劉佳男，夏群，李宏達(dá)，魏冬

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頸椎融合術(shù)后在體運(yùn)動(dòng)學(xué)研究進(jìn)展

劉佳男1，夏群2，李宏達(dá)1，魏冬3

摘要：通過(guò)查閱頸椎融合術(shù)后有關(guān)在體運(yùn)動(dòng)學(xué)文獻(xiàn)，從融合相鄰節(jié)段椎體間運(yùn)動(dòng)范圍的改變、剩余運(yùn)動(dòng)節(jié)段在頸椎整體活動(dòng)度中所占比例變化規(guī)律、融合相鄰節(jié)段小關(guān)節(jié)運(yùn)動(dòng)模式以及相鄰節(jié)段旋轉(zhuǎn)中心的位置偏移等方面進(jìn)行歸納總結(jié)。以期能發(fā)現(xiàn)融合術(shù)后相鄰椎體退變的早期征兆，為臨床上相鄰節(jié)段病理改變（ASP）的治療提供理論依據(jù)。目前，相關(guān)運(yùn)動(dòng)學(xué)研究多局限于對(duì)頸椎矢狀面屈伸活動(dòng)的觀察，鮮有三維空間內(nèi)的6個(gè)自由度（6DOF）運(yùn)動(dòng)數(shù)據(jù)報(bào)道。另外，相關(guān)運(yùn)動(dòng)學(xué)研究并沒(méi)有終止?fàn)幷摚珹SP是由過(guò)度運(yùn)動(dòng)引起，還是頸椎病病程自然發(fā)展的結(jié)果仍存在爭(zhēng)議。長(zhǎng)期隨訪的大樣本隨機(jī)對(duì)照研究，獲得精確的6DOF運(yùn)動(dòng)學(xué)參數(shù)或許是解決爭(zhēng)議的最佳途徑。

關(guān)鍵詞：脊柱融合術(shù)；頸椎；綜述；頸椎前路減壓融合術(shù)；相鄰節(jié)段病理改變；先天性頸椎融合

作者單位：1天津醫(yī)科大學(xué)研究生院（郵編300070）；2武警后勤學(xué)院附屬醫(yī)院骨科醫(yī)院；3天津中醫(yī)藥大學(xué)研究生院

自20世紀(jì)50年代首次報(bào)道頸椎前路減壓融合術(shù)（ante?rior cervical decompression and fusion，ACDF）起，ACDF逐漸成為治療神經(jīng)根型和脊髓型頸椎病的標(biāo)準(zhǔn)術(shù)式，其治療效果已得到臨床醫(yī)生的廣泛認(rèn)同。但隨著臨床資料的累積，也出現(xiàn)了對(duì)頸椎融合術(shù)的質(zhì)疑，爭(zhēng)論的焦點(diǎn)主要集中在頸椎融合術(shù)是否會(huì)加速相鄰節(jié)段退變的發(fā)生。本文旨在對(duì)頸椎融合術(shù)后相關(guān)運(yùn)動(dòng)學(xué)研究進(jìn)行綜合比較，希望可以闡釋頸椎融合術(shù)后相鄰節(jié)段退變的機(jī)制。

1　融合相鄰節(jié)段運(yùn)動(dòng)范圍（range-of-motion，ROM）的變化特點(diǎn)

目前，臨床上常采用頸椎生理曲度、整體及各節(jié)段運(yùn)動(dòng)范圍等參數(shù)來(lái)評(píng)價(jià)融合術(shù)后相鄰節(jié)段運(yùn)動(dòng)學(xué)改變。多數(shù)學(xué)者認(rèn)為融合術(shù)會(huì)使頸椎剩余節(jié)段的活動(dòng)度重新分配，相鄰節(jié)段ROM代償性增大[1-4]。Baba等[1]通過(guò)比較手術(shù)前后不同隨訪時(shí)段的動(dòng)力位X線片發(fā)現(xiàn)，融合術(shù)使相鄰節(jié)段椎體間ROM較術(shù)前均明顯增大，且在多節(jié)段融合固定的患者中表現(xiàn)更為明顯。而Powell等[2]通過(guò)應(yīng)用計(jì)算機(jī)定量分析方法（quantitative radiographic analysis，QMA）比較ACDF患者手術(shù)前后各節(jié)段ROM等參數(shù)時(shí)也發(fā)現(xiàn)，術(shù)后24個(gè)月時(shí)單節(jié)段ACDF患者頭側(cè)相鄰節(jié)段ROM較術(shù)前相比明顯增大。而Anderst等[4]應(yīng)用二維-三維匹配技術(shù)發(fā)現(xiàn)，與正常人相比，ACDF患者頭側(cè)相鄰節(jié)段的最大前屈角度明顯減小，而最大后伸角度明顯增大。另一些文獻(xiàn)的結(jié)果則提示，融合術(shù)不僅會(huì)影響相鄰節(jié)段的運(yùn)動(dòng)學(xué)特征，甚至非相鄰節(jié)段也可能出現(xiàn)活動(dòng)度代償增大[5-7]。

但是，并非所有學(xué)者的研究結(jié)果都支持相鄰節(jié)段ROM代償性增大這一結(jié)論[8-13]。McDonald等[12]通過(guò)比較ACDF和人工間盤(pán)置換術(shù)后患者12個(gè)月的隨訪結(jié)果發(fā)現(xiàn)，2種術(shù)式手術(shù)相鄰節(jié)段在屈伸和軸向旋轉(zhuǎn)運(yùn)動(dòng)時(shí)活動(dòng)范圍差異無(wú)統(tǒng)計(jì)學(xué)意義。Sasso等[8]對(duì)242例行ACDF手術(shù)的患者進(jìn)行了平均24個(gè)月的隨訪也發(fā)現(xiàn)，對(duì)比最后一次隨訪的常規(guī)動(dòng)力位X線片結(jié)果，沒(méi)有證據(jù)顯示手術(shù)相鄰節(jié)段存在運(yùn)動(dòng)學(xué)改變。對(duì)此，有學(xué)者分析認(rèn)為，雖然ROM是臨床上評(píng)價(jià)術(shù)后療效的經(jīng)典運(yùn)動(dòng)學(xué)指標(biāo)，但其受研究對(duì)象個(gè)體差異、測(cè)量技術(shù)及隨訪時(shí)間的影響較大，研究結(jié)果可能遭到干擾[14-17]。因?yàn)?，即便?duì)同一對(duì)象進(jìn)行研究，若采用不同的測(cè)量技術(shù)[4]或選擇不同的運(yùn)動(dòng)方向和速度[18-19]，均可能對(duì)ROM的數(shù)值產(chǎn)生影響。

2　融合后剩余運(yùn)動(dòng)節(jié)段在頸椎整體活動(dòng)度中所占比例的變化規(guī)律

頸椎上連顱骨，下接胸椎，是脊柱中靈活性最大、活動(dòng)頻率最高的節(jié)段。只有7個(gè)椎體共同運(yùn)動(dòng)，才能使頸椎和諧地屈伸、旋轉(zhuǎn)。以屈伸運(yùn)動(dòng)為例，Wu等[20]報(bào)道了48例正常人C2～C7各節(jié)段在頸椎屈伸運(yùn)動(dòng)時(shí)所占比例，發(fā)現(xiàn)在頸椎各個(gè)節(jié)段中C4～C5節(jié)段所占比例最大，C5～C6、C3～C4節(jié)段次之，而C2～C3節(jié)段所占比例最低。其他學(xué)者對(duì)正常人頸椎在體運(yùn)動(dòng)進(jìn)行研究也發(fā)現(xiàn)了類(lèi)似的趨勢(shì)[21-23]。

但是不同于正常人頸椎各節(jié)段活動(dòng)時(shí)的比例特點(diǎn)，融合術(shù)減少了頸椎運(yùn)動(dòng)節(jié)段的數(shù)目，必然使剩余節(jié)段所占百分比增大。有學(xué)者提出，可以通過(guò)研究頸椎融合術(shù)后剩余運(yùn)動(dòng)節(jié)段占頸椎整體ROM中比例的變化趨勢(shì)，來(lái)分析融合術(shù)式對(duì)頸椎運(yùn)動(dòng)的影響，并認(rèn)為這種比例的變化趨勢(shì)極可能反映了融合術(shù)后椎間盤(pán)負(fù)荷的變化情況。Auerbach等[7]報(bào)道了頸椎融合術(shù)后2年，頸椎剩余運(yùn)動(dòng)節(jié)段在整體屈伸運(yùn)動(dòng)時(shí)所占比例的變化規(guī)律，發(fā)現(xiàn)融合尾側(cè)相鄰節(jié)段及頭側(cè)3個(gè)節(jié)段所占比例均顯著增加，其中以尾側(cè)相鄰節(jié)段增加幅度最大，而相對(duì)融合節(jié)段最遠(yuǎn)的頭側(cè)第4節(jié)段所占比例與術(shù)前相比差異無(wú)統(tǒng)計(jì)學(xué)意義。近年來(lái)為了更真實(shí)、全面地反映比例的變化規(guī)律，也有學(xué)者利用動(dòng)態(tài)射影技術(shù)，繪制了C5～C6節(jié)段融合固定患者及正常成年人最大屈伸運(yùn)動(dòng)（并定義為100%）時(shí)各運(yùn)動(dòng)節(jié)段所占比例的變化曲線，發(fā)現(xiàn)正常人的C2～C3、C3～C4、C4～C5節(jié)段在頸椎整體運(yùn)動(dòng)的起始及接近最大ROM時(shí)所占的比例較小，在50%最大ROM時(shí)所占比例最大，表現(xiàn)為一條單峰凸曲線；而C5～C6、C6～C7節(jié)段所占比例則剛好相反，即在運(yùn)動(dòng)起始及接近最大ROM時(shí)所占的比例最大，在中度ROM時(shí)，所占比例較小，表現(xiàn)為一條單峰凹曲線；但對(duì)于頸椎融合術(shù)后的患者而言，由于手術(shù)節(jié)段所占的比例由剩余活動(dòng)節(jié)段代償，其頭側(cè)C4～C5節(jié)段在30%～95%最大ROM范圍內(nèi)所占比例較正常人顯著增加，而尾側(cè)C6～C7節(jié)段所占比例在整個(gè)屈伸運(yùn)動(dòng)中均顯著增加；但值得注意的是，融合術(shù)后患者非手術(shù)相鄰節(jié)段（C2～C3、C3～C4）的ROM所占比例與正常對(duì)照組相比差異無(wú)統(tǒng)計(jì)學(xué)意義[24]。這一結(jié)果或許可以從側(cè)面印證Hilibrand等[25]報(bào)道的融合術(shù)后患者退行性病理改變多出現(xiàn)在相鄰節(jié)段，且尾側(cè)相鄰節(jié)段較頭側(cè)更容易發(fā)生的結(jié)論。因?yàn)闊o(wú)論屈伸多大幅度，即使融合術(shù)后患者減少了日常的活動(dòng)度，尾側(cè)相鄰節(jié)段比例增加量始終高于頭側(cè)。

3　相鄰節(jié)段小關(guān)節(jié)的運(yùn)動(dòng)模式

頸椎小關(guān)節(jié)（cervical facet joints, CFJ）由相鄰上下頸椎關(guān)節(jié)突的關(guān)節(jié)面組成，具有一定的穩(wěn)定性及在一定范圍內(nèi)的伸屈和旋轉(zhuǎn)運(yùn)動(dòng)功能，可與前方的椎間關(guān)節(jié)共同維持頸椎的穩(wěn)定。若頸椎小關(guān)節(jié)出現(xiàn)過(guò)度形變可能導(dǎo)致頸部揮鞭損傷或慢性疼痛的出現(xiàn)。

目前，國(guó)內(nèi)外鮮有文獻(xiàn)報(bào)道融合術(shù)后小關(guān)節(jié)在體運(yùn)動(dòng)學(xué)情況。曾有文獻(xiàn)報(bào)道了單節(jié)段ACDF術(shù)后患者屈伸活動(dòng)時(shí)的小關(guān)節(jié)形變數(shù)據(jù)，并與正常對(duì)照組進(jìn)行比較；與以往學(xué)者利用離體標(biāo)本所得到的數(shù)據(jù)不同，作者認(rèn)為在屈伸活動(dòng)時(shí)，頸椎各節(jié)段的小關(guān)節(jié)形變量不同，且同一小關(guān)節(jié)不同解剖部位的形變量也存在差異；為了便于分析屈伸運(yùn)動(dòng)與關(guān)節(jié)形變之間的潛在關(guān)系，作者計(jì)算出每屈伸1°時(shí)各節(jié)段、各解剖部位的關(guān)節(jié)形變量，并定義為小關(guān)節(jié)形變速率，發(fā)現(xiàn)與正常組相比融合術(shù)后相鄰節(jié)段小關(guān)節(jié)形變速率明顯減少，從而認(rèn)為融合術(shù)會(huì)導(dǎo)致相鄰節(jié)段小關(guān)節(jié)出現(xiàn)運(yùn)動(dòng)學(xué)改變[26]。

4　相鄰節(jié)段旋轉(zhuǎn)中心的位置偏移

雖然頸椎曲度、整體及各節(jié)段ROM等參數(shù)是評(píng)價(jià)融合術(shù)后長(zhǎng)期療效的重要方法，但這些參數(shù)只能用于頸椎運(yùn)動(dòng)的量變?cè)u(píng)價(jià)，如各節(jié)段的角度、位移變化。旋轉(zhuǎn)中心作為脊柱運(yùn)動(dòng)力學(xué)研究的一個(gè)重要定性指標(biāo)，能將椎體的位移和角度運(yùn)動(dòng)統(tǒng)一起來(lái)考慮，以闡釋相鄰椎體間的運(yùn)動(dòng)特征。相較于ROM等參數(shù)，其能更直觀地發(fā)現(xiàn)椎體間運(yùn)動(dòng)模式的改變。因此，有學(xué)者提出旋轉(zhuǎn)中心及瞬時(shí)旋轉(zhuǎn)中心的概念，以各節(jié)段運(yùn)動(dòng)產(chǎn)生的機(jī)制作為切入點(diǎn)，探索融合術(shù)后相鄰節(jié)段的旋轉(zhuǎn)中心及瞬時(shí)旋轉(zhuǎn)中心位置是否會(huì)偏離正常范圍。屈伸運(yùn)動(dòng)時(shí)正常人下頸椎各節(jié)段的旋轉(zhuǎn)中心自C2到C7逐漸上移，且C2～C3節(jié)段瞬時(shí)旋轉(zhuǎn)中心在矢狀軸上存在最大位移，各節(jié)段位移幅度自上而下逐漸減少。Anderst 等[27]將單節(jié)段ACDF術(shù)后患者屈伸運(yùn)動(dòng)的瞬時(shí)旋轉(zhuǎn)中心軌跡與正常對(duì)照組進(jìn)行比較，未發(fā)現(xiàn)2組之間存在差異。但Powell等[2]通過(guò)計(jì)算機(jī)定量分析方法，對(duì)比ACDF和人工間盤(pán)置換術(shù)后相鄰節(jié)段的旋轉(zhuǎn)中心改變發(fā)現(xiàn)，術(shù)后2年時(shí)雖然兩種術(shù)式間ROM差異無(wú)統(tǒng)計(jì)學(xué)意義，但其頭側(cè)相鄰節(jié)段旋轉(zhuǎn)中心位置在矢狀軸上存在差異，ACDF術(shù)后患者的旋轉(zhuǎn)中心更靠前。而融合術(shù)后鄰近節(jié)段旋轉(zhuǎn)中心的改變可能會(huì)影響椎體后部小關(guān)節(jié)的負(fù)重和椎間盤(pán)纖維環(huán)的張力，從而導(dǎo)致退變的發(fā)生[28]。

5　相鄰節(jié)段病理改變與過(guò)度運(yùn)動(dòng)的關(guān)系

融合術(shù)后相鄰節(jié)段病理改變（adjacent segment patholo?gy，ASP）是一系列相鄰節(jié)段異常病變的統(tǒng)稱(chēng)。Hilibrand等[29]將其分為影像學(xué)相鄰節(jié)段退變（adjacent segment degenera?tion，ASDeg）與相鄰節(jié)段疾?。╝djacent segment disease，ASDz）兩大類(lèi)。既往文獻(xiàn)報(bào)道的相鄰節(jié)段退變發(fā)生率平均為47.33%（16%～96%），而與之相比，相鄰節(jié)段疾病的平均發(fā)生率只有11.99%（1.8%～36%）[30]。目前ASP的發(fā)生機(jī)制尚未完全明確[31]，一種觀點(diǎn)認(rèn)為融合術(shù)后脊柱運(yùn)動(dòng)學(xué)及運(yùn)動(dòng)力學(xué)發(fā)生改變是其重要原因[29]。頸椎融合術(shù)使本應(yīng)該發(fā)生在手術(shù)節(jié)段椎體間的關(guān)節(jié)形變量轉(zhuǎn)移到頭尾兩端，致使其應(yīng)力集中，造成鄰近椎體的應(yīng)力分布及運(yùn)動(dòng)模式的改變。相鄰節(jié)段出現(xiàn)活動(dòng)代償增大和穩(wěn)定性丟失的生物力學(xué)及運(yùn)動(dòng)學(xué)改變，導(dǎo)致其退變加速[32-34]。

但也有學(xué)者的研究并不認(rèn)同上述觀點(diǎn)。Anderson等[35]利用Meta分析對(duì)12篇文獻(xiàn)進(jìn)行系統(tǒng)性研究發(fā)現(xiàn)，在2年的隨訪時(shí)間內(nèi)融合術(shù)式與非融合術(shù)式相比，手術(shù)鄰近節(jié)段的運(yùn)動(dòng)學(xué)參數(shù)差異無(wú)統(tǒng)計(jì)學(xué)意義。另一篇Meta分析的結(jié)果同樣顯示，ACDF與人工間盤(pán)置換術(shù)后患者相鄰節(jié)段疾病的再手術(shù)率差異無(wú)統(tǒng)計(jì)學(xué)意義[36]。另外，Hilibrand等[25]認(rèn)為ACDF術(shù)后患者會(huì)以每年2.9%的發(fā)生率出現(xiàn)相鄰節(jié)段疾病，并預(yù)計(jì)10年內(nèi)新發(fā)相鄰節(jié)段疾病將高達(dá)25.6%，但作者同樣認(rèn)為頸椎疾病的自然發(fā)展進(jìn)程也是導(dǎo)致相鄰節(jié)段退變的重要因素之一。

6　從先天性頸椎融合看ASP的發(fā)生

先天性頸椎融合因存在2個(gè)或2個(gè)以上椎體相互融合，與手術(shù)所致醫(yī)源性頸椎椎體融合類(lèi)似，且臨床上同樣常見(jiàn)該類(lèi)患者因融合相鄰節(jié)段退變而需手術(shù)治療的現(xiàn)象。Pizzutillo 等[37]曾對(duì)111例先天頸椎融合患者的過(guò)屈過(guò)伸位X線片進(jìn)行分析，發(fā)現(xiàn)患者頭側(cè)非融合節(jié)段平均椎體間ROM大于正常對(duì)照組，而尾側(cè)非融合節(jié)段的整體ROM減少，并認(rèn)為患者融合相鄰的上頸段由于過(guò)度運(yùn)動(dòng)有神經(jīng)受損的危險(xiǎn)，而患者融合相鄰的下頸段由于運(yùn)動(dòng)學(xué)改變?nèi)菀讓?dǎo)致退行性疾患。Leivseth等[38]測(cè)量了25例平均40歲的頸椎先天融合患者的椎間盤(pán)高度、椎體高度及融合鄰近節(jié)段的ROM后，只發(fā)現(xiàn)尾側(cè)鄰近節(jié)段椎間盤(pán)高度小于正常組，融合鄰近節(jié)段ROM未發(fā)現(xiàn)變化。Nagib等[39]發(fā)現(xiàn)先天融合患者往往在20～30年后才出現(xiàn)融合相鄰節(jié)段疾病而需要手術(shù)治療。這些發(fā)現(xiàn)或許提示目前頸椎融合術(shù)后隨訪時(shí)間相對(duì)不足，短期隨訪很可能得出假陰性的結(jié)果。

綜上所述，學(xué)者們分別從相鄰節(jié)段ROM改變、剩余運(yùn)動(dòng)節(jié)段比例變化規(guī)律、小關(guān)節(jié)運(yùn)動(dòng)模式及旋轉(zhuǎn)中心位置等角度對(duì)融合術(shù)的影響進(jìn)行了探討，以期能發(fā)現(xiàn)術(shù)后早期退變的征兆，為臨床上ASP的治療提供理論依據(jù)。但豐富的運(yùn)動(dòng)學(xué)研究并沒(méi)有終止?fàn)幷?，而且目前關(guān)于頸椎融合術(shù)后在體運(yùn)動(dòng)學(xué)研究大多僅局限于矢狀面上的屈伸活動(dòng)，即多局限于單平面的腰椎運(yùn)動(dòng)學(xué)觀察，鮮有三維空間內(nèi)的6個(gè)自由度（6-degree-of-freedom，6DOF）運(yùn)動(dòng)數(shù)據(jù)報(bào)道。長(zhǎng)期隨訪的大樣本隨機(jī)對(duì)照研究，精確測(cè)量ACDF術(shù)后患者生物力學(xué)及運(yùn)動(dòng)學(xué)參數(shù)是解決爭(zhēng)議的最佳途徑。先天融合患者多在椎體融合后20～30年，鄰近節(jié)段出現(xiàn)運(yùn)動(dòng)學(xué)參數(shù)的改變且鄰近節(jié)段疾病發(fā)生率逐漸增高。這一鮮明對(duì)比或許可以提示頸椎融合術(shù)可能是相鄰節(jié)段退變的主要原因之一，之所以未被大多數(shù)文獻(xiàn)證實(shí)，可能是目前隨訪觀察的時(shí)間過(guò)短所致。因此，臨床上迫切需要更長(zhǎng)時(shí)間隨訪的循證醫(yī)學(xué)證據(jù)出現(xiàn)。

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（2015-11-18收稿2015-12-29修回）

（本文編輯魏杰）

細(xì)胞與分子生物學(xué)

Research progress of in-vivo kinematics after cervical arthrodesis

LIU Jia′nan1，XIA Qun2，LI Hongda1，WEI Dong3
1 Tianjin Medical University, Tianjin 300070, China; 2 Department of Orthopedics of Affiliated Hospital of Logistics University of Chinese People′s Armed Police Forces；3 Tianjin University of Traditional Chinese Medicine Corresponding Author and Reviser E-mail：xiaqun6@163.com

Abstract:Related literature and studies concerning the kinematics in patients after cervical arthrodesis have extensive?ly reviewed and comprehensively analyzed in 4 terms of changes in adjacent segment range of motion, motion segment per?cent contributions, motion pattern of cervical facet joints, and deviated center of rotation at adjacent segments. These report?ed researches of in-vivo kinematics after cervical arthrodesis are almost on the sagittal plane. Few data have been reported on the 6DOFkinematics under physiological loadingconditions. Whether adjacent segment pathology caused by hypermobili?ty remains controversial. Long-term follow-up of large sample randomized controlled studies and obtaining the accurate 6DOFkinematics are the best way to resolve controversy.

Key words:spinal fusion; cervical vertebrae; review; anterior cervical decompression and fusion; adjacent segment pa?thology; congenital cervical fusion

中圖分類(lèi)號(hào)：R681.5+3

文獻(xiàn)標(biāo)志碼：A

DOI：10.11958/20150317

基金項(xiàng)目:國(guó)家自然科學(xué)基金資助項(xiàng)目(81572199)

作者簡(jiǎn)介：劉佳男(1990),男,碩士在讀，主要從事脊柱外科研究

通訊作者及審校者E-mail：xiaqun6@163.com