卓成龍 丁立祥

頸椎椎管成形術(shù)治療多節(jié)段頸椎管狹窄

卓成龍 丁立祥

丁立祥 教授

多節(jié)段頸椎管狹窄的原因有很多,其中最為常見的是頸椎病或后縱韌帶骨化(ossification of posterior longitudinal ligament, OPLL)。椎管減壓既可以前路進(jìn)行,也可以選擇后路進(jìn)行。對(duì)于多節(jié)段病變,尤其伴有OPLL患者,由于手術(shù)安全性的考慮,其手術(shù)方案傾向于采用后路減壓。后路頸椎減壓手術(shù)包括椎板切除術(shù)和椎管成形術(shù),其中以椎管成形術(shù)最為常用,根據(jù)椎管成形減壓方式差異,其主要術(shù)式分為2大類:單開門與雙開門椎管成形術(shù)[1-2]。而此2種基本術(shù)式又衍生出諸多手術(shù)術(shù)式,并于臨床或基礎(chǔ)方面又有了新的研究。

1 手術(shù)適應(yīng)證

椎管成形術(shù)可以在不用去除前方病變的條件下,間接解除脊髓和神經(jīng)根管的壓迫。通過保留后方結(jié)構(gòu),該術(shù)式可以維持脊柱穩(wěn)定和力線,減少因椎板切除引起的后凸和不穩(wěn)[3]。絕大部分學(xué)者均認(rèn)為后路手術(shù)的指征是[4-5]:(1)≥3 個(gè)節(jié)段的脊髓型頸椎病或影像學(xué)提示多節(jié)段脊髓腹背側(cè)受壓者;(2)發(fā)育性和退變性頸椎管狹窄所致頸脊髓病(包括頸椎管狹窄合并無骨折脫位型頸脊髓損傷);(3)多節(jié)段受累的頸椎OPLL所致頸脊髓病;(4)黃韌帶肥厚或骨化壓迫脊髓背側(cè)所致頸脊髓病;(5)頸前路術(shù)后療效不佳者。Braly等[5]認(rèn)為禁忌證是既往頸椎后路手術(shù)病史、黃韌帶骨化、硬膜外纖維化患者。

Hirabayashi等[6]通過CT比較單開門和雙開門頸椎椎管在C5、C6擴(kuò)大的程度,確定兩者的手術(shù)適應(yīng)證。單開門適應(yīng)證是脊髓型頸椎病(CSM)伴單側(cè)神經(jīng)根病變、重度凸出的OPLL、棘突太小無法行雙開門者,雙開門適應(yīng)證是通常的CSM、小和輕微凸出的OPLL、CSM伴雙側(cè)神經(jīng)根病變、頸椎管狹窄伴不穩(wěn)定(必須后路脊柱內(nèi)固定手術(shù))者。

2 術(shù)式的近期發(fā)展

2.1 單開門椎管成形術(shù) Hirabayashi術(shù)式影響深遠(yuǎn),并不斷涌現(xiàn)出不同的改良方法,如全(en-bloc)椎管成形術(shù)(Ito和Tsuji’s方法)(圖1)。近期Ding等[7]對(duì)CSM伴發(fā)黃韌帶肥厚患者施行C3、C5、C7椎板切除術(shù)并咬除肥厚的黃韌帶,用Centerpiece鋼板與棘突自體骨移植組裝,對(duì)C4、C6椎板弓重建,鉸鏈側(cè)骨碎屑填充。Arantes Júnior等[8]對(duì)86例多節(jié)段脊髓型頸椎病(MCSM)患者采用一種新型的雙開門術(shù)式(圖2)。該術(shù)式對(duì)C3～C4椎板一側(cè)單開門,而C5～C6椎板對(duì)側(cè)單開門,這可對(duì)C5神經(jīng)根雙側(cè)減壓,C2/C7可行部分椎扳切除術(shù),C2棘突與C3椎板、C4椎板與C5椎板、C6椎板與C7棘突分別進(jìn)行縫線固定,首先和最重要的縫線固定是C4椎板與C5棘突。該術(shù)式療效滿意,不需要異體骨或其他固定材料,建議用于老年人。

Tabaraee等[9]發(fā)現(xiàn)金屬微型板較結(jié)構(gòu)性肋骨同種異體支柱手術(shù)時(shí)間短、術(shù)后制動(dòng)少。Park等[10]發(fā)現(xiàn)只用鋼板在早期骨愈合中不能提供足夠的穩(wěn)定,鉸鏈側(cè)會(huì)發(fā)生延遲的再骨折(9%,1周)。Chen等[11]認(rèn)為Centerpiece微型板固定組較縫合懸掛組未增加完全骨折率,可能促進(jìn)Ⅰ型完全鉸鏈骨折的骨融合。

2.2 雙開門椎管成形術(shù) Kurokawa雙開門術(shù)式也不斷涌現(xiàn)出新的改良方法。近期Mehdain等[12]設(shè)計(jì)一種改良的Kurokawa術(shù)式,對(duì)C4、C5、C6棘突間置入骨塊后,用3條頜面部鈦板(16～18孔)、2 mm螺釘固定,術(shù)中共出血200 ml,2.5 h完成。鈦板和骨塊的組合不僅極大限度的增加椎管面積,且無“彈性回彈”,這種鈦板廉價(jià)、速效,擴(kuò)大后方骨性神經(jīng)根管,保護(hù)骨肌肉組織便于術(shù)后運(yùn)動(dòng)。Oh等[13]在咬除棘突后,將PEEK板(MAXPACER°R)用2枚8 mm鈦釘固定在撐開的椎板上。Harshavardhana等[14]將自體髂嵴骨填充在分開的棘突(C2、C7保留肌肉附著)間隙,微型鈦板與前側(cè)的移植骨錨定、用螺釘與后側(cè)的結(jié)構(gòu)固定,術(shù)后未使用外固定支具。

Park等[15]采用箱型椎管擴(kuò)大成形術(shù)(圖3)對(duì)36例OPLL和12例CSM患者進(jìn)行減壓,微型鋼板置于兩椎板之間,用8 mm的椎板間螺釘固定,箱型椎管擴(kuò)大成形術(shù)可創(chuàng)造出最大程度的椎管擴(kuò)大,椎板間螺釘固定良好且未造成神經(jīng)功能缺損。Kim等[16]認(rèn)為90°箱型椎管成形術(shù)可能會(huì)引起硬膜瘢痕組織形成、后凸,仍需長(zhǎng)期隨訪。Tani等[17]使用鈦質(zhì)箱型棘突間隔物,兩側(cè)各有一臂便于螺釘固定。

注:(A)單開門椎管成形術(shù)頂面觀(Hiraba-yashi方法),三個(gè)椎板被向兩側(cè)掀起。(B)單開門軸位像,椎板被絲線維持張開。(C)全(en-bloc)椎管成形術(shù)(Ito和Tsujis方法)。(D)植骨塊和小鋼板維持掙開的椎管間隙圖1 單開門椎管成形術(shù)圖2 新型雙開門術(shù)式注:(A)雙開門椎管成形術(shù),Kurokawa方法頂面觀。(B)移植骨條置于劈開的棘突間。(C)Tomita方法的軸面觀。(D)椎板向兩側(cè)擴(kuò)大。圖3 箱型椎管擴(kuò)大成形術(shù)可獲最大程度的椎管擴(kuò)張

2.3 保留肌肉附著,重建復(fù)合體 在保留肌肉附著方面,Sakaura等[18]對(duì)保留C2、C7棘突的C3～C6椎管成形術(shù)隨訪平均9年,長(zhǎng)期療效滿意。 Kotani等[19]保留頸多裂肌、頸半棘肌的附著,對(duì)減壓節(jié)段已切除的棘突再縫合固定,術(shù)后在軸性痛、生活質(zhì)量評(píng)分(QOL)、預(yù)防深部伸肌萎縮較傳統(tǒng)術(shù)式表現(xiàn)出巨大優(yōu)勢(shì)。Shiraishi等[20]報(bào)道了幾種新的術(shù)式,選擇性單一椎管成形術(shù)、保留肌肉的椎間孔切開術(shù)、保留肌肉的后路寰樞椎內(nèi)固定術(shù)。Umeda等[21]對(duì)C4～C6予以椎管成形術(shù)(用羥磷灰石間隔物),C3和C7部分椎板切除術(shù),或C3椎板全切、C7部分椎板切除術(shù)。

在后方韌帶復(fù)合體方面,Lin等[23]明確證實(shí)椎管成形術(shù)嚴(yán)重影響頸椎矢狀位平衡,術(shù)后頸椎易于前傾,隨著對(duì)復(fù)合體的破壞度增加,矢狀位平衡的缺失增大。Sinha等[24]使用單側(cè)后路中線路徑予以雙開門,保留后張力帶和椎旁深層伸肌的附著,且未損傷附著在棘突上的對(duì)側(cè)椎旁肌肉。Abdullah等[25]使用微型板伴異體支柱骨移植重建椎板,保留后方復(fù)合體。

2.4 椎管成形術(shù)聯(lián)合內(nèi)固定 在側(cè)塊固定方面,Jiang等[26]對(duì)CSM伴多節(jié)段椎管狹窄患者采用單開門聯(lián)合側(cè)塊鋼板螺釘固定,Chen等[27]對(duì)OPLL伴頸椎不穩(wěn)予以后路椎管成形術(shù)聯(lián)合側(cè)塊螺釘固定。劉永皚等[28]發(fā)現(xiàn)單開門聯(lián)合側(cè)塊螺釘固定術(shù)后有較低的軸性癥狀(AS)發(fā)生率(6.0%)。

Miyamoto等[29]首次研究對(duì)CSM伴后凸畸形(>5°)患者予以單獨(dú)椎管成形術(shù)(laminoplasty alone,LP)與使用椎弓根螺釘或側(cè)塊螺釘矯正后凸畸形的后路重建手術(shù)(posterior reconstruction surgery,PR)之間的差異,PR組、LP組JOA評(píng)分回復(fù)率分別為44.5%、32.6%,術(shù)后后凸角度分別為(4.0±8.6)°、(8.0±6.0)°,C2-7角度PR組改善至(-11.6±6.2)°、LP組惡化至(0.5±12.7)°。

Kim等[30]首次報(bào)道經(jīng)關(guān)節(jié)突螺釘(transarticular screw,TAS)聯(lián)合含HA間隔物的生物可吸收左旋聚丙交酯螺釘對(duì)C4/C5內(nèi)固定,隨訪1年后確認(rèn)C4/C5融合,生物活性螺釘被新生骨填充、HA促進(jìn)骨誘導(dǎo)。

3 術(shù)后主要并發(fā)癥

3.1 術(shù)后AS AS是指椎管成形術(shù)后遺留或發(fā)生頸肩背部疼痛、僵硬、頸項(xiàng)活動(dòng)受限等癥狀,1999年Kawaguchi等[31]稱為AS。Wang等[32]統(tǒng)計(jì)1996～2009年的26篇納入1297例患者,AS的發(fā)生率為5.2%～61.5%。但也有文獻(xiàn)發(fā)現(xiàn)術(shù)后有無軸性痛與術(shù)前即有軸性痛無關(guān)。認(rèn)為椎管成形術(shù)可能不是造成AS的主要原因,但可被其加劇。軸性痛的潛在來源包括頸椎間盤、肌肉組織、關(guān)節(jié)突關(guān)節(jié)、脊髓和神經(jīng)根。Sakaura等[33]證實(shí)保留樞椎下深部肌肉無異于減輕AS,認(rèn)為椎管成形術(shù)后不良反應(yīng)主要源于剝離C2、C7棘突的附著肌肉。在減少AS方面,Mesfin等[34]認(rèn)為對(duì)C3施行椎板切除術(shù)而不是椎管成形術(shù)來保留頸半棘肌在C2的附著、盡量避免對(duì)C7施行椎管成形術(shù)以保留斜方肌和菱形肌的附著、對(duì)頸半棘肌及其筋膜予以精致的多層縫合以減少死腔和肌萎縮。Wang等[35]建議一些更加微創(chuàng)的椎管成形術(shù)、術(shù)后早期頸椎活動(dòng)度(ROM)鍛煉、使用短的或不使用外固定器、盡量少的手術(shù)暴露。

3.2 ROM減少 Duetzmann等[36]綜述2390例患者術(shù)后仍有50%的ROM減少,并不優(yōu)于椎板切除術(shù)和融合。Hyun等[37]觀察術(shù)后頸椎活動(dòng),認(rèn)為ROM的減少與時(shí)間有關(guān)。Nagamoto等[38]第1次記錄了椎管成形術(shù)后3D節(jié)段性動(dòng)態(tài)改變,盡管6月后C2～C7 ROM屈伸顯著降低,但代表頸椎總ROM的 枕骨-T1 ROM 在屈伸、旋轉(zhuǎn)方面未顯著降低,認(rèn)為由枕骨-C2 的節(jié)段性運(yùn)動(dòng)增加所致部分代償。他認(rèn)為其他絕大部分人研究的ROM是側(cè)位片2D的屈伸,而不是精準(zhǔn)的3D改變。

Machino等[39]報(bào)道了520例椎管成形術(shù)后頸椎矢狀序列和ROM,矢狀序列改變輕微(只增加1.8°的前凸),ROM保留率達(dá)87.9%,這與早期移除頸支具、術(shù)后頸肌鍛煉、一些操作改良有關(guān)。Uehara等[40]對(duì)13例不穩(wěn)定性CSM患者的受壓節(jié)段予以單開門成形術(shù),不穩(wěn)定節(jié)段聯(lián)合頸椎椎弓根螺釘內(nèi)固定,不穩(wěn)定椎最大屈位與最大伸位的滑脫角從術(shù)前(9.0±5.5)°(2°～20°) 變化到最后隨訪的(1.6±1.9)°(0°～5°),滑脫角差異有顯著性提高(P=0.043),且無神經(jīng)血管并發(fā)癥。因此,術(shù)中減少小關(guān)節(jié)損傷,保護(hù)韌帶肌肉的附著,減少減壓節(jié)段,必要時(shí)予以脊柱內(nèi)固定,術(shù)后較短的使用支具和較早的功能鍛煉,加快神經(jīng)功能恢復(fù),從而減少ROM的丟失和后凸畸形的發(fā)生。

3.3 C5神經(jīng)根麻痹 表現(xiàn)為三角肌癱瘓、肩部感覺減退,以C5神經(jīng)根麻痹最為常見。Gu等[41]選擇25篇文獻(xiàn)的綜述認(rèn)為,單開門、雙開門椎管擴(kuò)大成形術(shù)的術(shù)后C5麻痹發(fā)生率分別為4.5%、3.1%,認(rèn)為過度的脊髓漂移、術(shù)前椎間孔狹窄、OPLL、男性等術(shù)后有較高的發(fā)生率。Sakaura等[42]總結(jié)絕大多數(shù)C5麻痹的病理學(xué)機(jī)制包括術(shù)中神經(jīng)根損傷、神經(jīng)根牽拉、脊髓缺血、節(jié)段性脊髓損傷、脊髓再灌注損傷。Yamanaka等[43]發(fā)現(xiàn)椎管成形術(shù)聯(lián)合脊柱融合術(shù)術(shù)后C5麻痹發(fā)生率較高,矯正脊柱后凸和脊柱滑脫使用后路內(nèi)固定可能是醫(yī)源性椎間孔狹窄所致C5麻痹的一種危險(xiǎn)因素。

Kaneyama等[44]明確證實(shí)單開門術(shù)后較雙開門術(shù)后C5麻痹風(fēng)險(xiǎn)高,認(rèn)為OPLL與單開門一樣是C5麻痹的危險(xiǎn)因素,單開門造成的不對(duì)稱減壓可能導(dǎo)致脊髓不平衡的旋轉(zhuǎn)運(yùn)動(dòng),建議對(duì)OPLL施行雙開門。

Katsumi等[45]報(bào)道141例單開門伴預(yù)防性雙側(cè)C4/C5椎間孔減壓術(shù),141例只行單開門,術(shù)后C5麻痹發(fā)生率分別為1.4%(2例)和6.4%(9例)。預(yù)防性雙側(cè)C4/C5椎間孔減壓術(shù)顯著減少術(shù)后C5麻痹,并認(rèn)為C5麻痹的主要病因是C5神經(jīng)根損傷,次要病因可能是頸椎管狹窄急性減壓所致的脊髓損傷,作者強(qiáng)烈建議單開門術(shù)中施行預(yù)防性雙側(cè)C4/C5椎間孔減壓術(shù)。Ohashi等[46]證實(shí)術(shù)中預(yù)防性雙側(cè)C4/C5椎間孔減壓術(shù)對(duì)術(shù)后影像學(xué)和臨床表現(xiàn)沒有負(fù)面作用,可有效預(yù)防C5麻痹。

以上的所有術(shù)式各有優(yōu)缺點(diǎn),隨著器械、工具更加精密,微創(chuàng)手術(shù)理念更加深入、普及,相信術(shù)后并發(fā)癥會(huì)更少,在獲得相同的療效同時(shí)對(duì)患者的創(chuàng)傷更小,術(shù)后恢復(fù)更快。

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100038北京市，北京世紀(jì)壇醫(yī)院脊柱外科

丁立祥，Email：dinglixiang@medmail

R 681.5

A

10.3969/j.issn.1003-9198.2015.11.003

2015-09-24)