颈腰痛患者颈椎矢状位序列的代偿机制

doi:10.3969/j.issn.2095-4344.0789

摘要/Abstract

摘要：

文章快速阅读：

文题释义：

颈椎矢状位序列：正常的颈椎矢状位序列是颈椎发挥功能重要因素，颈椎矢状位序列异常对患者脊柱整体功能和生活质量产生不利影响。然而，颈椎矢状位序列改变与颈部疼痛的相关性是有争议的，有文献指出由于创伤和颈椎间盘退变引起颈椎前凸的减小会引起急、慢性颈部疼痛，而另外有文献指出颈椎前凸的改变与颈痛无明显的相关性。

颈椎前凸：颈椎前凸对颈痛治疗和预后非常重要，颈椎的生理性前凸维持了颈椎的生物力学平衡，颈椎矢状位曲度的改变易引起颈椎失稳，可能会诱发轻重不同的临床症状。然而，颈椎曲度的改变与颈痛之间的关系并不是很明确，有研究认为颈椎曲度改变导致颈部肌肉做功增加，短期内可代偿，失代偿后可导致颈痛和颈椎不稳。另外，其他研究者发现脊柱前凸和颈部疼痛之间没有关联。

摘要

背景：颈痛是非常常见的症状，但对于颈痛的病因诊断仍然困难，颈痛和颈椎矢状位序列之间的关系仍旧有很多争议。

目的：探讨颈腰痛患者颈椎矢状位序列可能存在的代偿机制。

方法：颈腰痛患者行站立位颈腰椎正侧位X射线检查。对照组为单纯颈痛患者、无颈部症状志愿者，行颈椎正侧位X射线检查，每组50人。测量颈-胸椎矢状位形态及序列参数包括C₀-C₂角、C₂-C₇角、C₂-C₇矢状面轴向距离、头部重心-C₇矢状面轴向距离、T₁倾斜角。所有参数均采用95%可信区间表示，各组所测参数以及C₀-C₂角+C₂-C₇角、C₂-C₇矢状面轴向距离与头部重心-C₇矢状面轴向距离之间的距离分别进行t 检验对比分析。

结果与结论：①颈腰痛患者C₀-C₂角为12.4°-20.7°，C₂-C₇角为5.6°-15.1°，T₁倾斜角为21.3°-25.8°，C₂-C₇矢状面轴向距离为14.2-20.8 mm，头部重心-C₇矢状面轴向距离为9.5-17.5 mm，C₀-C₂角+C₂-C₇角为23.1°- 30.7°，C₂-C₇矢状面轴向距离与头部重心-C₇矢状面轴向距离之间的距离为1.4-6.6 mm；②颈痛患者C₀-C₂角的值为15.6°-18.6°，C₂-C₇角的值为7.7°-13.1°，T₁倾斜角的值为23.1°-26.0°，C₂-C₇矢状面轴向距离值为13.5-17.7 mm，头部重心-C₇矢状面轴向距离值为10.5-17.2 mm，C₀-C₂角+C₂-C₇ 角的值为25.3°- 29.6°，C₂-C₇矢状面轴向距离与头部重心-C₇矢状面轴向距离之间的距离为-0.5-4.6 mm；③无症状志愿者C₀-C₂角为11.8°-17.9°，C₂-C₇角为7.7°-13.9°，T₁倾斜角为21.7°-24.5°，C₂-C₇矢状面轴向距离值为12.1-18.5 mm，头部重心-C₇矢状面轴向距离为6.4-15.3 mm，C₀-C₂角+C₂-C₇角为24.1°-28.8°，C₂-C₇矢状面轴向距离与头部重心-C₇矢状面轴向距离之间的距离为1.9-7.4 mm；④各组内男女之间各参数差异无显著性意义 (P > 0.05)，组间各参数之间差异也无显著性意义(P > 0.05)；⑤综上，颈腰痛患者、单纯颈痛患者和无症状者颈椎矢状位所测参数无明显差异，颈腰痛患者的颈椎矢状位序列代偿无特异性，还需要进一步寻求更为敏感的矢状位参数。

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程
ORCID: 0000-0003-0449-6536(张光明)

关键词: 颈痛, 颈腰痛, 颈椎矢状位序列, 脊柱植入物

Abstract:

BACKGROUND: Neck pain is a very common symptom, but it is still difficult to diagnose the etiology of neck pain. The relationship between neck pain and cervical sagittal alignment remains controversial.

OBJECTIVE: To investigate the possible compensatory mechanism of cervical sagittal alignment in patients with neck-low back pain.

METHODS: The patients with neck-low back pain were examined by neck and lumbar X-ray. The control group contained the patients with neck pain and without volunteers with cervical symptoms. The X-ray examination of the cervical spine was performed. Each group included 50 patients. Cervical-thoracic lateral radiographs were taken to analyze the following parameters: Occiput-C₂ angle; C₂-C₇ angle; C₂-C₇ sagittal vertical axial (SVA), (center gravity of head, CGH)-C₇SVA; T₁ slope. All parameters were expressed by 95% confidence interval, and the C₀-C₂ angle, C₂-C₇ angle, C₂-C₇ SVA and CGH-G7 SVA distance between groups were analyzed by t test.

RESULTS AND CONCLUSION: (1) The value of the Occiput-C₂ angle was 12.4°-20.7°; C₂-C₇ angle was 5.6°-15.1°; T₁ slope was 21.3°-25.8°; C₂-C₇ SVA was 14.2-20.8 mm; CGH-C₇ SVA was 9.5-17.5 mm; C₀-C₂ angle + C₂-C₇angle was 23.1°-30.7°; C₂-C₇ SVA -CGH-C₇ SVA was 1.4-6.6 mm in patients with neck-low back pain. (2) The value of the Occiput-C₂ angle was 15.6°-18.6°; C₂-C₇ angle was 7.7°-13.1°; T₁ slope was 23.1°-26.0°; C₂-C₇ SVA was 13.5-17.7 mm; CGH-C₇ SVA was 10.5-17.2 mm; C₀-C₂ angle + C₂-C₇ angle was 25.3°-29.6°; C₂-C₇ SVA -CGH-C₇SVA was -0.5-4.6 mm in patients with neck back pain. (3) The Occiput-C₂ angle was 11.8°-17.9°; C₂-C₇ angle was 7.7°-13.9°; T₁ slope was 21.7°-24.5°; C₂-C₇ SVA was 12.1-18.5 mm; CGH-C₇ SVA was 6.4-15.3 mm; C₀-C₂ angle + C₂-C₇ angle was 24.1°-28.8°; the distance between C₂-C₇ SVA and CGH-C₇ SVA was 1.9-7.4 mm in patients without symptoms. (4) There was no statistical significance in each parameter between males and females in each group (P > 0.05); and no significant difference in each parameter was determined between groups (P > 0.05). (5) In summary, there were no significant differences in the sagittal cervical parameters among patients with neck-low back pain and those with neck pain and those without symptoms. There was no specificity in the sagittal alignment compensation of the cervical spine in patients with neck-low back pain. More sensitive sagittal parameters should be studied.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

Key words: Cervical Vertebrae, Neck Pain, Low Back Pain, Tissue Engineering

中图分类号:

R318

张光明，阮志勇，胡荣胜，陈农，高如峰，潘福根. 颈腰痛患者颈椎矢状位序列的代偿机制[J]. 中国组织工程研究, 2018, 22(19): 3072-3076.

Zhang Guang-ming, Ruan Zhi-yong, Hu Rong-sheng, Chen Nong, Gao Ru-feng, Pan Fu-gen . Compensatory mechanism of cervical sagittal alignment in patients with neck-low back pain[J]. Chinese Journal of Tissue Engineering Research, 2018, 22(19): 3072-3076.

图/表（结果） 1

2.1 参与者数量分析 按意向性处理，研究纳入颈腰痛患者、单纯颈痛患者和无症状志愿者各50名，所有人年龄为18-35岁，平均年龄29岁。全部进入结果分析，无脱落。试验流程图见图2。

2.2 颈腰痛组各参数测量结果 颈腰痛患者C₀-C₂角的值为12.4°-20.7°，C₂-C₇角的值为5.6°-15.1°，T₁倾斜角的值为21.3°-25.8°，C₂-C₇矢状面轴向距离的值为14.2- 20.8 mm，头部重心-C₇矢状面轴向距离值为9.5-17.5 mm， C₀-C₂角+C₂-C₇角的值为23.1°-30.7°，C₂-C₇矢状面轴向距离与头部重心-C7矢状面轴向距离之间的距离为1.4- 6.6 mm，男女之间各参数比较差异无显著性意义，见表1。

2.3 单纯颈痛组各参数测量结果 单纯颈痛患者C₀-C₂ 角的值为15.6°-18.6°，C₂-C₇角的值为7.7°-13.1°，T₁倾斜角的值为23.1°-26.0°，C₂-C₇矢状面轴向距离的值为13.5-17.7 mm，头部重心-C₇矢状面轴向距离的值为10.5-17.2 mm，C₀-C₂角+C₂-C₇角的值为25.3°-29.6°，C₂-C₇矢状面轴向距离与头部重心-C₇矢状面轴向距离之间的距离为-0.5-4.6 mm，男女之间各参数比较差异无显著性意义，见表2。

2.4 无症状组各参数测量结果及组间对比 无症状志愿者C₀-C₂角的值为11.8°-17.9°，C₂-C₇角的值为7.7°-13.9°，T₁倾斜角的值为21.7°-24.5°，C₂-C₇矢状面轴向距离值为12.1-18.5 mm，头部重心-C₇矢状面轴向距离值为6.4- 15.3 mm，C₀-C₂角+C₂-C₇角的值为24.1°-28.8°，C₂-C₇矢状面轴向距离与头部重心-C₇矢状面轴向距离之间的距离为1.9-7.4 mm，男女之间各参数比较差异无显著性意义，见表3。颈腰痛患者、单纯颈痛患者和无症状志愿者颈椎矢状位各参数比较差异无显著性意义，见表4-6。

参考文献

[1] Cote P, van der Velde G, Cassidy JD, et al. The burden and determinants of neck pain in workers: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. J Manipulative Physiol Ther. 2009;32(2 Suppl): S70-86.

[2] Cote P, Kristman V, Vidmar M, et al. The prevalence and incidence of work absenteeism involving neck pain: a cohort of Ontario lost-time claimants. J Manipulative Physiol Ther. 2009;32(2 Suppl): S219-226.

[3] Mizutani J, Verma K, Endo K, et al. Global Spinal Alignment in Cervical Kyphotic Deformity: The Importance of Head Position and Thoracolumbar Alignment in the Compensatory Mechanism. Neurosurgery. 2017.

[4] Merrill RK, Kim JS, Leven DM, et al. Beyond pelvic incidence-lumbar lordosis mismatch: the importance of assessing the entire spine to achieve global sagittal alignment. Global Spine J. 2017;7(6): 536-542.

[5] Nordin M, Carragee EJ, Hogg-Johnson S, et al. Assessment of neck pain and its associated disorders: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. J Manipulative Physiol Ther. 2009;32(2 Suppl): S117-140.

[6] Kumagai G, Ono A, Numasawa T, et al. Association between roentgenographic findings of the cervical spine and neck symptoms in a Japanese community population. J Orthop Sci. 2014;19(3): 390-397.

[7] Grob D, Frauenfelder H, Mannion AF. The association between cervical spine curvature and neck pain. Eur Spine J. 2007;16(5): 669-678

[8] Beltsios M, Savvidou O, Mitsiokapa EA, et al. Sagittal alignment of the cervical spine after neck injury. Eur J Orthop Surg Traumatol. 2013;23 Suppl 1:S47-51.

[9] Singhatanadgige W, Kang DG, Luksanapruksa P, et al. Correlation and reliability of cervical sagittal alignment parameters between lateral cervical radiograph and lateral whole-body EOS stereoradiograph. Global Spine J. 2016;6(6): 548-554.

[10] Scheer JK, Tang JA, Smith JS, et al. Cervical spine alignment, sagittal deformity, and clinical implications: a review. J Neurosurg Spine. 2013; 19(2): 141-159.

[11] Tsunoda D, Iizuka Y, Iizuka H, et al. Associations between neck and shoulder pain (called katakori in Japanese) and sagittal spinal alignment parameters among the general population. J Orthop Sci. 2013;18(2): 216-219.

[12] Wang K, Deng Z, Li Z, et al. The Influence of Natural Head Position on the Cervical Sagittal Alignment. J Healthc Eng. 2017.

[13] Cote P, Cassidy JD, Carroll LJ, et al. The annual incidence and course of neck pain in the general population: a population-based cohort study. Pain. 2004;112(3): 267-273.

[14] Oshima Y, Takeshita K, Taniguchi Y, et al. Effect of preoperative sagittal balance on cervical laminoplasty outcomes. Spine (Phila Pa 1976). 2016;41(21): E1265-E1270.

[15] Patwardhan AG, Khayatzadeh S, Havey RM, et al. Cervical sagittal balance: a biomechanical perspective can help clinical practice. Eur Spine J. 2017.

[16] Harrison DE, Harrison DD, Janik TJ, et al. Comparison of axial and flexural stresses in lordosis and three buckled configurations of the cervical spine. Clin Biomech (Bristol, Avon). 2001;16(4): 276-284.

[17] Dulhunty J. Evaluation of axial and flexural stresses in the vertebral body cortex and trabecular bone in lordosis and two sagittal cervical translation configurations with an elliptical shell model. J Manipulative Physiol Ther. 2003;26(9): 608-612.

[18] Kwon TH, Park YK, Moon HJ. The relationship between neck pain and cervical alignment in young female nursing staff. J Korean Neurosurg Soc. 2015;58(3): 231-235.

[19] Lippa L, Lippa L, Cacciola F. Loss of cervical lordosis: What is the prognosis? J Craniovertebr Junction Spine. 2017;8(1): 9-14.

[20] Christensen ST, Hartvigsen J. Spinal curves and health: a systematic critical review of the epidemiological literature dealing with associations between sagittal spinal curves and health. J Manipulative Physiol Ther. 2008;31(9): 690-714.

[21] Harrison DE, Harrison DD, Betz JJ, et al. Increasing the cervical lordosis with chiropractic biophysics seated combined extension-compression and transverse load cervical traction with cervical manipulation: nonrandomized clinical control trial. J Manipulative Physiol Ther. 2003;26(3): 139-151.

[22] 任龙喜,何玉宝,郭函,等.颈部疼痛程度与颈椎曲度相关性的临床观察[J].中国脊柱脊髓杂志,2011,21(9):750-753.

[23] Harrison DE, Cailliet R, Harrison DD, et al. A new 3-point bending traction method for restoring cervical lordosis and cervical manipulation: a nonrandomized clinical controlled trial. Arch Phys Med Rehabil. 2002;83(4): 447-453.

[24] Protopsaltis TS, Scheer JK, Terran JS, et al. How the neck affects the back: changes in regional cervical sagittal alignment correlate to HRQOL improvement in adult thoracolumbar deformity patients at 2-year follow-up. J Neurosurg Spine. 2015;23(2): 153-158.

[25] Diebo BG, Varghese JJ, Lafage R, et al. Sagittal alignment of the spine: What do you need to know? Clin Neurol Neurosurg. 2015;139:295-301.

[26] Yu M, Silvestre C, Mouton T, et al. Analysis of the cervical spine sagittal alignment in young idiopathic scoliosis: a morphological classification of 120 cases. Eur Spine J. 2013;22(11): 2372-2381.

[27] Knott PT, Mardjetko SM, Techy F. The use of the T1 sagittal angle in predicting overall sagittal balance of the spine. Spine J. 2010;10(11): 994-998.

[28] Lee SH, Kim KT, Seo EM, et al. The influence of thoracic inlet alignment on the craniocervical sagittal balance in asymptomatic adults. J Spinal Disord Tech. 2012;25(2): E41-47.

[29] 赵文奎,于淼,韦峰,等.无症状成人颈椎矢状位曲度分析及其与全脊柱矢状位参数的关系[J].中国脊柱脊髓杂志,2015,25(3): 231-238.

[30] Lee CS, Chung SS, Kang KC, et al. Normal patterns of sagittal alignment of the spine in young adults radiological analysis in a Korean population. Spine (Phila Pa 1976).2011;36(25): E1648-1654.

引言

材料方法

讨论

颈椎是脊柱非常复杂的部分，它不仅支持头部的质量，而且相对于胸腰椎有着更大的活动度^[9]。因此复杂的颈部区域更容易产生疾病，这不可避免地导致颈椎的矢状位序列发生改变，甚至有些严重的患者需要手术矫形^[10]。而正常的颈椎矢状位序列是颈椎发挥功能重要因素，颈椎矢状位序列异常对患者脊柱整体功能和生活质量产生不利影响^[11-12]。而颈痛是非常常见的临床症状，40岁以上人群有20%的人经历过颈部疼痛^[11]，在社会层面，颈部疼痛对工作缺勤和医疗保健支出有重大影响。有文献通过对颈痛患者的回顾性分析认为年龄大于45岁是颈痛的易感因素^[13]，但随着现代工作、生活方式的改变，长期伏案工作以及长时间面对电脑、手机，颈痛逐渐出现年轻化的趋势。

即使在医学技术发达的今天，对颈部疼痛病因的准确诊断仍然是非常困难的。但有人提出颈椎前凸对颈痛治疗和预后非常重要，颈椎的生理性前凸维持了颈椎的生物力学平衡，颈椎矢状位曲度的改变易引起颈椎失稳，可能会诱发轻重不同的临床症状^[14-15]。然而，颈椎曲度的改变与颈痛之间的关系并不是很明确，有研究认为颈椎曲度改变导致颈部肌肉做功增加，短期内可代偿，失代偿后可导致颈痛和颈椎不稳^[16-17]。另外，其他研究者发现脊柱前凸和颈部疼痛之间没有关联^[18]，在一篇文献综述中认为颈椎曲线没有什么预后意义^[19]。此外，一项最近的系统性评价得出结论：颈椎前凸和疼痛之间的联系不受流行病学证据的支持，尽管许多研究发现有关联，但方法学的质量并不高^[20]。

Harrison等^[21]曾报道30例颈部疼痛患者通过颈部推拿和牵引治疗后颈椎前凸增加，发现与颈部疼痛的减轻是一致的。然而，作者承认他们的研究设计不允许提出这样的结果。另外，如果发现治疗后出现颈椎前凸的变化，如果缺乏对照组来比较变化的差异或测量误差的估计，这种变化不能归因于这项治疗措施的干预。根据Cooperstein等的研究表明，通过推拿治疗来改变颈椎的曲度仍欠缺明确的证据支持，而且也无法区分颈椎曲度自然改变和治疗后的改变。

国内外文献主要集中在单纯的颈痛患者的颈椎的局部与整体矢状位曲度与无症状人群的对比^[21-23]，没有将整个脊柱-骨盆纳入研究，而且研究结果之间存在矛盾。但是颈椎的曲度和胸椎、腰椎-骨盆的曲度互为影响和代偿，在颈椎的影响下，胸椎、腰椎和骨盆都会发生代偿性变化来保持水平凝视^[24]。当腰椎前凸减小，会通过颈椎的过度前凸，胸椎后凸减少或骨盆后倾来代偿；胸椎的过度后凸是由颈椎和腰椎过度前凸或骨盆后倾来代偿^[25]。然而，在临床工作中发现部分患者存在颈痛和腰痛症状相互关联，当颈痛出现时，腰痛也会出现，对于引起这种现象的原因少有文献报道，因此假设：同时存在颈痛和腰痛患者的颈椎和腰椎矢状位序列可能存在代偿不良，导致颈椎矢状位序列与单纯颈痛人群可能会有不同。该文选择18-35岁的年轻颈腰痛患者、颈痛患者和无症状志愿者作为研究对象，可以保证脊柱-骨盆发育成熟，也尽可能减少由于退变性疾病对实验结果造成的影响。通过测量发现上颈椎和下颈椎矢状位参数波动范围较大，提示颈椎矢状位形态的多样性，国外也有学者根据颈椎矢状位形态将颈椎分为4种类型：前凸形、直立型、鹅颈型、后凸型^[26]。而颈腰痛组T₁倾斜角为21.3°-25.8°，颈痛组T₁倾斜角为23.1°-26.0°，无症状组T₁倾斜角为21.7°-24.5°，相对较为稳定，可作为颈椎矫形的参照角度^[27-28]。

在该研究中，所测参数与国内学者赵文奎等^[29]所测参数基本相符，与国外学者Lee等^[30]所测参数有所差异，表明人种和地区差异可导致颈椎矢状位参数测量值的不同。颈腰痛组、颈痛组和无症状组内男女之间的颈椎矢状位参数无明显差异，表明不同性别之间的颈椎矢状位形态差异不大。颈腰痛组、颈痛组和无症状组的颈椎矢状位参数之间也无明显差异，原因可能与颈椎矢状位形态的多样性或颈椎的代偿能力较强有关，也可能是代偿部位出现在胸椎或腰椎-骨盆等节段，还有可能与选择参数有关，该研究所选择的参数都是常用颈椎矢状位参数，可能需要更为敏感的参数来代表颈椎矢状位曲度。

该研究主要是对不同症状人群的横向比较，且选择的样本量相对较小，会对试验结果的准确性造成影响，需要扩大样本并进行纵向研究，且需要将全部脊柱的矢状位序列纳入研究。也没有将颈部疼痛的严重程度与颈椎矢状位参数做相关性分析。但是此研究对于同时具有颈痛和腰痛病人的颈椎矢状位参数做了详细的测量与研究，可以反映颈椎矢状位曲度在腰痛状态下代偿后的结果，有助于对全脊柱矢状位平衡的理解。

结论：颈腰痛患者、颈痛患者和无症状者颈椎矢状位所测参数无明显差异，颈腰痛患者的颈椎矢状位序列代偿可能并无特异性，但仍需要寻求更为敏感的矢状位参数进一步研究。

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程