经椎弓根入路内镜下手术治疗颈脊髓腹侧中央硬性压迫的可行性及早期临床疗效观察

Feasibility and early clinical outcomes of endoscopic trans-pedicular approach for ventral central rigid compression of cervical spinal cord

中文关键词:  脊髓型颈椎病  经椎弓根入路  经骨内镜手术  后纵韧带骨化  脊髓腹侧中央硬性压迫

英文关键词:Cervical spondylotic myelopathy  Trans-pedicular approach  Trans-osseous endoscopic surgery  Ossification of posterior longitudinal ligament  Ventral central rigid compression of spinal cord

中文摘要:

  【摘要】 目的：评估经椎弓根入路（trans-pedicular approach，TPA）内镜下手术减压治疗颈脊髓腹侧中央硬性压迫的可行性、安全性及早期临床疗效。方法：测量C3～C7节段TPA相关颈椎解剖参数，评价7mm直径骨隧道的接受率；采用有限元生物力学模拟，计算TPA术后颈椎活动度及骨应力分布的变化；在离体颈椎标本上，经椎体后缘注射骨水泥构建脊髓腹侧中央硬性压迫模型，随后在内镜辅助下行TPA模拟手术，观察能否解除压迫；回顾性分析2020年1月～2022年1月15例行TPA内镜手术的脊髓型颈椎病患者临床资料，记录手术时间、术中出血量及手术相关并发症，评估术前和术后日本骨科学会（Japanese Orthopaedic Association，JOA）评分、颈痛视觉模拟量表（visual analog scale，VAS）评分，并通过CT和MRI观察侧块骨缺损愈合及脊髓受压变化，所有病例均随访至少12个月。结果：C3～C5节段7mm骨隧道接受率为100%，C6为93.33%，C7为20%。生物力学模拟显示，TPA术后颈椎后伸时手术侧椎弓根处峰值应力较未手术组显著增高，而手术节段活动度与术前无显著差异。大体标本模型注射骨水泥后可形成稳定的腹侧硬性压迫，镜下TPA模拟手术能成功解除该压迫。15例患者均顺利完成手术，无术中及术后神经血管并发症；手术时间121.3±20.3min（80～150min），术中出血量41.7±28.3mL（5～80mL）。术后12个月时JOA评分由术前的12.2±1.7分升至16.0±1.2分，颈部VAS评分由6.5±1.9分降至2.9±1.1分，差异均有统计学意义（P<0.001）。末次随访CT示侧块骨缺损显著缩小，MRI示手术节段脊髓腹侧受压得到有效解除。结论：颈椎内镜经椎弓根入路具备解剖可行性，符合生物力学原则，手术可操作性良好；初步临床应用表明该入路治疗颈脊髓腹侧中央硬性压迫安全、有效，早期疗效满意。

英文摘要:

  【Abstract】 Objectives: To evaluate the feasibility, safety, and early clinical efficacy of trans-pedicular approach (TPA) endoscopic decompression for the treatment of ventral central hard compression of the cervical spinal cord. Methods: The anatomical parameters related to TPA at C3-C7 levels were measured, and the feasibility rate of a 7-mm-diameter bone tunnel was assessed. Finite element biomechanical simulation was performed to analyze changes in cervical range of motion and bone stress distribution after TPA. A ventral central hard compression model of the spinal cord was created by injecting bone cement into the posterior aspect of the vertebral bodies of cadaveric cervical spine specimens, followed by simulated TPA surgery under endoscopic guidance to observe whether decompression could be achieved. Clinical data of 15 patients with cervical spondylotic myelopathy(CSM) who underwent TPA endoscopic surgery between January 2020 and January 2022 were retrospectively analyzed. The operative time, intraoperative blood loss, and surgery-related complications were recorded. The Japanese Orthopaedic Association(JOA) score and neck pain visual analog scale(VAS) score were assessed preoperatively and postoperatively, and CT and MRI were used to evaluate healing of the lateral mass bone defect and changes in spinal cord compression. All patients were followed up for at least 12 months. Results: The feasibility rate of a 7-mm bone tunnel was 100% at C3-C5, 93.33% at C6, and 20% at C7. Biomechanical simulation showed that during cervical extension after TPA, the peak stress at the operated pedicle was significantly higher than that in the non-operated group, whereas the range of motion at the operated segment showed no significant difference from the preoperative state. In the cadaveric model, injection of bone cement resulted in a stable ventral hard compression, which was successfully relieved by simulated TPA surgery under endoscopy. All 15 patients underwent surgery successfully without intraoperative or postoperative neurovascular complications. The mean operative time was 121.3±20.3min (range, 80-150min), and the mean intraoperative blood loss was 41.7±28.3mL(range, 5-80mL). At 12 months postoperatively, the JOA score improved from 12.2±1.7 to 16.0±1.2, and the neck VAS score decreased from 6.5±1.9 to 2.9±1.1(both P<0.001). At the final follow-up, CT showed a significant reduction in the lateral mass bone defect, and MRI demonstrated effective decompression of the ventral spinal cord at the operated segment. Conclusions: Cervical endoscopic TPA has anatomical feasibility, conforms to biomechanical principles, and possesses good surgical operability. Preliminary clinical application suggests that this approach is safe and effective for treating CSM caused by ventral central hard compression, with satisfactory early outcomes.