颈椎板成形术后颈椎轴性症状的基础与临床研究
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摘要
1颈后路椎板成形术后椎间盘内TNF-α含量变化的实验研究
目的:颈椎后路椎板成形术后颈椎轴性症状有较高的发生率,其发生的具体机制并不十分清楚,所以目前临床上缺乏有针对性的方法预防或治疗颈椎板成形术后的轴性疼痛。有假说认为颈椎板成形术后轴性症状的发生可能与颈椎后伸肌群损伤、颈神经后支刺激激惹、椎后小关节功能紊乱有关,但均缺乏相关实验研究证据。颈椎板成形术后轴性症状的分布特点提示其发生可能与前方椎间盘退变有关,相邻节段退变加速可能是造成颈椎板成形术后轴性症状发生的未被认识的原因之一。但传统观念认为相邻节段退变问题是前路减压融合术的固有问题,后路手术一般不会发生,因此我们设计了此项实验研究,目的是通过实验手段明确颈椎板成形术是否会加速前方椎间盘退变及其与颈椎轴性症状发生的关系。
方法:成年山羊60只,随机分为两组,实验组行颈3-6单开门椎板成形术,对照组动物单纯切开皮肤后予以缝合。分别于术前、术后行颈椎x线检查,测量颈椎曲度指数,观察手术前、后颈椎曲度的变化情况。于术后4、8、12周,采用Masson染色和HE染色观察两组动物术后颈2-3、颈3-4、颈4-5、颈5-6、颈6-7节段纤维环结构的变化和髓核组织学形态的改变。于术后4、8、12周采用ELISA方法测定颈2-3、颈3-4、颈4-5、颈5-6、颈6-7节段TNF-α含量的变化。
结果:(1)对照组动物术前颈椎曲度指数为42.90%±5.88%,术后4、8、12周颈椎曲度指数分别为42.44%±5.70%、41.61%±5.48%、39.49%±5.67%,较术前均无统计学意义变化。实验组动物术前颈椎曲度指数为45.04%±5.14%,术后4、8、12周颈椎曲度分别为39.03%±8.66%、38.92%±8.03%、36.51%±9.11%,术后4、8、12周颈椎曲度指数较术前均有显著意义的丢失,P<0.01。(2)对照组动物术后4、8、12周光镜下观察椎间盘结构正常。实验组动物术后4周Masson染色和HE染色下见纤维环板层结构和髓核内细胞成份正常,术后8周,颈2-3和颈6-7椎间盘纤维环胶原结构轻度紊乱,胶原结构轻度松散,可见有微小裂隙,髓核内软骨细胞增生。术后12周,颈2-3和颈6-7椎间盘纤维环板层结构明显紊乱,出现明显中断,髓核内软骨细胞增生明显。颈3-4、颈4-5、颈5-6节段纤维环在术后12周也出现轻度紊乱,髓核内髓核内软骨细胞轻度增生。3)实验组动物术后4周颈2-3、颈3-4、颈4-5、颈5-6、颈6-7椎间盘内TNF-α含量分别为6.66±1.43ng/ml、5.50±0.78 ng/ml、6.02±1.27 ng/ml、5.97±1.47 ng/ml、6.60±1.70 ng/ml,术后8周分别为9.93±1.63 ng/ml、5.79±1.21 ng/ml、6.31±1.54 ng/ml、7.10±1.54 ng/ml、8.97±1.75 ng/ml,术后12周分别为12.17±2.48 ng/ml、6.72±1.26 ng/ml、7.64±1.52 ng/ml、7.23±2.28 ng/ml、11.36±2.25 ng/ml,各节段椎间盘内TNF-α含量呈逐渐上升趋势,其中颈2-3,颈6-7椎间盘内TNF-α含量升高较为明显,术后8周和术后12周实验组动物颈2-3和颈6-7节段椎间盘内TNF-α含量显著高于对照组,P<0.01。
结论:(1)颈椎板成形术后可以造成椎间盘内TNF-α含量的增加,加速椎间盘退变。(2)颈椎板成形术后同样存在相邻节段退变问题。(3)盘源性疼痛是造成颈椎板成形术后轴性疼痛的重要机制之一。
2颈半棘肌肌止及其神经支配的临床解剖学观察
目的:颈椎后路椎板成形术后颈半棘肌肌止有较高的不愈合率,导致颈椎术后后伸稳定性大部分丧失,引起轴性症状。目前,颈椎板成形术后颈半棘肌肌止愈合不良的原因并不清楚,以往的研究多着眼于保留颈半棘肌形态的完整性,对于颈半棘肌的神经支配和其止点的解剖形态关注不够。而目前国内、外关于颈椎后方入路相关的神经、肌肉解剖学研究结果报道不多,关于国人颈半棘肌止点的临床解剖学数据亦未见报道。因此我们进行了此项研究,试图从临床解剖学角度寻找术后颈半棘肌肌止不愈合的原因,并为提出相应的改良术式提供思路。
方法:成年人防腐尸体标本26具,其中男性14具,女性12具。截取包括部分枕骨和上6个胸椎的颈胸段脊柱进行观察。首先在手术显微镜下观察颈神经后支及其分支的走行分布特点,明确颈神经后内侧支与颈半棘肌、头半棘肌、多裂肌的解剖关系以及颈椎后方手术时中容易造成损伤的因素,并测量颈3-8颈神经后支及后内侧支的长度。显露颈半棘肌在肌2棘突上的肌止后观察测量如下内容:(1)颈半棘肌三角率,即双侧半棘肌在颈2棘突上的肌止构成的等腰三角形的高和底边的比值。(2)颈2棘突长度,即颈2棘突顶点至颈2双侧下关节突下缘连线的垂直距离。(3)颈2棘突角,即沿颈2棘突双侧分叉做直线,测量两条直线所成的角度。
结果:(1)颈3-8颈神经后支自脊神经发出,行向后内,分别经颈神经后支骨纤维孔和骨纤维管,分布于颈部肌肉、关节突关节及枕颈部皮肤。(2)颈半棘肌在其从上胸椎到颈2棘突止点的较长过程中,仅接受颈4、5颈神经后内侧支支配。(3)颈3-8颈神经后支的平均长度为:4.92±1.22mm、3.01±0.96mm、3.21±0.87mm、5.12±1.21mm、7.05±1.02mm、9.98±2.01mm,颈3-8颈神经后内侧支的平均长度分别为:13.24±2.14mm、16.88±3.21mm、17.02±1.92mm、15.83±3.02mm、13.05±2.93mm、12.71±1.09mm。4)颈2棘突以及颈半棘肌肌止形态存在广泛变异,这为术中修复颈半棘肌肌止带来了一定的困难,成年男性颈2棘突角为44.6°±18.0°,女性颈2棘突角为63.0°±14.7°,两组间比较差别具有统计学意义P=0.005。5)颈半棘肌三角率与颈2棘突角成正相关P=0.003。
结论:(1)颈半棘肌自身的神经支配特点和颈椎后路手术时由于各支原因损伤颈4、5神经后内侧支是引起颈半棘肌功能下降和其肌止不愈合的原因之一,精准的临床解剖知识有利于减少颈神经后支的损伤,降低后期轴性症状的发生。(2)颈半棘肌肌止形态存在广泛变异,这为术中修复半棘肌肌止带来一定的困难。(3)颈半棘肌三角率与颈2棘突角成正相关。借助颈2棘突CT三维重建影像,可以初步预测颈半棘肌肌止形态,为术中修复和重建颈半棘肌提供有价值的信息。
3保留颈半棘肌肌止的椎板成形术对颈椎轴性症状的影响
目的:脊髓型颈椎病行颈椎板成形术后的神经功能改善可持续10余年,但是术后持续的轴性症状常常可对患者的生活质量造成严重影响。目前有学者前调保留颈椎后伸肌群的功能尤其是颈半棘肌的结构和功能的完整性以防止术后轴性症状的发生。在传统的颈3-7椎板成形术中为获得颈3椎板的充分显露,保留颈半棘肌在颈2棘突上的肌止是十分困难的,因此只能在关闭切口时对剥离的颈半棘肌肌止进行缝合修复。即便如此,经过缝合修复的颈半棘肌肌止仍有较高的不愈合率。为了完整保留颈半棘肌的结构和功能,我们对传统椎板成形术进行改良,将颈3-7椎板翻转成形改变为颈4-7椎板成形、颈3椎板切除,这样在实现椎板成形、神经减压的同时避免了对颈半棘肌肌止的剥离。本研究的目的是明确这种改良的颈4-7成形的椎板成形术较之传统的椎板成形术是否能够有效降低术后颈椎轴性症状的发生。
方法: 2002年3月至2005年3月,接受颈3椎板切除的椎板成形术并获得完整随访的44例颈椎病患者作为试验组(A组),同期接受传统椎板成形术并得到完整随访的50例患者作为对照组(B组),对两组患者手术前、后的JOA评分、颈椎曲度指数、颈椎活动度、轴性症状严重程度进行比较评估。
结果: A组患者JOA评分恢复率为59.2%±11.3%,B组患者JOA评分恢复率为60.1%±19.5%,两组患者间JOA恢复率无统计学意义差别。A组患者术后有明显轴性症状的患者的比例为25.0%,B组患者术后有明显轴性症状的患者的比例为54.0% ,两组患者间颈椎轴性症状的发生情况的比较差异有统计学意义(P <0.05)。A组患者术后颈椎曲度指数丢失2.1%±1.6%,B组患者术后颈椎曲度指数丢失6.4%±3.2,两组患者术后颈椎曲度变化的差异有统计学意义(P<0.01)。A组患者手术后颈椎活动度丢失2.1°±1.6°,B组患者手术后颈椎活动度丢失4.6°±4.0°两组患者术后颈椎活动度丢失程度比较有统计学意义的差异(P<0.01)。
结论:和传统的颈3-7椎板成形术相比,颈3椎板切除的椎板成形术在获得良好神经减压效果同时,可以维持颈半棘肌结构和功能的完整性,减少对颈椎后伸机制的破坏,从而减少术后颈椎轴性症状的发生。颈3切除颈4-7椎板成形术具有和传统的颈3-7椎板成形术相同的手术适应症,是一种有效降低术后轴性症状发生的手术方式。
1 An experimental study of TNF-αcontent of intervertebral discs after open-door laminoplasty
Objectives:Axial symptoms have an high occurrence rate,but the exactly mechanism of axial symptoms still remains unknown,so there are no methods at present to prevent or treat axial symptoms effectively after laminoplasty.Extensor musculature injury、ventral rami of cervical never irration and zygapophysial joint disorders are considered to be the main causes to postoperative axial symptoms,but all these hypotheses lack sound testimony. Clinical research results showed that the distribution area of postoperative axial symptoms had some segmental character,and this imply the occurrence of axial symptoms maybe due to intervertral disc degeneration,adjacent disc disease may be an unknown cause to postoperative axial symptoms.But conventional theory regard the adjancent disc disease as an inheretigate problem of anterior intervertebral fusion ,and as laminoplasty do not perform intervertebral fusion,so it will not interfere intervertebral degenerative process.we designed this study in order to make clear whether or not laminoplasy can promote the intervertebral degenerative process and the relationship between axial symptoms and adjacent disease.
Methods:60 adult goats were divided into two groups,the experimental group underwent C3-C6 laminoplasty and the control group had a posterior incision made and the skin immediately closed.Lateral cervical spine radiographs were obtained preoperatively and 4 weeks、8 weeks and 12 weeks after operation and cervical curvature index(CCI)were measured.After the goats were killed,histological changes of interveterbral disc were observed using Masson and HE stain 12 weeks after operation. TNF-αlevel of C2-3、C3-4、C4-5、C5-6、C6-7 was also measured using ELISA kit at 4 weeks、 8 weeks and 12 weeks after operation.
Results:(1)In control group,preoperative CCI was42.90%±5.88%,and postoperative CCI was 42.44%±5.70%、41.61%±5.48%and39.49%±5.67% in 4weeks、8weeks and 12 weeks after operation respectively,and no significient difference was found. But in experimental group,preoperative CCI was 45.04%±5.14%,and postoperative CCI was respectively 39.03%±8.66%、38.92%±8.03% and 36.51%±9.11% in 4weeks、8weeks and 12 weeks after operation,significient difference was found between preoperative CCI and 8 and 12 weeks postoperative CCI. P<0.01. (2)Histological observation showed that construction of intervertebral discs were normal both in control group 4 weeks、8 weeks and 12 weeks after operation and experimental group 4 weeks after operation,which collagen bundles were parallel、at right angles to the bundles of the adjacent lamellae and chondrocytes embedded in amorphous extracellular matrix with central clumped notochordal cells .In experimental group,mild disorganisation such as loss of the organized parallel arrangement of the lamellar fibres、tiny tears、and cellular proliferation in some areas were present in C2-3 and C6-7 interverbral discs 8 weeks after operation, and apparent loss of the distinct lamellar borders、extensive clefs and proliferation of chondrocyte were found in C2-3 and C6-7 interverbral discs 12 weeks after operation.Slight disorganization was also observed in C3-4、C4-5、C5-6 interverbral discs 12 weeks after operation in experimental group.(3)In experimental group,the TNF-αcontent of C2-3、C3-4、C4-5、C5-6、C6-7 intervertebral disc was 6.66±1.43ng/ml、5.50±0.78 ng/ml、6.02±1.27 ng/ml、5.97±1.47 ng/ml、6.60±1.70 ng/ml in 4 weeks after operation,and 9.93±1.63 ng/ml、5.79±1.21 ng/ml、6.31±1.54 ng/ml、7.10±1.54 ng/ml、8.97±1.75 ng/ml in 8 weeks after operation,and 12.17±2.48 ng/ml、6.72±1.26 ng/ml、7.64±1.52 ng/ml、7.23±2.28 ng/ml、11.36±2.25 ng/ml in 12 weeks after operation.The tendency of TNF-αcontent in intervertebral discs was increasing.This tendency was apparent in C2-3 and C6-7 intervertebral discs. the TNF-αcontent of C2-3 and C6-7 disc in experimental group was higher than that in control group 8 and 12 weeks after operation,P<0.01.
Conclusions: ( 1 ) Laminoplasty can lead to TNF-αcontent of intervertebral discs increase postoperatively,which imply that degenerative process of intervertebral discs are promoted postoperatively. (2)The adjacent segment disease can occur similarly after laimnoplasty. (3)Pain originated form disc degeneration may be an important mechanism of axial symptom after laminoplasty.
2 Anatomic Study of the Insertion and innervation of Semispinalis Cervicis
Objective:Some patients who had cervical laminoplasty with subsequent substantial loss of extention stability have shown failed healing of repaired semispinalis cervicis,and the unhealing of semispinalis cervicis will result in postoperative axial symptom .At present,the exactly reason for this pheno- mon still remains unknown.Most investigaton focous on how to preserve the integrity of semispinalis during operation,but little attention has been paid to the C2 insertion and innervating patterns of SSC. Precise anatomic study- results about the nerves and muscles in the posterior cervical spine was lack both domestic and abroad,and anatomic data of Chinese C2 insertion of SSC was also not available.So,we did this anatomic reseach,in order to find some clues for the unhealing of SSC after laminoplasty and imports for modified- operation methods.
Methods:26 Chinese embalmed spines (14males and 12 females)were harvested for this study.Each of these 26 spines was sectioned form the base of occipital bone to the frist six thoracic vertebrae.Ramification course and distribution of cervical dorsal rami nerve and its anatomic relationship with the semispinalis cervicis,semispinalis capitis and multifidus was observed,and the risks for the cervical dorsal rami injury were also investigated.The length of the dorsal rami trunks and medial branches were also easured.After the soft connective tissues was thoroughly removed from the bony opening between the bilateral SSC insertions, the following parameters were -measured:(1)The C2 triangle ratio:the bilateral SSC insertions in C2 appeared to be triangular in the caudal view.The isosceles triangle created by the bilateral SSC insertions was referred to as C2 triangle,and width and height of that triangle were measured.The ratio of width to height was calculated referred to as C2 triangle ratio.(2)C2 length:a line was drawn across the surfaces of the inferior margins of the bilateral C2 inferior facets,and the distance between that line and the top of the C2 spinous process was measured as C2 length in the caudal view.(3)C2 angle:two lines were drawn by joining the cephalous apex with the bilateral caudal ends of the C2 spinous process,and the angle between the two lines was measured as the C2 angle in the back view.
Results:(1) C3-8 dorsal rami arises from the spinal nerves,passing through osseofibrous aperture、osseofibrous cannl and tendinous decusssation fibers of semispinalis cervicis and multifidus muscle,and then supplied nuchal muscles、cervical zygapophysial joints and nuchal skin.2)The semispinalis cervicis is a composite muscle originate from the thoracic transverse processes of the frist six thoracic vertebrae and insert into the cervical spinous processes from C2 to C5.Despite its long running distances,the motor branches of SSC innervations originated from only two levels of the cervical dorsal rami.(3)At C3-8,the mean lengths of the DR trunks were 4.92±1.22mm、3.01±0.96mm、3.21±0.87mm、5.12±1.21mm、7.05±1.02mm、9.98±2.01mm respectively,and the mean length of the MB portion from point B to point P were 13.24±2.14mm、16.88±3.21mm、17.02±1.92mm、15.83±3.02mm、13.05±2.93mm、12.71±1.09mm respectively.(4)There were considerable individual variations in the morphologic features of the C2 spinous process and the C2 insertion of the semispinalis cervicis. The mean C2 angle was 44.6°±18.0°in males , and63.0°±14.7°in females,significant difficience was seen between two groups, P=0.005. (5)The C2 triangle ratio and C2 angle correlated with one another,P=0.003.
Conclusions: (1)The innervating patterns of SSC and C4、C5MB injury during operation due to various reasons are the main cause of postoperative unhealing and deficiency of SSC,and a precise knowledge of the cervical dorsal rami anatomy and the innervating patterns of the paravertebral muscles is necessary for avoidance of inadvertent injuries to the nerves and occurance of axial symptom.(2)There were considerable individual variations in the morphologic features of the C2 spinous process and the C2 insertion of the semispinalis cervicis,this will bring in great difficulties for reattachment of SSC during laminoplasty.(3) Preoperative prediction of the morphologic features insertion at the original site is possible by measuring the opening angle of the C2 spinous process using three dimensional computed tomography because the muscle insertion correlated with the angle of the C2 spinousprocess.This information may be useful in reattaching the semispinalis cervicis during cervical laminoplasty.
3 The impact on cervical axial symptom of modified open-door laminoplasy preserving the semispinalis cervicis insertion
Objectives: cervical lamnoplasty has been reported to produce stable long-term neurologic improvement for cervical myelopathy, with benefits lasting over 10 years.However, the persistent axial symptoms after cervical laminoplasty often spoil patients’quality of life.Many authors have reported the risk factors of the axial symptoms, and some authors emphasized the importance of preserving the posterior muscles, especially the semispinalis cervicis (SSC) for preventing the symptoms. In conventional C3–C7 laminoplasty, however, it is very difficult to preserve the SSC insertion into C2 while opening the C3 lamina. Therefore, the SSC insertion in C2 has been transiently detached from the C2 spinous process and then repaired to the C2 spinous process at the time of wound closure. In laminoplasty,however, postoperative nonrepair of the SSC was reported to be found in some patients in whom the SSC insertion in C2 had been repaired to the C2 spinous process. For complete preservation of the SSC inserted in C2, therefore, the authors changed the laminoplastic procedure from C3–C7 laminoplasty to C4–C7 laminoplasty with C3 laminectomy in 2002. The purpose of this study was to clarify prospectively whether this modified laminoplasty preserving the SSC insertion into C2 could reduce the axial symptoms compared with C3–C7 laminoplasty reattaching the SSC to C2.
Methods: Since March 2001 to March 2005,Forty-four patients who underwent modified open-door laminoplasy with semispinalis cervicis insert intact were included in this study(Group A). Fifty patients who underwent convitional open-door laminoplasty in the authors’department during the same period served as control(Group B). Preoperative and postoperative Japanese Orthopedic Association(JOA) scores ,the degree of axial symptom, ranges of neck motion, cervical curvature indices were recorded and compared.
Results: The average recovery rate was 59.2%±11.3%for group A and 60.1%±19.5% for group B.There was no significant difference in JOA recovery rate between two groups.The rate of patients with evident axial symptoms was 25.0% in group A and 54.0% in group B,and the difference was statistically significant(P <0.05). Loss of cervical curvature index was 2.1%±1.6% in group A and 6.4%±3.2% in group B, and the different was of statistically significant(P< 0.01)。At the same time,loss of ranges of neck motion was 4.6°±4.0°in group A and 11.6°±7.8°in group B,significant difference was also seen (P< 0.01).
Conclusions :Modified open-door laminoplasy with C3 Laminectomy is less invasive to the posterior extensor mechanism and can perserve semispinalis cervicis insert intact.This new procedure has the same surgical indications as C3-7 laminoplasty and is effective in preventing postoperative axial symptoms with adequate decompression of the spinal cord.
目的:颈椎后路椎板成形术后颈椎轴性症状有较高的发生率,其发生的具体机制并不十分清楚,所以目前临床上缺乏有针对性的方法预防或治疗颈椎板成形术后的轴性疼痛。有假说认为颈椎板成形术后轴性症状的发生可能与颈椎后伸肌群损伤、颈神经后支刺激激惹、椎后小关节功能紊乱有关,但均缺乏相关实验研究证据。颈椎板成形术后轴性症状的分布特点提示其发生可能与前方椎间盘退变有关,相邻节段退变加速可能是造成颈椎板成形术后轴性症状发生的未被认识的原因之一。但传统观念认为相邻节段退变问题是前路减压融合术的固有问题,后路手术一般不会发生,因此我们设计了此项实验研究,目的是通过实验手段明确颈椎板成形术是否会加速前方椎间盘退变及其与颈椎轴性症状发生的关系。
方法:成年山羊60只,随机分为两组,实验组行颈3-6单开门椎板成形术,对照组动物单纯切开皮肤后予以缝合。分别于术前、术后行颈椎x线检查,测量颈椎曲度指数,观察手术前、后颈椎曲度的变化情况。于术后4、8、12周,采用Masson染色和HE染色观察两组动物术后颈2-3、颈3-4、颈4-5、颈5-6、颈6-7节段纤维环结构的变化和髓核组织学形态的改变。于术后4、8、12周采用ELISA方法测定颈2-3、颈3-4、颈4-5、颈5-6、颈6-7节段TNF-α含量的变化。
结果:(1)对照组动物术前颈椎曲度指数为42.90%±5.88%,术后4、8、12周颈椎曲度指数分别为42.44%±5.70%、41.61%±5.48%、39.49%±5.67%,较术前均无统计学意义变化。实验组动物术前颈椎曲度指数为45.04%±5.14%,术后4、8、12周颈椎曲度分别为39.03%±8.66%、38.92%±8.03%、36.51%±9.11%,术后4、8、12周颈椎曲度指数较术前均有显著意义的丢失,P<0.01。(2)对照组动物术后4、8、12周光镜下观察椎间盘结构正常。实验组动物术后4周Masson染色和HE染色下见纤维环板层结构和髓核内细胞成份正常,术后8周,颈2-3和颈6-7椎间盘纤维环胶原结构轻度紊乱,胶原结构轻度松散,可见有微小裂隙,髓核内软骨细胞增生。术后12周,颈2-3和颈6-7椎间盘纤维环板层结构明显紊乱,出现明显中断,髓核内软骨细胞增生明显。颈3-4、颈4-5、颈5-6节段纤维环在术后12周也出现轻度紊乱,髓核内髓核内软骨细胞轻度增生。3)实验组动物术后4周颈2-3、颈3-4、颈4-5、颈5-6、颈6-7椎间盘内TNF-α含量分别为6.66±1.43ng/ml、5.50±0.78 ng/ml、6.02±1.27 ng/ml、5.97±1.47 ng/ml、6.60±1.70 ng/ml,术后8周分别为9.93±1.63 ng/ml、5.79±1.21 ng/ml、6.31±1.54 ng/ml、7.10±1.54 ng/ml、8.97±1.75 ng/ml,术后12周分别为12.17±2.48 ng/ml、6.72±1.26 ng/ml、7.64±1.52 ng/ml、7.23±2.28 ng/ml、11.36±2.25 ng/ml,各节段椎间盘内TNF-α含量呈逐渐上升趋势,其中颈2-3,颈6-7椎间盘内TNF-α含量升高较为明显,术后8周和术后12周实验组动物颈2-3和颈6-7节段椎间盘内TNF-α含量显著高于对照组,P<0.01。
结论:(1)颈椎板成形术后可以造成椎间盘内TNF-α含量的增加,加速椎间盘退变。(2)颈椎板成形术后同样存在相邻节段退变问题。(3)盘源性疼痛是造成颈椎板成形术后轴性疼痛的重要机制之一。
2颈半棘肌肌止及其神经支配的临床解剖学观察
目的:颈椎后路椎板成形术后颈半棘肌肌止有较高的不愈合率,导致颈椎术后后伸稳定性大部分丧失,引起轴性症状。目前,颈椎板成形术后颈半棘肌肌止愈合不良的原因并不清楚,以往的研究多着眼于保留颈半棘肌形态的完整性,对于颈半棘肌的神经支配和其止点的解剖形态关注不够。而目前国内、外关于颈椎后方入路相关的神经、肌肉解剖学研究结果报道不多,关于国人颈半棘肌止点的临床解剖学数据亦未见报道。因此我们进行了此项研究,试图从临床解剖学角度寻找术后颈半棘肌肌止不愈合的原因,并为提出相应的改良术式提供思路。
方法:成年人防腐尸体标本26具,其中男性14具,女性12具。截取包括部分枕骨和上6个胸椎的颈胸段脊柱进行观察。首先在手术显微镜下观察颈神经后支及其分支的走行分布特点,明确颈神经后内侧支与颈半棘肌、头半棘肌、多裂肌的解剖关系以及颈椎后方手术时中容易造成损伤的因素,并测量颈3-8颈神经后支及后内侧支的长度。显露颈半棘肌在肌2棘突上的肌止后观察测量如下内容:(1)颈半棘肌三角率,即双侧半棘肌在颈2棘突上的肌止构成的等腰三角形的高和底边的比值。(2)颈2棘突长度,即颈2棘突顶点至颈2双侧下关节突下缘连线的垂直距离。(3)颈2棘突角,即沿颈2棘突双侧分叉做直线,测量两条直线所成的角度。
结果:(1)颈3-8颈神经后支自脊神经发出,行向后内,分别经颈神经后支骨纤维孔和骨纤维管,分布于颈部肌肉、关节突关节及枕颈部皮肤。(2)颈半棘肌在其从上胸椎到颈2棘突止点的较长过程中,仅接受颈4、5颈神经后内侧支支配。(3)颈3-8颈神经后支的平均长度为:4.92±1.22mm、3.01±0.96mm、3.21±0.87mm、5.12±1.21mm、7.05±1.02mm、9.98±2.01mm,颈3-8颈神经后内侧支的平均长度分别为:13.24±2.14mm、16.88±3.21mm、17.02±1.92mm、15.83±3.02mm、13.05±2.93mm、12.71±1.09mm。4)颈2棘突以及颈半棘肌肌止形态存在广泛变异,这为术中修复颈半棘肌肌止带来了一定的困难,成年男性颈2棘突角为44.6°±18.0°,女性颈2棘突角为63.0°±14.7°,两组间比较差别具有统计学意义P=0.005。5)颈半棘肌三角率与颈2棘突角成正相关P=0.003。
结论:(1)颈半棘肌自身的神经支配特点和颈椎后路手术时由于各支原因损伤颈4、5神经后内侧支是引起颈半棘肌功能下降和其肌止不愈合的原因之一,精准的临床解剖知识有利于减少颈神经后支的损伤,降低后期轴性症状的发生。(2)颈半棘肌肌止形态存在广泛变异,这为术中修复半棘肌肌止带来一定的困难。(3)颈半棘肌三角率与颈2棘突角成正相关。借助颈2棘突CT三维重建影像,可以初步预测颈半棘肌肌止形态,为术中修复和重建颈半棘肌提供有价值的信息。
3保留颈半棘肌肌止的椎板成形术对颈椎轴性症状的影响
目的:脊髓型颈椎病行颈椎板成形术后的神经功能改善可持续10余年,但是术后持续的轴性症状常常可对患者的生活质量造成严重影响。目前有学者前调保留颈椎后伸肌群的功能尤其是颈半棘肌的结构和功能的完整性以防止术后轴性症状的发生。在传统的颈3-7椎板成形术中为获得颈3椎板的充分显露,保留颈半棘肌在颈2棘突上的肌止是十分困难的,因此只能在关闭切口时对剥离的颈半棘肌肌止进行缝合修复。即便如此,经过缝合修复的颈半棘肌肌止仍有较高的不愈合率。为了完整保留颈半棘肌的结构和功能,我们对传统椎板成形术进行改良,将颈3-7椎板翻转成形改变为颈4-7椎板成形、颈3椎板切除,这样在实现椎板成形、神经减压的同时避免了对颈半棘肌肌止的剥离。本研究的目的是明确这种改良的颈4-7成形的椎板成形术较之传统的椎板成形术是否能够有效降低术后颈椎轴性症状的发生。
方法: 2002年3月至2005年3月,接受颈3椎板切除的椎板成形术并获得完整随访的44例颈椎病患者作为试验组(A组),同期接受传统椎板成形术并得到完整随访的50例患者作为对照组(B组),对两组患者手术前、后的JOA评分、颈椎曲度指数、颈椎活动度、轴性症状严重程度进行比较评估。
结果: A组患者JOA评分恢复率为59.2%±11.3%,B组患者JOA评分恢复率为60.1%±19.5%,两组患者间JOA恢复率无统计学意义差别。A组患者术后有明显轴性症状的患者的比例为25.0%,B组患者术后有明显轴性症状的患者的比例为54.0% ,两组患者间颈椎轴性症状的发生情况的比较差异有统计学意义(P <0.05)。A组患者术后颈椎曲度指数丢失2.1%±1.6%,B组患者术后颈椎曲度指数丢失6.4%±3.2,两组患者术后颈椎曲度变化的差异有统计学意义(P<0.01)。A组患者手术后颈椎活动度丢失2.1°±1.6°,B组患者手术后颈椎活动度丢失4.6°±4.0°两组患者术后颈椎活动度丢失程度比较有统计学意义的差异(P<0.01)。
结论:和传统的颈3-7椎板成形术相比,颈3椎板切除的椎板成形术在获得良好神经减压效果同时,可以维持颈半棘肌结构和功能的完整性,减少对颈椎后伸机制的破坏,从而减少术后颈椎轴性症状的发生。颈3切除颈4-7椎板成形术具有和传统的颈3-7椎板成形术相同的手术适应症,是一种有效降低术后轴性症状发生的手术方式。
1 An experimental study of TNF-αcontent of intervertebral discs after open-door laminoplasty
Objectives:Axial symptoms have an high occurrence rate,but the exactly mechanism of axial symptoms still remains unknown,so there are no methods at present to prevent or treat axial symptoms effectively after laminoplasty.Extensor musculature injury、ventral rami of cervical never irration and zygapophysial joint disorders are considered to be the main causes to postoperative axial symptoms,but all these hypotheses lack sound testimony. Clinical research results showed that the distribution area of postoperative axial symptoms had some segmental character,and this imply the occurrence of axial symptoms maybe due to intervertral disc degeneration,adjacent disc disease may be an unknown cause to postoperative axial symptoms.But conventional theory regard the adjancent disc disease as an inheretigate problem of anterior intervertebral fusion ,and as laminoplasty do not perform intervertebral fusion,so it will not interfere intervertebral degenerative process.we designed this study in order to make clear whether or not laminoplasy can promote the intervertebral degenerative process and the relationship between axial symptoms and adjacent disease.
Methods:60 adult goats were divided into two groups,the experimental group underwent C3-C6 laminoplasty and the control group had a posterior incision made and the skin immediately closed.Lateral cervical spine radiographs were obtained preoperatively and 4 weeks、8 weeks and 12 weeks after operation and cervical curvature index(CCI)were measured.After the goats were killed,histological changes of interveterbral disc were observed using Masson and HE stain 12 weeks after operation. TNF-αlevel of C2-3、C3-4、C4-5、C5-6、C6-7 was also measured using ELISA kit at 4 weeks、 8 weeks and 12 weeks after operation.
Results:(1)In control group,preoperative CCI was42.90%±5.88%,and postoperative CCI was 42.44%±5.70%、41.61%±5.48%and39.49%±5.67% in 4weeks、8weeks and 12 weeks after operation respectively,and no significient difference was found. But in experimental group,preoperative CCI was 45.04%±5.14%,and postoperative CCI was respectively 39.03%±8.66%、38.92%±8.03% and 36.51%±9.11% in 4weeks、8weeks and 12 weeks after operation,significient difference was found between preoperative CCI and 8 and 12 weeks postoperative CCI. P<0.01. (2)Histological observation showed that construction of intervertebral discs were normal both in control group 4 weeks、8 weeks and 12 weeks after operation and experimental group 4 weeks after operation,which collagen bundles were parallel、at right angles to the bundles of the adjacent lamellae and chondrocytes embedded in amorphous extracellular matrix with central clumped notochordal cells .In experimental group,mild disorganisation such as loss of the organized parallel arrangement of the lamellar fibres、tiny tears、and cellular proliferation in some areas were present in C2-3 and C6-7 interverbral discs 8 weeks after operation, and apparent loss of the distinct lamellar borders、extensive clefs and proliferation of chondrocyte were found in C2-3 and C6-7 interverbral discs 12 weeks after operation.Slight disorganization was also observed in C3-4、C4-5、C5-6 interverbral discs 12 weeks after operation in experimental group.(3)In experimental group,the TNF-αcontent of C2-3、C3-4、C4-5、C5-6、C6-7 intervertebral disc was 6.66±1.43ng/ml、5.50±0.78 ng/ml、6.02±1.27 ng/ml、5.97±1.47 ng/ml、6.60±1.70 ng/ml in 4 weeks after operation,and 9.93±1.63 ng/ml、5.79±1.21 ng/ml、6.31±1.54 ng/ml、7.10±1.54 ng/ml、8.97±1.75 ng/ml in 8 weeks after operation,and 12.17±2.48 ng/ml、6.72±1.26 ng/ml、7.64±1.52 ng/ml、7.23±2.28 ng/ml、11.36±2.25 ng/ml in 12 weeks after operation.The tendency of TNF-αcontent in intervertebral discs was increasing.This tendency was apparent in C2-3 and C6-7 intervertebral discs. the TNF-αcontent of C2-3 and C6-7 disc in experimental group was higher than that in control group 8 and 12 weeks after operation,P<0.01.
Conclusions: ( 1 ) Laminoplasty can lead to TNF-αcontent of intervertebral discs increase postoperatively,which imply that degenerative process of intervertebral discs are promoted postoperatively. (2)The adjacent segment disease can occur similarly after laimnoplasty. (3)Pain originated form disc degeneration may be an important mechanism of axial symptom after laminoplasty.
2 Anatomic Study of the Insertion and innervation of Semispinalis Cervicis
Objective:Some patients who had cervical laminoplasty with subsequent substantial loss of extention stability have shown failed healing of repaired semispinalis cervicis,and the unhealing of semispinalis cervicis will result in postoperative axial symptom .At present,the exactly reason for this pheno- mon still remains unknown.Most investigaton focous on how to preserve the integrity of semispinalis during operation,but little attention has been paid to the C2 insertion and innervating patterns of SSC. Precise anatomic study- results about the nerves and muscles in the posterior cervical spine was lack both domestic and abroad,and anatomic data of Chinese C2 insertion of SSC was also not available.So,we did this anatomic reseach,in order to find some clues for the unhealing of SSC after laminoplasty and imports for modified- operation methods.
Methods:26 Chinese embalmed spines (14males and 12 females)were harvested for this study.Each of these 26 spines was sectioned form the base of occipital bone to the frist six thoracic vertebrae.Ramification course and distribution of cervical dorsal rami nerve and its anatomic relationship with the semispinalis cervicis,semispinalis capitis and multifidus was observed,and the risks for the cervical dorsal rami injury were also investigated.The length of the dorsal rami trunks and medial branches were also easured.After the soft connective tissues was thoroughly removed from the bony opening between the bilateral SSC insertions, the following parameters were -measured:(1)The C2 triangle ratio:the bilateral SSC insertions in C2 appeared to be triangular in the caudal view.The isosceles triangle created by the bilateral SSC insertions was referred to as C2 triangle,and width and height of that triangle were measured.The ratio of width to height was calculated referred to as C2 triangle ratio.(2)C2 length:a line was drawn across the surfaces of the inferior margins of the bilateral C2 inferior facets,and the distance between that line and the top of the C2 spinous process was measured as C2 length in the caudal view.(3)C2 angle:two lines were drawn by joining the cephalous apex with the bilateral caudal ends of the C2 spinous process,and the angle between the two lines was measured as the C2 angle in the back view.
Results:(1) C3-8 dorsal rami arises from the spinal nerves,passing through osseofibrous aperture、osseofibrous cannl and tendinous decusssation fibers of semispinalis cervicis and multifidus muscle,and then supplied nuchal muscles、cervical zygapophysial joints and nuchal skin.2)The semispinalis cervicis is a composite muscle originate from the thoracic transverse processes of the frist six thoracic vertebrae and insert into the cervical spinous processes from C2 to C5.Despite its long running distances,the motor branches of SSC innervations originated from only two levels of the cervical dorsal rami.(3)At C3-8,the mean lengths of the DR trunks were 4.92±1.22mm、3.01±0.96mm、3.21±0.87mm、5.12±1.21mm、7.05±1.02mm、9.98±2.01mm respectively,and the mean length of the MB portion from point B to point P were 13.24±2.14mm、16.88±3.21mm、17.02±1.92mm、15.83±3.02mm、13.05±2.93mm、12.71±1.09mm respectively.(4)There were considerable individual variations in the morphologic features of the C2 spinous process and the C2 insertion of the semispinalis cervicis. The mean C2 angle was 44.6°±18.0°in males , and63.0°±14.7°in females,significant difficience was seen between two groups, P=0.005. (5)The C2 triangle ratio and C2 angle correlated with one another,P=0.003.
Conclusions: (1)The innervating patterns of SSC and C4、C5MB injury during operation due to various reasons are the main cause of postoperative unhealing and deficiency of SSC,and a precise knowledge of the cervical dorsal rami anatomy and the innervating patterns of the paravertebral muscles is necessary for avoidance of inadvertent injuries to the nerves and occurance of axial symptom.(2)There were considerable individual variations in the morphologic features of the C2 spinous process and the C2 insertion of the semispinalis cervicis,this will bring in great difficulties for reattachment of SSC during laminoplasty.(3) Preoperative prediction of the morphologic features insertion at the original site is possible by measuring the opening angle of the C2 spinous process using three dimensional computed tomography because the muscle insertion correlated with the angle of the C2 spinousprocess.This information may be useful in reattaching the semispinalis cervicis during cervical laminoplasty.
3 The impact on cervical axial symptom of modified open-door laminoplasy preserving the semispinalis cervicis insertion
Objectives: cervical lamnoplasty has been reported to produce stable long-term neurologic improvement for cervical myelopathy, with benefits lasting over 10 years.However, the persistent axial symptoms after cervical laminoplasty often spoil patients’quality of life.Many authors have reported the risk factors of the axial symptoms, and some authors emphasized the importance of preserving the posterior muscles, especially the semispinalis cervicis (SSC) for preventing the symptoms. In conventional C3–C7 laminoplasty, however, it is very difficult to preserve the SSC insertion into C2 while opening the C3 lamina. Therefore, the SSC insertion in C2 has been transiently detached from the C2 spinous process and then repaired to the C2 spinous process at the time of wound closure. In laminoplasty,however, postoperative nonrepair of the SSC was reported to be found in some patients in whom the SSC insertion in C2 had been repaired to the C2 spinous process. For complete preservation of the SSC inserted in C2, therefore, the authors changed the laminoplastic procedure from C3–C7 laminoplasty to C4–C7 laminoplasty with C3 laminectomy in 2002. The purpose of this study was to clarify prospectively whether this modified laminoplasty preserving the SSC insertion into C2 could reduce the axial symptoms compared with C3–C7 laminoplasty reattaching the SSC to C2.
Methods: Since March 2001 to March 2005,Forty-four patients who underwent modified open-door laminoplasy with semispinalis cervicis insert intact were included in this study(Group A). Fifty patients who underwent convitional open-door laminoplasty in the authors’department during the same period served as control(Group B). Preoperative and postoperative Japanese Orthopedic Association(JOA) scores ,the degree of axial symptom, ranges of neck motion, cervical curvature indices were recorded and compared.
Results: The average recovery rate was 59.2%±11.3%for group A and 60.1%±19.5% for group B.There was no significant difference in JOA recovery rate between two groups.The rate of patients with evident axial symptoms was 25.0% in group A and 54.0% in group B,and the difference was statistically significant(P <0.05). Loss of cervical curvature index was 2.1%±1.6% in group A and 6.4%±3.2% in group B, and the different was of statistically significant(P< 0.01)。At the same time,loss of ranges of neck motion was 4.6°±4.0°in group A and 11.6°±7.8°in group B,significant difference was also seen (P< 0.01).
Conclusions :Modified open-door laminoplasy with C3 Laminectomy is less invasive to the posterior extensor mechanism and can perserve semispinalis cervicis insert intact.This new procedure has the same surgical indications as C3-7 laminoplasty and is effective in preventing postoperative axial symptoms with adequate decompression of the spinal cord.
引文
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