应用人工颈椎椎间盘置换治疗合并Klippel-Feil综合征脊髓型颈椎病2例报道

对于脊髓型颈椎病和神经根型颈椎病,颈椎椎间盘置换手术是一种比较有价值的治疗方法[1-6]。传统的前路颈椎椎间盘切除融合术对于脊髓型颈椎病和神经根型颈椎病仍然是目前最有效的治疗方法。前路颈椎椎间盘切除融合术后大部分患者对手术疗效满意,然而仍有部分患者存在颈部疼痛,尽管术后神经功能改善或者根性疼痛消失。有学者认为颈部疼痛和邻近节段退变有关,在融合节段邻近椎间盘存在退变的病理变化[7-8]。前路颈椎椎间盘切     

发育性颈椎管狭窄与颈椎前路融合术后邻近节段退变的关系分析

正颈椎前路融合术被认为是外科治疗颈椎病的重要术式,近年来国内手术量逐年增多[1]。颈椎融合术后邻近节段椎间盘应力增加,由此引发的邻近节段退变也日益受到关注[2]。现代医学认为发育性颈椎管狭窄可致颈椎管的储备空间较少,退变或外伤因素易引发脊髓受损,颈椎前路融合术邻近节段退行性改变可再次压迫神经产生脊髓病或神经根病[3]。然而目前有关发育性颈椎管狭窄与颈椎前路融合术后邻近节段退变关系的研究较少,为此笔者展开了临     

颈椎人工椎间盘置换术——我们的未来?

尽管颈椎前路融合术是20世纪治疗颈椎退变性疾病的重要方法，但是越来越多的学者研究发现，前路融合术后相邻节段的继发性退变和不稳定可以造成原有的症状复发或加重，已经成为影响颈椎前路手术治疗颈椎病远期疗效的一个重要因素。融合后手术节段获得的是一种非生理状态的稳定，失去了相应的运动节段，造成颈椎总活动度减少，相邻节段出现退变加快，一些患者甚至需要再次接受相邻节段的融合术。颈椎人工椎间盘置换术的设计理念是代替原来的椎间盘并行使其功能，实现保留运动节段、减少相邻节段继发性退变的目的。     

颈椎融合术后相邻节段椎间盘退变研究进展

颈椎病是临床常见疾病,严重影响了人们的生活,目前的治疗仍以减压固定融合为金标准。但随着病例数的增加及该项技术在临床中的广泛应用,发现颈椎融合术后加速了相邻节段退变的发生,甚至产生了相邻节段椎间盘退变疾病。近年来研究认为颈椎融合术后改变了颈椎的正常生物力学环境,使得相邻节段椎间盘应力增加从而加速相邻节段退变的发生,但仍有部分学者认为颈椎退变主要是自然史的因素。本文就颈椎术后相邻节段退变的病因以及影响因素的进展做一综述。     

理性认识邻近节段退变，慎重开展颈椎混合术式

自20世纪50年代Smith和Robinson报道颈椎前路减压融合术（anterior cervical decompression and fusion,ACDF）以来,ACDF逐渐成为颈椎退变性疾病的主要手术方式之一。但近年来,颈椎前路融合术后邻近节段退变问题备受国内外学者的关注。在此背景下,以颈椎人工椎间盘置换术（cervical artificial disc replacement, CADR）为代表的颈椎非融合技术应运而生,并取得了良好的短期临床治疗效果。对于多节段颈椎退变性疾病,有学者提出采用CADR与ACDF进行联合治疗,即Hybrid 术式。     

颈椎椎间融合术后邻近节段椎间盘退变的临床观察

目的：观察颈椎椎间融合术后邻近节段椎间盘退变的程度。方法：随访40例颈体融合术后患者,颈部和神经系统体检,行X线及MRI检查,观察椎体融合术后邻近节段退变的发生时间和程度。结果：颈椎体融合术邻近节段退变发生率为86％,约1－11年发生退变,平均9年,严重者发生椎间盘突出不全瘫。结论：颈椎体融合术后邻近节段退变容易发生,故对术后患者的指导和处理非常重要。     

颈椎前路融合术后的影像学变化:一项166例长期随访研究

正颈椎前路融合术后邻近节段常继发退变,目前尚不清楚退变程度与哪些因素相关。作者随访了166例颈椎前路融合术病例,随访时间5~30年,平均12.7年。观察邻近节段椎间盘高度丢失、骨赘形成、终板硬化、小关节退变以及颈椎弧度的改变。结果发现,90%患者邻近节段骨赘加重,离融合节段越近退变就越严重,与术前退变程度呈负相关。时间越久退变越严重。患者年龄、融合节     

对颈椎融合与非融合手术选择的审视

颈椎人工椎间盘置换术的设计理念是通过保留颈椎手术节段的活动性,减少以往前路减压融合术带来的相邻节段的退变加速。经过将近10年的临床应用和长期随访,我们对于这个先进理念的认识也逐渐深入。从文献报告的数据可以看出,不论是中期随访还是远期随访,颈椎人工椎间盘置换术确实减少了以往的前路融合术后相邻节段继发性退变的发生率。     

颈椎人工椎间盘置换术

颈椎前路椎间盘切除植骨融合术一直被认为是治疗颈椎退变性疾病的成熟而标准化的前路手术.但部分患者术后出现相邻节段继发性退变和不稳定,导致手术远期疗效差、满意度低.     

颈椎术后邻近节段退变研究进展

脊柱融合固定是众多脊柱疾病行之有效的治疗方法,但随着时间的推移,部分患者手术邻近节段逐渐退变并出现症状,从而引发对其发病率、发病机制、影响因素、预防治疗策略等的大量研究.一般认为颈椎前路融合固定较后路融合固定更易引起邻近节段退变,本身已有退变者术后退变发病率更高.颈椎术后邻近节段退变的确切机制还不清楚,但融合内固定、部位脊柱生理曲度异常等引起生物力学应力改变、邻近节段活动度增加、关节面载荷和椎间盘内压力增加在病程发展中起重要作用.影响邻近节段退变的因素还包括融合节段的多少、融合术式和部位、邻近椎间盘状况、术前疾病类型等.尽可能地保留运动节段能减少邻近节段退变的发生率,人工颈椎间盘置换等治疗效果良好.     

The change of adjacent segment after cervical disc arthroplasty compared with anterior cervical discectomy and fusion: a meta-analysis of randomized controlled trials

Background Context

Many meta-analyses have been performed to study the efficacy of cervical disc arthroplasty (CDA) compared with anterior cervical discectomy and fusion (ACDF); however, there are few data referring to adjacent segment within these meta-analyses, or investigators are unable to arrive at the same conclusion in the few meta-analyses about adjacent segment. With the increased concerns surrounding adjacent segment degeneration (ASDeg) and adjacent segment disease (ASDis) after anterior cervical surgery, it is necessary to perform a comprehensive meta-analysis to analyze adjacent segment parameters.

颈椎椎间盘置换术与前路颈椎椎间盘切除融合术对相邻节段病变参数影响的荟萃分析

目的对颈椎椎间盘置换术(CDA)和前路颈椎椎间盘切除融合术(ACDF)在相邻节段退行性变(ASDeg)、相邻节段疾病(ASDis)、相邻节段再手术(ASR)及相邻节段活动度(ROM)的影响方面进行荟萃分析。方法检索PubMed、Medline、EMbase及Cochrane图书馆等数据库,检索文献为2018年6月前发表的CDA与ACDF的随机对照研究(RCT),采用Cochrane系统评价指南的评分量表对纳入文献的随机方法和偏倚进行评估。主要提取的数据包括随访时间,ASDeg、ASDis和ASR发生率,相邻节段ROM。同时采用亚组分析和敏感性分析研究其高异质性。结果共33篇RCT文献纳入研究。CDA组ASR发生率明显低于ACDF组,差异有统计学意义(P<0.05);以随访时间进行亚组分析显示,随着随访时间延长,CDA组ASR发生率下降的优势增加。2年内2组的ASDeg发生率差异无统计学意义,2年后CDA组ASDeg发生率明显低于ACDF组,差异有统计学意义(P<0.05)。2组的ASDis发生率差异无统计学意义。CDA组相邻节段ROM低于ACDF组,但差异无统计学意义。结论相较于ACDF,CDA可降低ASDeg和ASR发生率,但在ASDis发生率和相邻节段ROM方面二者差异无统计学意义。     

Evidence-based analysis of adjacent segment degeneration and disease after ACDF: a systematic review

Background context

Follow-up studies of patients undergoing anterior cervical discectomy and interbody fusion (ACDF) have demonstrated varying degrees of radiographic degeneration at adjacent levels, with most cases being asymptomatic (adjacent segment degeneration, ASDeg) and far fewer being symptomatic (adjacent segment disease, ASDz). Controversy remains as to whether these conditions are related to altered biomechanics or represent the natural history of cervical spondylosis at the adjacent segment.

Purpose

To provide an evidence-based analysis of the peer-reviewed literature on clinical studies of ASDeg and ASDz after ACDF.

Study design/setting

Systematic review of existing literature.

Methods

The MEDLINE database was queried for clinical studies reporting ASDeg and/or ASDz after ACDF. Articles written in the English language with a minimum follow-up of 2 years were independently reviewed and analyzed by two authors, and the level of evidence was assigned. Data were pooled to generate summary outcomes and organized by number of levels, technique, and graft/implants.

Results

Of the 238 articles returned from the MEDLINE database query, 14 met inclusion criteria. An average of 168 patients was enrolled per study with an average follow-up of 106.5 months. Graft materials, cage design, plate fixation system, and length of fusion varied widely. Additionally, no clear standard was seen for radiographic assessment modalities (eg, plain lateral radiograph, flexion-extension radiographs, computed tomography, or magnetic resonance imaging). Validated clinical outcome measures were used in 43% (6/14) of the studies. The average incidence of ASDeg was 47.33% (459.14/970) with a range from 16% to 96%. The frequency-weighted average for ASDz was 11.99% (263.70/2,199) with a range from 1.80% to 36.00%. Follow-up ranged from 24 to 296 months with no reliable commonalities, which prohibited a meta-analysis.

Conclusions

This review highlights the heterogeneous methodology of the peer-reviewed literature on ASDeg and ASDz after ACDF and the paucity of high-level clinical data published on these conditions. Despite the low level of evidence to define the incidence of ASDeg and ASDz, it is clear that radiographic ASDeg is more common than symptomatic ASDz, indicating that adjacent segment pathology remains subclinical in a large subset of patients. This analysis underscores the need for standardized radiographic measures in the assessment of ASDeg and validated clinical outcome measures for ASDz after ACDF. Consistent methodology and multi-surgeon collaboration may improve the quality of clinical data on ASDeg and ASDz and elucidate the true etiology and incidence of these conditions.     

颈椎前路减压人工颈椎间盘置换术与融合术治疗单节段颈椎间盘突出症的短期疗效比较

背景：颈前路椎间盘切除植骨融合术（ACDF）能够为有症状的颈椎病患者提供较好的治疗效果,但颈椎融合可导致相邻节段椎间盘内部应力增加,加速邻近节段椎间盘的退变。颈椎人工椎间盘置换术（ACDR）作为最具代表性的颈椎前路非融合技术,为颈椎间盘突出症的治疗提供了另外一种外科手段。目的：比较ACDR和ACDF治疗单节段颈椎间盘突出症的临床效果。方法：2009年1月至2012年2月,61例单节段颈椎间盘突出症患者接受Discover人工颈椎间盘置换手术（置换组,26例）或ACDF手术（融合组,35例）。分别在术前,术后1周,术后3、6、12及24个月对患者进行疼痛视觉模拟评分（VAS）、日本矫形外科协会（JOA）评分及影像学评估,同时记录患者并发症及二次手术情况。结果：最终,52例患者（融合组29例,置换组23例）获得平均15.3个月（12-24个月）随访。两组患者术后各随访时间点的颈痛、上肢痛VAS和JOA评分,较术前均有改善（P〈0.05）,但两组间无显著统计学差异（P〉0.05）。置换组术后手术节段及邻近节段屈伸活动度与术前比较无统计学差异（P〉0.05）。融合组融合成功率为90.5%。置换组中2例患者术后6个月时假体有〈3 mm的前移,l例术后发生脑脊液漏。融合组中1例患者发生邻椎病并接受二次手术治疗。结论：单节段Discover人工颈椎间盘置换术和ACDF均可明显缓解颈椎间盘突出症患者的症状。间盘置换还能减少手术邻近节段代偿活动度的增加,有望预防相邻节段退变的发生。     

人工椎间盘置换术治疗跳跃型多节段颈椎病的中期疗效

 目的 评价 Bryan 人工间盘置换术治疗跳跃型多节段颈椎病的疗效。方法 回顾性分析 2002 年 2 月至 2012 年 5 月接受 Bryan 间盘置换术（Bryan 组）或颈前路减压植骨融合术（ACDF 组）治疗的跳跃型多节段颈椎病患者相关资料。临床功能评估采用日本矫形外科协会（Japanese orthopaedic association,JOA）评分、颈椎功能障碍指数（neck disability index,NDI）、疼痛视觉模拟评分（visual analoguc scale,VAS）,影像学评估采用颈椎矢状位曲度、颈椎整体活动度及中间节段活动度,并于末次随访时评估邻近节段退变情况。结果 49 例患者随访超过 24 个月,Bryan 组 18 例,ACDF 组 31 例。两组患者性别、年龄、疾病类型等人口学资料的差异无统计学意义。两组患者术后 JOA、NDI、VAS 评分均较术前有明显改善。两组间各时间节点比较仅末次随访时 VAS 评分的差异有统计学意义。Bryan 组术后轴性症状发生率、颈椎活动度和未手术节段活动度分别为 11.1%、35.5°±5.9°和 7.3°±1.4°,ACDF 组分别为 45.2%、24.5°±6.2°、10.1°±1.6°,差异均有统计学意义。Bryan 组患者邻近节段无明显退变,ACDF 组 2 例出现退变,但无需再次手术。结论 应用 Bryan 间盘置换术治疗跳跃型多节段颈椎病,可有效改善神经功能,保留颈椎整体活动度,减少未手术节段活动度的代偿性增加,从而降低邻近节段退变及轴性症状发生率。     

Cervical adjacent segment pathology following fusion: Is it due to fusion?

Adjacent segment pathology affects 25% of patients within ten years of anterior cervical diskectomy and fusion (ACDF). Laboratory studies demonstrate fused segments increase adjacent level stress including elevated intradiscal pressure and increased range of motion. Radiographic adjacent segment pathology (RASP) has been associated to ACDF in multiple statistically significant studies. Randomized controlled trials (RCTs) comparing anterior cervical discectomy and arthroplasty (ACDA) and ACDF have confirmed ACDF accelerates RASP. The question of greatest clinical interest is whether ACDA, artificial disc surgery, results in fewer adjacent level surgeries than ACDF. Current RCT follow up results reveal only non statistically significant trends favoring ACDA yet the post operative periods are only two to four years. Statistically significant increased RASP in ACDF patients however is already documented. The RCT patients’ average ages are in the mid forties with an expected longevity of up to forty more years. Early statistically significant increased RASP in the ACDF patients supports our prediction that given sufficient follow up of ten or more years, fusion will lead to statistically significant higher rate of adjacent level surgery compared to artificial disc surgery.     

人工颈椎椎间盘置换与颈前路减压融合术治疗脊髓型颈椎病的疗效分析

目的比较人工颈椎椎间盘置换术与颈前路椎间盘切除减压植骨融合术(anterior cervical discectomy and fu-sion,ACDF)治疗脊髓型颈椎病的临床疗效。方法回顾性分析本院收治的人工颈椎椎间盘置换术及ACDF治疗的脊髓型颈椎病病例。测量所有患者颈椎活动度(range of motion,ROM),置换节段及相邻节段的ROM,并行日本骨科学会(Japanese Orthopaedic Association,JOA)评分及Odom分级。结果所有患者术后JOA评分和Odom功能评定均得到显著改善。置换组术后颈椎ROM、置换节段及其邻近间隙平均ROM无明显改变,差异无统计学意义(P>0.05)。ACDF组患者中,术后颈椎ROM显著减小,邻近间隙ROM明显增大,差异有统计学意义(P<0.05)。置换组术后邻近节段的ROM明显小于ACDF组,差异有统计学意义(P<0.01)。结论人工颈椎椎间盘置换术能保持颈椎ROM,避免邻近节段退变,早、中期疗效满意,远期效果尚有待临床进一步研究。     

A prospective,randomised, controlled multicentre study comparing cervical disc replacement with anterior cervical decompression and fusion

Purpose

Total cervical artificial disc replacement (TDR) simulates normal disc structure, thus avoiding the drawbacks of anterior cervical decompression and fusion (ACDF). This prospective, randomized, controlled and multicentre study aimed to evaluate clinical and radiographic outcomes by comparing cervical disc replacement using Mobi-C disc prostheses with ACDF.

Methods

This prospective, randomized, controlled and multicentre study consisted of 111 patients undergoing single-level Mobi-C disc prosthesis replacement (TDR group, n?=?55) or ACDF (n?=?56) from February 2008 to November 2009 at 11 medical centres across China. Patients were assessed before surgery, at seven days postoperation and one, three, six, 12, 24, 36 and 48 months postoperation. Clinical and neurological outcome was determined by measuring the Japanese Orthopaedic Association (JOA) scores, visual analogue scale (VAS) and Neck Disability Index (NDI). Static and dynamic radiographs were obtained of the cervical curvature, the functional spinal unit (FSU) angle and range of motion (ROM) of the cervical spine, FSU angle and treated and adjacent segments.

Results

A total of 111 patients were included and randomly assigned to either Mobi-C disc prosthesis replacement or ACDF. JOA, VAS and NDI showed statistically significant improvements 48 months after surgery (P?p?>?0.05). ROM in the ACDF group was significantly reduced at one month and remained so throughout the follow-up. By 48-months, more ACDF patients required secondary surgery (four of 56 patients).

Conclusions

Although ACDF may increase the risk of additional surgery, clinical outcomes indicated that both Mobi-C artificial cervical disc replacement and ACDF were reliable. Radiographic data showed that ROM of the cervical spine, FSU angle and treated and adjacent segments were relatively better reconstructed and maintained in the Mobi-C group compared with those in the ACDF group.     

ActivC人工颈椎间盘置换术与颈前路椎间盘切除融合治疗单节段颈椎病的早期疗效比较

目的:观察比较Activ C人工颈椎间盘置换术(ACDR)和颈前路椎间盘切除融合(ACDF)治疗单节段颈椎病的早期临床效果。方法:自2009年7月至2012年9月,76例单节段颈椎病患者接受Activ C人工颈椎间盘置换手术(置换组)或颈前路椎间盘切除融合手术(融合组).其中置换组28例,男18例,女10例,年龄32～62岁,平均(45.2±6.2)岁;融合组48例,男28例,女20例,年龄33～60岁,平均(45.8±6.4)岁。分别在术前,术后1周,术后3、6、12、24个月,对患者进行疼痛视觉模拟评分(VAS)、日本矫形外科协会(JOA)脊髓功能评分和生活质量量表(SF-36)评估及影像学评估。结果:76例患者均获得随访,时间6～24个月,平均13.2个月。颈痛、上肢痛的VAS评分及JOA评分,术后均有改善(p<0.05),两组间差异无统计学意义(p>0.05).两组患者SF-36躯体评分、精神评分术后均有明显上升(p<0.05),置换组优于融合组(p<0.05).置换组术后手术节段及邻近节段屈伸活动度与术前比较差异无统计学意义(p>0.05).置换组中1例患者在6个月时椎体后缘周围出现异位骨化,1年随访时暂无融合现象;融合组中1例患者发生邻椎病并接受二次手术治疗。结论:单节段Activ C人工颈椎间盘置换术早期临床效果满意,能减少邻近节段退变,远期效果有待临床进一步研究。     

腰椎融合术后邻近节段退化的系统回顾分析

目的探讨腰椎融合术导致融合邻近节段退化(ASDet)发生的概率、发病机制及危险因素。方法通过计算机检索和人工检索,对近30年来国内外发表的关于腰椎融合术导致邻近节段退化的文献进行系统回顾。结果共搜索到301篇相关文献,筛选出30篇符合入选标准的文献。本研究发现ASDet发病率波动在6.3%～100%,邻近节段退变(ASDeg)发病率波动范围8%～100%,邻近节段疾病(ASDis)发病率波动范围6.3%～27.4%。ASDeg平均发病率高于ASDis,P=6.751×10-7(P<0.05)。多种影响因素参与ASDet的发生。结论 ASDet、ASDeg、ASDis发病率差异较大。目前ASDet发生的机制仍不明,绝大多数学者认为与手术引起的邻近节段生物力学机制改变有关。年龄大于60岁、使用内固定器械、损伤上方小关节、改变腰椎前凸和骶倾角、破坏腰椎后方组织结构、已绝经妇女是邻近节段退化性疾病发生的危险因素。然而长节段融合是否导致ASDet的发病率增高还有待进一步研究。