【作者】 房佐忠；

【导师】 李康华；

【作者基本信息】 中南大学 ， 外科学， 2007， 博士

【摘要】 颈椎病是常见的脊柱退行性疾患。经前路减压、椎体间植骨融合术已成为治疗颈椎病的有效手段，然而，大量的临床和实验研究发现该手术方式由于改变了相邻节段椎间盘内压力、节间运动力学和关节突关节应力，从而导致邻近节段退变。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。单节段人工颈椎间盘置换已有较多的生物力学研究和临床报道，但颈椎病变常累及两个或两个以上节段，双节段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。颈椎关节突关节具有十分重要的生物力学意义，其主要功能是承受压缩、牵拉、剪切及扭转等不同类型的载荷，双侧关节突关节和椎间盘构成了运动节段的稳定。颈椎病手术后关节突关节退变速度和程度是评估疗效的重要指标之一，而关节突关节退变与其生物力学性能密切相关，因此，对关节突关节内压力的研究具有重要意义。目前，国内外尚未见双节段人工颈椎间盘置换对邻近上位节段关节突关节影响的实验和临床研究。由于颈椎的生理特点，C_4/5和C_5/6在生理状况下承受的应力最大，因此，颈椎退变最常发生在这两个节段。本课题从生物力学和临床上对C_4/5和C_5/6双节段人工颈椎间盘置换对关节突关节的影响进行了研究：（1）探讨新鲜尸体标本C_4/5和C_5/6椎间盘摘除、椎间融合前路内固定和人工椎间盘置换模型在不同载荷下对C_4/5和邻近上位节段C_3/4关节突关节内压力的影响；（2）观察C_4/5～C_5/6双节段人工颈椎间盘置换的早期临床疗效和前路椎间融合术的临床疗效，以及对邻近上位节段关节突关节的影响。第一部分双节段人工颈椎间盘置换对邻近上位关节突关节压力影响的实验研究目的探讨双节段颈椎椎间盘摘除、人工椎间盘置换和前路椎间融合内固定对邻近上位节段关节突关节内压力的影响，为临床运用双节段人工颈椎间盘置换提供参考依据。方法取11具新鲜完整的青壮年下颈段标本，按实验先后分别制成C_4/5和C_5/6完整组、椎间盘摘除组、椎间盘置换组和C₄～C₆椎间融合组共四组标本模型，在标本上施加轴向、侧弯、前屈和后伸分级载荷，采用自行设计的圆片状微型阻电式压力传感器，分别测量各组各分级载荷下C_4/5和邻近上位节段C_3/4关节突关节内的压力负荷。比较各组间的压力大小，用SPSS11.5统计软件包进行统计学分析。结果四组标本模型在轴向、侧弯、前屈和后伸四种工况下，C_4/5和C_3/4关节突关节内的压力变化分别是：①完整组、摘除组、置换组和融合组C_3/4（融合上位节段）压力均随载荷增加而增大；②融合组C_4/5（融合节段）关节突关节内压力为0；③人工椎间盘置换组与椎间盘完整组压力接近，无统计学差异（P＞0.05）；④载荷在100N以下时，椎间盘摘除组小于完整组和置换组相比，均有显著性差异（P＜0.05）；⑤载荷在100N以上时，椎间盘摘除组大于完整组和置换组，均有显著性差异（P＜0.05）；⑥融合组C_3/4关节突关节内的压力明显大于其它各组，均有显著性差异（P＜0.05）。结论①双节段人工颈椎间盘置换后置换节段C_4/5和邻近上位节段C_3/4关节突关节内的压力与正常组接近，提示双节段人工颈椎间盘置换符合颈椎正常生物力学要求；②颈椎椎间盘摘除后C_4/5和邻近上位节段C_3/4关节突关节内的压力在小载荷下降低，但随着载荷增加（大于100N），其压力大于正常组，提示颈椎间盘摘除后，改变了颈椎应力的分布，可能是导致其发生退变或退变加速的原因之一；③C₄～C₆双节段椎间融合内固定后邻近上位节段C_3/4关节突关节压力明显增大，可能是导致其发生退变或退变加速的原因之一。第二部分双节段人工颈椎间盘置换对邻近上位关节突关节影响的早期临床观察目的观察C_4/5、C_5/6双节段人工颈椎间盘置换的早期疗效和双节段颈前路融合内固定术的临床疗效，探讨其对邻近上位关节突关节退变的影响。方法收集双节段颈椎病变而接受手术病例35例，按照手术方式及随访时间分为三组：（1）C_4/5、C_5/6双节段人工颈椎间盘置换组5例，随访12个月～22个月，平均14.66个月；（2）前路植骨融合内固定短期随访组（融合组一）15例，随访12个月～30个月，平均15.75个月；（3）前路植骨融合内固定中长期随访组（融合组二）15例，随访5年～8年，平均6.75年。记录术前和6月、12个月、2年、5年、末次随访时的JOA分值、Odom评级，X线观察邻近上位节段C_3/4活动度，CT扫描分析术后6月、1年、2年和5年手术邻近上位节段C_3/4关节突关节的退变程度。运用SPSS11.5统计软件比较分析各组各时段的JOA评分、Odom评级、邻近上位节段活动度和关节突关节的退变程度。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＜0.05）。2．术后6月人工椎间盘置换组与融合组一的JOA评分、Odom评级、邻近上位节段活动度和关节突关节的退变程度比较均无统计学差异（P＞0.05）。3．融合组一和融合组二术后1年与术后6月的JOA评分、Odom评级和关节突关节的退变程度比较均无统计学差异（P＞0.05）；但邻近上位节段活动度增大（P＜0.05）。4．融合组二术后5年与1年、2年比较，JOA评分、Odom评级改善率降低（P＜0.05），邻近上位节段活动度增加（P＜0.05），关节突关节的退变率增加（P＜0.05）。结论：1．双节段ACDR是治疗多节段颈椎病的有效方法之一，术后早期疗效满意，邻近上位节段活动度良好，邻近上位关节突关节无明显退变。2．双节段颈前路减压椎体间融合内固定术也是治疗多节段颈椎病的有效手段之一，手术早期邻近上位关节突关节无明显退变；中远期邻近上位关节突关节发生退变，长期过度应力积累可能是导致其退变的原因。3．由于我们的临床病例较少，应用时间尚短，因此，双节段人工颈椎问盘置换术中远期疗效是否优于颈椎前路融合内固定术，尚需进一步的研究。颈椎的侧块分别向头侧突出的上关节突和向尾侧突出的下关节突以及中间的峡部组成，左右各一。颈椎侧块是侧块螺钉固定技术的基础。因此，作者另对颈椎侧块解剖作了相关研究，通过解剖和影像学测量探讨了颈椎侧块与其周围重要毗邻结构的解剖关系，评价颈椎侧块螺钉固定技术的安全性，为临床颈椎侧块螺钉置入提供解剖学依据；颈椎侧块的应用解剖与影像学测量及其临床意义目的：观测正常成人C₃～C₇颈椎侧块与周围重要毗邻结构的解剖关系，评价临床颈椎侧块螺钉固定技术的安全性，为临床颈椎侧块螺钉固定术提供解剖学依据方法：①选取正常成人颈椎新鲜标本11具和防腐标本10具，观测C₃～C₇颈椎侧块与上、下位神经根的解剖关系（D1和D2）；②选取正常成人颈椎侧位X线片40例，测量颈椎侧块上关节突关节面的倾角（α角）；③选取20份正常成人颈椎侧块中点水平CT断层扫描片，以侧块中点内侧1mm为0点，测量0点至横突孔外缘的连线与正中矢状面的夹角（β角）、0点至侧块前外侧缘的距离（D3）以及0点至侧块前外侧缘的连线与正中矢状面的夹角（θ角）。结果：①颈脊神经根自侧块上关节突前外侧穿出，侧块前外侧缘中点至上位神经根的距离很小，平均为2.38-2.77mm；至下位神经根的距离较远，平均为6.72-7.06mm；②C3-C7上关节面倾角值为50.9-59.1°之间，C3＞C4＞C5＜C6＜C7，C5倾角最小，C7最大；③侧块中点水平CT断层扫描片测量结果显示：侧块后方中点偏内1mm 0点至横突孔外缘的连线与正中矢状面的夹角在C3-C5为向内倾，均值分别为3.0°、3.2°、2.7°，C6为向外倾，均值为7.1°；0点至侧块前外侧缘的距离为11.8-13.5mm；0点至侧块前外侧缘的连线与正中矢状面的夹角为33.4-34.1°结论：①根据实体解剖学观测结果，颈椎侧块的上关节突距离上位神经根很近，提示上关节突退变易影响上位神经根，导致上位神经根受压；②根据解剖学观测和影像学测量结果，以侧块后方中点或偏内1mm进钉，保持进钉方向头倾35-45°和外倾10-30°，均不会对椎动脉和神经根构成威胁；③由于侧块的个体差异较大，侧块螺钉内固定术中，为使螺钉获得最大的把持力，实行置钉技术的个体化是有必要的。即根据术前影像学测量结果与术中测深相结合的方法选择置钉方向和螺钉长度。更多还原

【Abstract】 Cervical spondylosis is a common degenerative spinal disease.Anterior cervical decompression and fusion is a effective mean forthe management of cervical spondylosis. But the incidence ofadjacent level intervertebal disc pathology secondary to anteriorcervical fusion, by changing the stress on zygapophyseal joints andthe motional mechanics between levels, has been well reported inclinical and laboratory studies. Artificial cervical discreplacements（ACDR） is a new technique developing in the recentyears to provide a new approach for the treatment of cervicalspondylosis. The purpose of ACDR is to replace degenerative discand exertion its function, and to preserve normal physiologicaloperative level motion and decrease the incidence of adjacent levelpathology secondary to anterior cervical fusion. ACDR at one levelhad a many of biomechanical studies and clinical reports. Butcervical spondylosis commonly involved in two or more level,whether two level ACDR measures up to normal cervicalbiomechanics is needed to further clinical and laboratory research.The zygapophyseal joints have a very great significance. Theybear different type of loadings such as compression, traction,shearing and torsion. The adjacent level degeneration is closelyrelated to its biomechanical property and it is one of the mostimportant values used in evaluating the outcomes of cervical surgicalinterventions. Therefore, biomechanical research on zygapophysealjoints has great clinical significance. The clinical and laboratoryresearch related with the influence of two level ACDR on superiorzygapophyseal joint had no reported at present.Cervical degeneration commonly involved in C_4/5 and C_5/6 twolevel owing to cervical physiological characteristic. The currentstudy was undertaken to investigate the influence of two level CADR on adjacent superior zygapophyseal joint from the followingbiomechanical and clinical aspects: （1）To investigate the influencearising from ACD, ACDF and ACDR at C_4/5 and C_5/6 two level freshcadaveric cervical specimens under various loadings on C_4/5 and C_3/4zygapophyseal joint pressures;（2）To observe the clinical early stageoutcomes of ACDR and clinical outcomes of ACDF at C_4/5 and C_5/6two level, and to investigate their influence on the degeneration ofadjacent superior zygapophyseal joint.CHAPTER ONE: The Laboratory Investigation of the Influencesof Two Level Cervical Artificial Disc Replacement on Adjacentsuperior Zygapophyseal Joint PressureObjectives: To investigate the influence caused by C_4/5 and C_5/6two level ACD, ACDR and ACDF on the pressures at C_4/5zygapophyseal joint and adjacent superior zygapophyseal joint C_3/4, thusto provide references for clinical application of two level ACDR.Methods: A total of 11 fresh and intact human cadaveric cervicalspines （C₃-T₁） were used in this investigation. According to thesequence of the experiment, all specimens were sequentiallyreconstructed at C_4/5 and C_5/6 with four model groups as 1) total discintact, 2) C_4/5 and C_5/6 discectomy, 3) C_4/5 and C_5/6 ACDR, and 4) C_4-6ACDF. Testing was performed in displacement control under axialrotation, lateral bending, flexion and extension loading modes onspecimens. A miniature wafer-like pressure transducers we designed byourselves was inserted to monitor adjacent superior zygapophyseal jointpressures and C_4/5 zygapophyseal joint under various grades of loading indifferent groups. Various pressures collected from different groups werecompared by statistic analysis through SPSS11.5 for windows solfware.Results: After the implementation of ACDR, ACD and ACDF at C_4/5 and C_5/6 by performing in displacement control under axialrotation, lateral bending, flexion and extension loading modes, the overalltrend of change at C_3/4 and C_4/5 zygapophyseal joint pressures is:①Thepressures in different groups were higher as the grades of the loadingwere higher. The pressures of ACDF at C_4/5 zygapophyseal joint was zero.②The pressures at C_3/4 and C_4/5 zygapophyseal joint of the ACDR groupcompared with the total disc intact group had no statistical significance（P＞0.05）.③The pressures in C_3/4 and C_4/5 zygapophyseal joint of theACD group compared with the total disc intact group and the ACDRgroup were lower in small loadings（under 100N） and higher in largeloadings（beyond 100N）. The pressure values of the ACD group comparedwith the total disc intact group and the ACDR group had statisticalsignificance （P＜0.05）.④The pressures at C_3/4 zygapophyseal joint ofACDF group were higher. The pressure values compared with the othershad statistical significance （P＜0.05）Conclusions: 1. The pressure values of C_4/5 zygapophyseal jointand adjacent superior level zygapophyseal joint C_3/4 at two levelACDR compared with the total disc intact group had no statisticalsignificance. Consequently, it suggests that two level ACDRmeasures up to normal cervical biological mechanics. 2. Thepressure values of C_4/5 zygapophyseal joint and adjacent superiorlevel zygapophyseal joint C_3/4 in two level ACD decreased in smallloadings, but the pressures were higher as the grades of the loadingwere larger. It suggests this has changed the distribution of stresswithin cervical spines and it is likely to be one of the reasons lead todegeneration of adjacent superior segment. 3. The increase of adjacentsuperior zygapophyseal joint pressure caused by ACDF is likely to be oneof the reasons that cause or accelerate the degeneration of adjacent superiorsegment. CHAPTER TWO: Clinical Observation of the Influences of Twolevel Cervical Artificial Disc Replacement on adjacentsuperior zygapophyseal joints at the Early Stage.Objectives: To observe the early stage outcomes of ACDR andthe clinical outcomes of ACDF at C_4/5 and C_5/6 two level and toinvestigate their Influences on the degeneration of adjacentsuperior zygapophysealjoints.Methods: 35 patients who underwent surgical interventions for thetreatment of cervical spondylosis were collected and grouped in threeaccording to the respective ways of surgery they underwent andthe length of following-up study: （1） 5 patients in ACDR groupwith a follow-up study of 12～22 months（average 14.66 months）; （2） 15patients in ACDF short term group （ACDF group one） with a follow-upstudy of 1～2.5 years（average 15.75 months）; （3） 15 patients in ACDFmedium and long term group （ACDF group two） with afollow-up study of 5～8 years（average 6.75 years）. The JapaneseOrthopedics Association Back scores （JOA）, the Odom grades and thefull range of motion shown by X ray of adjacent superior segments in bothpre-opemtion and post-operation, i.e., 6 months, 1 year, 2 years and 5 yearsthereafter were analyzed, and the degrees of degeneration revealed by CTscans on adjacent superior zygapophyseal joints at post-operative stage, i.e.,6 months, 1 year, 2 years and 5 years thereafter were analyzed as well.SPSS11.5 for windows software was used to undertake a comparativeanalysis among various groups at various stages.Results: 1. The post-operative JOA scores and Odom grades haveobviously increased in three groups （P＜0.01）. 2. For 6 months afteroperation, the different JOA scores, Odom grades, the ranges of motionof adjacent superior segments and degeneration of adjacent superiorzygapophyseal joints in ACDR group and ACDF group one have no statistic significance （P＞0.05）. 3. For 6- month and 12-monthpost-operative follow-up, the different JOA scores, Odom grades anddegeneration of adjacent superior zygapophyseal joints in ACDF groupone and ACDF group two had no statistic difference （P＞0.05）;But theranges of motion of adjacent superior segments in two groups haveincreased（P＜0.05）. 4. the JOA scores and Odom grades of 5 yearpost-operative compared with 1-year post-operative follow-up and 2-yearpost-operative follow-up in ACDF group two had statisticalsignificance（P＜0.05）. The ranges of motion of adjacent superiorsegments had increased（P＜0.05）. Degeneration of adjacent superiorzygapophyseal joints finds the increased （P＜0.05）.Conclusions: 1. Two level ACDR is one of effective therapeuticmeans in many segments cervical spondylosis. The clinical therapeuticeffect of the early stage of postoperation is satisfactory. The ranges ofmotion of adjacent superior segments were good. adjacent superiorzygapophyseal joints had no obvious degeneration. 2. Two level ACDF isalso one of effective therapeutic means in many segments cervicalspondylosis. Degeneration of adjacent superior zygapophyseal joints at theearly stage of postoperation are not obvious. Degeneration of adjacentsuperior zygapophyseal joints at the medium and long stage ofpostoperation is likely to be relation with accumulated stress. 2. Themedium and long term Clinical effect of ACDF decreases anddegeneration occurs in adjacent superior zygapophyseal joints. 3. Wehave no enough clinical cases with two level ACDR and the time ofapplication of it is shorter, so a further observation related to medium andlong term Clinical effect of ACDR is necessary. Appendix:Superior and inferior zygapophyseal and medical isthmus make upof the cervical lateral masses. Superior and inferior zygapophysealbetween adjacent segments form the zygapophyseal joint. The bilateralzygapophyseal joints and cervical disc contribute jointly the stability tocervical spine. Cervical lateral mass is the foundation of the technique oflateral mass screw fixation. The purpose of current study is to evaluatethe safety of the technique of the screw fixation of cervical lateral massby observing and measuring the relation between cervical lateralmasses（C₃～C₇） and their adjacent anatomical structures, thus to provideanatomical reference for clinical application of the technique;The Applied Anatomy and the Radiological Measurementsof the Cervical Lateral Mass and their Clinical significanceObjectives: To evaluate the safety of the technique of the screwfixation of cervical lateral mass by observing and measuring therelation between cervical lateral masses（C₃-C₇） and their adjacentanatomical structures, thus to provide anatomical reference forclinical application of the technique.Methods:①A total of 21 adult’s human cadaveric cervicalspine（Including 11 fresh-frozen cervical spine and 10 preservativecadavers, and C₃～T₁ segment spine）were used in this study toobserve and measure the distances（D₁ and D₂）between C₃～C₇cervical lateral masses and their adjacent cervical nerveroots（including superior nerve roots and inferior nerve roots ）;②Atotal of 40 adult’s lateral cervical radiographs were selected tomeasure the inclination angles of the uparticular facet of lateralmasses（αangle）;③A total of 20 CT scanning with mid-line ofadult’s cervical lateral mass were used in the study. We defined thelmm point internal of the midpoint of lateral masses as O point and measure the angles（βangles） between the line from O point to theoutskirts of the transverse foramen and sagittal plane; the distancebetween O point and front-outside of lateral masses; and theangles（θangles） between the line from O point to the front-outsideof lateral masses and sagittal plane.Results:①The cervical nerve roots are traversing from thefront-outsides of the lateral masses. In the up-outside quadrant therearen’t nerve roots. The distances（D₁） from the midpoint of front-outsides of lateral masses to the superior nerve roots are small, rangefrom 2.38～2.77mm; The distances（D₂） from the midpoint of thefront-outside of lateral masses to the inferior nerve roots are far from6.72～7.06mm;②The inclination angles of uparticular facet oflateral（αangle） in C₃～C₇ are range from 50.9～59.10°, C₃＞C₄＞C₅＜C₆＜C₇, it is the smallest in C₅ and it is the largest in C₇.③Theoutcomes of CT scanning measurement of the cervical lateral masses:the angles（βangle） between the line from O point to the outsides ofthe transverse foramen and sagittal plane incline to inside in C₃～C₅,average value is respectiveiy 3.0°,3.2°,2.7°. It incline to outside inC₆, average value is 7.1°; The distances from O point to thefront-outside of lateral masses are range from 11.8～13.5mm; Theangles（θangle） between the line from O point to the front-outsideof the lateral masses and sagittal plane are rang from33.4-34.1°.Conclusions:①According to the anatomical observation andmeasurement of cervical lateral masses, the distance between lateralmass and superior nerve root is small. It suggests the degenerationsof uparticular easily affects the superior nerve root.②According tothe results from the observation of anatomy and the measurement ofradiographs, the screw penetration of cervical lateral massesmaintain ahead-incline 35～45°and outside-incline 10～30°, thevertebral artery and nerve roots don’t be injured.③For thedifference of the lateral mass in different person, practising the difference of the screw penetration in the screw fixation of lateralmasses according to different person is necessary for the largestgrisping of the screw.更多还原