C5神經根麻痹

1、C5 nerve root palsy following decompression of the cervical spineZhu xi The Orthopaedics of General Hospital of NMU J. Z. Guzman, BS, From Icahn School of Medicine at Mount Sinai, New York,United States Bone Joint J 2014;96-B:9505.Preface vC5 nerve root palsy is a rare and potentially debilitating c

2、omplication of cervical spine surgery. Currently, however, there are no guidelines to help surgeons to prevent or treat this complication.v頸頸 5 神經根麻痹較為少見，是頸椎術后可能出現神經根麻痹較為少見，是頸椎術后可能出現的較為嚴重的并發(fā)癥，然而，到目前為止，尚沒的較為嚴重的并發(fā)癥，然而，到目前為止，尚沒有相關指南幫助外科醫(yī)師預防和治療有相關指南幫助外科醫(yī)師預防和治療 C5 神經根神經根麻痹。麻痹。Prefacev We carried out a sy

3、stematic review of the literature to identify the causes of this complication and options for its prevention and treatment. Searches of PubMed, Embase and Medline yielded 60 articles for inclusion, most of which addressed C5 palsy as a complication of surgery.v 為此，作者對文獻進行了系統(tǒng)回顧和總結，以明確該并發(fā)為此，作者對文獻進行了系統(tǒng)

4、回顧和總結，以明確該并發(fā)癥發(fā)生的原因，探討其預防和治療的方法。檢索癥發(fā)生的原因，探討其預防和治療的方法。檢索PubMed，EMBASE和和MEDLINE選出選出60篇文章，其篇文章，其中大部分將中大部分將C5麻痹作為手術并發(fā)癥。麻痹作為手術并發(fā)癥。PrefacevAlthough many possible causes were given, most authors supported posterior migration of the spinal cord with tethering of the nerve root as being the most likely.v盡管存在許

5、多可能的致病因素，但多數作者認為盡管存在許多可能的致病因素，但多數作者認為頸椎術后脊髓向后漂移、進而引起神經根牽拉是頸椎術后脊髓向后漂移、進而引起神經根牽拉是最可能的因素。最可能的因素。MATERIALS AND METHODSv We performed a systematic search with PubMed 、Embase、Medline of the years between 2000 and 2013 using the terms “C5 palsy” and “cervical spine”.The criteria for inclusion were the rele

6、vance of the articles to the aetiology, outcome, prevention and treatment of a post-operative C5 nerve root palsy.The level of evidence of each article was determined using the methods of the Oxford Centre for Evidence Based Medicine.v 作者以作者以“C5麻痹麻痹”和和“頸椎頸椎”作為關鍵詞對作為關鍵詞對2000-2013年期間在年期間在PubMed、EMBASE

7、和和MEDLINE上的文獻進行了系統(tǒng)檢索。納入上的文獻進行了系統(tǒng)檢索。納入標準為：文章需要與術后標準為：文章需要與術后C5神經根麻痹的病因學、結果、預防及治神經根麻痹的病因學、結果、預防及治療相關。每一篇論文的證據等級均采用牛津循證醫(yī)學中心的方法進行療相關。每一篇論文的證據等級均采用牛津循證醫(yī)學中心的方法進行確定。確定。Resultsv Anterior Decompression：Analysis of the literature revealed an incidence of C5 root palsy after anterior decompression of between 0

8、% and 26.4%.v Two-level corpectomy with autograft fusion and plate fixation had the highest incidence at 26.4%.v 前路減壓：頸前路減壓術后前路減壓：頸前路減壓術后 C5 神經根麻痹的發(fā)生率為神經根麻痹的發(fā)生率為 0%-26.4%。v 兩節(jié)段椎體次全切植骨融合固定術后的發(fā)生率最高，為兩節(jié)段椎體次全切植骨融合固定術后的發(fā)生率最高，為26.4%。ResultsResultsv Shibuya et and Wada et both reported lower incidences at

9、8.8% and 4%, respectively, in their studies of subtotal corpectomy.v Anterior hybrid decompression,in which a single-level corpectomy and singlelevel discectomy is performed, had an incidence of 1.9%.v Using a similar hybrid technique, Odate et reported an incidence of 3%.v Shibuya團隊和團隊和Wada團隊報道頸椎次全

10、切術后團隊報道頸椎次全切術后C5神經根麻痹的發(fā)神經根麻痹的發(fā)生率分別為生率分別為8.8%及及4%。v 前路混合式減壓（前路混合式減壓（單節(jié)段單節(jié)段ACCF和和ACDF）術后的發(fā)生率為）術后的發(fā)生率為1.9%。v 同樣采用混合式技術，同樣采用混合式技術，Odate等報道的發(fā)生率則為等報道的發(fā)生率則為3%。Resultsv Due to some studies which evaluated several procedures, we considered each evaluation separately. Overall, 20 evaluations of anterior decom

11、pression resulted in an incidence of 7.7%.v 由于一些研究是針對手術方式進行分析的，因此我們對不由于一些研究是針對手術方式進行分析的，因此我們對不同術式的并發(fā)癥分別進行了評估。結果表明，有關前路減同術式的并發(fā)癥分別進行了評估。結果表明，有關前路減壓的壓的20項研究的發(fā)生率為項研究的發(fā)生率為7.7%。Resultsv Posterior Decompression：The incidence of C5 nerve root palsy after posterior decompression was between 0% and 50%.v Lami

12、noplasty of various types resultedin an incidence of up to 17%.v Cervical expansive laminoplasty resulted in a 4%.v While a concurrent bilateral foraminotomy decreased the incidence to 0.6%.v 后路減壓：頸后路減壓術后后路減壓：頸后路減壓術后C5神經根麻痹的發(fā)生率在神經根麻痹的發(fā)生率在 0%-50% 之間之間。v 各種類型的椎板成形術的發(fā)生率最高可達各種類型的椎板成形術的發(fā)生率最高可達17%。v 頸椎管擴大

13、成形術后的發(fā)生率為頸椎管擴大成形術后的發(fā)生率為4%。v 而同時行椎間孔切開術后而同時行椎間孔切開術后C5神經根麻痹的發(fā)生率則降低到神經根麻痹的發(fā)生率則降低到 0.6%。ResultsResultsv A retrospective review by Katsumi which considered open door laminoplasty with C4/C5 foraminotomy, gave a 1.4% incidence of C5 root palsy which further supports the use of prophylactic foraminotomy in

14、 the prevention of a C5 palsy.Overall,v articles which addressed posterior decompression yielded a mean incidence of 7.8%.v Katsumi 等進行了一項回顧性研究，認為椎管成形術同時行等進行了一項回顧性研究，認為椎管成形術同時行C4/C5 椎間孔切開術患者術后椎間孔切開術患者術后C5神經根麻痹的發(fā)生率為神經根麻痹的發(fā)生率為 1.4%，這也進一步支持預防性椎間孔切開有助于預防這也進一步支持預防性椎間孔切開有助于預防 C5 神經根麻痹。神經根麻痹。v 總的來講，頸后路減壓術后

15、總的來講，頸后路減壓術后 C5 神經根麻痹的平均發(fā)生率為神經根麻痹的平均發(fā)生率為 7.8%。Resultsv Cervical spondylotic myelopathy:We found that laminoplasty was the most commonly studied procedure for the treatment of this condition and the primary focus of many papers which addressed this problem were the use of different techniques to help

16、 avert a C5 nerve root palsy.v 脊髓型頸椎?。鹤蛋宄尚涡g是治療脊髓型頸椎病最常用的脊髓型頸椎病：椎板成形術是治療脊髓型頸椎病最常用的方法方法,而且許多研究的主要目的是如何避免術后而且許多研究的主要目的是如何避免術后 C5 神經神經根麻痹。根麻痹。Resultsv While not reaching statistical significance, the wide-door group had an incidence of C5 palsy of 5.3% while the narrow-door group had an instance of 0%.v

17、 Due to the fact that a narrow open door decreasesv the potential space for movement of the spinal cord, these authors, as well as others, support the concept that a narrow door decreases the amount of posterior shift of the thecal sac.v 然而，雖然沒有達到統(tǒng)計學意義，開門較寬組然而，雖然沒有達到統(tǒng)計學意義，開門較寬組 C5 神經根麻痹的發(fā)生神經根麻痹的發(fā)生率為

18、率為 5.3%，開門較窄組的發(fā)生率則為，開門較窄組的發(fā)生率則為 0%。事實上，由于窄開門。事實上，由于窄開門可以減少脊髓漂移的空間，多數學者認為該方法可以有效降低硬膜囊可以減少脊髓漂移的空間，多數學者認為該方法可以有效降低硬膜囊受牽連的程度。受牽連的程度。Resultsv Ossification of the posterior longitudinal ligament (OPLL):These authors supported the tethering theory and state that laminectomy,in particular, allows posterior

19、shift of the cord at C5 because of over-restoration of the cervical lordosis by surgical instrumentation.v 頸椎后縱韌帶骨化癥頸椎后縱韌帶骨化癥OPLL：這些作者認為栓系理論（脊：這些作者認為栓系理論（脊髓向后漂移導致的神經根栓系）是該并發(fā)癥發(fā)生的重要原髓向后漂移導致的神經根栓系）是該并發(fā)癥發(fā)生的重要原因，同時他們認為，因，同時他們認為，內固定內固定重建使得頸椎重建使得頸椎前前曲過度恢復，曲過度恢復，進而造成進而造成 C5 水平脊髓向后漂移。水平脊髓向后漂移。Resultsv The po

20、sterior hybrid technique, in which laminoplasty is performed with lateral mass screw fixation, is an alternative technique to simple laminoplasty but still has the potential to cause a C5 root palsy. Two studies44,51 considered patients with OPLL and concurrent segmental instability. After surgical

21、decompression, their neurological symptoms had improved and their Japanese Orthopaedic Association (JOA) scores were better in the long term than in those who had only undergone laminoplasty. Despite this, the overall rate of C5 root palsy was similar in both groups and the authors.v 椎板成形及側塊螺釘固定等后路組

22、合式技術是椎板成形術之外的治療椎板成形及側塊螺釘固定等后路組合式技術是椎板成形術之外的治療選擇，有研究認為選擇，有研究認為 OPLL 患者同時存在頸椎節(jié)段不穩(wěn)，減壓術后患患者同時存在頸椎節(jié)段不穩(wěn)，減壓術后患 者神經功能改善，與僅行椎板成形術者相比，其遠期者神經功能改善，與僅行椎板成形術者相比，其遠期 JOA 評分更好。評分更好。盡管如此，兩組患者總體盡管如此，兩組患者總體 C5 神經根麻痹的發(fā)生率相近。因此，作者神經根麻痹的發(fā)生率相近。因此，作者也認為，混合式手術技術在預防也認為，混合式手術技術在預防 C5 神經根麻痹方面并無明確的優(yōu)勢。神經根麻痹方面并無明確的優(yōu)勢。Resultsv Prev

23、ention:Early detection of a C5 root palsy using neurophysiological monitoring can potentially avert post-operative neurological deficits.v 預防：應用神經電生理監(jiān)測早期發(fā)現預防：應用神經電生理監(jiān)測早期發(fā)現 C5 神經根麻痹能夠神經根麻痹能夠避免術后神經功能損傷。避免術后神經功能損傷。DiscussionvIt is difficult to interpret the 7.7% mean incidence of C5 palsy after anterio

24、r decompression when compared with that of 7.8% after posterior decompression.v相對于經后路減壓術后相對于經后路減壓術后 7.8% 的的 C5 神經根麻神經根麻痹發(fā)生率，很難解釋頸前路減壓術后的平均發(fā)生痹發(fā)生率，很難解釋頸前路減壓術后的平均發(fā)生率為率為 7.7%。Discussionv The origin of post-operative C5 palsy is likely to be multifactorial; however, posterior movement of the thecal sac c

25、ausing traction on the nerve root proved to be the most common postulated theory in our search.Anterior and posterior decompression are both believed to.Conclusionv 雖然關于術后雖然關于術后 C5 神經根麻痹的發(fā)生是多因素的，但是我神經根麻痹的發(fā)生是多因素的，但是我們的研究表明，減壓術后硬膜囊的向后漂移對神經根的牽們的研究表明，減壓術后硬膜囊的向后漂移對神經根的牽拉（栓系效應）是目前最常見拉（栓系效應）是目前最常見 / 流行的假設理論，而且流行的假設理論，而且無論前路還是后路手術均會引起硬膜囊的向后漂移。無論前路還是后路手術均會引起硬膜囊的向后漂移。Conclusionv Early detection and pre