成人无骨折脱位型颈髓损伤手术与非手术治疗的临床研究

发布时间：2018-06-05 02:53

本文选题：颈髓损伤 + 无骨折脱位　；参考：《河北医科大学》2015年硕士论文

【摘要】：无骨折脱位型颈髓损伤(Cervical spinal cord injury without fracture and dislocation)即国际上统一命名的无放射影像学异常的颈髓损伤(cervical spinal cord injury without radiographic abnormality,CSCIWORA)是一种特殊类型的脊髓损伤,特指颈部受到外伤后,经X线、CT等检查手段,颈椎未发现明显骨折或脱位的一种临床常见疾病,占颈髓损伤的37%~52%。此病好发于两类人群:儿童及颈椎既往存在病变的成年人。儿童因颈部的椎旁肌肉韧带、关节囊等弹性较好,易产生一过性颈部牵拉致颈椎脱位,由于上述原因脱位的颈椎又迅速复原,致颈髓牵拉受伤。对于成人而言,由于既往颈椎存在基础病变,如椎管狭窄致储备空间减小、椎间盘膨出或突出以及后纵韧带钙化(Ossification of posterior longitudinal ligament,OPLL)等病变,即使轻微的外力也可致颈髓损伤,尤其是颈椎过度后伸及屈曲时,椎管矢状径变窄、椎间盘突出加重以及黄韧带皱褶向椎管内突出都可致脊髓受压,产生临床症状。由于CSCIWORA的隐匿性以及症状滞后性的特点,漏诊率较高,且X线、CT无阳性表现,只有通过MRI才能发现颈髓损伤,因此对临床医师技术水平要求相对较高,如果不及时诊断或者治疗方法不得当,都会产生严重后果。CSCIWORA的病因仍然没有研究透彻,多数认为是多种因素共同作用的结果,其最直接的致伤因素多为摔伤、坠落伤以及事故伤等,其共同点是头颈部受到外力均不大。目前其治疗方法多数学者也各抒己见,缺乏理论性依据,本文应用相关评分标准及统计学方法对其治疗提供一定的理论依据,为临床上CSCIWORA的治疗起到一定的帮助作用。目的:CSCIWORA采取手术还是非手术治疗,目前还存在着一定的争议,为获得手术治疗的理论依据,本研究旨在对患有CSCIWORA已经实施手术和保守治疗的患者在入院时、出院时、出院后三个月和六个月的功能评分对比结果应用统计学方法进行处理,从而得出CSCIWORA的有效治疗方法。方法:取自河北医科大学第三医院创伤急救病区于2013年8月至2014年10月份收治的CSCIWORA患者总共30例,其中男性共24例,女性共6例,年龄区间在26岁~66岁,平均年龄为48.1岁。最终门诊随访10例,电话随访20例,除2例予以手术的失访2例未手术的死亡外,其余26例患者均得到有效随访,随访期间20个月,并将随访到的26例病例分为两组,A组13例实施手术,B组13例未手术,手术均由我科室主任医师在入院后七日内完成。应用日本骨科学会(JOA)评分标准对所有入选病例在入院、出院、三个月、六个月时评分并分别计算出其JOA增加幅度,应用两独立样本t检验并对比其结果;然后应用国际脊髓损伤协会(American Spinal Injury Association,ASIA)神经分级标准在入院时和出院后六个月随访时进行功能评价,应用秩和检验,对所得结果进行分析。结果:对所得结果应用统计学软件SPSS13.0分析,计量资料用?X±S表示。对A组与B组治疗前后JOA评分别行两独立样本t检验,入院P0.05(无显著性差异),出院P0.1;三个月P0.05;六个月P0.05(有显著性差异)。应用两独立样本t检验分别对A组入院时、出院时、三个月、六个月时的JOA评分增加幅度与B组入院时、出院时、三个月、六个月时JOA评分增加幅度相对比,结果P0.05(有显著性差异)。运用ASIA神经分级标准进行评估,在入院及出院六个月随访,并对其神经功能的恢复情况进行等级划分,并应用Mann-Whitney U秩和检验,出院后六个月时P0.05,有统计学意义。在所有入选的病历中,由于2例患者入院时全瘫,脊髓神经功能恢复较差,其余患者均有不同程度的恢复。ASIA分级:A组术前A级1例,B级3例,C级8例,D级1例,E级0例;术后A级0例,B级1例,C级2例,D级8例,E级2例。B组术前A级1例,B级2例,C级7例,D级3例,E级0例;术后A级1例,B级1例,C级7例,D级4例,E级0例。结论:对于CSCIWORA患者,积极手术治疗,可给脊髓神经功能早期恢复创造条件,非手术治疗对CSCIWORA患者功能恢复疗效不明显,手术可以解除压迫稳定颈椎,对后期脊髓功能恢复十分有利。
[Abstract]:Cervical spinal cord injury (Cervical spinal cord injury without fracture and dislocation) is an internationally unified nomenclature of cervical spinal cord injury without radiological abnormalities (cervical spinal cord injury) is a special type of spinal cord injury, especially after cervical trauma. Line, CT and other methods of examination, the cervical spine has not found a common clinical disease of fracture or dislocation. The 37%~52%. disease, which accounts for the cervical spinal cord injury, occurs in two groups of people: children and adults with previous cervical spondylosis. The flexibility of the paravertebral muscle ligaments and the joint sac of the cervical vertebrae is better, and it is easy to produce a sexual cervical distraction resulting in cervical dislocation. The cervical spine is rapidly restored and caused by cervical pulping injury. For adults, the underlying cervical lesions, such as spinal stenosis, decrease in reserve space, intervertebral disc swelling or protruding, and posterior longitudinal ligament calcification (Ossification of posterior longitudinal ligament, OPLL), even minor external forces It can cause cervical spinal cord injury, especially when the cervical vertebra is overstretched and flexed, the sagittal diameter of the spinal canal is narrowed, the disc herniation is aggravated, and the Yellow toughened fold to the spinal canal can cause the spinal cord compression to produce the clinical symptoms. Due to the concealment of CSCIWORA and the hysteresis of the symptoms, the missed diagnosis rate is high, and the X - ray, CT is not positive, only through MRI. Cervical spinal cord injury can be found, so the technical level of clinicians is relatively high. If not timely diagnosis or treatment is not appropriate, the cause of serious consequences of.CSCIWORA still has no thorough research, most of which are considered to be the result of a variety of factors, and most of the most direct injury factors are falls, falling injuries and things. Therefore, the common point is that the external force of the head and neck is not very large. At present, the methods of treatment for many mathematicians also express their own views and lack theoretical basis. This paper provides a certain theoretical basis for the treatment of CSCIWORA with relevant scoring criteria and statistical methods, which can help the treatment of clinical treatment. Objective: to take the operation of CSCIWORA. In order to obtain the theoretical basis of surgical treatment, the purpose of this study is to provide a theoretical basis for surgical treatment. The purpose of this study is to deal with the functional score comparison of three months and six months after discharge to the patients who have already performed the operation and conservative treatment of CSCIWORA. Methods: RA effective treatment methods. Methods: a total of 30 cases of CSCIWORA patients were treated from August 2013 to October 2014 in Third Hospital of Hebei Medical University. There were 24 cases of male and 6 women. The age range was 26 years old and the average age was 48.1 years. 10 cases were followed up and 20 cases were followed up by telephone, except 2 cases were operated on. The remaining 26 cases were followed up effectively, and the rest of the remaining 2 cases were followed up for 20 months, and 26 cases were divided into two groups, 13 cases in group A were operated, and 13 cases in group B were not operated. All the operations were completed within seven days after the admission by the chief physician of the Department. All selected diseases should be used by the Japanese Department of orthopedics Society (JOA) score standard. The patients were hospitalized, discharged, three months, six months, and calculated the JOA increase, using two independent samples t test and compared the results. Then, the International Spinal Cord Injury Association (American Spinal Injury Association, ASIA) neural grading standard was evaluated at admission and six months after discharge, and the rank was applied. The results were analyzed. Results: the results were analyzed with statistical software SPSS13.0 and X + S for measurement data. The JOA scores of group A and B group were two independent samples t test, P0.05 (no significant difference), discharge P0.1, three month P0.05, six month P0.05 (significant difference). Two independent samples were applied. When the t test was admitted to the group A, the increase of JOA score at three months and six months was compared with that of the group B. The JOA score increased at discharge, three months and six months, and the result was P0.05 (significant difference). The recovery was graded, and the Mann-Whitney U rank sum test was applied to P0.05 after six months of discharge. In all the selected cases, 2 patients were completely paralyzed at admission, the spinal nerve function was poorly restored, and the rest of the patients had different degrees of Restorer.ASIA classification: A group a class a 1 cases, B grade 3 cases, C class 8 cases, D grade. 1 cases, 0 cases of grade E, 0 cases of class A, 1 cases of class B, 2 cases of C class, 8 cases of class D, 2 cases of.B in group E, 2 cases of B, 7 cases of C, 3, E, B level 1, C class, C class, grade, etc. The effect of functional recovery is not obvious. Surgery can relieve compression and stabilize the cervical vertebra, which is beneficial to the recovery of spinal cord function in the later stage.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R651.2

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