頸椎椎管成形術治療多節段頸椎管狹窄

卓成龍 丁立祥

頸椎椎管成形術治療多節段頸椎管狹窄

卓成龍 丁立祥

丁立祥 教授

多節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行,也可以選擇后路進行。對于多節段病變,尤其伴有OPLL患者,由于手術安全性的考慮,其手術方案傾向于采用后路減壓。后路頸椎減壓手術包括椎板切除術和椎管成形術,其中以椎管成形術最為常用,根據椎管成形減壓方式差異,其主要術式分為2大類:單開門與雙開門椎管成形術[1-2]。而此2種基本術式又衍生出諸多手術術式,并于臨床或基礎方面又有了新的研究。

1 手術適應證

椎管成形術可以在不用去除前方病變的條件下,間接解除脊髓和神經根管的壓迫。通過保留后方結構,該術式可以維持脊柱穩定和力線,減少因椎板切除引起的后凸和不穩[3]。絕大部分學者均認為后路手術的指征是[4-5]:(1)≥3 個節段的脊髓型頸椎病或影像學提示多節段脊髓腹背側受壓者;(2)發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所致頸脊髓病;(5)頸前路術后療效不佳者。Braly等[5]認為禁忌證是既往頸椎后路手術病史、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擴大的程度,確定兩者的手術適應證。單開門適應證是脊髓型頸椎病(CSM)伴單側神經根病變、重度凸出的OPLL、棘突太小無法行雙開門者,雙開門適應證是通常的CSM、小和輕微凸出的OPLL、CSM伴雙側神經根病變、頸椎管狹窄伴不穩定(必須后路脊柱內固定手術)者。

2 術式的近期發展

2.1 單開門椎管成形術 Hirabayashi術式影響深遠,并不斷涌現出不同的改良方法,如全(en-bloc)椎管成形術(Ito和Tsuji’s方法)(圖1)。近期Ding等[7]對CSM伴發黃韌帶肥厚患者施行C3、C5、C7椎板切除術并咬除肥厚的黃韌帶,用Centerpiece鋼板與棘突自體骨移植組裝,對C4、C6椎板弓重建,鉸鏈側骨碎屑填充。Arantes Júnior等[8]對86例多節段脊髓型頸椎病(MCSM)患者采用一種新型的雙開門術式(圖2)。該術式對C3～C4椎板一側單開門,而C5～C6椎板對側單開門,這可對C5神經根雙側減壓,C2/C7可行部分椎扳切除術,C2棘突與C3椎板、C4椎板與C5椎板、C6椎板與C7棘突分別進行縫線固定,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]發現金屬微型板較結構性肋骨同種異體支柱手術時間短、術后制動少。Park等[10]發現只用鋼板在早期骨愈合中不能提供足夠的穩定,鉸鏈側會發生延遲的再骨折(9%,1周)。Chen等[11]認為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Ⅰ型完全鉸鏈骨折的骨融合。

2.2 雙開門椎管成形術 Kurokawa雙開門術式也不斷涌現出新的改良方法。近期Mehdain等[12]設計一種改良的Kurokawa術式,對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、速效,擴大后方骨性神經根管,保護骨肌肉組織便于術后運動。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,微型鈦板與前側的移植骨錨定、用螺釘與后側的結構固定,術后未使用外固定支具。

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

注:(A)單開門椎管成形術頂面觀(Hiraba-yashi方法),三個椎板被向兩側掀起。(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(Ito和Tsujis方法)。(D)植骨塊和小鋼板維持掙開的椎管間隙圖1 單開門椎管成形術圖2 新型雙開門術式注:(A)雙開門椎管成形術,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)椎板向兩側擴大。圖3 箱型椎管擴大成形術可獲最大程度的椎管擴張

2.3 保留肌肉附著,重建復合體 在保留肌肉附著方面,Sakaura等[18]對保留C2、C7棘突的C3～C6椎管成形術隨訪平均9年,長期療效滿意。 Kotani等[19]保留頸多裂肌、頸半棘肌的附著,對減壓節段已切除的棘突再縫合固定,術后在軸性痛、生活質量評分(QOL)、預防深部伸肌萎縮較傳統術式表現出巨大優勢。Shiraishi等[20]報道了幾種新的術式,選擇性單一椎管成形術、保留肌肉的椎間孔切開術、保留肌肉的后路寰樞椎內固定術。Umeda等[21]對C4～C6予以椎管成形術(用羥磷灰石間隔物),C3和C7部分椎板切除術,或C3椎板全切、C7部分椎板切除術。

在后方韌帶復合體方面,Lin等[23]明確證實椎管成形術嚴重影響頸椎矢狀位平衡,術后頸椎易于前傾,隨著對復合體的破壞度增加,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側椎旁肌肉。Abdullah等[25]使用微型板伴異體支柱骨移植重建椎板,保留后方復合體。

2.4 椎管成形術聯合內固定 在側塊固定方面,Jiang等[26]對CSM伴多節段椎管狹窄患者采用單開門聯合側塊鋼板螺釘固定,Chen等[27]對OPLL伴頸椎不穩予以后路椎管成形術聯合側塊螺釘固定。劉永皚等[28]發現單開門聯合側塊螺釘固定術后有較低的軸性癥狀(AS)發生率(6.0%)。

Miyamoto等[29]首次研究對CSM伴后凸畸形(>5°)患者予以單獨椎管成形術(laminoplasty alone,LP)與使用椎弓根螺釘或側塊螺釘矯正后凸畸形的后路重建手術(posterior reconstruction surgery,PR)之間的差異,PR組、LP組JOA評分回復率分別為44.5%、32.6%,術后后凸角度分別為(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]首次報道經關節突螺釘(transarticular screw,TAS)聯合含HA間隔物的生物可吸收左旋聚丙交酯螺釘對C4/C5內固定,隨訪1年后確認C4/C5融合,生物活性螺釘被新生骨填充、HA促進骨誘導。

3 術后主要并發癥

3.1 術后AS AS是指椎管成形術后遺留或發生頸肩背部疼痛、僵硬、頸項活動受限等癥狀,1999年Kawaguchi等[31]稱為AS。Wang等[32]統計1996～2009年的26篇納入1297例患者,AS的發生率為5.2%～61.5%。但也有文獻發現術后有無軸性痛與術前即有軸性痛無關。認為椎管成形術可能不是造成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、關節突關節、脊髓和神經根。Sakaura等[33]證實保留樞椎下深部肌肉無異于減輕AS,認為椎管成形術后不良反應主要源于剝離C2、C7棘突的附著肌肉。在減少AS方面,Mesfin等[34]認為對C3施行椎板切除術而不是椎管成形術來保留頸半棘肌在C2的附著、盡量避免對C7施行椎管成形術以保留斜方肌和菱形肌的附著、對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]建議一些更加微創的椎管成形術、術后早期頸椎活動度(ROM)鍛煉、使用短的或不使用外固定器、盡量少的手術暴露。

3.2 ROM減少 Duetzmann等[36]綜述2390例患者術后仍有50%的ROM減少,并不優于椎板切除術和融合。Hyun等[37]觀察術后頸椎活動,認為ROM的減少與時間有關。Nagamoto等[38]第1次記錄了椎管成形術后3D節段性動態改變,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、旋轉方面未顯著降低,認為由枕骨-C2 的節段性運動增加所致部分代償。他認為其他絕大部分人研究的ROM是側位片2D的屈伸,而不是精準的3D改變。

Machino等[39]報道了520例椎管成形術后頸椎矢狀序列和ROM,矢狀序列改變輕微(只增加1.8°的前凸),ROM保留率達87.9%,這與早期移除頸支具、術后頸肌鍛煉、一些操作改良有關。Uehara等[40]對13例不穩定性CSM患者的受壓節段予以單開門成形術,不穩定節段聯合頸椎椎弓根螺釘內固定,不穩定椎最大屈位與最大伸位的滑脫角從術前(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),且無神經血管并發癥。因此,術中減少小關節損傷,保護韌帶肌肉的附著,減少減壓節段,必要時予以脊柱內固定,術后較短的使用支具和較早的功能鍛煉,加快神經功能恢復,從而減少ROM的丟失和后凸畸形的發生。

3.3 C5神經根麻痹 表現為三角肌癱瘓、肩部感覺減退,以C5神經根麻痹最為常見。Gu等[41]選擇25篇文獻的綜述認為,單開門、雙開門椎管擴大成形術的術后C5麻痹發生率分別為4.5%、3.1%,認為過度的脊髓漂移、術前椎間孔狹窄、OPLL、男性等術后有較高的發生率。Sakaura等[42]總結絕大多數C5麻痹的病理學機制包括術中神經根損傷、神經根牽拉、脊髓缺血、節段性脊髓損傷、脊髓再灌注損傷。Yamanaka等[43]發現椎管成形術聯合脊柱融合術術后C5麻痹發生率較高,矯正脊柱后凸和脊柱滑脫使用后路內固定可能是醫源性椎間孔狹窄所致C5麻痹的一種危險因素。

Kaneyama等[44]明確證實單開門術后較雙開門術后C5麻痹風險高,認為OPLL與單開門一樣是C5麻痹的危險因素,單開門造成的不對稱減壓可能導致脊髓不平衡的旋轉運動,建議對OPLL施行雙開門。

Katsumi等[45]報道141例單開門伴預防性雙側C4/C5椎間孔減壓術,141例只行單開門,術后C5麻痹發生率分別為1.4%(2例)和6.4%(9例)。預防性雙側C4/C5椎間孔減壓術顯著減少術后C5麻痹,并認為C5麻痹的主要病因是C5神經根損傷,次要病因可能是頸椎管狹窄急性減壓所致的脊髓損傷,作者強烈建議單開門術中施行預防性雙側C4/C5椎間孔減壓術。Ohashi等[46]證實術中預防性雙側C4/C5椎間孔減壓術對術后影像學和臨床表現沒有負面作用,可有效預防C5麻痹。

以上的所有術式各有優缺點,隨著器械、工具更加精密,微創手術理念更加深入、普及,相信術后并發癥會更少,在獲得相同的療效同時對患者的創傷更小,術后恢復更快。

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100038北京市，北京世紀壇醫院脊柱外科

丁立祥，Email：dinglixiang@medmail

R 681.5

A

10.3969/j.issn.1003-9198.2015.11.003

2015-09-24)