田偉 王含

（北京積水潭醫(yī)院脊柱外科，北京100035）

頸椎后路椎板成形術(shù)起源于20世紀(jì)70年代，其療效可靠，并能夠明顯減少椎板切除術(shù)后嚴(yán)重并發(fā)癥的發(fā)生率。目前是治療多節(jié)段頸椎管狹窄癥和后縱韌帶骨化癥的常用方法。本文分別對(duì)椎板成形術(shù)的起源和發(fā)展、適應(yīng)證、療效和并發(fā)癥等進(jìn)行介紹，并介紹積水潭醫(yī)院設(shè)計(jì)的改良術(shù)式——SLAC手術(shù)及相關(guān)經(jīng)驗(yàn)。我們認(rèn)為，棘突縱割式椎管擴(kuò)大將成為椎板成形術(shù)今后的發(fā)展方向，人工骨的應(yīng)用將在椎板成形術(shù)中起到重要作用。

1 椎板成形術(shù)的起源和發(fā)展

在椎板成形術(shù)出現(xiàn)之前的很長(zhǎng)一段時(shí)間內(nèi)，椎板切除術(shù)作為多節(jié)段病變的首選手術(shù)方法，能夠良好的完成脊髓減壓的任務(wù)。但其并發(fā)癥卻屢有出現(xiàn)。磨鉆的應(yīng)用使得椎板切除術(shù)快速進(jìn)步，但仍沒(méi)有解決術(shù)后頸椎易損傷、椎體后骨贅形成、曲度錯(cuò)亂等并發(fā)癥[1]。椎板切除后還會(huì)導(dǎo)致頸椎不穩(wěn)定，很多醫(yī)生為預(yù)防不穩(wěn)定繼發(fā)更嚴(yán)重的癥狀，進(jìn)行長(zhǎng)節(jié)段后方固定融合，導(dǎo)致頸椎活動(dòng)嚴(yán)重受限，鄰節(jié)病高發(fā)，并有融合失敗風(fēng)險(xiǎn)。另一嚴(yán)重并發(fā)癥是硬膜外瘢痕形成，后方肌肉組織瘢痕會(huì)導(dǎo)致術(shù)后持續(xù)頭痛、頸痛癥狀，嚴(yán)重者可出現(xiàn)神經(jīng)癥狀惡化[2]。

1973年，Oyama介紹了一種新型后方減壓術(shù)式，他在切除棘突后將相應(yīng)的椎板削薄，用高速磨鉆或椎板咬骨鉗在每一個(gè)椎板上切出一個(gè)橫置的Z字。薄層椎板被切割成兩段，向后外方移動(dòng)擴(kuò)大椎管容積，用縫線或金屬絲固定在擴(kuò)大的位置上[3]。這種Z字成形術(shù)雖然還遺留了椎板切除術(shù)的一些問(wèn)題，但它開(kāi)創(chuàng)了保留后方結(jié)構(gòu)的先河。

1977年，Hirabayashi設(shè)計(jì)了一種更為大膽的成形手術(shù)，后于Spine雜志上介紹了這種方法[1,4]。手術(shù)將C2-C7的棘突和椎板暴露清楚后，用磨鉆在椎板和小關(guān)節(jié)之間做出深及黃韌帶的骨槽，一側(cè)切斷椎板，另一側(cè)需小心保留很薄的椎板內(nèi)側(cè)皮質(zhì)。術(shù)者用剝離子或刮勺翹起椎板開(kāi)口、助手用Kocher鉗夾棘突向外旋轉(zhuǎn)，共同完成擴(kuò)大椎板的動(dòng)作。Hirabayashi強(qiáng)調(diào)不要因夾持不緊讓打開(kāi)的椎板復(fù)位，傷及已向后移動(dòng)的脊髓。固定方法最早使用縫線在關(guān)門一側(cè)的小關(guān)節(jié)囊和棘突之間作懸吊，之后逐漸發(fā)展出鈦板、自體及異體骨和陶瓷墊片等一些內(nèi)置物，固定效果良好[5]。Hirabayashi術(shù)式一經(jīng)問(wèn)世便引起巨大反響，并沿用至今，英文簡(jiǎn)稱“open-door”。在我國(guó)稱之為單開(kāi)門椎管擴(kuò)大椎板成形術(shù)，常簡(jiǎn)稱為單開(kāi)門手術(shù)，又譯為平林（Hirabayashi）法。

平林法問(wèn)世之后，椎板成形術(shù)加速發(fā)展。Hukuda法彌補(bǔ)了平林法椎管不對(duì)稱擴(kuò)大的缺點(diǎn)[6]。Hukuda在椎板兩側(cè)均作出不切斷椎板的側(cè)溝，再用磨鉆或椎板咬骨鉗自后正中線打開(kāi)棘突，完成椎管擴(kuò)大。雙側(cè)椎板用縫線懸吊于小關(guān)節(jié)囊，椎管保持敞開(kāi)狀態(tài)完成手術(shù)。后人改進(jìn)Hukuda法，用骨塊、陶瓷等封閉其間隙，重建完整的椎弓形態(tài)。比較著名的是Kurokawa改良方法，他將棘突后半部分切除后進(jìn)行自體骨移植封閉棘突間隙[7]。Tomita改良方法則將線鋸應(yīng)用于打開(kāi)棘突，也稱T-saw法[8]。Hase首先使用陶瓷封閉棘突間隙，重建椎板弓的結(jié)構(gòu)[9]。此類方法根據(jù)創(chuàng)始人姓氏分別被譯為小林（Hukuda）法、黑川（Kurokawa）法、富田（Tomita）法，英文稱“French door”，取意此開(kāi)門方法與法式大門相似，也稱“bilateral open-door”或“double-door”。在我國(guó)稱之為雙開(kāi)門椎管擴(kuò)大椎板成形術(shù)，常簡(jiǎn)稱為雙開(kāi)門手術(shù)。

由于椎板成形術(shù)可與椎板切除術(shù)獲得相同的減壓效果[10]，并保留了頸椎后方的重要結(jié)構(gòu)，并發(fā)癥明顯減少，后被廣泛應(yīng)用于臨床，成為使用最多的頸椎后路術(shù)式。椎板成形術(shù)的發(fā)展常伴隨兩類術(shù)式孰優(yōu)孰劣的討論，單開(kāi)門和雙開(kāi)門手術(shù)均能獲得良好減壓效果，有研究認(rèn)為雙開(kāi)門雖手術(shù)時(shí)間稍長(zhǎng)，但術(shù)中出血量和圍手術(shù)期并發(fā)癥較少，特別是軸性癥狀發(fā)生率低[11]。

椎板成形術(shù)的改良方法不勝枚舉。對(duì)于脊髓型合并神經(jīng)根型患者，有學(xué)者將椎板成形術(shù)與Frykholm在1951年設(shè)計(jì)的Key-hole術(shù)相結(jié)合，獲得了良好的神經(jīng)減壓效果[12-14]。有學(xué)者認(rèn)為脊髓壓迫僅發(fā)生在關(guān)節(jié)水平，骨水平的脊髓不受壓，故設(shè)計(jì)了分段的部分椎板切除術(shù)（SPL），取得不錯(cuò)的效果[15,16]。其他輔助方法如術(shù)中超聲評(píng)估、圍術(shù)期氨甲環(huán)酸等增加了手術(shù)的安全性[17-19]。隨著微創(chuàng)外科概念的興起，有人采用肌間入路行椎板成形術(shù)獲得良好效果，未發(fā)現(xiàn)曲度丟失或ROM下降等情況[16]。

2 椎板成形術(shù)的適應(yīng)證

椎板成形術(shù)有兩大主要適應(yīng)證。

退行性頸椎管狹窄癥-脊髓型（CCS-M）最為常見(jiàn)，此疾病之前被籠統(tǒng)地稱為脊髓型頸椎?。–SM）。Clarke等在50年代觀察了120例脊髓型頸椎病患者的自然病程，發(fā)現(xiàn)75%的患者癥狀反復(fù)出現(xiàn)，66%有新發(fā)或惡化的神經(jīng)癥狀，但也有2例患者癥狀自發(fā)緩解[20]。其他研究認(rèn)為輕度脊髓型頸椎病可以通過(guò)保守治療獲益，手術(shù)雖然可以快速緩解癥狀，但長(zhǎng)期隨訪與保守治療效果無(wú)差異[21,22]。當(dāng)患者出現(xiàn)癥狀持續(xù)不緩解甚至加重、大小便功能障礙、進(jìn)行性肌力下降、明顯走路不穩(wěn)、雙手協(xié)調(diào)性喪失等癥狀，需要盡快手術(shù)干預(yù)。其他表現(xiàn)如疼痛、輕度肌力下降和感覺(jué)異常如果對(duì)患者帶來(lái)了不能忍受的影響，也可以考慮手術(shù)治療[23]。

頸椎后縱韌帶骨化癥（OPLL）是椎板成形術(shù)的第二大適應(yīng)證。沒(méi)有脊髓癥狀的OPLL患者中83.3%癥狀進(jìn)展緩慢，無(wú)需手術(shù)治療[24]。而有明確脊髓壓迫者均能從手術(shù)中獲益。OPLL患者行保守治療時(shí)脊髓損傷幾率是正常人的32倍，而脊髓損傷致殘的幾率高達(dá)100多倍[25]。

此外，發(fā)育性頸椎管狹窄癥、其他類型的退行性頸椎管狹窄癥、頸椎間盤突出癥、頸椎黃韌帶骨化癥、脊髓腫瘤等也可視情況使用椎板成形術(shù)治療[26-28]。有報(bào)道稱椎板成形術(shù)可以作為治療頸椎前路術(shù)后臨近節(jié)段病變的方法，但其證據(jù)尚不充分[29]。

上述疾病大部分有前路和后路兩種手術(shù)選擇。

選擇手術(shù)入路通?？紤]下列因素：矢狀位序列、受累節(jié)段數(shù)、狹窄形態(tài)、既往手術(shù)史、骨密度等。有人認(rèn)為頸椎后凸患者行后路減壓手術(shù)時(shí)脊髓漂移空間不大，有可能導(dǎo)致前方的壓迫無(wú)法解除，療效不佳[30]。椎板成形術(shù)的中期效果不如前路固定融合術(shù)，前方有明確壓迫并局限在1～2個(gè)節(jié)段的患者適合前路手術(shù)[31]。3個(gè)或3個(gè)以上節(jié)段病變時(shí)，需固定融合節(jié)段過(guò)長(zhǎng)，容易導(dǎo)致如內(nèi)固定失敗、融合率差、頸部僵硬及鄰近節(jié)段退變等一系列問(wèn)題[32,33]。對(duì)于多節(jié)段CCS和OPLL患者，有研究稱前路手術(shù)在術(shù)后早期療效較好，但并發(fā)癥比后路手術(shù)多，隨著時(shí)間推移，后路手術(shù)的療效可與前路相當(dāng)。一般認(rèn)為除了OPLL占位大于60%或頸椎后凸等情況，椎板成形術(shù)是更好的選擇[34-36]。K-line被提出用來(lái)指導(dǎo)手術(shù)入路選擇，有研究稱越過(guò)K-line的OPLL做椎板成形術(shù)效果較差[37]。也有人認(rèn)為OPLL行前路或后路的區(qū)別不大[38,39]。

總結(jié)起來(lái)，頸椎椎板成形術(shù)的適應(yīng)證為三節(jié)段及以上的有明顯脊髓壓迫表現(xiàn)上述疾病[40]。

椎板成形術(shù)的絕對(duì)禁忌證很少，通常認(rèn)為頸椎后凸是其禁忌證，但在實(shí)際運(yùn)用中往往需要個(gè)體化判斷。有試驗(yàn)表明術(shù)前C2-C7前凸小于3°的患者術(shù)中監(jiān)測(cè)脊髓漂浮不滿意，并降低臨床療效[41]。有人選擇在椎板成形術(shù)同時(shí)行側(cè)塊或椎弓根固定融合術(shù)以恢復(fù)頸椎前凸，達(dá)到良好減壓目的。退行性頸椎管狹窄癥患者年齡較大，有研究表明65歲以上老年人術(shù)前與術(shù)后JOA評(píng)分雖較低，但其增加值并不低，故高齡不是椎板成形術(shù)的禁忌證[42,43]。但年輕患者應(yīng)慎重選擇后路手術(shù)。術(shù)前要明確診斷，當(dāng)頸椎病合并其他疾病如脊髓結(jié)節(jié)病時(shí)，手術(shù)效果較差[44]。

3 椎板成形術(shù)的療效、并發(fā)癥及預(yù)后

3.1 療效

3.1.1 神經(jīng)癥狀：大多數(shù)研究表明椎板成形術(shù)在緩解術(shù)前神經(jīng)癥狀方面效果很好。行走功能往往是脊髓壓迫患者最期望恢復(fù)的，有學(xué)者稱80%的術(shù)前行走不穩(wěn)患者可好轉(zhuǎn)。也有觀察研究顯示術(shù)后下肢運(yùn)動(dòng)功能和上肢感覺(jué)功能的改善率較低，容易成為遺留癥狀[45,46]。為統(tǒng)一療效指標(biāo)，多數(shù)學(xué)者使用JOA評(píng)分評(píng)價(jià)，其中JOA改善率的計(jì)算方法是：（術(shù)后JOA-術(shù)前JOA）/（17-術(shù)前JOA）×100%。文獻(xiàn)中報(bào)道的中短期JOA改善率一般在50%～70%，與術(shù)前脊髓癥狀的嚴(yán)重程度相關(guān)，而與具體術(shù)式無(wú)關(guān)[8,47-64]。單開(kāi)門和雙開(kāi)門手術(shù)都能提供足夠的脊髓漂移空間[65]。隨機(jī)對(duì)照試驗(yàn)表明單開(kāi)門和雙開(kāi)門的JOA評(píng)分改善率無(wú)差異[11]。一般認(rèn)為兩種術(shù)式的神經(jīng)減壓效果相似。目前超過(guò)10年長(zhǎng)期隨訪JOA改善率仍能保持在55%～60%[66,67]。

語(yǔ)篇環(huán)境主要體現(xiàn)的是語(yǔ)言的整體性，也就是畫(huà)面、聲音和字幕這三者有機(jī)結(jié)合的一個(gè)整體。故事，情節(jié)，畫(huà)面以及人物的各個(gè)要素都是相互依存的，缺一不可。語(yǔ)篇限制下的策略就是時(shí)刻要保持人物對(duì)白的連貫性，使得更具推理性和邏輯性。同時(shí)，也要重點(diǎn)關(guān)注說(shuō)話人的語(yǔ)氣、動(dòng)作、內(nèi)心、情感的表達(dá)，使得譯文符合影片的整體語(yǔ)境。

大部分研究稱兩大適應(yīng)證之間無(wú)明顯療效差異。也有研究稱雖然一部分OPLL患者長(zhǎng)期隨訪癥狀有進(jìn)展，CSM較OPLL改善稍好，但更加重要的決定因素是術(shù)前癥狀嚴(yán)重程度和持續(xù)時(shí)間[68]。另一研究認(rèn)為OPLL雖有自然進(jìn)展傾向，但長(zhǎng)期隨訪顯示僅20%的患者出現(xiàn)癥狀反復(fù)[62]。

脊髓壓迫體征在術(shù)后半年內(nèi)可基本緩解。其中Babinski征和肱橈反射亢進(jìn)多數(shù)恢復(fù)正常，且是有效的復(fù)發(fā)觀察指標(biāo)。而Hoffman征的變化不夠敏感[69]

3.1.2 術(shù)后頸椎曲度：目前仍沒(méi)有可以完全預(yù)防椎板成形術(shù)后后凸形成的辦法[70]。根據(jù)報(bào)道，術(shù)后曲度丟失比一般在22%～53%[50,51,53,58,68,71-73]。個(gè)別研究使用后方固定能保持較好的曲度[60]。近年來(lái)由于特別強(qiáng)調(diào)對(duì)頸后肌群的保護(hù)，以及各種改良術(shù)式的出現(xiàn)，讓術(shù)前后凸不再是絕對(duì)手術(shù)禁忌，有研究稱49.2%的后凸能在術(shù)后轉(zhuǎn)變?yōu)榍巴?，但同時(shí)有7.2%的前凸成為后凸[74]。另有研究稱前凸角小的患者術(shù)后轉(zhuǎn)為后凸的可能性大，術(shù)前小于10°就需特別注意[75]。

3.1.3 術(shù)后頸椎活動(dòng)度：文獻(xiàn)報(bào)道的頸椎活動(dòng)度（ROM）下降在30%～70%之間[9,66,76]，平均約50%[77]，早期手術(shù)甚至更低[62]。ROM下降造成的不良后果包括頸部僵硬及鄰近節(jié)段退變等。有報(bào)道稱術(shù)后ROM呈逐漸下降的趨勢(shì)，但下降的速率逐漸減緩，18個(gè)月后停止下降。OPLL患者術(shù)后ROM下降更大[77]。一些學(xué)者認(rèn)為術(shù)后ROM下降的原因是頸后伸肌群剝離過(guò)多。術(shù)中保護(hù)頸后伸肌群，特別是頸半棘肌，可以維持ROM及曲度，也能減少軸性癥狀發(fā)生[78-80]。另一可能導(dǎo)致ROM下降原因是自發(fā)椎板融合，原因可能與小關(guān)節(jié)和椎旁肌的攣縮有關(guān)[81-83]。術(shù)后早期活動(dòng)對(duì)預(yù)防融合有效[9]。有研究表明術(shù)后佩戴頸托4周比佩戴8周的ROM保持更好[81]，也有佩戴2周的研究取得了較好的結(jié)果[74]。由于多節(jié)段前路或后路融合對(duì)ROM極大的影響，椎板成形術(shù)在此方面仍占優(yōu)勢(shì)。有趣的是，一些學(xué)者視術(shù)后頸部僵硬為必要，相比椎板切除術(shù)后ROM顯著上升[84]，椎板成形術(shù)能減小頸部活動(dòng)時(shí)可能給脊髓帶來(lái)的損傷[51]。

3.2 并發(fā)癥

有研究稱頸椎手術(shù)總并發(fā)癥率約5%[85]。椎板成形術(shù)的一般并發(fā)癥如術(shù)后血腫、術(shù)后感染、圍手術(shù)期死亡發(fā)生率低[86]。術(shù)后傷口感染發(fā)生率約2%，而傷口特殊處理可降低感染率[87]。椎板成形術(shù)靜脈血栓風(fēng)險(xiǎn)稍高于前路固定手術(shù)，但比后路固定手術(shù)低。由于下肢深靜脈血栓和肺栓塞顯著提高死亡率和住院時(shí)間，術(shù)前要特別注意高?；颊叩脑u(píng)估和治療[88]。0.8%的患者術(shù)后出現(xiàn)腦脊液漏，可行頭高位持續(xù)蛛網(wǎng)膜下腔引流治療[89]。

3.2.1 神經(jīng)癥狀惡化：椎板成形術(shù)后神經(jīng)癥狀惡化并不罕見(jiàn)，多由椎板固定失敗引起。向后翻起的椎板有復(fù)位傾向，固定不穩(wěn)或內(nèi)置物斷裂等原因均可導(dǎo)致“再關(guān)門”發(fā)生，壓迫已經(jīng)向后移動(dòng)的脊髓，造成神經(jīng)癥狀惡化。有研究表明椎板閉合的發(fā)生率是33%，且發(fā)生椎板閉合后JOA評(píng)分有下降趨勢(shì)，故推薦使用間隔物以降低椎板閉合風(fēng)險(xiǎn)[90]。另外，術(shù)中過(guò)度磨削使得關(guān)門一側(cè)的椎板全層斷裂，骨折端移位也可壓迫脊髓。術(shù)后CT一般能發(fā)現(xiàn)惡化原因，決定是否二次手術(shù)及其方式[2]。有研究稱OPLL患者術(shù)后3.1%出現(xiàn)下肢功能惡化，并與OPLL占位面積和厚度相關(guān)，但術(shù)后半年部分神經(jīng)功能可以恢復(fù)[91]。

3.2.2 軸性癥狀：軸性癥狀（axial symptoms）是Hosono最早報(bào)道的，他發(fā)現(xiàn)椎板成形術(shù)后頻發(fā)頸項(xiàng)部、肩部疼痛，且后路手術(shù)明顯高于前路手術(shù)[92]。軸性癥狀很常見(jiàn)，文獻(xiàn)報(bào)道的發(fā)生率為5.2%～61.5%，甚至有高達(dá)80%的報(bào)道[93]。通常術(shù)后很快出現(xiàn)，并在1年內(nèi)緩解。疼痛的來(lái)源包括間盤、肌肉、小關(guān)節(jié)、脊髓和神經(jīng)根[94]。產(chǎn)生機(jī)制尚不明確，但疼痛往往伴隨頸部僵硬感，與術(shù)后ROM受限同時(shí)發(fā)生[95]。考慮可能與長(zhǎng)時(shí)間、大范圍暴露、剝離等同樣影響ROM的手術(shù)操作有關(guān)[96]。有研究表明C6棘突較長(zhǎng)者術(shù)后軸性癥狀發(fā)生率高[97]。預(yù)防軸性癥狀對(duì)于椎板成形術(shù)至關(guān)重要。術(shù)后早期活動(dòng)，縮短頸托佩戴時(shí)間、減少手術(shù)暴露、保護(hù)頸半棘肌C2止點(diǎn)、重建伸肌群等可預(yù)防軸性癥狀[94,98,99]。NSAIDS類藥物、頸部鍛煉等方法可能對(duì)已出現(xiàn)的癥狀有效。

3.2.3 C5神經(jīng)根麻痹：神經(jīng)根損傷是后路減壓手術(shù)常見(jiàn)的并發(fā)癥，有些學(xué)者發(fā)現(xiàn)在術(shù)中非常仔細(xì)地保護(hù)神經(jīng)根的情況下，術(shù)后仍有麻痹情況出現(xiàn)，尤其是出現(xiàn)在C5神經(jīng)根。此類報(bào)道較多，多表現(xiàn)為三角肌肌力下降和肩痛，感覺(jué)受累少。這一特殊現(xiàn)象被命名為C5神經(jīng)根麻痹（C5palsy）。文獻(xiàn)中平均發(fā)生率約為4.6%～4.8%[100,101]。有研究認(rèn)為其在不同術(shù)式、不同疾病間的發(fā)生率無(wú)明顯差異[100]。但也有研究表明OPLL、術(shù)后前凸增大、單開(kāi)門手術(shù)等情況易出現(xiàn)C5麻痹[102,103]。C5麻痹的發(fā)生機(jī)制尚不清楚，有人認(rèn)為這并非術(shù)中神經(jīng)根或脊髓損傷直接引起[104]。也有人認(rèn)為其與醫(yī)源性損傷、脊髓移位牽拉、脊髓缺血和再灌注損傷有關(guān)[101]。其中由于脊髓向后移動(dòng)時(shí)對(duì)神經(jīng)根造成牽拉，神經(jīng)根在椎間孔內(nèi)移動(dòng)時(shí)的機(jī)械損傷原因被較多人認(rèn)可[105,106]。針對(duì)此原因，有學(xué)者建議在行椎板成形術(shù)同時(shí)同時(shí)行椎間孔切開(kāi)（key-hole）術(shù)，試圖讓神經(jīng)根不受椎間孔的限制，以預(yù)防C5麻痹，但效果不十分確切，甚至有神經(jīng)根麻痹發(fā)生率不降反升的報(bào)道[100,107]。另有同類研究稱此方法有效[108]。有人試圖控制開(kāi)門程度，讓脊髓有限制地后移，控制硬膜的膨脹以預(yù)防C5神經(jīng)根麻痹，獲得了一定的效果[109]。C5麻痹患者的神經(jīng)功能可以恢復(fù)，預(yù)后良好，肌力下降通常在1年內(nèi)恢復(fù)或接近正常，癥狀越重需要越長(zhǎng)時(shí)間的恢復(fù)過(guò)程[100]。

3.3 預(yù)后

研究表明，手術(shù)時(shí)年齡小于60歲、術(shù)前病程小于1年者，術(shù)后JOA改善率較高，手指10 s屈伸試驗(yàn)恢復(fù)較快，預(yù)后較好[110,111]，但年輕OPLL患者仍可能快速進(jìn)展從而影響預(yù)后[112]。有研究稱術(shù)后24 h內(nèi)手指15 s屈伸試驗(yàn)會(huì)有明顯改善，并能預(yù)測(cè)長(zhǎng)期預(yù)后[113]。術(shù)前脊髓高信號(hào)累及節(jié)段多、脊髓壓縮比低被認(rèn)為是預(yù)后較差的表現(xiàn)[114]。另外，術(shù)前神經(jīng)電位、術(shù)前K-line位置、術(shù)后是否存在脊髓前方壓迫（ACS）、是否合并糖尿病等因素也能影響預(yù)后[115-118]。椎板成形術(shù)后需要二次手術(shù)的原因包括手術(shù)技術(shù)失誤、術(shù)后癥狀不緩解、疾病自然進(jìn)程導(dǎo)致的癥狀再發(fā)等。有報(bào)道稱9.2%的患者需要翻修手術(shù)，其中67%是疾病自然進(jìn)程所致。所以醫(yī)生需在術(shù)前告知患者此可能性[119]。

4 SSLLAACC手術(shù)

積水潭醫(yī)院學(xué)習(xí)國(guó)際先進(jìn)經(jīng)驗(yàn)，借鑒Hukuda、Kurokawa、Nakano[120]、Tomita[121]等方法，20世紀(jì)90年代起開(kāi)展椎板成形術(shù)7年，我院和國(guó)內(nèi)廠家合作，自主研發(fā)、生產(chǎn)了由天然珊瑚煅造制作的棘突間隔物，稱為珊瑚人工骨（coralline hydroxyapatite，CHA，圖1），替代自體骨做間隔物進(jìn)行棘突縱割雙開(kāi)門椎管擴(kuò)大椎板成形術(shù)。手術(shù)中應(yīng)用線鋸（threadwire saw，T-saw）割開(kāi)棘突。我們?nèi)∈中g(shù)關(guān)鍵步驟英文（spinous process splitting laminoplasty using coralline hydroxyapatite）的首字母，定名為SLAC手術(shù)。

圖1 積水潭醫(yī)院合作研發(fā)的珊瑚人工骨

SLAC-Ⅰ型手術(shù)步驟簡(jiǎn)述如下：頸正中切口，暴露C2-T1棘突，剪下的頸半棘肌用絲線標(biāo)記；分別從C7/T1和C2/3間隙切除部分黃韌帶，從C7/T1椎間隙穿入特制的硬膜外導(dǎo)管，至C2/3椎間隙穿出，從導(dǎo)管內(nèi)穿入T-saw，縱行劈開(kāi)C3-C7棘突；用高速磨鉆在C3-C7兩側(cè)椎板根部、小關(guān)節(jié)內(nèi)側(cè)做側(cè)溝；正中掀開(kāi)棘突，擴(kuò)大椎管并去除粘連壓迫組織；見(jiàn)到硬膜囊后移并有明顯搏動(dòng)后，于各劈開(kāi)棘突間植入珊瑚人工骨，絲線固定于棘突；交叉縫合兩側(cè)頸半棘肌，逐層關(guān)閉切口。對(duì)于累及C2節(jié)段的高位脊髓壓迫患者，使用磨鉆對(duì)C2椎板行Dome減壓，可獲得良好減壓效果[122]。

SLAC手術(shù)的關(guān)鍵在于魔鉆、線鋸和珊瑚人工骨的使用[123-125]。高速磨鉆已成為頸椎后路手術(shù)不可或缺的器械，可以明顯提高手術(shù)安全性，減少手術(shù)時(shí)間。T-saw在椎板成形術(shù)中的應(yīng)用安全、有效[8,73]。其操作具有解剖學(xué)基礎(chǔ)，即棘突和椎板匯聚部位下方與硬膜囊上方之間存在腔隙。當(dāng)柔軟、光滑的特制導(dǎo)管穿出后再置入線鋸，不易對(duì)脊髓造成損傷。特殊情況如嚴(yán)重頸椎管狹窄病例，可在狹窄處兩側(cè)分段穿入兩套管及線鋸。T-saw可一次性將擬成形的椎板棘突割開(kāi)，操作比磨鉆易于控制，神經(jīng)損傷可能小，對(duì)稱縱割成功率高，割面平整，可與CHA間隔物良好貼附，易于固定融合。

早期研究顯示，棘突縱割后應(yīng)用羥基磷灰石做間隔物，可獲得良好的椎管擴(kuò)大效果和融合率[120]。用人工骨撐開(kāi)棘突封閉椎管，可以避免椎管再關(guān)門和硬膜外瘢痕形成，可以很好地保持原有生物力學(xué)特性[126]。我們?cè)趪?guó)內(nèi)首先設(shè)計(jì)并使用了珊瑚人工骨，它是以天然珊瑚為原料，經(jīng)復(fù)雜熱液交換反應(yīng)制成。具有良好的生物相容性、骨傳導(dǎo)性，其孔隙率和孔徑大小符合頸椎后路手術(shù)要求，特有的梯形結(jié)構(gòu)符合棘突敞開(kāi)角度。應(yīng)用CHA后，我院SLAC手術(shù)時(shí)間明顯縮短，術(shù)中出血量減少，并避免了取骨部位（一般在髂骨）術(shù)后血腫、疼痛、骨折等并發(fā)癥。隨訪2年顯示其與棘突的融合率達(dá)到83.5%，并有所時(shí)間而增加的趨勢(shì)。即使有少量不愈合情況，由于棘突不是主要負(fù)重部位，對(duì)療效無(wú)明顯影響。

SLAC術(shù)后棘突位置居中，有利于頸后部肌群的止點(diǎn)重建，達(dá)到左右平衡，最大限度地維持了頸椎的穩(wěn)定性。頸半棘肌和C2、C7椎板在保持頸椎前凸方面起重要作用，是頸椎主要的穩(wěn)定結(jié)構(gòu)，其剝離會(huì)導(dǎo)致曲度丟失[127-130]，相關(guān)癥狀惡化危險(xiǎn)增加[131]。我們十分重視頸部后伸肌群的保護(hù)重建，雖然早期隨訪發(fā)現(xiàn)術(shù)后有曲度恢復(fù)和軸性疼痛減少趨勢(shì)，說(shuō)明了后部肌群軟組織功能有所恢復(fù)。但重建肌群的方法困難，有一定的失敗率。

我院從2001年開(kāi)始采用保留C2和C7棘突肌肉止點(diǎn)的方法，盡可能少的破壞頸部后方伸肌組群，保持術(shù)后前凸，防止術(shù)后軸性疼痛。改良后術(shù)式稱為SLAC-Ⅱ型手術(shù)（圖2）。具體方法包括：保留C2和C7棘突肌肉止點(diǎn)，特別注意保護(hù)頸半棘肌在C2棘突的止點(diǎn)；改原來(lái)的C3椎板成型術(shù)為椎板切除術(shù)；改C7椎板成形術(shù)為C7頭側(cè)部分椎板切除，注意保護(hù)椎旁肌的止點(diǎn)；C4-C6仍行人工骨間隔的椎板成形術(shù)。

圖2 SLAC-Ⅱ型手術(shù)

我院設(shè)計(jì)的SLAC-Ⅱ型手術(shù)對(duì)頸后肌群的影響大大降低，沒(méi)有剝離再重建過(guò)程。SLAC-Ⅰ型做C3椎板成形術(shù)，應(yīng)用間隔物的寬度一般為15～20 mm，而C2棘突上頸半棘肌的止點(diǎn)平均寬度為10.6 mm[132]，使得在C2棘突上原位重建止點(diǎn)十分困難，有一定失敗率，成功重建的位置往往也位于原止點(diǎn)外側(cè)。改良后的術(shù)式將C3椎板成形改為椎板切除，不需破壞C2原本的肌肉止點(diǎn)，可以獲得同樣的神經(jīng)減壓效果，手術(shù)操作更加簡(jiǎn)單，并能減少軸性癥狀發(fā)生率[133]。C7椎板在頸椎穩(wěn)定性方面有重要作用，保留C7棘突能減少軸性癥狀發(fā)生[134,135]。C3-C6椎板成形術(shù)在手術(shù)時(shí)間、切口長(zhǎng)度、軸性癥狀發(fā)生率等方面優(yōu)于C3-7椎板成形術(shù)[136]。由于切除了C3椎板，C7椎板頭側(cè)也做了部分減壓，SLAC-Ⅱ型手術(shù)的減壓范圍十分充分，較C3-C6椎板成形術(shù)還大，能避免術(shù)后C7節(jié)段繼續(xù)狹窄。改良后只需植入3塊珊瑚人工骨，減少了線鋸需要劈開(kāi)的范圍和磨鉆需要做門軸的數(shù)量，手術(shù)時(shí)間較前明顯縮短。松開(kāi)拉鉤后，由于良好的保留了頸半棘肌等頸后部肌群，肌肉層有自然合攏的趨勢(shì)，使傷口縫合、愈合更加容易。術(shù)前存在明顯后凸一般是椎板成形術(shù)的禁忌證，但也可在SLAC手術(shù)時(shí)同時(shí)后路側(cè)塊或椎弓根內(nèi)固定，可獲得良好效果并減少C5神經(jīng)根牽拉[137]。

進(jìn)行此項(xiàng)術(shù)式改良后，我院對(duì)比研究顯示[64,138]，SLAC-Ⅰ型和Ⅱ型手術(shù)的JOA評(píng)分改善率分別為43.4%和46.9%，差異無(wú)統(tǒng)計(jì)學(xué)意義。說(shuō)明Ⅱ型手術(shù)雖然減少了椎板成形范圍，但減壓效果是相同的，神經(jīng)功能恢復(fù)方面和Ⅰ型相似。手術(shù)時(shí)間從126 min縮短到97 min。術(shù)中出血量相等。Ⅱ型C2-C7前凸角術(shù)后僅下降1.9°，ROM保留了術(shù)前的86.5%，明顯好于Ⅰ型。軸性癥狀在Ⅰ型和Ⅱ型發(fā)生率分別為38%和15%，Ⅱ型新出現(xiàn)的軸性疼痛比例較低。兩組合計(jì)5%出現(xiàn)C5神經(jīng)根牽拉癥狀，神經(jīng)根麻痹、三角肌肌力減弱的共2%，組間無(wú)差異。可見(jiàn)SLAC-Ⅱ型在手術(shù)時(shí)間、術(shù)后頸椎曲度、ROM和軸性癥狀發(fā)生率等方面均優(yōu)于SLAC-Ⅰ型手術(shù)。

SLAC圍手術(shù)期處理也經(jīng)歷了較大變化。隨著手術(shù)技術(shù)的改進(jìn)和觀念的轉(zhuǎn)變，術(shù)后臥床時(shí)間從之前的3～6 d縮短至1 d，一般術(shù)后6 h可在護(hù)士幫助下軸向翻身，術(shù)后1 d可坐起，術(shù)后2 d可下地活動(dòng)，并鼓勵(lì)患者早期進(jìn)行功能鍛煉。預(yù)防性抗生素使用從之前的5～7 d縮短為術(shù)后24 h，個(gè)別情況延長(zhǎng)至48 h。佩戴頸托時(shí)間從最早的3～6個(gè)月以上逐漸縮短至2周，以避免術(shù)后ROM過(guò)多丟失[139-141]。

結(jié)語(yǔ)

椎板成形術(shù)作為頸椎后路的常用術(shù)式，已成為治療多節(jié)段脊髓壓迫疾病的首選方法。單開(kāi)門手術(shù)在我國(guó)應(yīng)用廣泛，Hirabayashi曾將其定位為“平民手術(shù)”，意指平林法對(duì)手術(shù)技術(shù)要求較低，減壓過(guò)程較簡(jiǎn)單，手術(shù)時(shí)間短、費(fèi)用低。但單開(kāi)門存在其固有缺陷，如椎管擴(kuò)大及后方結(jié)構(gòu)不對(duì)稱，術(shù)后曲度、活動(dòng)度下降較多，軸性癥狀發(fā)生較多，“再關(guān)門”發(fā)生率較高等。而我們?cè)谑褂脙?nèi)固定物降低了關(guān)門風(fēng)險(xiǎn)的同時(shí)，也大大增加了手術(shù)時(shí)間和費(fèi)用，失去了平林法的優(yōu)勢(shì)。相比之下，雙開(kāi)門手術(shù)療效相當(dāng)，并發(fā)癥明顯減少，患者獲益增加[11,142]。我們相信，隨著技術(shù)的進(jìn)步和普及，棘突縱割方法將成為椎板成形術(shù)的發(fā)展方向。珊瑚人工骨已經(jīng)取得了很好的效果，但我們?nèi)云诖龘碛懈霉钦T導(dǎo)性人工骨的出現(xiàn)。希望我國(guó)脊柱外科醫(yī)師和研究者今后能在椎板成形術(shù)的發(fā)展中做出杰出的貢獻(xiàn)。

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