新人999严重颈椎病如何治疗配图，仅供参考
4. Treatment# Treatment
Summary
For mild cases,conservative treatment is primarily selected; however,there is currently insufficient evidence concerning treatment outcomes. Surgery is considered suitable for progressive myelopathy whenever conservative treatment fails. Surgical methods primarily include the anterior approach (anterior decompression and fusion (ADF)) and the posterior approach (laminoplasty,laminectomy,and posterior decompression and fusion). While each method has shortcomings and advantages,historically,in Japan,laminoplasty has been developed and expanded. Thus,the posterior approach is commonly performed. In the surgical treatment of CSM,typical prognostic factors include age,preoperative severity,length of disease duration,and signal intensity changes on preoperative T1-weighted MRI and T2-weighted MRI.
Cervical ADF are particularly indicated for patients with pathologic compression on the anterior side,patients with alignment presenting kyphosis,and patients with relatively few affected intervertebral spaces. Cervical ADF are primarily performed by anterior cervical discectomy and fusion (ACDF),anterior cervical corpectomy and fusion (ACCF),and the ACDF and ACCF hybrid methods. In recent years,various anterior instrumentations,such as plates and cages,have been developed.
Meanwhile,the therapeutic outcomes of laminoplasty for CSM are also favorable. Various preventive measures are implemented to reduce axial pain and prevent C5 palsy. The characteristics and indications of patients who should receive concurrent fusion have not yet been elucidated.
Although many articles recommend fusion surgery by the posterior approach for CSM with athetoid cerebral palsy,loosening of the screws should be monitored because it readily leads to repeat surgery. It has been reported that while surgery for CSM with Parkinsons disease improves some symptoms,overall,the improvement is inferior.
Regarding spinal cord monitoring in cervical spine surgery for compressive cervical myelopathy including CSM,postoperative neurological deterioration can be predicted to a certain extent; however,further examination is needed concerning prevention. A multicenter,prospective study with consistent monitoring of modalities and alarm points is a future task.
Commentary
Conservative treatment for CSM is primarily administered for mild cases. Methods performed include therapy using an apparatus where the neck could rest (external fixation of the cervical area using a collar),),cervical traction therapy ),and lifestyle guidance regarding neck postures. Furthermore,pharmacotherapy,anti-inflammatory analgesics,vitamin B12,muscle relaxants,anti-anxiety drugs,prostaglandin preparations ),and steroids have been used. A few studies with a high level of evidence about these conservative treatments exist. Surgery is considered suitable for progressive myelopathy unresponsive to conservative treatment. Attention has been drawn to the involvement of compressive factors (static factors) and dynamic factors as onset factors of CSM. Therefore,in surgical treatment,it is important to eliminate compressive and dynamic factors. The anterior approach aims to control dynamic factors and improve neurological symptoms by removing compressive factors and performing fusion. For laminoplasty,the most common type of posterior approach,the spinal cord is indirectly decompressed by expanding the spinal cord via the posterior approach. Various laminoplasty procedures have been reported,such as Hattoris ),Hirabayashis ),and Kurokawas methods (split spinous process method) ). In recent years,as a means to alleviate axial pain,nuchal muscle-preserving surgery,such as Shiraishis method ),and surgery to preserve the muscle groups attached to the spinal processes of C2 and C7 have been performed,). Furthermore,for patients with instability and poor alignment,there is posterior decompression and fusion ). Concerning which method,i.e.,posterior decompression alone or posterior decompression and fusion,provides good outcomes is controversial. In the surgical treatment of CSM,typical prognostic factors include age,preoperative severity,length of disease duration,and signal intensity changes on preoperative T1-weighted MRI and T2-weighted MRI. In a study of combined T1- and T2-weighted imaging,surgical outcomes were determined with greater sensitivity than by T2-weighted imaging alone ). While it has been reported that using T2-weighted imaging alone does not necessarily mean poor outcomes,T1-weighted low-signal intensity is a finding suggesting poor outcomes ). Other factors affecting surgical outcomes include anteroposterior spinal canal diameter,spondylolisthesis,preoperative cervical alignment,cross-sectional area of the spinal cord,and pre- to postoperative MRI changes.
With cervical ADF,anterior elements of compression on the spinal cord can be directly decompressed,and the spinal cord can be protected by fusion at the level of spinal cord damage. To date,good improvement in neurological symptoms has been reported (JOA score improvement rate of 49.4%-72.9%) - ),and it has been widely used as the treatment method for cervical degenerative disease. In the 1950s,Robinson,Smith et al. ),and Cloward et al. ) reported anterior cervical decompression and fusion (i.e.,ACDF),which involved extraction of the intervertebral disc and bone grafting by anterior approach. Thereafter,for more than 60 years,ACDF became the standard surgical treatment for the cervical spine,and it is considered suitable for patients with compression elements on the anterior side,patients with kyphosis,and patients with few affected intervertebral spaces ). Later,Boni and Denaro et al. reported subtotal resection (corpectomy) of the intervertebral disc and the vertebral body (leaving the lateral wall),with decompression and fusion,i.e.,ACCF ). This became a particularly effective method for patients with compressive lesions at the vertebral body level.
Meanwhile,extended corpectomies can cause problems in reconstruction,such as dislodgment of bone graft or plate ),and thus,in recent years,a hybrid method has been reported,wherein extended decompression and fusion are performed with corpectomy at the required level only,along with discectomy ). Anterior procedure has problems,such as bone graft subsidence,displacement,and adjacent intervertebral space damage. In recent years,there has been remarkable progress in anterior instrumentation,such as plates and cages. Artificial total disc replacement (TDR) was developed to prevent damage to adjacent segments that can easily occur after anterior cervical fusion,which had been conventionally widely performed,). By inserting an artificial intervertebral disc and maintaining mobility without fusing the intervertebral segment,TDR reduces the load on the adjacent intervertebral segment compared to fusion ),reducing recurrence and repeat surgery ).
The level of patient satisfaction in laminoplasty is high ),with a rate of improvement in neurological symptoms of approximately 55%-60% ). There are many reports comparing the spinous process-splitting double-door method and open-door laminoplasty. Some reports indicate that the outcomes of the two procedures are comparable - ). One meta-analysis found that the rate of spinal canal enlargement was greater with the open-door procedure than with the double-door method; however,it was reported that there is no persuasive evidence to demonstrate which procedure is superior ). A separate systematic review concluded that determining which procedure is better is difficult ). Compared with conventional laminectomy,skip laminectomy allowed more postoperative movement,lessening axial pain and improving the range of motion ). In recent years,fusion procedures have increased primarily among reports from overseas. Posterior decompression combined with fusion using posterior instrumentation along with laminoplasty and laminectomy might be more beneficial than using laminoplasty alone in restoring normal cervical lordosis ),stabilizing intervertebral mobility,and preventing postoperative kyphosis deformity ). However,compared with laminoplasty,it has been reported that the incidence of postoperative neurological complications is higher in laminectomy combined with fusion ). In fusion,C5 palsy occurs at a high incidence,the palsy is more serious,and it can develop as multiple cervical nerve root disorders,taking time to recover ).
CSM accompanied by athetoid cerebral palsy has characteristics of severe cervical spondylotic changes and kyphotic deformities due to involuntary movement. Thus,the treatment required differs from that of normal CSM ). The incidences of complications and revision surgeries are high. The rate of revision surgeries caused by a loosening of the screws is not low at 10%-30%. Therefore,several articles recommend surgery using botulinum injections and strong internal fixation. In patients with Parkinsons disease,the overall improvement in QOL was inferior,and the improvement in pain-related symptoms was significantly inferior ). Although there was little improvement in QOL,surgery is advantageous in improving the symptoms associated with pain ).
Several reports that examined the usefulness of predicting postoperative neurological deterioration in surgery for compressive cervical myelopathy,including CSM,could be found. Intraoperative muscle evoked potential (MEP) is a useful test in surgery for CSM. In the future,a checklist of responses when the MEP changes must be created,and responses must be standardized ). Only some reports examined the usefulness of intraoperative spinal cord monitoring for preventing postoperative exacerbation of neurological symptoms. To clarify the effectiveness of spinal cord monitoring for postoperative neurological deterioration prevention,a multicenter prospective study with standardized conditions is needed,such as the monitoring modality and alarm point.
# Recommendations
Conservative treatment
# Summary
Although the evidence is weak for patients with mild-to-moderate CSM,it is suggested that conservative treatment can prevent exacerbation of symptoms and delay progression. However,surgical treatment should be considered when conservative treatment is unsuccessful and symptoms progress.
# Commentary
For severe and progressive CSM,surgery is likely the first choice of treatment. However,there are few reports regarding the treatment choice for mild-to-moderate CSM. Thus,it is difficult to draw a definite conclusion. Previous reports describe traction therapy,brace-wearing,pharmacotherapy,and a combination of these.
# Cervical traction
Patients receiving conservative treatment showed a significant improvement in JOA scores after treatment,although the improvement was not as good as that with surgical treatment ).
# Brace therapy
A study investigates 52 patients with compressive myelopathy wearing a brace for at least 8 h per day for a mean of 3 months ). During the mean observation period of 3 years,patients with CSM showed a slight improvement in the mean JOA score; however,the positive outcome group with a score improvement of 1 point or more,or a score maintained at 15 points or more,accounted for 72%. Neurological symptoms were exacerbated in 10 out of the 52 patients (19%) receiving surgery at a later date.
# Pharmacotherapy
Anti-inflammatory analgesics,muscle relaxants,and steroids are used to treat CSM-related pain and spastic paralysis; however,no evidence exists regarding the effectiveness of the drugs for CSM-related palsy and numbness. Prostaglandin E1 is used for mild cases,and it has been reported to improve JOA and 10-second test scores and balance disturbance ). However,there was no control group set,and the level of evidence could not be stated to be high.
# Choice of surgical method: ADF,laminoplasty,or posterior decompression with fusion (PDF)
Summary
There is no clear recommendation regarding whether to perform ADF,laminoplasty,or PDF for CSM. There are certain merits and demerits associated with each method. Thus,selecting the surgical procedure according to each patient is important.
Commentary
We conducted a meta-analysis comparing ADF with laminoplasty without fusion ). The difference between the two groups was not observed in pre- to postoperative JOA scores. With regard to cervical alignment,the sagittal alignment following ADF was better than after laminoplasty. Regarding complications,the overall incidence was high in ADF,and the rate of revision surgery was also significantly high in ADF. In contrast,postoperative C5 palsy and cervical pain became common with laminoplasty.
In a meta-analysis comparing ADF with PDF ),the pre- and postoperative JOA scores showed no difference between ADF and PDF. In contrast,concerning cervical alignment,the preoperative angle became smaller in ADF,but the postoperative lordosis angle was significantly larger in ADF. Furthermore,the postoperative NDI results were better in ADF than in PDF. Regarding complications,the incidences were comparable between the two groups. The incidence of neurological complications,focusing on C5 palsy,was significantly higher in PDF than in ADF.
We also conducted a meta-analysis comparing laminoplasty and PDF ). Overall,there is no difference in the outcomes of both procedures. Some reports concluded that laminoplasty is superior primarily based on the low invasiveness,such as volume of blood loss and length of hospital stay,etc.,),and other reports concluded the usefulness of PDF based on maintaining correction and some surgical outcomes (in particular,axial pain),). There are merits and demerits in ach method. Thus,selecting the surgical procedure according to each patient is important.
# Future topics
Evaluation using intraoperative ultrasound
# Summary
In laminoplasty and ADF for CSM,several authors investigated the usefulness of intraoperative ultrasound to predict postoperative recovery of neurological symptoms; however,the evidence was poor,and it is difficult to find common evaluation indices with high reliability.
# Commentary
In laminoplasty,previous studies reported that floating of the ventral side of the spinal cord from the dura on intraoperative ultrasound evaluation was a factor in predicting the improvement in neurological symptoms,).
In ADF,it is reported that ultrasound evaluation can confirm that decompression is adequate following anterior decompression,and ultrasound is an extremely useful evaluation method ).
# Cervical collar
Summary
After laminoplasty and ADF for CSM,evidence was inconclusive as to whether wearing a cervical collar after surgery improves postoperative outcomes or not.
Commentary
Laminoplasty: There was only one report of clinical research examining the effects of wearing a cervical collar after laminoplasty for patients with CSM ). There was no difference at 1 year after surgery between patients with postoperative cervical collar and those without. It was concluded that wearing a cervical collar after surgery is ineffective.
ADF: A previous systematic review concluded that wearing a collar after cervical spine surgery is unlikely to benefit clinical symptoms and bone union ). However,these studies included relatively young patients. The age of onset of CSM in the subject of this guideline was greater than that of the patient group in these clinical studies. Therefore,a difference in background,such as bone fragility,could have resulted in the advantageous aspect seen in bone union from wearing a collar after surgery.
# Postoperative rehabilitation
Summary
Evidence is lacking concerning the effect of rehabilitation in improving clinical symptoms following surgical treatment for CSM.
Commentary
Many institutions perform rehabilitation following laminoplasty for CSM; however,the present systematic review found no clinical research broadly examining whether or not rehabilitation helps improving clinical symptoms.
While evidence demonstrating the effectiveness of postoperative rehabilitation in promoting patient recovery may be limited,our clinical experience in dealing with patients satisfied with their recovery strongly suggests that rehabilitation is effective.","department":"
