【作者】 胡朝晖；

【导师】 李康华；

【作者基本信息】 中南大学 ， 外科学， 2007， 博士

【摘要】 颈椎病是严重的颈椎退变性疾病，也是脊椎外科的常见病。颈椎退变性疾病早期采用保守治疗，手术是治疗颈椎退变性疾病的最后选择。颈椎前路减压植骨融合是治疗颈椎退变性疾病的有效治疗手段，但颈椎间融合后，导致邻近节段的活动度增大，促使邻近节段发生退变或原有退变加重。人工颈椎间盘置换术是近年发展的新技术，其目的是替代病变的椎间盘并行使其功能，保留运动节段和减少相邻节段继发性退变，为颈椎病治疗提供了新的途径。但是，人工颈椎椎间盘能否达到正常椎间盘的力学性能要求，尚有待进一步的研究。颈椎间孔大小对椎间孔狭窄和神经根型颈椎病的诊断具有决定性意义。颈椎间孔形态改变与其生物力学性能密切相关，又是评估临床疗效的重要指标之一。因此，对颈椎间孔形态的研究具有重要意义。但颈椎人工椎间盘能否恢复正常的椎间盘功能，以及对邻近节段有无影响，尤其是CADR后对邻近上位椎间孔影响的生物力学实验和临床研究尚未见报道。本课题从以下三个方面进行研究：（1）采用X线、CT和尸体标本实体测量颈椎间孔，并进行比较，为实验和临床提供资料。（2）探讨C_4／5、C_5／6ADR组、椎间盘完整组、椎间盘摘除组、前路椎间植骨融合组不同状态不同载荷下，对邻近上位(C_3／4、C_4／5)椎间孔的影响。（3）观察5例C_4／5、C_5／6ADR和30例同节段前路植骨融合内固定术后的临床疗效，比较两种手术方式对邻近上位椎间孔形态的影响。第一章颈椎间孔的解剖学和影像学测量目的为生物力学研究和临床颈部疾患诊治提供解剖学和影像学资料。方法陈旧防腐标本9具；新鲜尸体9具，标本男10具，女8具。对C2-T1颈椎间孔高度和宽度进行实体测量；行颈椎双斜位X线测量；CT扫描三维重建测量。对测量结果用SPSS13软件进行统计分析，检验水准为α=0.05。结果1、实体测量的颈椎间孔高度平均值为7.36±0.48mm，宽度平均值为5.35±0.52mm；X线测量的颈椎间孔高度平均值为9.60±0.58mm，宽度平均值为6.85±0.78mm。CT测量的颈椎间孔高度平均值为7.42±0.50mm，宽度平均值为5.41±0.52mm。2、实体测量值、CT测量值和X线测量值比较：实体测量的椎间孔平均高度值和CT测量值小于X线测量值，有统计学意义（P＜0.01）。实体测量椎间孔平均宽度值和CT测量值小于X线测量值，有统计学意义（P＜0.01）。CT测量值与实体测量值比较没有统计学意义。3、CT测量与实体测量的椎间孔平均高度约为X线测量值的78％；CT测量与实体测量的椎间孔平均宽度约为X线测量值的80％。4、实体测量值、CT测量值和X线测量值分别作椎间孔高度和宽度的线性相关分析，实体测量值和CT测量值呈高度正相关性；CT测量值和X线测量值存在明显正相关性；实体测量值和X线测量值存在明显正相关性。结论1、实体标本测量值和CT测量值小于X线测量值，但三者之间有明显正相关性。2、螺旋CT可以方便，准确地测量颈椎间孔的高度和宽度。第二章双节段人工颈椎间盘置换后邻近上位椎间孔形态改变的生物力学研究目的探讨颈椎C_4／5、C_5／6ADR、椎间盘摘除、前路椎间融合内固定后对邻近上位椎间孔形态改变的影响，为临床应用CADR提供理论依据。方法新鲜成人尸体颈椎标本11具（C₃—T₁），对C_4／5、C_5／6完整组、髓核摘除组、ADR组以及椎间融合内固定组，在不同载荷下测量不同状态邻近上位椎间孔高度、宽度的改变，并比较加载前后组内及组间的变化范围。对测量结果用SPSS13软件进行统计分析，检验水准为α=0.05。结果C4／5、C5／6ADR、椎间盘摘除、椎间融合后，在轴向、前屈、后伸、侧弯加载状态下，其邻近上位(C_3／4、C_4／5)椎间孔变化为：（1）CADR组与完整组、椎间盘摘除组接近，差异无统计学意义（P＞0.05）；小于椎间融合组，差异有统计学意义（P＜0.05）。（2）椎间盘摘除组小于椎间融合组，差异有统计学意义（P＜0.05）。（3）椎间融合组大于完整组，差异有统计学意义（P＜0.05）。（4）颈椎间孔随不同体位改变较大：屈曲、对侧弯时增大，在轴向、后伸、同侧弯时减小。结论1．首次采用生物力学方法，研究C_4／5、C_5／6CADR、椎间盘摘除、椎间融合对邻近上位椎间孔大小的影响。发现CADR后其邻近上位椎间孔变化接近正常，椎间融合后其邻近上位椎间孔变化明显，初步证明CADR符合颈椎正常的生物力学要求，为临床应用人工颈椎间盘提供了理论依据。2．椎间融合后邻近上位椎间孔孔径变化明显，可能是引起颈椎退变和／或退变加速的原因之一。3．颈椎间孔随不同体位改变较大：屈曲、对侧弯时增大，在轴向、后伸、同侧弯时减小。第三章双节段人工颈椎间盘置换后邻近上位椎间孔形态改变的临床观察目的观察C_4／5、C_5／6ADR和前路融合内固定术的临床疗效，探讨不同术式对邻近上位椎间孔的影响。方法收集1998年1月～2006年2月因C_4／5、C_5／6椎间盘病变而接受手术病例35例，按照手术方式及随访时间分为3组：（1）CADR组5例，随访时间12～27月，平均14.7月；（2）前路植骨融合内固定短期随访组（融合组一）15例，随访时间12～30月，平均15.8月；（3）前路植骨融合内固定中长期随访组（融合组二）15例，随访时间5～8年，平均6.75年。分析术前和术后6月、1年、2年、5年时的JOA评分、Odom评级、影像学资料。运用SPSS 13统计软件分析患者C_3／4椎间孔高度、宽度和椎间隙高度与C₃椎体高度的比值R1、R2、R以及JOA评分、Odom评级。结果（1）三组术后各随访段的JOA评分、Odom评级较术前均有提高，差异有统计学意义（P＜0.01）。术后6月CADR组与融合组一JOA评分、Odom评级比较，差异无统计学意义（P＞0.05），术后12月融合组一与融合组二比较，差异无统计学意义（P＞0.05），术后5年融合组二JOA评分、Odom评级出现下降，与组内术后12个月、2年比较，差异有显著性（P＜0.01）。（2）CADR组与融合组一术后各随访段R1、R2、R与术前比较，差异无统计学意义（P＞0.05）；融合组二术后12月、2年R1、R2、R，与术前比较，差异无统计学意义（P＞0.05），术后5年R1、R2、R显著下降，与术后12月、2年比较，差异有统计学意义（P＜0.01）。结论1．CADR和前路植骨融合内固定术治疗颈椎间盘疾患的近期疗效较好，对邻近上位椎间孔孔径影响不明显，中远期疗效有待进一步观察。2．前路植骨融合内固定术后中远期邻近上位椎间孔孔径变小，是颈椎退变或加速退变原因之一。更多还原

【Abstract】 The cervical spondylosis is a serious cervical spinal degenerativedisease,also very common in adult.In early stage we take conservativeways to treat the disease,operation is the last choice.Cervical spineanterior decompression and bone grafting fusion procedure is an effectivemethod to treat cervical degenerative disease,but the motion of adjacentincreases when interbody fuse,which causes the adjacent segmentdegeneration or aggravate the primary degeneration.Cervical artificialdisc replacement （CADR） is a new technique to replace the affected discand exercise its function, with reservation of the movement ofcorresponding segment, and decrease adjacent degeneration.The intervertebral foramen dimension possesses decisivesignificance for the diagnosis of cervical intervertebral foramen stenosisand cervicalspondylotic radiculopathy. The study on the morphometricchange of cervical intervertebral foramen has important significancebecause it is closely related to biomechanical characters and is one of theimportant indexes for evaluation of clinical efficiency. However there isno report whether the artificial disc can fulfill all function of the disc, orhave side effect on the adjacent disc or intervertebral foramen, especiallythe inferior one.The study is to perform from the following three aspects: （1） Toprovide data for experiment and clinic through the observation andcomparison of the cervical intervertebral foramen of cadaver、CT andadults’ X ray. （2） To explore the morphometric change of superior (C_3/4、C_4/5) intervertebral foramen under different status and loading amonggroups of (C_4/5、C_5/6)ADR, normal disc, discectomy, anterior fusion. （3） Tocompare the morphometric change of superior (C_3/4、C_4/5) intervertebralforamen after (C_4/5、C_5/6)ADR and anterior fusion at same level. Chapter One: The Anatomic and imageologic Measurement of theCervical Intervertebral ForamenObjective To provide data of anatomy and imageology for theresearch of the biomechanical effect on the superior cervical foramen andthe diagnosis and treatment of clinical cervical diseases.Method To observe the height、width of C₂～T₁ cervicalintervertebral foramina from 18 antiseptic adult cervical speciments byanatomy、CT and X-ray examination. All the data are analyzed withSPSS13 （α=0.05）. There is statistical significance when P is smaller than0.05.Result The intervertebral foramen average height and width of theintegrity group without loading were 7.36±0.48mm and 5.35±0.52mm.The intervertebral foramen average height and width from X-ray were9.60±0.58mm and 6.85±0.78mm. The intervertebral foramen averageheight and width from CT were 7.42±0.50mm and 5.41±0.52mm. Thereis statistical significance in the Paired-Sample T test of the averagewidth and average height of intervertebral foramen between anatomyand X-ray examination. There is statistical significance in thePaired-Sample T test of the average width and average height ofintervertebral foramen between CT and X-ray examination.But there isnot statistical significance in the Paired-Sample T test of the averagewidth and average height of intervertebral foramen between anatomyand CT examination.The percentage of height of intervertebral foramenbetween anatomy and X-ray examination is 78％and of width is 80％.The measuremen numerical value of cadaver from anatomy and CT issmaller than that from X ray. They are analyzed correlation of theaverage width and average height of intervertebral foramen amonganatomy、CT and X-ray examination.Conclusion The measuremen numerical value of cadaver fromanatomy and CT is smaller than that of X ray. They are positive correlation among anatomy、CT and X-ray.CT is convenience andexactitude in measurement the intervertebral foramen height and width.Chapter Two: The Biomechanical Research of the MorphometricChange of the Adjacent Superior Cervical Intervertebral ForamenAfter Two Level Artificial Disc ReplacementObjective We explore the cervical intervertebral foramina height,width change of C_3/4、C_4/5 foramen pre- and post C_4/5、C_5/6 discetomy,CADR, and the intervertebral fusion in all the five different test conditionand different loading in order to provide theoretical basis for clinic.Method 11 fresh cervical spinal specimens（C1-T1） obtained fromyoung adult cadavers during the biomechanical measurement, Specimensare divided into integrity group, discectomy group, artificial discreplacement group and intervertebral fusion group of C_4/5、C_5/6. TheC_3/4、C_4/5 intervertebral foraminal dimension including height and widthand the range of variety（ROV） among the four groups before and afterloading are measured with migration sensor in each group duringdifferent movement and loading. All the data are analyzed with SPSS13.There is statistical significance when P is smaller than 0.05.Result The cervical intervertebral foramina height, width change ofC_3/4、C_4/5 foramen pre- and post C_4/5、C_5/6 discetomy, CADR, and theintervertebral fusion in all the five different test condition and differentloading are as followed: there is no difference between the integrity groupand discectomy, integrity and CADR, discectomy and CADR groups inall the five different test condition（P＞0.05）. There is significantdifference between integrity and fusion group, discectomy and fusiongroup, artificial disc replacement and fusion group（P＜0.05）, we find thatthe ROV of superior intervetebral foramen height and width in fusiongroup is bigger than in other groups（P＜0.01） and in artificial disc replacement group is similar to that in the integrity group. The C_3/4、C_4/5intervetebral foramen height and width of the integrity group, thediscectomy, CADR and intervertebral fusion group increasedsignificantly during flexion and contralateral bending （P＜0.01）. whiledecreased significantly during axial, extension and ipslateralbending（P＜0.01）.Conclusion 1、The first time to compare the effect on the adjacentsuperior inter-foramina among the CADR, discectomy and intervertebralfusion group with the biomechanic method.we find that the ROV ofsuperior intervetebral foramen height and width in fusion group is biggerthan in other groups（P＜0.01） and in artificial disc replacement group issimilar to that in the integrity group.The results initial prove that CADRaccords with the cervical normal desire of vitodynamics and providetheoretical basis for clinical CADR.2、Dimension of adjacent superiorcervical intervetebral foramen in fusion group variated greatly andthis is probably one of causes which can lead to cervical degeneration oraccelerated degeneration. 3、Dimension of adjacent superior cervicalintervetebral foramen increased significantly during flexion andcontralateral bending（P＜0.01）while decreased significantly during axial,extension and ipslateral bending（P＜0.01）.4、Dimension of inferiorcervical intervetebral foramen changes with the change of loading. Chapter Three: The Clinical Research of the Morphometric Changeof the Adjacent Superior Intervertebral Foramen After Two LevelArtificial Disc ReplacementObjective To observe the clinical results of the patients whoaccepted the Brayn artificial disc replacement and cervical interbodyfusion and analysis the effect on the adjacent inferior cervicalintervertebral foramen.Method 35 cases of C_4/5、C_5/6 prolapse of intervertebral disc whoaccepted the artificial disc replacement and the intervertebral fusion arefollowed from 1998 to 2006. 35 cases are divided into three groupsaccording to the way of operation and time as followed:the group ofartificial disc replacement,.the first group of intervertebral fusion and thesecond group of intervertebral fusion, the score of JOA, the rank ofOdom, the X-ray film of pre-operation and 6, 12, 24 months, 5yearspost-operation are collected. The clinical effect are evaluated throughanalyzing the score of JOA and the rank of Odom with the paired-sampleT test and chi-square test. The intervertebral disc height, the height andwidth of intervertebral foramen are measured directly on the film inoblique position at different period, and calculate the ratioR1, R2, Rbetween the height, width of foramen, the intervertebral disc height andthe vertebral height. All the data are analyzed with SPSS 13.Result （1） There are significant difference between pre-operationand different period post- operation（P＜0.01）. The score of JOA and therank of Odom increased significantly in different period post- operationin the three group. There are not difference in 6 months post- operation inscore of JOA and rank of Odom between the group of artificial discreplacement and the first group of intervertebral fusion（P＞0.05）. Thereare not difference in 12 months post- operation in score of JOA and rankof Odom between the group one and two of intervertebral fusion（P＞0.05）. The score of JOA and rank of Odom decreased in 5 years post- operation and there are difference between 5 years and 12,24months post- operation（P＜0.01）in group two of intervertebral fusion.（2）There are not difference of R1、R2、R between pre-operation anddifferent period post- operation（P＞0.05） in the group of artificial discreplacement and the group one. There are not difference of R1、R2、R between pre-operation and 12,24 months post- operation（P＞0.05） inthe group two. There are difference of R1、R2、R between 5 years and12,24 months post- operation（P＜0.01）in group two.Conclusion 1.The recent curative effect is comparatively good inthe cervical artificial disc replacement and anterior intervertebralfusion, and there is no obvious influence on adjacent superiorintervertebral foramen.2. Adjacent superior intervertebral foramenbecomes smaller in middle-long period in anterior intervertebral fusion,and it may be one of causes of cervicalspondylotic radiculopathy.3. Themiddle-long curative effect in CADR need advanced observation.更多还原