脊髓型颈椎病手术入路及减压融合方式的选择策略  

The strategy selection of surgical approach and decompression and fusion for cervical spondylotic myelopathy

作　　者：关晓明 马迅 Guan Xiaoming;Ma Xun(Department of Orthopaedics,Shanxi Bethune Hospital(Shanxi Academy of Medical Sciences),Taiyuan 030032,China)

机构地区：[1]山西白求恩医院(山西医学科学院)骨科,太原030032

出　　处：《中华骨科杂志》2019年第23期1478-1484,共7页Chinese Journal of Orthopaedics

摘　　要：脊髓型颈椎病是骨科常见病及多发病,尤其是多节段脊髓型颈椎病,致病因素多样,临床症状重,影像学表现复杂,大多伴有严重的神经功能损害,严重影响患者的生活质量,部分患者甚至在轻微外伤后即出现严重的颈脊髓损伤症状,危及生命.因此需早诊断,早治疗,手术治疗是目前最为有效的方法,可以有效解除脊髓压迫因素,重建颈椎功能稳定性.但是如何选择手术入路及减压融合方式是临床争议的焦点.脊髓型颈椎病手术治疗的首要目的是彻底解除对脊髓的压迫,因此结合影像学特点决定减压和重建术式是手术成功的关键.致压因素主要位于脊髓前方,以椎间盘突出、轻度骨赘或局限性后纵韧带骨化为主,病变节段少,致压范围小,颈椎后凸或局部后凸畸形,手术易于切除致压物和需要矫正矢状位失衡者,可以采用前方入路;减压融合方式可选择经椎间隙、经椎体次全切或混合减压方式,另外为了更多地保留颈椎活动功能可以选择人工椎间盘置换和融合固定相结合的方式.致压因素主要位于脊髓后方,黄韧带肥厚或骨化,先天性发育性椎管狭窄,脊髓前方致压因素多,范围大,病变节段长,难以从前方彻底切除,前路手术风险极大者,可采用后方入路;虽然后路手术为间接减压,但借助脊髓后移能起到改善神经功能的作用,并发症少,安全性相对较高.另外经后入路还可以利用椎弓根或侧块螺钉达到减压效果,并矫正后凸畸形.两种入路及相关减压方式,均有各自的手术绝对适应证与相对适应证.前后路联合手术具有彻底减压和坚强固定的优势,但创伤大、风险高,临床应用需谨慎.无论如何选择入路,均应以完善的影像学资料结合临床症状与体征为基础,明确脊髓的致压病理因素、脊髓损害的轻重、受压范围的大小和责任节段,进而制定个体化手术方案.Cervical spondylotic myelopathy is a common and frequently-occurring disease in Orthopaedics,especially with multi-segmental cervical spondylotic myelopathy.There are several pathogenic factors for cervical spondylotic myelopathy.The clinical symptoms are serious,and the imaging manifestations are complex.Most of them are accompanied by serious neurological damage,which seriously affects the quality of life of patients.Furthermore,some patients have serious cervical spinal cord injury symptoms,which endanger their lives after mild trauma.Therefore,early diagnosis,early treatment and surgery are the most effective methods at present,which could effectively eliminate the factors of spinal cord compression and reconstruct the stability of cervical spine function.However,the choice of surgical approach and decompression fusion has always been the focus of debate.The primary purpose of surgery for cervical spondylotic myelopathy is to completely relieve the compression of spinal cord.According to the imaging characteristics of cervical spondylotic myelopathy,it is the key to the success of the operation to determine the decompression and reconstruction of cervical spondylotic myelopathy.Anterior approach can be adopted in patients with the compression factors located in front of the spinal cord,including disc protrusion,mild osteophyte or local ossification posterior longitudinal ligament,less lesion segments,small compression range,cervical kyphosis or local kyphosis deformity,easy resection of compression and sagittal imbalance correction.Decompression fusion can be selected through intervertebral space,subtotal vertebral body resection and mixed decompression for fusion and fixation.In order to retain the active function of cervical vertebrae,artificial disc replacement and fusion can be selected.For patients with the compression factors located in the posterior part of the spinal cord,including ligamentumflavum hypertrophy or ossification,congenital developmental spinal canal stenosis,there are many factors causin

关 键 词：脊髓型颈椎病 后纵韧带骨化 手术入路 病变节段 黄韧带肥厚 后凸畸形 减压效果 轻微外伤 

分 类 号：R68[医药卫生—骨科学]