摘要
在颈性眩晕的诸多致病因素中，颈椎不稳（本文指下颈椎不稳）是导致其发病的一个重要因素。治疗颈椎不稳所致的颈性眩晕方法很多，PLDD术做为一种新的微创技术在临床上对颈性眩晕的病人疗效显著。本实验通过临床实际观测，选择适合于颈椎PLDD术且患有颈间盘突出，并伴有病椎间隙不稳的32例病人进行观测。
32例病人年龄在30至67岁之间，平均年龄为53岁，患者以眩晕，耳鸣为主要症状，有的伴有颈、肩、背部麻木或钝痛等症状。术前已排除耳鼻喉科及神经内科方面病因。将32例病人分为：中青年组（S组），年龄在30岁至40岁之间，共9人；中老年组（P组）：年龄在40至67岁之间，共23人。比较术前、术后3天，28天的颈椎侧位片，动力性侧位片上不稳椎体间的角度位移，椎体水平位移，椎间隙高度的变化。方法是：将自制的贴有10厘米长铅条的塑料直尺架固定于胶版架上，在给患者拍片时，调整直尺架的距离，使架子上的铅条垂直于地面，并且与颈前部中线处于同一水平，然后摄颈椎X光片，这样铅条和患者
的颈椎就处于同一X线投照条件下，并且在一张X光片子上。
然后，将每张X光片子上的铅尺的长度描记在纸上，并将它分成十等份，则每份的长度为“1厘米”，再以它为长度单位用游标卡尺来测量与它同一张X光片子上的椎体水平位移，椎间隙的高度。用角度测量器从X光片上测量椎间的角度位移。将每个病人术前、术后3天、28天的测得值进行自身对照和统计学分析。
如果病椎间隙上下相邻的两个椎体后缘的水平距离大于3.5mm，则提示该椎间隙存在不稳；
如果病椎间的休息位侧位片上角度位移大于11度，或动力性侧位片上角度位移大于20度时，则提示该椎间隙存在不稳；
如果对椎间隙的测量值小于4.0mm，则提示该椎体间隙高度降低；若测量值在4.0-5.0mm之间，则表明该椎间隙高度在正常范围内。
术前测量结果显示：
32例病人的病变颈椎间隙上下相邻椎体的水平位移96.9%大于3.5mm；病变间隙相邻椎体间93.8%的椎体角度位移在中立位时大于11度，而在动力性侧位片上91%大于20度；91%的病椎间隙高度小于4mm。在P组这一变化更明显。根据White的下颈椎不稳的临床判定标准得出结论：32例病人在PLDD术前病椎间
隙存在不稳，P组明显。
术后3天的自身对照结果显示：
病变椎间隙相邻椎体水平位移均比术前增加，角度位移增加，病椎间隙高度比术前降低。表明，PLDD术后早期病椎间隙不稳程度加重。
以颈托固定至术后28天，测量结果显示：
91%的病变间隙相邻椎体水平位移距离小于等于3.5mm；91%的病椎间隙角度位移小于11度或20度；椎间隙高度则与术后3天测得值无统计学变化。说明：术后28天病椎间隙重新获得了稳定。White评分结果：32例病例共33个病椎间隙，在术前有32例得分大于5分；术后3天则有33例大于或等于5分（MRI评分未计入），术后28天，得分均小于5分。
PLDD是通过激光所产生的能量而将部分椎体间髓核汽化，来减少病变间盘的体积和压力，从而缓解对脊髓、椎动脉及交感神经的压迫和刺激，改善椎-基底动脉的血运，以达到治疗的目的。强激光的热效应引起髓核组织学的病理变化与不同类型的激光有关。髓核的受损程度与其对激光的吸收、散热及受照射处的激光的功率大小、激光的照射方式、时间、面积、能量分布等因素有关。胶原蛋白在55度—60度时即凝固定性；在300℃至400
℃时出现炭化，到500℃以上则出现燃烧，千度以上出现汽化。
髓核在受强激光照射后出现汽化，最先在纤维环中央出现一个空腔，腔内没有组织和细胞；术后约2周，这个空腔与周围的纤维环界面清楚，腔内长入纤维及成纤维细胞并分布在新生的毛细血管周围。在术后4周，空腔被肉芽组织和纤维组织填充。病变椎间隙由不稳定恢复到稳定。
颈椎不稳主要与外伤及退化等因素有关，本实验的32例下颈椎不稳所致的眩晕患者无明确的颈部外伤史。在颈椎存在不稳时，则椎动脉易受明显牵拉或者形成拆叠样弯曲，影响血供。同时椎动脉周围的交感神经受不稳椎节的机械性刺激和突出的间盘组织压迫或刺激，以及周围组织的轻度水肿和炎性反应所释放的化学物质的刺激而兴奋性增加，引起椎动脉痉挛，直接导致椎-基底动脉供血不足，从而使前庭供血减少引起眩晕。
本实验术前测量结果显示：P组病椎间隙高度及水平位移、角度位移变化明显，主要是由于中老年病人椎间盘及髓核含水量减少，髓核弹性降低，椎体周围附属组织结构松弛，弹性差所致，因而不稳程度较S组加重。
在术后3天，由于激光的热作用，髓核被大部分汽化，纤维环内部出现空腔，椎体间接触面积减小，且椎间高度降低，椎体
周围附属结构更加松弛，虽然不稳加重，但由于椎间高度降低，使痉挛的椎动脉的牵张程度减低；同时由于间盘内压降低，突出物部分回缩，减轻了对脊髓的刺激；交感神经兴奋性降低，椎动脉痉挛得到缓解，供血得以改善，使前庭神经核及内听动脉血流量增加；更有可能的是短程高温热疗可使水肿的软组织及交感神经丛得以消除肿胀，患者的眩晕和耳鸣症状因此得到改善。
由于颈托的保护，术后病椎间隙制动至28天。椎间隙内的空腔被大量肉芽组织和纤维组织充填，椎间出现纤维?
Cervical vertebra lability , especially the lower cervical vertebra in this artical, is the main reason for vertigo produced by neck .There are a lot of methods to treat this vertigo. PLDD has demonstrated striking effect as a tiny trauma technique. In this experiment we observed 32 patients who suit PLDD and have cervical protrusion.
We collected 32 patients whose age is between 30 years old and 67 years old, the average age is 53 years old, their main symptoms is vertigo and tinnitus, and some of them have numbness or dull pain in the neck, shoulder and back. We ranged these patients into three groups according to their age: S group has nine patients whose age are between 30 years old and 40 years old.; P group has 23 patients whose age between 40 years old and 67 years old. Before PLDD we excluded some reasons for vertigo such as Ear nose roar disease and the nerve internal medicine disease. By comparing the lateral photograph of abnormal cervical vertebra and the dynamic lateral photograph we can found out the changes of the angle migration, the horizontal displacement and the height of intervertebral space .
Method: We fix a plastic ruler adhered a ten-centiliter-long lead bar to a rubber support, we can adjust the distance of ruler in order to
make the lead bar perpendicular to horizontal plane in photographing; At the same time we kept the lead bar in the surface of the central line of the anterior part of neck, thus all is under the same condition.
After that, we traced the length of every lead ruler, and divided them into ten parts, each part is one centiliter, using this ruler to measure the horizontal displacement of adjacent vertebra, the angle displacement and the height of the intervertebral space in the same photo. Choose the same patient’s result of the third day and the 28th day as auto-control and make statistics analysis.
If the distance of the adjacent posterior border of vertebra is more than 3.5mm, it means this vertebra is not steady, if the angle displacement in rest position is larger than 110 and in dynamic position more than 20 0.it also means the vertebra is unstable.
If the measured value of the intervertebral space is no more than 4.0mm，it means that the height of vertebral body is reduced，otherwise it is in the normal scope.
Before PLDD，the measure result shows: the abnormal cervical vertebra of 32 patients demonstrated horizontal displacement which is more than 3.5mm，and the angle displacement between the gap of adjacent vertebra is larger than 110 in rest position，and in the dynamic lateral position is larger than 200 .
On the third day of PLDD, the measure result shows:
The horizontal displacement of the adjacent abnormal vertebra gap increases, so it is with the angle displacement but the altitude of the adjacent vertebra gap reduces. Which suggestes that the cervical lability aggravates.
On the 28th day of neck support, the result shows:
The horizontal displacement of adjacent vertebra is no more than 3.5mm, the angle displacement in rest position is smaller than 110. And in the dynamic lateral position is smaller than 200; the height of the intervertebral space does not have obvious changes. Which tells us in 28 days ill vertebras get to stabilize again.
By using laser which can produce energy and make most or part nucleus pulposus vaporization, we can ruduce the pressure and volume of intervertebral discs, thus it can alleviate the stimulation and oppression on myelvertebra artery and improve the blood supply of the vertebral-base artery, at last we would reached the purpose of treatment. The healing effect of strong laser arouses different kind of pathology relevant to the type of laser. the damage degree of nucleus pulposus is related to many factors such as the absorption of laser, the distribution of heat, the duty of the laser, the exposure mod, time, area and energy distribution. Collagen in 55~60℃ will denaturate. When in 300~400℃, it arises charring; in more than 500℃, it arises combustion, and in more than 1000℃ arises vapori
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