摘要
颈椎间盘突出症是指由于椎间盘退变,纤维环破裂,髓核突出压迫神经或/和脊髓而产生的一系列综合症。我们把由于外伤或退变导致颈椎间盘纤维环破裂,间盘组织游离至后纵韧带后方,压迫颈髓和神经出现相应临床症状,称为硬膜外型颈椎间盘突出症。
颈椎间盘突出症与腰椎间盘突出症在发病率,发病机制,病理形态,临床表现,治疗方法和治疗预后等方面都有差异。颈椎间盘突出症的发病率低,约为全部椎间盘突出症的4%--6%,为腰椎间盘突出症的十分之一,硬膜外型颈椎间盘突出症更少。因此了解硬膜外型颈椎间盘突出症的临床一般规律和详细的颈椎解剖学知识对于脊柱专科医生就显必要。
本文第一部分的目的是探讨硬膜外型颈椎间盘突出症的临床表现,MRI特征,诊断和手术治疗。方法:对本院2004年1月-2007年1月确诊的35例硬膜外型颈椎间盘突出症病人的临床表现,颈椎前路椎间盘切除植骨融合术及手术疗效进行回顾性分析。结果:35例中28例获得随访,平均随访时间7.8月,根据JOA评分标准,评定手术疗效,优22例,良3例,可1例,差1例,总优良率达89.3﹪。结论:硬膜外型颈椎间盘突出症是颈椎间盘突出症的特殊类型,占颈椎间盘突出症20-30﹪,发病可能与外伤有关,病程长短不一,年龄较颈椎病轻,50岁以前多见;硬膜外型颈椎间盘突出的MRI表现有其特殊性,术前可以通过阅片获得初步诊断;颈椎前路手术要求精确操作,切除后纵韧带,彻底取出游离髓核,才能够解除脊髓压迫。手术疗效满意,是治愈该病的有效方法。
本文第二部分的目的是通过观察正常成人颈椎后纵韧带的宽度、结构及分布,为临床工作提供解剖学依据。材料与方法:采集10具福尔马林浸泡过的尸体的颈段脊柱标本,均为中国人。从C2椎体上缘至C7-T1间盘及关节突下缘行整块状椎板切除术。手术显微镜下测量C3至C7节段椎间隙平面及椎体平面后纵韧带的宽度并对测量结果进行统计学分析。手术显微镜下观察颈椎后纵韧带分层和走行,观察颈椎椎内前静脉丛的位置和分布。光镜下观察颈椎间盘后纤维环与后纵韧带的组织学结构。结果:后纵韧带随着椎体宽度变化而变化,但是其宽度在间盘平面和椎体平面相当。后纵韧带分三层,颈椎间盘后方中央有三层后纵韧带纤维覆盖,旁中央只有两层后纵韧带纤维覆盖。旁中央相对中央处是个薄弱区,髓核可能有此处脱出,游离到硬膜外腔。椎内前静脉丛位于后纵韧带间,纤维环成环形结构包绕中央的髓核。结论:本实验揭示了颈椎特有的解剖结构,为临床工作提供了依据。
The first part of this article is to explore the clinical feature , MRI manifestation ,diagnosis and surgical treatment for the epidural cervical disc extrusion(ECDE).Method: 35 cases undergoing operation by anterior approach from January 2004 to January 2007 were approved to be ECDE and their clinical data , anterior discetomy and intervertebral bonegraft fusion , and operative effect were reviewd. Result: 28cases were sufficient follow-up in 35 cases.The mean time of follow-up was 7.8 months.The curative effect was analysed on the JOA grade method(17 grades).The clinical outcome was graded as execellent in 22 cases,good in 3 cases,effective in 1case,ineffective in 1case.89.3 percent was fine.Conclusion: ECDE is a special type of cervical disc protrution/extrusion,of which ECDE ranged from 20 percent to 30 percent. ECDE developed maybe after injuries,in short or long history, and commonly in younger than 50 years old . The patients of ECDE were younger than that of cervical spondylosis. The specific MRI manifestation could help to diagnose ECDE before operation. To relive the spinal cord compression requires operating precisely , incising the posterior longitudinal ligament and removing the extruded nucleus pulposus completely . The satisfying result showed that surgical operation was an effective treatment for ECDE.
The second part of this article is to provide some anatomic data for the clinical research by observing the width, structure and distribution of the cervical posterior longitudinal ligament (PLL) in human adults. Method: Whole cervical spinal columns from C2 through C7 were from 10 Formalin-fixed human adultcadavers of Chinese origin. In 10 columns, en block laminectomy were done. The segmental widths of the cervical PLL were measured under a surgical microscope, and the measuremental results were analysed by statistics softwares. The layers, orientation and distribution of the cervical PLL and the cervical anterior interal vertebral venous plexus were observed. We also make histological observations of the cervical posterior annulus fibrosus and PLL by a light microscope. Result: The change of the widths of the cervical PLL accompanied with that of the cervical segments, but no differences were detected in PLL widths between the segmental ligment at the vertebral bodies and intervertebral discs on all levels. The cervical PLL was made up of three layers. All of three layers coverd over the back middle part of the posterior annulus fibrosus, otherwise there were only two layers covering on the back lateral-middle part of the posterior annulus fibrosus. So the lateral-middle area on the back of the cervical intervertebral disc was relatively weaker than the middle area. And the nucleus pulposus may be extrude from the ruptured cervical posterior annulus fibrosus at the lateral-middle area more easilier than at the middle area, and become sequestered nucleus pulposus in epidural space. The cervical anterior intervertebral venous plexus was embedded between the superficial and deep layers of the cervical PLL. And the cervical nucleus pulposus was surrounded by the annulus fibrosus, the shape of which was a ring . Conclusion: our experiment showed some characters of the cervical spine, and provided some anatomic acknowledge for the clinical work.
引文
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