Two kinds of decompression and implant internal fixation for the treatment of cervical spinal stenosis: C5 nerve root palsy and stability

doi:10.3969/j.issn.2095-4344.2013.35.020

Abstract

Abstract:

BACKGROUND: Some scholars suggest that the nerve root palsy after cervical spinal stenosis treated with decompression and implant internal fixation is related with the cervical stability and cervical lordosis, but there is controversial.
OBJECTIVE: To explore the C5 nerve root palsy and stability after cervical spinal stenosis treated with posterior laminectomy lateral mass fixation and single-door decompression laminoplasty.
METHODS: Twenty-nine cervical spinal stenosis patients were selected and treated with posterior decompression and implant internal fixation. Posterior laminectomy lateral mass fixation for the treatment of cervical spinal stenosis: C_3-6 lateral mass and C₇ pedicel screw internal fixation was performed and caused rough surface on the facet joint; the unstable segment was confirmed according to the preoperative anteraposterior plain film and dynamic radiographs combined with MRI and CT images, and then the corresponding segments were treated with lateral mass internal fixation, single-door decompression laminoplasty and laminoplasty.
RESULTS AND CONCLUSION: All the 29 cervical spinal stenosis patients were followed-up for 8 months to 2.3 years. Among them, 14 cases were treated with posterior laminectomy lateral mass fixation, two cases had nerve root palsy in the early stage after implantation, three cases had incomplete paralysis after long-term symptom recurrence and treated with second surgery of scar remove and decompression; 15 cases were treated with single-door decompression laminoplasty, and one case had C₅ never root palsy and shoulder abduction dysfunctionafter treatment, no preoperative symptom recurrence. The nerve root palsy will restored in 6 weeks for shortest and 9 months for longest. As the limitation of the case number, it is not clear whether there were significant differences in the correlation between C₅ nerve root palsy and segmental stability, cervical lordosis, spinal decompression degree and the range for spinal cord shift, as well as the nerve root palsy degree and the cervical spinal stenosis recurrence caused by forward scar between two treatment methods, so accumulation observation of the cases and clinical experience are needed.

Key words: bone and joint implants, academic discussion of bone and joint, cervical spinal stenosis, lateral mass screw internal fixation, laminectomy, single-door decompression, laminoplasty, nerve root palsy

CLC Number:

R318

Liang Wei-zhi, Gao Jin-wei, Fu Lei, Cui Xiao-hu, Jia Jun-feng. Two kinds of decompression and implant internal fixation for the treatment of cervical spinal stenosis: C₅ nerve root palsy and stability[J]. Chinese Journal of Tissue Engineering Research, 2013, 17(35): 6345-6350.

Figures/Tables 2

2.1 相关研究资料的获取采用检索CNKI数据库的方法获取[4]。 2.2 资料检索方式检索时间范围2008至2012年，中文检索词为“椎管狭窄；颈椎；稳定；神经根麻痹”，共检索出相关文献93篇，学术期刊数据库文献47篇，硕士学位论文数据库文献19篇，博士学位论文数据库文献11篇，中国会议论文数据库文献12篇，国际会议论文数据库文献4篇。最终纳入结果分析的文献共4篇[5-8]。入选标准：①检索结果中，其内容与颈椎管狭窄症减压植入内固定后椎体稳定性研究有关，与颈椎管狭窄症减压植入内固定后神经根麻痹研究有关，排除与研究目的不相关的文献以及护理内容的文献。②检索文献体例为论著和病例报告等，均为一次性文献，排除综述类文献。③排除同一作者的相似和重复研究，只选取其中1篇纳入分析。④纳入颈椎管狭窄症减压植入内固定后椎体稳定性研究的文献。⑤纳入颈椎管狭窄症减压植入内固定后神经根麻痹研究的文献。 2.3 颈椎管狭窄症减压植入内固定后椎体稳定性的相关研究金毅等[5]研究颈椎侧块内固定加后路单开门治疗颈椎管狭窄合并颈椎不稳定的疗效，选取18 例颈椎管狭窄合并颈椎不稳定患者，采用Ⅰ期后路单开门减压加侧块内固定、椎间小关节植骨融合治疗。神经功能按ASIA分级系统评定，拍颈椎X射线片，观察小关节融合情况。18例患者随访平均14个月，治疗后神经功能有不同程度恢复，治疗后3-6个月复查椎间小关节100%融合。可见，侧块内固定加单开门治疗颈椎管狭窄伴不稳定是疗效确切、术式简便的治疗方法。方军等[6]研究后路寰枢椎椎弓根螺钉固定治疗寰枢椎不稳的可行性，选取2004年1月至2010年3月的38例寰枢椎脱位、骨折以及肿瘤或肿瘤样病变并有明显高位颈脊髓受压症状及体征的患者，应用后路寰枢椎椎弓根螺钉固定技术治疗，男29例，女9例；年龄18-63岁，平均41.6岁。其中新鲜外伤17例，陈旧性外伤21例，术中在直视下行 C1、C2置钉复位固定，取髂骨椎板间植骨，治疗后定期观察椎体复位、内固定、骨融合、临床变化及并发症情况，治疗后颈托固定3个月。38例152枚螺钉均成功置入，复位固定满意，治疗后36例获3-26个月随访，平均14.8个月，患者均在3-6个月寰枢椎骨性融合，未发现螺钉松动、断钉和寰枢椎再移位现象。 2.4 颈椎管狭窄症减压植入内固定后神经根麻痹的相关研究李君等[7]比较颈后路单开门椎管成形与椎板切除内固定治疗多节段脊髓型颈椎病后C5神经根麻痹的发生率，并分析其原因。选取2005年1月至2010年6月因多节段颈脊髓病变分别接受椎管成形的患者27例(A组)，减压3-6个节段。同期接受椎板切除内固定治疗的患者41例(B组)，减压3个节段。随访12-46个月(平均22个月)；两组治疗前后以Cobb法测量颈椎前凸角度，以lshihara法测定颈椎曲度指数(cervical curvature index，CCI)，其结果见表1。"

A组C5神经麻痹发生率为3.7%(1/27)，B组发生率为22.0%(9/41)，差异有显著性意义(χ2=4.32，P < 0.05)，10例颈椎神经根麻痹患者平均于治疗后14个月肌力恢复至4级以上。B1组治疗前后颈椎曲度指数改变率为(38.07±18.03)%，B2组为(22.81±12.71)%，两组差异有显著性意义(t =2.88，P < 0.05)。可见，相比颈后路椎板切除内固定，椎管成形治疗后C5神经根麻痹发生率低。C5神经根麻痹可能与颈后路治疗后颈椎前凸增加有关。神经根拴系效应是其重要的发病机制之一。巩腾[8]回顾性分析297例脊髓型颈椎病行外科治疗患者，因颈间盘退变性突出所致193例，其中经前路间盘摘除、植骨及钛制钉板系统内固定126例，经后路全椎板切除减压67例。因后纵韧带骨化所致104例，全部行后路全椎板切除减压。297例随访患者中，有37例(前路组共计126例)和36例(包括退变性突出9例，后纵韧带骨化27例，后路组共计171例)发生上肢麻痹症状。按照美国脊髓损伤研究会和国际截瘫学会推荐各髓节主要支配肌节或皮节的定位标准，并以此定位治疗后受累脊髓节段与上肢麻痹症状间关系，比较发生并发症的麻痹组和未发生并发症的非麻痹组患者治疗后神经功能障碍及MRI高信号改变、颈椎曲度和脊髓漂移距离差异。随访麻痹患者中，大部分患者治疗后即刻发现有中指(C7)和小指(C8)为主的全指或尺侧三指刺痛或麻木、过电感等感觉障碍；合并中指屈指或握力(C8)或小指伸展(T1)肌力下降等运动障碍，绝大多数患者为多节段神经受累的运动和感觉混合障碍型，而治疗后上肢麻痹症状以肘窝桡侧(C5)或桡侧半手指、拇指(C6)感觉异常；屈肘(C5)或伸腕(C6)运动障碍为主要表现的患者占少数。发生并发症的患者均自行逐渐缓解，前、后路两组减压后上肢远端麻痹发生率均远较上肢近端麻痹症状为高；颈膨大以上部位和颈膨大本身节段减压时的两样本麻痹症状发生率间差异无统计学意义；前、后路组中麻痹组和非麻痹组间在颈椎曲度变化值及脊髓漂移程度方面的差异均无统计学意义；术后T2像高信号区范围或强度较前扩大或增强者更易并发上肢麻痹；多数患者治疗后T2像上新出现的高信号区为在纵向上邻近术前水平分布；麻痹组和非麻痹组随访患者在T1像上均未发生异常信号改变。此神经并发症与手术操作不慎损伤颈髓内下运动神经元通路及入路有关，与单一神经根麻痹损害症状不符，上肢麻痹症状发生与否与颈椎曲度变化及脊髓漂移距离等参数无显著相关。"

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Two kinds of decompression and implant internal fixation for the treatment of cervical spinal stenosis: C₅ nerve root palsy and stability

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