外伤性颈椎间盘撕裂的诊断和治疗策略

Diagnosis and treatment of traumatic cervical intervertebral disc tear

中文关键词:  颈椎  脊髓损伤  颈椎间盘  撕裂  MRI

英文关键词:Cervical spine  Spinal cord injury  Cervical intervertebral disc  Tear  No fracture and dislocation

中文摘要:

  【摘要】 目的：探讨外伤性颈椎间盘撕裂的病例特点，MRI诊断特征和治疗策略。方法：回顾分析我组自2015年6月～2018年6月收治的外伤性颈椎间盘撕裂伴脊髓损伤患者46例，男34例，女12例；年龄21~74岁，平均年龄（51.0±12.3）岁。其中车祸伤为27例，高处坠落伤11例，跌倒损伤8例。46例患者中，40例存在颜面擦皮伤。术前进行ASIA分级，所有患者术前行X线、CT、MRI检查，其中MRI检查必须有脂肪抑制序列。根据术前MRI影像结果判断椎间盘存在撕裂的可能，并记录能判断椎间盘撕裂的MRI影像信号特征，术式采用前路损伤节段的ACDF手术。所有前路手术患者全麻后，颈部摆过伸位，透视，部分椎间盘撕裂的节段，会呈现上位椎体向后方移位。如术前高度怀疑椎间盘撕裂，术中未见撕裂，则术中给予次椎间盘造影。将术前MRI特征的影像学表现与术中探查的结果进行对比，总结MRI特征性影像学表现。比较术前、术后1周、术后1个月和末次随访时颈痛的VAS评分及Oswestry功能障碍指数（ODI）。结果：46例患者B级2例，C级7例，D级26例，E级11例，术后末次随访D级1例，E级45例，病例特点为神经损伤轻，而且术后恢复效果好。根据术前MRI影像特征及术中实际探查椎间盘损伤结果分析，将椎间盘撕裂的MRI特征表现分为典型表现和不典型表现两种类型。全麻下后颈部后伸位透视及术中椎间盘造影及对判断椎间盘损伤有一定辅助意义。术中发现46例患者并不都是一个节段椎间盘撕裂，2个节段椎间盘撕裂的有12例，3个节段椎间盘撕裂的有3例，共有74个椎间盘撕裂。前路ACDF手术治疗椎间盘撕裂疗效满意。46例患者完成随访时间为6.0±1.3个月（4～8个月）。所有患者在随访过程中均逐渐改善，术后1周、1个月及末次随访时的VAS评分及ODI与术前比较均显著性改善（P＜0.05）。结论：外伤性颈椎间盘撕裂患者脊髓损伤轻，术后神经恢复较好，MRI检查有特征性影像表现能明确诊断外伤性颈椎间盘撕裂，颈椎前路ACDF手术是针对病因治疗，效果满意。

英文摘要:

  【Abstract】 Objectives: To investigate the characteristics of traumatic cervical intervertebral disc tear, the diagnostic features of MRI and the treatment strategy. Methods: From June 2015 to June 2018, 46 patients with traumatic cervical intervertebral disc tear and spinal cord injury, 34 males and 12 females, with an average age of 51.0±12.3 years ranging from 21 to 74 years, were retrospectively analyzed. Among them, 27 were injured in traffic accidents, 11 were injured by falling and 8 were injured by tumbling. Of all patients, 40 had facial abrasion. ASIA scale, X-ray, CT and MRI examination were performed before operation in all patients, and fat suppression sequence was required in MRI examination. Disc tear was diagnosed according to MRI, and the MRI imaging characteristics was recorded. ACDF was chosen in anterior segment injury. After general anesthesia in anterior approach, the upper vertebral body would show posterior displacement in partial disc tear segments in X-ray under cervical hyperextension position. Subdiscography would be given for the case with high preoperative suspicion of disc tear but found no tear in operation. The MRI characteristics were recorded after compared with intraoperative exploration. The VAS score and Oswestry dysfunction index (ODI) of neck pain before operation, 1 week after operation, 1 month after operation and at the last follow-up were compared. Results： Of the 46 patients, there were 2 cases of grade B, 7 cases of grade C, 26 cases of grade D and 11 cases of grade E. At final follow-up, there were one case of grade D and 45 cases of grade E, with mild nerve injury and good recovery after operation. According to preoperative MRI characteristics and actual disc injury during operation, the MRI characteristics of disc tear could be divided into two types: typical and atypical. Posterior X-ray under cervical hyperextension position and intraoperative discography under general anesthesia were helpful for judging disc injury. A total of 74 disc tear were found in the 46 patients, including 12 patients with two segmental disc tear, and 3 patients with three segmental disc tear. Anterior ACDF was effective in the treatment of intervertebral disc tear. All patients improved gradually during the follow-up of 6.0±1.3 months(4-8 months). VAS score and ODI were significantly improved at 1 week, 1 month after operation and the last follow-up(P<0.05). Conclusions： Traumatic cervical intervertebral disc tear accompany with mild spinal cord injury, and can be diagnosed according to MRI characteristic findings. Anterior cervical ACDF surgery is targeted at the etiology, which can achieve good nerve recovery and satisfactory outcomes.