C5神經(jīng)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(jīng)根麻痹較為少見，是頸椎術(shù)后可能出現(xiàn)神經(jīng)根麻痹較為少見，是頸椎術(shù)后可能出現(xiàn)的較為嚴(yán)重的并發(fā)癥，然而，到目前為止，尚沒的較為嚴(yán)重的并發(fā)癥，然而，到目前為止，尚沒有相關(guān)指南幫助外科醫(yī)師預(yù)防和治療有相關(guān)指南幫助外科醫(yī)師預(yù)防和治療 C5 神經(jīng)根神經(jīng)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(xiàn)進(jìn)行了系統(tǒng)回顧和總結(jié)，以明確該并發(fā)為此，作者對文獻(xiàn)進(jìn)行了系統(tǒng)

4、回顧和總結(jié)，以明確該并發(fā)癥發(fā)生的原因，探討其預(yù)防和治療的方法。檢索癥發(fā)生的原因，探討其預(yù)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(shù)并發(fā)癥。麻痹作為手術(shù)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(shù)作者認(rèn)為盡管存在許多可能的致病因素，但多數(shù)作者認(rèn)為頸椎術(shù)后脊髓向后漂移、進(jìn)而引起神經(jīng)根牽拉是頸椎術(shù)后脊髓向后漂移、進(jìn)而引起神經(jīng)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(guān)鍵詞對作為關(guān)鍵詞對2000-2013年期間在年期間在PubMed、EMBASE

7、和和MEDLINE上的文獻(xiàn)進(jìn)行了系統(tǒng)檢索。納入上的文獻(xiàn)進(jìn)行了系統(tǒng)檢索。納入標(biāo)準(zhǔn)為：文章需要與術(shù)后標(biāo)準(zhǔn)為：文章需要與術(shù)后C5神經(jīng)根麻痹的病因?qū)W、結(jié)果、預(yù)防及治神經(jīng)根麻痹的病因?qū)W、結(jié)果、預(yù)防及治療相關(guān)。每一篇論文的證據(jù)等級均采用牛津循證醫(yī)學(xué)中心的方法進(jìn)行療相關(guān)。每一篇論文的證據(jù)等級均采用牛津循證醫(yī)學(xué)中心的方法進(jìn)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(shù)后前路減壓：頸前路減壓術(shù)后 C5 神經(jīng)根麻痹的發(fā)生率為神經(jīng)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(shù)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(shù)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(tuán)隊(duì)和團(tuán)隊(duì)和Wada團(tuán)隊(duì)報(bào)道頸椎次全

10、切術(shù)后團(tuán)隊(duì)報(bào)道頸椎次全切術(shù)后C5神經(jīng)根麻痹的發(fā)神經(jīng)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(shù)后的發(fā)生率為）術(shù)后的發(fā)生率為1.9%。v 同樣采用混合式技術(shù)，同樣采用混合式技術(shù)，Odate等報(bào)道的發(fā)生率則為等報(bào)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(shù)方式進(jìn)行分析的，因此我們對不由于一些研究是針對手術(shù)方式進(jìn)行分析的，因此我們對不同術(shù)式的并發(fā)癥分別進(jìn)行了評估。結(jié)果表明，有關(guān)前路減同術(shù)式的并發(fā)癥分別進(jìn)行了評估。結(jié)果表明，有關(guān)前路減壓的壓的20項(xiàng)研究的發(fā)生率為項(xiàng)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(shù)后后路減壓：頸后路減壓術(shù)后C5神經(jīng)根麻痹的發(fā)生率在神經(jīng)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(shù)的發(fā)生率最高可達(dá)各種類型的椎板成形術(shù)的發(fā)生率最高可達(dá)17%。v 頸椎管擴(kuò)大

13、成形術(shù)后的發(fā)生率為頸椎管擴(kuò)大成形術(shù)后的發(fā)生率為4%。v 而同時(shí)行椎間孔切開術(shù)后而同時(shí)行椎間孔切開術(shù)后C5神經(jīng)根麻痹的發(fā)生率則降低到神經(jīng)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(jìn)行了一項(xiàng)回顧性研究，認(rèn)為椎管成形術(shù)同時(shí)行等進(jìn)行了一項(xiàng)回顧性研究，認(rèn)為椎管成形術(shù)同時(shí)行C4/C5 椎間孔切開術(shù)患者術(shù)后椎間孔切開術(shù)患者術(shù)后C5神經(jīng)根麻痹的發(fā)生率為神經(jīng)根麻痹的發(fā)生率為 1.4%，這也進(jìn)一步支持預(yù)防性椎間孔切開有助于預(yù)防這也進(jìn)一步支持預(yù)防性椎間孔切開有助于預(yù)防 C5 神經(jīng)根麻痹。神經(jīng)根麻痹。v 總的來講，頸后路減壓術(shù)后

15、總的來講，頸后路減壓術(shù)后 C5 神經(jīng)根麻痹的平均發(fā)生率為神經(jīng)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 脊髓型頸椎病：椎板成形術(shù)是治療脊髓型頸椎病最常用的脊髓型頸椎?。鹤蛋宄尚涡g(shù)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(shù)后而且許多研究的主要目的是如何避免術(shù)后 C5 神經(jīng)神經(jīng)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(dá)到統(tǒng)計(jì)學(xué)意義，開門較寬組然而，雖然沒有達(dá)到統(tǒng)計(jì)學(xué)意義，開門較寬組 C5 神經(jīng)根麻痹的發(fā)生神經(jīng)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(shí)上，由于窄開門。事實(shí)上，由于窄開門可以減少脊髓漂移的空間，多數(shù)學(xué)者認(rèn)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(shù)學(xué)者認(rèn)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(rèn)為栓系理論（脊：這些作者認(rèn)為栓系理論（脊髓向后漂移導(dǎo)致的神經(jīng)根栓系）是該并發(fā)癥發(fā)生的重要原髓向后漂移導(dǎo)致的神經(jīng)根栓系）是該并發(fā)癥發(fā)生的重要原因，同時(shí)他們認(rèn)為，因，同時(shí)他們認(rèn)為，內(nèi)固定內(nèi)固定重建使得頸椎重建使得頸椎前前曲過度恢復(fù)，曲過度恢復(fù)，進(jìn)而造成進(jìn)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(cè)塊螺釘固定等后路組

22、合式技術(shù)是椎板成形術(shù)之外的治療椎板成形及側(cè)塊螺釘固定等后路組合式技術(shù)是椎板成形術(shù)之外的治療選擇，有研究認(rèn)為選擇，有研究認(rèn)為 OPLL 患者同時(shí)存在頸椎節(jié)段不穩(wěn)，減壓術(shù)后患患者同時(shí)存在頸椎節(jié)段不穩(wěn)，減壓術(shù)后患 者神經(jīng)功能改善，與僅行椎板成形術(shù)者相比，其遠(yuǎn)期者神經(jīng)功能改善，與僅行椎板成形術(shù)者相比，其遠(yuǎn)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(jīng)根麻痹的發(fā)生率相近。因此，作者神經(jīng)根麻痹的發(fā)生率相近。因此，作者也認(rèn)為，混合式手術(shù)技術(shù)在預(yù)防也認(rèn)為，混合式手術(shù)技術(shù)在預(yù)防 C5 神經(jīng)根麻痹方面并無明確的優(yōu)勢。神經(jīng)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(yù)防：應(yīng)用神經(jīng)電生理監(jiān)測早期發(fā)現(xiàn)預(yù)防：應(yīng)用神經(jīng)電生理監(jiān)測早期發(fā)現(xiàn) C5 神經(jīng)根麻痹能夠神經(jīng)根麻痹能夠避免術(shù)后神經(jīng)功能損傷。避免術(shù)后神經(jīng)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(jīng)后路減壓術(shù)后相對于經(jīng)后路減壓術(shù)后 7.8% 的的 C5 神經(jīng)根麻神經(jīng)根麻痹發(fā)生率，很難解釋頸前路減壓術(shù)后的平均發(fā)生痹發(fā)生率，很難解釋頸前路減壓術(shù)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(guān)于術(shù)后雖然關(guān)于術(shù)后 C5 神經(jīng)根麻痹的發(fā)生是多因素的，但是我神經(jīng)根麻痹的發(fā)生是多因素的，但是我們的研究表明，減壓術(shù)后硬膜囊的向后漂移對神經(jīng)根的牽們的研究表明，減壓術(shù)后硬膜囊的向后漂移對神經(jīng)根的牽拉（栓系效應(yīng)）是目前最常見拉（栓系效應(yīng)）是目前最常見 / 流行的假設(shè)理論，而且流行的假設(shè)理論，而且無論前路還是后路手術(shù)均會引起硬膜囊的向后漂移。無論前路還是后路手術(shù)均會引起硬膜囊的向后漂移。Conclusionv Early detection and pre