慢性脊髓型颈椎病及其手术治疗效果。方法:回顾性分析2013年3月至2018年3月收治的19例不伴随感觉障碍的慢性脊髓型颈椎病患者,此类患者均无颈椎水平以下的脊髓和神经压迫,且无其他的神经系统疾病。19例患者均行颈椎管减压治疗。手术前后用日本骨科协会(Japanese Orthopaedic Association,JOA)评分判定神经功能;使用徒手肌力评定法(manual muscle test,MMT)评估患者四肢肌力;利用磁共振成像(magnetic resonance imaging,MRI)测量患者受压节段脊髓膨起程度。所有患者随访时间为12~48个月,平均随访时间为28.6个月。结果:19例患者在术前均有不同程度的四肢运动功能障碍和上运动神经元损害所致的病理反射,巴宾斯基征阳性19例,霍夫曼征阳性11例,查多克征阳性3例,但所有患者均无肢体感觉异常。术后初期,患者症状较术前均明显改善。患者伤口均为Ⅰ期愈合,无并发症发生。术后患者四肢平均肌力评估改善率为89.2%,术后末次随访JOA评分平均为(14.4±1.2)分,较术前(10.2±1.5)分差异有统计学意义(P<0.01);MRI测量最狭窄处硬膜囊平均横截面积由(89.7±4.2)mm2增加至(156.0±6.5)mm2,较术前增加73.9%,差异有统计学意义(P<0.01)。矢状位、水平位MRI均显示受压脊髓膨起良好。结论:不伴随感觉障碍的慢性脊髓型颈椎病以上运动神经元损害的四肢不全瘫为临床表现,以无肢体感觉异常为特征。在临床诊疗中,易与运动神经元病混淆。提高对该型颈椎病的认识和鉴别能力,尽早进行外科干预,采取颈椎前路或后路减压手术可有效解除脊髓压迫,取得满意的治疗结果,有利于促进患者术后快速康复、提高患者的生活质量。

Objective:To describe cases of chronic cervical spondylotic myelopathy(CCSM)without sensory disorders and surgical outcomes.Methods:Between March 2013 and March 2018,19 patients with CCSM without sensory disorders secondary to cervical spinal stenosis were treated in Department of Orthopedic Surgery,Tianjin Medical University General Hospital.There was no spinal cord compression under the cervical spine,no cauda equine compression,no other neurological disease.All patients underwent surgical decompression with fixation treatment.Japanese Orthopaedic Association(JOA)scoring system were applied to evaluate the neurological function;manual muscle test(MMT)scoring system were used to evaluate the limbs muscle strength;cross-sectional area at the level of compression of the dural sac preoperatively and 1.5 months postoperatively were calculated by MRI.The following up period ranged from 12 to 48 months(mean,28.6 months).Results:Preoperatively,all 19 patients exhibited varying degrees of limbs motor dysfunction and pathological reflexes resulting from an upper motor neuron lesion.19 patients exhibited a positive Babinski sign;11 exhibited a positive Hoffman sign;3 exhibited a positive Chaddock sign.All patients are without sensory disorders.Postoperatively,the initial symptoms were significantly alleviated.All the incisions healed by first intention.There was no complication of neurologic function deterioration,meningitis,wound infection.The mean calculated muscle strength recovery rate was 89.2%.Mean JOA score increased from(10.2±1.5)preoperatively to(14.4±1.2)at the final follow-up(t=-15.24,P<0.01).MRI indicated that the cross-sectional area at the level of maximum compression of the dural sac increased from(89.7±4.2)mm2 preoperatively to(156.0±6.5)mm2 postoperatively.Both sagittal MRI and axial MRI scan showed that compressed deformity of the spinal cord returned to normal.Conclusion:CCSM caused by cervical spinal stenosis can be no sensory disorders,which is easy to be confused with neurological motor neuron disease.A full-scale understanding of this type of cervical spondylosis and appropriate surgical decompression with fixation may be an effective treatment option for this syndrome.