脊柱外科杂志  2024, Vol.22 Issue(5): 289-294   PDF    
颈椎后路单侧显露椎管扩大椎板成形术治疗颈椎后路单开门椎管扩大椎板成形术后的骨化进展
沈晓龙, 徐辰, 钟华建, 王睿哲, 张子凡, 文国庆, 吴卉乔, 刘洋, 王新伟, 陈华江, 魏磊鑫, 袁文     
海军军医大学长征医院骨科, 上海 200003
摘要: 目的 探讨采用颈椎后路单侧显露椎管扩大椎板成形术治疗颈椎后路单开门椎管扩大椎板成形术后骨化进展的可行性和有效性。方法 2021年6月—2023年3月,采用颈椎后路单侧显露椎管扩大椎板成形术治疗颈椎后路单开门椎管扩大椎板成形术后骨化进展患者12例。记录翻修手术的手术时间、术中出血量、术后引流量及手术并发症情况。于术前、术后12个月及末次随访时采用疼痛视觉模拟量表(VAS)评分评估颈部疼痛程度;采用颈椎功能障碍指数(NDI)评价颈椎功能;采用日本骨科学会(JOA)评分评估神经功能状况。测量术前、术后12个月及末次随访时C2~7 Cobb角、颈椎活动度(ROM)、T1倾斜角、C2~7矢状面平衡(SVA)及椎管横截面积。结果 所有手术顺利完成,所有患者均未发生明显神经损伤、深部感染等严重并发症。手术时间为(105.38±19.06)min,术中出血量为(128.44±33.62)mL,术后引流量为(142.51±25.38)mL。所有患者随访12~33(22.64±6.72)个月。翻修术后12个月、末次随访VAS评分、NDI及JOA评分较术前明显改善,差异均有统计学意义(P < 0.05)。翻修术后12个月、末次随访时C2~7 Cobb角、ROM、T1倾斜角及C2~7 SVA较术前无明显变化,差异无统计学意义(P>0.05)。翻修术后12个月、末次随访时椎管横截面积较术前明显增加,差异均有统计学意义(P < 0.05)。随访中无钛板断裂等严重内置物并发症发生。结论 采用颈椎后路单侧显露椎管扩大椎板成形术治疗颈椎后路单开门椎管扩大椎板成形术后的骨化进展安全、有效。翻修手术明显改善了患者的神经功能、保留了颈椎ROM。
关键词: 颈椎    骨化,后纵韧带    减压术,外科    再手术    
Posterior cervical unilaterally exposed spinal laminoplasty for treatment of ossification progression after posterior cervical single-door laminoplasty
Shen Xiaolong, Xu Chen, Zhong Huajian, Wang Ruizhe, Zhang Zifan, Wen Guoqing, Wu Huiqiao, Liu Yang, Wang Xinwei, Chen Huajiang, Wei Leixin, Yuan Wen     
Department of Orthopaedics, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
Abstract: Objective To explore the feasibility and effectiveness of using posterior cervical unilaterally exposed laminoplasty to revise the ossification progression after posterior cervical single-door laminoplasty. Methods From June 2021 to March 2023, 12 patients of ossification progression after single-door laminoplasty were treated by posterior cervical unilaterally exposed laminoplasty. The operation time, intraoperative blood loss, postoperative drainage volume and complications were recorded. At pre-operation, postoperative 12 months and the final follow-up, the visual analogue scale(VAS) score was used to evaluate the intensity of neck pain, and the neck disability index(NDI) was used to evaluate the cervical function, and the Japanese Orthopedic Association(JOA) score was used to evaluate the neurological function. The C2-7 Cobb angle, range of motion(ROM), T1 slope, C2-7 sagittal vertical axis(SVA) and cross-sectional area of spinal canal were measured. Results All the operations were successfully completed. No postoperative complications such as nerve injury and infection occurred. The operation time was(105.38±19.06) min, the intraoperative blood loss was(128.44±33.62) mL, and the postoperative drainage volume was(142.51±25.38) mL. All the patients were followed up for 12 - 33(22.64±6.72) months. The VAS scores, NDI and JOA scores of the patients at postoperative 12 months and the final follow-up showed significant improvement compared with those at pre-operation, all with a statistical significance difference(P < 0.05). There were no significant differences in the C2-7 Cobb angle, ROM, T1 slope, and C2-7 SVA at postoperative 12 months and the final follow-up compared with those at pre-operation(P>0.05). The cross-sectional area of spinal canal at postoperative 12 months and the final follow-up showed a significant increase compared with those at pre-operation, all with a statistical significance difference(P < 0.05). No serious implant complications such as titanium plate fracture or displacement occurred during the follow-up. Conclusions As a revision surgery for ossification progression after posterior cervical single-door laminoplasty, posterior cervical unilaterally exposed laminoplasty is a safe and effective procedure. It can significantly improve the patient's neurological function and effectively preserve the cervical ROM.
Key words: Cervical vertebrae    Ossification, posterior longitudinal ligament    Decompression, surgical    Reoperation    

颈椎后纵韧带骨化症(OPLL)临床较为常见,如果患者伴有严重的神经症状,手术是最有效的治疗方法,颈椎后路单开门椎管扩大椎板成形术是最常用的术式之一,该术式在显著改善患者神经功能的同时,能有效保留颈椎活动度(ROM),是治疗颈椎OPLL的理想术式。然而,由于骨化物没有去除,颈椎后路单开门椎管扩大椎板成形术后骨化继续进展、神经症状再加重的病例并不少见。既往研究[1-3]报道,针对此类患者可采用颈椎前路减压融合术及颈椎后路椎板切除侧块螺钉内固定融合术进行翻修,但存在手术难度高、创伤大、并发症多等不足。针对此类患者,本研究组尝试采用颈椎后路单侧显露椎管扩大椎板成形术进行翻修,现报告如下。

1 资料与方法 1.1 一般资料

纳入标准:①颈椎后路单开门椎管扩大椎板成形术后骨化进展、神经症状加重。骨化进展的评价标准为在颈椎任意水平相同层面横断面CT上骨化物前后径增加≥2 mm。②年龄30 ~ 80岁。排除标准:①首次手术开门侧无钛板固定;②须辅助侧块螺钉内固定。根据上述标准,纳入2021年6月—2023年3月采用颈椎后路单侧显露椎管扩大椎板成形术对颈椎后路单开门椎管扩大椎板成形术后骨化进展的12例患者进行翻修,其中男8例、女4例,年龄为49 ~ 76(60.37±8.23)岁,翻修手术距上次手术时间3.5 ~ 14.0(8.12±3.45)年。翻修术前患者骨化物前后径增加(3.38±0.76)mm,其中骨化物进展位于C3/C4水平1例、C4水平2例、C4/C5水平3例、C5水平3例、C5/C6水平2例、C6水平1例。翻修手术中,7例患者采用了完全单侧显露技术,相对上一次手术,翻修手术节段未扩大;5例患者采用了单侧显露并对侧通道辅助技术(单侧显露选择性通道技术),相对上一次手术,翻修手术节段有扩大延长。

1.2 手术方法

患者全身麻醉后取俯卧位,沿原手术切口切开皮肤、皮下筋膜,显露棘突,于上次手术的铰链侧显露需要翻修区域的椎板及侧块内缘(图 1a),在椎板与侧块交界处用4 mm磨钻磨除表层骨皮质,用枪状咬骨钳咬除剩余骨质(图 1b),用椎板夹持器夹持椎板并旋转,逐个掀开开门,使用ARCH钛板螺钉固定开门侧(强生,美国)。常规生理盐水冲洗,放置负压引流管后关闭切口,术后48 ~ 72 h拔除引流管,术后第二天患者可佩戴颈托下床活动。详细手术过程可参考本研究组前期发表的文章[4-6]。如翻修手术需要延长手术节段,翻修时开门侧单侧显露,延长节段的椎板需要置入可扩张通道制作铰链(图 1cd),具体可参考本研究组提出的单侧显露选择性通道技术[6]

图 1 颈椎后路单侧显露椎管扩大椎板成形术的关键步骤 Fig. 1 Key steps of posterior cervical unilaterally exposed spinal laminoplasty a:在原手术的铰链侧进行单侧显露(C3~7)  b:在C3~7椎板与侧块交界处制作骨槽,用枪状咬骨钳咬除椎板剩余骨质  c:在C7对侧置入通道,在通道下制作铰链  d:手术结束时C3~6对侧肌肉韧带完好无损,C7铰链侧肌肉损伤很小,容纳通道的肌肉裂隙用脑棉片填塞临时止血 a: Unilateral exposure on hinge side of previous surgery(C3-7)  b: Gutter is made with a high-speed burr, and medial walls of bony gutter are completely resected  c: Expandable channel is inserted at other side of C7, and gutter is made with a high-speed burr under channel  d: At end of surgery, muscles and ligaments are intact at hinge side of C3-6, and mild damaged at C7. Muscle gap is filled with sterile cotton piece for temporary hemostasis
1.3 评价指标

记录患者手术时间、术中出血量、术后引流量及并发症发生情况。于术前、术后12个月及末次随访时采用疼痛视觉模拟量表(VAS)评分[7]评估颈部疼痛程度;采用颈椎功能障碍指数(NDI)[8]评价颈椎功能;采用日本骨科学会(JOA)评分[9]评估神经功能状况。JOA评分改善率(%)=(术后JOA评分-术前JOA评分)/(17分-术前JOA评分)×100%。

术前、术后12个月及末次随访时在侧位X线片上测量C2~7 Cobb角、颈椎ROM、C2~7矢状面平衡(SVA)、T1倾斜角及椎管横截面积。椎管横截面积采用原始骨性椎管测量法,即椎管面积测量区域包含骨化物区域[6]。为了减少测量误差,所有数据由2名高年资主治医师分别测量,然后取平均值。手术节段椎管横截面积取各节段平均值。

1.4 统计学处理

采用SPSS 18.0软件对数据进行统计分析,符合正态分布的计量资料以x±s表示,不同时间点的计量资料比较采用重复测量方差分析;以P < 0.05为差异有统计学意义。

2 结果

所有手术顺利完成,所有患者均未发生明显神经损伤、深部感染等严重并发症。手术时间为(105.38±19.06)min,术中出血量为(128.44±33.62)mL,术后引流量为(142.51±25.38)mL。所有患者随访12 ~ 33(22.64±6.72)个月。翻修术后12个月、末次随访时颈痛VAS评分、NDI及JOA评分较术前明显改善,差异均有统计学意义(P < 0.05,表 1)。翻修术后12个月、末次随访时C2~7 Cobb角、ROM、T1倾斜角及C2~7 SVA较术前无明显变化,差异无统计学意义(P > 0.05,表 1)。翻修术后12个月、末次随访时椎管横截面积较术前明显增加,差异均有统计学意义(P < 0.05,表 1)。

表 1 翻修手术前后患者临床指标 Tab. 1 Clinical indexes of all patients before and after revision surgery 

1例患者术中发生脑脊液漏,经非手术治疗后好转;2例患者术后切口延迟愈合,细菌培养均为阴性,考虑脂肪液化可能,经2周清洁换药后切口愈合。随访中无钛板断裂等严重内置物并发症发生。典型病例影像学资料见图 2~4

图 2 第一次术前典型病例影像学资料 Fig. 2 Imaging data of a typical case before first surgery a、b:术前正侧位X线片示颈椎曲度变直  c:术前矢状位CT示颈椎OPLL,椎管狭窄  d:术前矢状位T2加权像MRI示C4,5节段脊髓受压、变性  e ~ i:C3~7节段术前横断面CT  j ~ n:C3~7节段术前横断面T2加权像MRI a, b: Preoperative anteroposterior and lateral roentgenographs show cervical curvature straighten  c: Preoperative sagittal CT shows OPLL and cervical stenosis  d: Preoperative sagittal T2WI MRI shows spinal cord compression and degeneration at C4, 5 level  e-i: Preoperative cross section CTs of C3-7 level  j-n: Preoperative cross section T2WI MRIs of C3-7 level

图 3 翻修术前典型病例影像学资料 Fig. 3 Imaging data of a typical case before revision surgery 患者第一次术后神经症状改善,但4年后神经症状再次加重  a、b:翻修术前正侧位X线片  c、d:翻修术前矢状位CT和T2加权像MRI示C4,5节段脊髓受压、变性  e ~ i:翻修术前C3~7节段横断面CT示骨化物较第一次术前明显进展,C5水平最为明显  j ~ n:翻修术前C3~7节段横断面T2加权像MRI Patient's neurological symptoms improved after first surgery, but worsened again 4 years later  a, b: Anteroposterior and lateral roentgenographs before revision surgery  c, d: Sagittal CT and T2WI MRI before revision surgery show spinal cord compression and degeneration at C4, 5 level  e-i: Cross section CTs at C3-7 level before revision surgery show significant progression of ossification compared to first surgery, with C5 level being most pronounced  j-n: Cross section T2WI MRIs at C3-7 level before revision surgery

图 4 翻修术后典型病例影像学资料 Fig. 4 Imaging data of a typical case after revision surgery a、b:翻修术后正侧位X线片  c、d:翻修术后矢状位CT和T2加权像MRI示C4,5节段脊髓减压彻底  e ~ i:翻修术后C3~7节段横断面CT  j ~ n:翻修术后C3~7节段横断面T2加权像MRI a, b: Anteroposterior and lateral roentgenographs after revision surgery  c, d: Sagittal CT and T2WI MRI after revision surgery show complete spinal cord decompression at C4, 5 level  e-i: Cross section CTs at C3-7 level after revision surgery  j-n: Cross section T2WI MRIs at C3-7 level after revision surgery
3 讨论

颈椎后路单开门椎管扩大椎板成形术治疗OPLL的优点:①减压效果优异,具有去除椎板、黄韧带对脊髓阻挡的直接减压作用,以及使脊髓向后方漂移的间接减压作用[10-12]。②保留颈椎ROM,这是前路或后路内固定融合术所不可企及的,颈椎后路单开门椎管扩大椎板成形术不跨越椎节,椎间相对活动不受影响,属于非融合手术,术后对患者的低头、后仰活动影响不大[10]。③手术操作简单、风险小,后路手术损伤脊髓、大血管的风险较前路小。骨化程度越重、骨化范围越广,颈椎后路单开门椎管扩大椎板成形术降低手术风险的优势越明显。④并发症少,相对于颈椎后路椎板切除内固定融合术,椎管扩大椎板成形术保留的结构多,术后C5神经根麻痹、脑脊液漏、轴性颈痛等发生率明显降低[13-14]。⑤降低二期前路手术的风险。后路手术后如果患者恢复不理想,需要二期做前路手术,由于后路手术后脊髓已向后漂移,脊髓前方的缓冲空间增大,这样就降低了前路手术对脊髓的干扰刺激,降低了前路手术中脊髓损伤的风险。

OPLL是一种慢性、进展性疾病,颈椎后路单开门椎管扩大椎板成形术后骨化有继续增大、进展的可能[15-16]。有研究[1]认为,混合型和连续型OPLL的年轻患者骨化进展的风险最高[17]。如果骨化持续进展,严重者会导致明显脊髓压迫症状,需要进行翻修手术。文献报道的翻修方式主要包含前路减压植骨融合术和后路椎板切除内固定融合术[3, 18],均为融合手术,术后颈椎活动功能丢失,且好发轴性颈痛;前路减压植骨融合术易发生神经损伤、硬膜撕裂、内置物失败等并发症;后路椎板切除内固定融合术易发生瘢痕粘连、椎管静脉丛出血、C5神经根病等并发症。

为了减少翻修手术的创伤、避免颈椎活动功能的丢失,本研究组尝试将前一次手术的开门侧钛板作为翻修时的铰链、前一次手术的铰链侧作为翻修时的开门侧,以钛板为旋转支点将椎板掀起并旋转,达到获得开门的效果(简称为单侧显露技术)。本研究结果显示,单侧显露技术的临床效果优异、椎管扩大显著。如果翻修时不需要延长手术节段,完全的单侧显露技术即可顺利完成翻修手术;如果翻修时需要延长手术节段,翻修时开门侧可以采用单侧显露技术,同时,可以在延长节段的椎板置入可扩张通道制作铰链,类似本研究组前期报道的单侧显露选择性通道技术[6]。相对于常见的融合翻修手术,单侧显露技术有如下优点。①单侧显露,降低手术创伤,减少出血量及手术时间。②患者快速康复,减少卧床时间和卧床并发症。③椎管扩大显著,神经功能恢复良好。④保留颈椎ROM,术后颈椎的活动功能得到最大程度的保留。⑤开门旋转椎板时,以钛板为铰链,大大降低了对侧椎板离断移位卡压脊髓的风险。

Ohaegbulam等[19]报道了椎板浮动的椎管扩大椎板成形术,术中于椎板两侧开槽、离断,用缝线将椎板、棘突悬吊固定于颈椎后方的筋膜韧带,36例患者采用此技术治疗,术后短期临床效果优异,其中19例患者随访超过5年,未发生颈椎不稳、后凸畸形等并发症。本研究采用的单侧显露技术与此相似,椎板间未进行植骨融合,随访过程中未发现螺钉松动脱落、钛板断裂的发生,推测原因可能:①单侧显露,创伤小,稳定结构破坏少;②钛板螺钉固定后,椎板棘突与侧块之间没有相对活动、不稳的刺激因素,固定效果可靠;③瘢痕修复将钛板螺钉包裹,相对位置更加稳定,瘢痕愈合后,钛板螺钉的固定作用可能会削弱。

综上,采用颈椎后路单侧显露椎管扩大椎板成形术翻修颈椎后路单开门椎管扩大椎板成形术后骨化进展安全、有效,明显改善了患者的神经功能、保留了颈椎ROM,且手术创伤小,患者术后恢复快。

参考文献
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