【作者】 梁磊；

【导师】 袁文；

【作者基本信息】 第二军医大学 ， 外科学（专业学位）， 2013， 博士

【摘要】 第一部分颈交感神经症状的临床鉴别1、病例分组与初步鉴别目的：探讨对颈交感神经症状进行鉴别诊断的意义。方法：门诊患者716例，按照是否存在良性阵发性位置性眩晕（BPPV）和颈部动脉（颈动脉、椎动脉）异常进行分组。采取相应治疗。对一般情况、颈椎病发生率、手术率、专科治疗和手术治疗的有效率进行组间对比和评价。结果：（1）BPPV患者370例，占51.68%。女性比例、颈椎病发病率、颈椎病手术率、术后交感神经症状改善率均与对照组有明显差异（P＜0.05）。年龄、专科治疗改善率与对照组差异无统计学意义(P>0.05)。（2）血管异常患者235例，占32.82%。女性比例、平均年龄、颈椎病发病率、术后交感神经症状改善率均与对照组有明显差异（P＜0.05）。颈椎病手术率、专科治疗改善率与对照组差异无统计学意义(P>0.05)。结论：（1）在女性患者中，应注意对BPPV的筛查与鉴别。（2）在50岁以上的男性患者中，应注意对颈部动脉异常的筛查与鉴别。（3）在BPPV或存在颈部动脉病变的患者中，手术治疗交感神经症状疗效不佳。2、良性阵发性位置性眩晕的鉴别和治疗目的：探讨良性阵发性位置性眩晕的鉴别意义和治疗方法。方法：诊断为BPPV并排除颈部血管异常的患者252例。根据是否存在颈椎病分为两组。颈椎病组采取脊柱外科专科治疗（手术、保守治疗）。非颈椎病组采取眩晕专科手法治疗。对两组治疗后交感神经症状的改善情况进行比较。结果：两组在女性比例、年龄上差异无统计学意义(P>0.05)。非颈椎病组交感神经症状治疗改善率明显好于颈椎病组治疗改善率（P＜0.05）。颈椎病组保守治疗与手术治疗改善率之间差异无统计学意义(P>0.05)。结论：BPPV患者的交感神经症状可经专科规范治疗得到明显改善，不应归结为颈交感神经症状，脊柱外科治疗（包括手术治疗）疗效不佳。3、颈部动脉异常的鉴别和治疗目的：探讨颈部动脉异常的鉴别意义和治疗方法。方法：存在颈部血管异常并排除BPPV的患者117例。根据是否存在颈椎病分为两组。颈椎病组采取脊柱外科专科治疗（手术、保守治疗）。非颈椎病组采取神经内科、血管外科等专科治疗。对两组治疗后交感神经症状的改善情况进行比较。结果：两组在男性比例、年龄上差异无统计学意义(P>0.05)。非颈椎病组交感神经症状治疗改善率明显好于颈椎病组手术治疗改善率（P＜0.05）。结论：颈部动脉异常患者的交感神经症状与其血管病变本身有关，可经专科规范治疗得到明显改善，不应归结为颈交感神经症状，脊柱外科手术治疗疗效不佳。4、颈交感神经症状患者X片表现观察目的：观察和分析颈交感神经症状患者的X片表现特点方法：研究样本中，排除BPPV和颈部血管异常的患者229例。根据是否存在颈椎病分为两组。拍摄颈椎正侧位和过伸过屈位X片。观察颈椎退变的典型表现（曲度异常、不稳等）和“沟环”结构的发生率。结果：两组在女性比例、年龄、曲度异常比例、“沟环”结构比例方面差异无统计学意义(P>0.05)。颈椎病组颈椎不稳发生率为36.2%，明显高于非颈椎病组。（P＜0.05）。两组的曲度异常均达60%以上。结论：颈椎曲度异常及不稳与颈交感症状的发生有关但都不是唯一因素，重建颈椎生理曲度或维持颈椎稳定性可能会缓解颈交感神经颈椎症状。第二部分新版《颈交感神经症状评分表》的编制及初步评价目的：编制新版《颈交感神经症状评分表》并评价信效度方法：在文献复习的基础上，按照Delphi法的原则，采用专家调查法和患者现场调查法进行两轮调查。分析数据，编制出新版《颈交感神经症状评分表》并进行重测信度、效标效度、区别效度的评价。结果：新版《颈交感神经症状评分表》由“眩晕”等10个条目构成。每个条目均可对某一症状的严重程度进行评价并附有相应的加权分值，计算全部条目的得分之和即为患者颈交感神经症状最终得分。以得分评价颈交感神经症状的总体严重程度。小于35为轻，35-45为中，大于45为重。检测表明，新版《颈交感神经症状评分表》具有良好的信度和效度。结论：新版《颈交感神经症状评分表》可作为评价颈交感神经症状严重程度的有效工具。第三部分颈交感神经症状分级治疗方案的建立和早期疗效观察目的：观察并探讨分级治疗方案治疗颈交感神经症状的早期疗效方法：前瞻性研究以交感神经症状为主要主诉的颈椎退变患者166例。依新版《颈交感神经症状评分表》(SSEQ)评分分为轻、中、重三级，分别记为S0、S1、S2。根据颈椎动力位片上是否存在颈椎不稳,分别记为P0、P1。分别采取相应治疗。观察比较治疗前（术前）、治疗后（术后）及末次随访时临床症状及相应影像学表现。手术病例综合采用新版《颈交感神经症状评分表》（SSEQ）、SF-36-MCS、SF-36-PCS、SAS及JOA等多种评分工具进行全面评价。结果：全部患者随访6-24个月，平均16.5个月。各组SSEQ、手术组SF-36-MCS、SF-36-PCS、SAS及JOA评分在治疗后（术后一周）、末次随访时与治疗前（术前）相比，均有统计学差异（P＜0.05）。结论：颈交感神经症状分级治疗方案和综合评价的早期效果良好。第四部分颈椎前路手术治疗伴交感神经症状颈椎病的疗效和机制分析1、后纵韧带在颈前路减压融合术治疗颈性眩晕中的作用目的：探讨后纵韧带因素对颈前路减压融合术治疗颈性眩晕效果的影响方法：回顾性研究行连续两个间隙颈椎前路减压融合术的35例颈性眩晕病人。依据术中是否切除后纵韧带分为两组（ACCF和ACDF）。对两组病例特点、治疗方法及眩晕症状的改善情况进行随访观察。结果：两组在一般情况方面（性别比、年龄、随访时间）差异无统计学意义(P>0.05)。组内比较，眩晕评分在术后2个月、末次随访时与术前相比，均有显著统计学差异（P＜0.05）。组间比较，两组眩晕评分在术前、术后2个月差异无统计学意义(P>0.05)；末次随访时，ACDF组的眩晕评分和主观满意率均明显差于ACCF组（P＜0.05）。结论：后纵韧带在颈前路减压术治疗颈性眩晕等症状的过程中发挥重要作用，术中彻底去除手术节段的后纵韧带有助于提高并维持手术治疗效果。2、前路经椎间隙减压融合术（ACDF）治疗伴交感神经症状颈椎病的疗效分析目的：探讨ACDF治疗伴交感神经症状颈椎病中的疗效方法：回顾性分析手术治疗的伴交感神经症状的颈椎病患者46例。全部行ACDF，术中均彻底切除病变间隙处后纵韧带。观察比较术前、术后1周及末次随访时临床症状及影像学表现。采用交感神经症状“20分法”和JOA17分法评分系统评定症状改善情况。在颈椎正侧位及伸屈动力位片上进行影像学评价。结果：交感神经症状评分与JOA评分在术后1周、末次随访时与术前相比，均有显著统计学差异（P＜0.05）。末次随访时主观满意率84.78%。结论：颈前路经椎间隙减压固定融合术结合术中彻底切除病变间隙处后纵韧带对伴交感神经症状颈椎病疗效良好。3、颈椎人工椎间盘置换术（TDR）治疗伴交感神经症状颈椎病的早期疗效目的：探讨颈椎间盘置换术治疗伴交感神经症状颈椎病的临床有效性方法：前瞻性随机对照实验。32例单间隙伴交感神经症状颈椎病的患者。随机分为两组。分别行TDR和经间隙减压固定融合术（ACDF）。两种术式术中均彻底去除减压节段后纵韧带。统计并分析患者术前、术后6个月及末次随访时临床症状及影像学表现。进行组内比较和组间比较。结果：组内比较，术后SSEQ、JOA、SF-36-PCS、SF-36-MCS较术前均明显改善（P＜0.05）。组间比较，各两组在时间点的相应评分差异无统计学意义(P>0.05)。影像学检查提示：TDR组手术节段颈椎活动度得到保留。结论：与颈椎融合手术相比，人工椎间盘置换术治疗单节段伴交感神经症状颈椎病早期效果良好并可保留手术节段的活动度。更多还原

【Abstract】 Part I1. Groups and initial differential diagnosisObjectives: To investigate the importance of preliminary differential diagnosis fromcervical sympathetic symptoms in outpatient department.Methods：716outpatients were grouped and given appropriate treatments concerning theexistence of BPPV and abnormal neck artery (carotid and vertebral arteries). The incidenceof cervical disease, surgery rates, neurological treatment and the efficiency of surgicaltreatment were evaluated and compared between different groups.Results：(1) In370patients with BPPV (51.68%), the ratio of women, incidence ofcervical spondylosis, cervical spondylosis surgery, improvement rate of postoperativesympathetic nerve symptom were significantly different from control group (P <0.05). Butthere were no significant difference in age and improvement of neurological treatment (P>0.05).(2) In235patients with vascular abnormalities (32.82%), there were significantdifference (P <0.05) in the proportion of women, average age, incidence of cervical disease,improvement of sympathetic nerve symptom postoperatively, compared with the controlgroup. There were no significant difference in the rate of surgery for cervical spondylosisand improvement of neurological treatment (P>0.05).Conclusion：It should be paid more attention to the screening and diagnosis of BPPV infemale patients and abnormal carotid artery in male patients over the age of50. In addition,the effect of surgical treatment for sympathetic symptoms is poor in the patients withBPPV or carotid artery disease.2.Differential diagnosis and treatment of benign paroxysmal positional vertigoObjectives: To investigate the differential diagnosis and treatment for BPPV.Methods：252patients without cervical vascular disease were diagnosed as BPPV. Theywere divided into two groups according to the presence of cervical disease (with or withoutcervical disease group). Cervical spondylosis group were given surgery and someconservative treatment). Non-cervical spondylosis group were given neurological therapy for vertigo. The improvement of sympathetic symptoms after treatment were evaluated andcompared.Results：There was no statistical difference (P>0.05) in age and proportion of womenbetween these two groups. There was better improvement of sympathetic symptoms afterneurological therapy in non-cervical spondylosis group (P <0.05). Between conservativetreatment and surgical treatment, there was no statistical difference of symptomimprovement in cervical spondylosis group (P>0.05).Conclusion：Sympathetic symptoms in BPPV patients can be significantly improved byneurological standard treatment. It shouldn’t be explained as cervical sympatheticsymptoms and the effect of spinal surgical treatment for this is poor.3. Differential diagnosis and treatment of the neck artery anomalousObjectives: To investigate the differential diagnosis and treatment for the neck arteryanomalous.Methods：117patients without BPPV were found the neck artery anomalous. They weredivided into two groups according to the presence of cervical disease (with or withoutcervical disease group). Cervical spondylosis group were given surgery and someconservative treatment). Non-cervical spondylosis group were given therapy either inneurology or vascular surgery. The improvement of sympathetic symptoms after treatmentwere evaluated and compared.Results：There was no statistical difference (P>0.05) in age and proportion of menbetween these two groups. There was better improvement of sympathetic symptoms aftertherapy by neurology or vascular surgery in non-cervical spondylosis group than insurgical treatment (P <0.05).Conclusion：Sympathetic symptoms in patients with neck artery anomalous can besignificantly improved by standard treatment. It shouldn’t be explained as cervicalsympathetic symptoms and the effect of spinal surgical treatment for this is poor.4. Observation of X-Ray in patients with cervical sympathetic symptomsObjectives: To investigate the characteristics of the cervical sympathetic symptoms in X-Ray radiographs.Methods：229patients without BPPV or the neck artery anomalous were divided into twogroups according to the presence of cervical disease (with or without cervical diseasegroup). Plain and flexion-extension radiographs were taken. Cervical curvatureabnormality, instability and so called “foramen arcuale” were measured and then statisticalanalysis was performedResults：There was no statistical difference (P>0.05) in age, proportion of women, ratesof cervical curvature abnormality and instability between these two groups. The rates ofinstability were higher in cervical spondylosis group than non-cervical spondylosis group(P <0.05). The rates of cervical curvature abnormality were beyond60%in both groups.Conclusion：Cervical curvature abnormality and instability may be an important but not anindependent factor that affects the cervical sympathetic symptoms．CSS may be releasedby way of reconstruct or keep the cervical curvature and stability.Part II Development and study on reliability and validit of a New CervicalSympathetic Symptoms Svaluation Questionnaire (CSSEQ)Objectives: To provide an objective，effective and standard tools to evaluate the cervicalsympathetic symptomsMethods：Based on literature reviews, double rounds investigation were performed in bothexperts and patients following the Delphi principle. A new Cervical SympatheticSymptoms Svaluation Questionnaire (CSSEQ) was developed by analysing the result ofthe double rounds consultation. After that, the re-measured reliability, inspected criteriavalidity and discriminatory validity of the new CSSEQ were examined.Results：The new CSSEQ includes10selected items such as“vertigo”. Each item, having aweighting coefficient, can be used to measure the severity of one Sympathetic symptoms.The sum of the whole items scores can be a tool in evaluating the total severity of thesympathetic symptoms which can be divided into three levels: less than35as mild,between35and45as medium and above45as serious. The results of evaluation showed that the new CSSEQ reflects the severity of sympathetic symptoms effectively withpreferable reliability and validityConclusion：The new CSSEQ is worthy of clinical application to evaluate the cervicalsympathetic symptoms.Part III Early outcome and analysis of treatment based on grading system forsympathetic symptoms in cervical degenerationObjectives: To investigate and discuss the appropriate treatment based on grading systemin treating sympathetic symptoms in cervical degeneration.Methods：A prospective study was performed on166patients with radiographic cervicaldegeneration and complains of sympathetic symptoms. The patients were divided into3groups (S0、S1、S2) according to the sympathetic symptoms evaluated by the New CervicalSympathetic Symptoms Svaluation Questionnaire (CSSEQ). Cervical stability andinstability showed in the dynamic slice were recorded as P0, P1respectively. Treatmentincluding both drugs for promoting blood circulation and manipulation, collar support oreven anterior discectomy and fusion surgery were given in different groups.Clinical andradiologic evaluations were taken and compared at baseline (pre-operation), post-treatment(post-operation) and final follow-up. Sympathetic symptoms and mental state in all thepatients were evaluated by the CSSEQ and the anxiety disorders scoring system (SAS)respectively. CSSEQ, Japanese Orthopedic Association (JOA), the Short Form-36HealthSurvey (SF-36) scoring system, and SAS were used used to assessment effects in patientsunderwent operation.Results: All the patients were followed up for6-24months (mean16.5months). Asignificant difference was observed regarding CSSEQ, SF-36, SAS and JOA scores beforetreatment (pre-operation), after treatment (post-operation) and final follow-up (p＜0.05).Conclusions: Sympathetic symptoms in patients with cervical degeneration can bemanaged successfully by the treatment based on grading system with promising earlyoutcomes. Part IV Effect and analysis of anterior decompression in treating cervical spondylosiscompanied by sympathetic symptoms1. Role of Posterior longitudinal ligament in treating cervical vertigo by anteriordecompression and fusionObjectives: To investigate the effect of anterior decompression and fusion with posteriorlongitudinal ligament resected in the treatment of cervical vertigo.Methods： A retrospective study was performed on35patients underwent anteriordecompression and fusion in2-levels for cervical vertigo. The patients were divided intotwo groups (ACCF, ACDF) according to whether the posterior longitudinal ligament at thearea of decompression was resected. The general conditions and clinical evaluations of thetwo groups were taken and compared at baseline,2month post-operation and finalfollow-up.Results: There was no significant difference in the general conditions between both groups(P>0.05). In each group, the vertigo scores is significant different between before surgeryand2month after surgery/at the final follow-up (p＜0.05).There was no significantdifference of the vertigo scores between both groups before surgery and2month aftersurgery (P>0.05). However, the vertigo scores and the subjective satisfactory rate inACDF group are significantly different from ACCF group at the final follow-up (p＜0.05)Conclusion： The posterior longitudinal ligament may play a significance role inpathological procedure of cervical vertigo, and it is ideal to remove the posteriorlongitudinal ligament at the area of decompression for a satisfactory and persistent effect2. Analysis of anterior discectomy and fusion for treating cervical spondylosiscompanied by sympathetic symptomsObjectives: To investigate surgical results of anterior discectomy and fusion in treatingcervical spondylosis companied by sympathetic symptoms.Methods：A retrospective study was performed on46patients with cervical spondylosismyelopathy or myelopathy and radiculopathy companied by sympathetic symptoms. Allthe compression levels underwent anterior discectomy and fusion surgery with posteriorlongitudinal ligament (PLL) resected at the area of decompression. Clinical and radiologic evaluations were taken and compared at baseline, one week post-operation and finalfollow-up. Neurological status was evaluated by Japanese Orthopedic Association (JOA)scores and sympathetic symptoms were evaluated with sympathetic symptoms20-pointscoring system. Antero-posterior, lateral and extension-flextion radiographs were used toevaluate the radiologic outcomes.Results: A significant difference was observed regarding sympathetic symptoms scoresand JOA scores before surgery and one week after surgery/at the final follow-up (p＜0.05). The subjective satisfactory rate was84.78%at the final follow-up.Conclusion：Cervical spondylosis companied by sympathetic symptoms can be managedsuccessfully by the anterior discectomy and fusion with resection of PLL at the area ofdecompression.3. Total disc replacement versus fusion for sympathetic symptoms in single levelcervical degenerative disc disease: a prospective randomized and controlled study.Objectives: To evaluate the clinical effectiveness of TDR in treating sympatheticsymptoms in single level cervical degenerative disc disease (DDD).Methods：A prospective randomized and controlled study was performed.32patients withsympathetic symptoms and compression in single level were enrolled and divided into twogroups at random: study group (17patients, receiving TDR, using a Discover prosthesis)and control group (15patients, receiving ACDF, using a Zero-p implant). The posteriorlongitudinal ligament (PLL) at the decompression level was resected before prosthesisimplanted in both groups. Clinical and radiologic evaluations were obtained preoperativelyafter6month and at the final postoperative follow-up.Results: In each group, a significant difference was observed regarding CSSEQscores,JOA scores, SF-36-MCS and SF-36-PCS scores between before surgery and oneweek after surgery/at the final follow-up (p＜0.05).There was no significant difference ofthe above scores between both groups (P>0.05). However, the range of motion (ROM) inthe treated segment was well preserved in the TDR group.Conclusion：TDR could relieve sympathetic symptoms in single level cervical DDD successfully with the same early results following as ACDF while preserving cervical spinesegmental motion.更多还原