頸椎減壓術(shù)后C5神經(jīng)根麻痹

·綜述·

頸椎減壓術(shù)后C5神經(jīng)根麻痹

李俊寬,黃穩(wěn)定,嚴(yán)望軍

作者單位:125000遼寧,海軍92493部隊(duì)醫(yī)院門診部(李俊寬)；上海,解放軍第411醫(yī)院骨科(黃穩(wěn)定)；第二軍醫(yī)大學(xué)長(zhǎng)征醫(yī)院骨科(嚴(yán)望軍)

通信作者:嚴(yán)望軍spinetumor@163.com

【關(guān)鍵詞】頸椎； 減壓術(shù),外科； 神經(jīng)根病； 綜述文獻(xiàn)

作者簡(jiǎn)介:李俊寬(1971—),本科,副主任醫(yī)師

【中圖分類號(hào)】R 681.531【文獻(xiàn)標(biāo)志碼】 A

DOI【】

收稿日期：(2014-11-28)

C5神經(jīng)根麻痹是頸椎術(shù)后較為常見(jiàn)的嚴(yán)重并發(fā)癥,嚴(yán)重影響患者生活質(zhì)量。其發(fā)生機(jī)制復(fù)雜,已成為脊柱外科領(lǐng)域關(guān)注的一項(xiàng)重要課題。目前該并發(fā)癥的特點(diǎn)及如何預(yù)防等方面取得了一定的成果[1-2]。本文對(duì)近年C5神經(jīng)根麻痹流行病學(xué)、病因?qū)W及如何預(yù)防該并發(fā)癥的發(fā)生等進(jìn)行了文獻(xiàn)回顧、分析。現(xiàn)綜述如下。

1C5神經(jīng)根麻痹臨床特點(diǎn)及發(fā)生率

頸前路及頸后路減壓術(shù)后均會(huì)導(dǎo)致C5神經(jīng)根麻痹,通常發(fā)生于術(shù)后24 h～2個(gè)月,大部分患者于術(shù)后1周內(nèi)出現(xiàn)癥狀,以單側(cè)癥狀最為常見(jiàn)?；颊咧饕憩F(xiàn)為三角肌和/或肱二頭肌麻痹、肌力減退,可同時(shí)伴有C5神經(jīng)支配區(qū)感覺(jué)障礙和/或頑固性疼痛[1-2]。

術(shù)后C5神經(jīng)根麻痹的發(fā)生率與手術(shù)方式、疾病類型有關(guān)。不同術(shù)式的發(fā)生率不同,頸前路減壓術(shù)后C5神經(jīng)根麻痹的發(fā)生率為0%～26.4%[1,3-6],平均為7.7%[1]。Liu等[7]報(bào)道多節(jié)段頸前路椎間盤切除融合術(shù)后的發(fā)生率為3.8%,混合式減壓(椎體次全切除并椎間盤切除植骨融合術(shù))術(shù)后的發(fā)生率為8.3%,雙節(jié)段椎體次全切術(shù)后的發(fā)生率為26.4%。Odate等[8]報(bào)道前路混合式減壓術(shù)后其發(fā)生率為 3.0%。

頸后路減壓術(shù)后C5神經(jīng)根麻痹的發(fā)生率為 0%～50.0%[9-14],平均為 7.8%[1]。其中頸椎椎板切除術(shù)后C5神經(jīng)根麻痹的發(fā)生率為2.4%～40.0%[1,14-15],椎板成形術(shù)后發(fā)生率為0%～50.0%[1,13]。Komagata等[11]報(bào)道單開(kāi)門椎板擴(kuò)大成形術(shù)后其發(fā)生率為4.0%。Katsumi等[12]報(bào)道單開(kāi)門椎板成形術(shù)同時(shí)行預(yù)防性C4/C5椎間孔切開(kāi)術(shù)后其發(fā)生率為 1.4%。Park等[13]報(bào)道單開(kāi)門椎板成形術(shù)后其發(fā)生率為8.9%,雙開(kāi)門術(shù)后其發(fā)生率為0%。頸椎前后聯(lián)合入路術(shù)后C5神經(jīng)根麻痹的研究報(bào)道較少。Nassr等[2]報(bào)道該術(shù)式減壓后其發(fā)生率為8.4%。

疾病類型也與術(shù)后C5神經(jīng)根麻痹的發(fā)生率有關(guān)[1]。Kim等[3]對(duì)頸椎退變性疾病前路減壓后C5神經(jīng)根麻痹的發(fā)生率進(jìn)行了對(duì)比,在神經(jīng)根型頸椎病、脊髓型頸椎病、混合型頸椎病及頸椎后縱韌帶骨化(ossification of posterior longitudinal ligament, OPLL)中其發(fā)生率分別為0、3.9%、16.7%、9.0%。Chen等[16]報(bào)道椎板切除融合術(shù)治療OPLL術(shù)后C5神經(jīng)根麻痹的發(fā)生率為18.0%。

2C5神經(jīng)根麻痹病因?qū)W及發(fā)生機(jī)制

迄今為止仍然沒(méi)有明確頸椎術(shù)后C5神經(jīng)根麻痹的發(fā)生機(jī)制,目前認(rèn)為是多種因素作用的結(jié)果,主要存在5種可能因素[1-2,5]：①頸椎椎管減壓后脊髓漂移牽拉神經(jīng)根；②節(jié)段性脊髓功能障礙；③術(shù)中神經(jīng)根損傷；④根動(dòng)脈血供減少引起脊髓缺血；⑤脊髓缺血再灌注損傷。

2.1脊髓漂移引起的神經(jīng)根栓系效應(yīng)

頸椎減壓術(shù)后脊髓向后漂移所導(dǎo)致的神經(jīng)根栓系繼發(fā)C5神經(jīng)根麻痹是目前公認(rèn)的假設(shè)理論。其解剖學(xué)基礎(chǔ)是[3,17-20]：①C5是頸椎生理曲度的頂點(diǎn),也是減壓區(qū)的中心點(diǎn),減壓后C5神經(jīng)根漂移的距離更大；②C5神經(jīng)根及其分支較其他神經(jīng)根短；③其他肌肉為雙重神經(jīng)支配,而三角肌僅有1支神經(jīng)根支配，更易受神經(jīng)根功能障礙的影響；④C4，5關(guān)節(jié)突增生退變或頸椎序列改變引起C4，5椎間孔狹窄。

Xia等[9]發(fā)現(xiàn)寬開(kāi)門組C5神經(jīng)根麻痹的發(fā)生率為 5.3%,窄開(kāi)門組的發(fā)生率則為 0%,其認(rèn)為窄開(kāi)門可以減少脊髓漂移的空間,降低C5神經(jīng)根麻痹的發(fā)生率。Zhang等[17]通過(guò)術(shù)前及術(shù)后 CT 影像對(duì)脊髓漂移的程度進(jìn)行了評(píng)估,椎板擴(kuò)大成形術(shù)后出現(xiàn)C5神經(jīng)根麻痹的患者脊髓向后漂移平均增加了4.11 mm,而沒(méi)有 C5神經(jīng)根麻痹的患者脊髓向后漂移平均增加了2.79 mm,兩者差異有統(tǒng)計(jì)學(xué)意義。Radcliff等[21]認(rèn)為椎板切除的寬度和脊髓漂移的程度是頸椎術(shù)后C5神經(jīng)根麻痹的危險(xiǎn)因素。Shiozaki等[22]通過(guò)MRI對(duì)椎板成形術(shù)后的脊髓狀態(tài)進(jìn)行了評(píng)估,與術(shù)后2周相比,術(shù)后24 h脊髓向后漂移程度明顯增加。Bydon等[23]研究發(fā)現(xiàn)C5神經(jīng)根麻痹組脊髓漂移程度及C4，5椎間孔狹窄程度均較非麻痹組大。Katsumi等[24]對(duì)椎板成形術(shù)后C5神經(jīng)根麻痹和非麻痹患者的影像資料進(jìn)行了分析,發(fā)現(xiàn)麻痹組椎間孔平均直徑為1.99 mm,非麻痹組平均為2.76 mm,兩者差異有統(tǒng)計(jì)學(xué)意義。Imagama等[25]發(fā)現(xiàn)C5神經(jīng)根麻痹患者C4，5椎間孔明顯狹窄、C5上關(guān)節(jié)突更大、C4，5脊髓漂移更加明顯。

頸椎減壓術(shù)后脊髓漂移引起的神經(jīng)根栓系效應(yīng)這一理論雖然被廣泛接受,但仍然無(wú)法合理解釋頸前路術(shù)后C5神經(jīng)根麻痹[26],因而該假說(shuō)還存在一定的局限性。

2.2脊髓病變導(dǎo)致功能障礙

研究[3-4，27-28]報(bào)道頸椎術(shù)后MRI T2像上出現(xiàn)脊髓高信號(hào)或高信號(hào)區(qū)域的異常擴(kuò)大,提示術(shù)后C5神經(jīng)根麻痹與脊髓灰質(zhì)病變存在一定的相關(guān)性[3-4,27-28]。Chiba等[27]認(rèn)為C5神經(jīng)根麻痹與MRI T2像脊髓中央灰質(zhì)的高信號(hào)區(qū)有關(guān),所有患者均出現(xiàn)上述影像學(xué)改變。Seichi等[28]對(duì)椎板成形術(shù)后MRI T2像脊髓高信號(hào)區(qū)域改變現(xiàn)象進(jìn)行了分析,發(fā)現(xiàn)上肢遠(yuǎn)端和彌散性麻痹與T2高信號(hào)區(qū)域擴(kuò)大有關(guān),認(rèn)為可能是脊髓功能障礙或病變所致。

然而,并不是所有具有該影像特點(diǎn)的患者都會(huì)出現(xiàn)C5神經(jīng)根麻痹。Chen等[16]對(duì)OPLL術(shù)前及術(shù)后脊髓狀態(tài)進(jìn)行了研究,發(fā)現(xiàn)術(shù)前MRI T2像C4，5水平脊髓高信號(hào)的患者術(shù)后并不都出現(xiàn)C5神經(jīng)根麻痹,而術(shù)后頸髓MRI T2像高信號(hào)也不是引起C5神經(jīng)根麻痹的因素。Katsumi等[24]認(rèn)為術(shù)前MRI T2像脊髓高信號(hào)改變與術(shù)后C5神經(jīng)根麻痹并無(wú)明顯相關(guān)性。脊髓高信號(hào)區(qū)域通常位于脊髓中央,而C5神經(jīng)根麻痹往往是單側(cè)表現(xiàn)。因此,節(jié)段性脊髓功能改變也不能合理解釋C5神經(jīng)根麻痹的發(fā)生機(jī)制。

2.3術(shù)中神經(jīng)根直接損傷

理論上講,術(shù)中神經(jīng)根直接損傷能夠解釋術(shù)中或術(shù)后即刻發(fā)生的C5神經(jīng)根麻痹。Uematsu等[29]發(fā)現(xiàn)術(shù)后即刻發(fā)生C5神經(jīng)根麻痹的患者多見(jiàn)于單開(kāi)門椎板成形術(shù)開(kāi)門一側(cè),提示可能是術(shù)中直接損傷神經(jīng)根所致。Fan等[30]報(bào)道術(shù)中電生理監(jiān)測(cè)發(fā)現(xiàn)醫(yī)源性神經(jīng)根損傷引起C5神經(jīng)根麻痹,同期行C4，5椎間孔減壓治療后恢復(fù)。

雖然術(shù)中神經(jīng)根直接損傷被視為C5神經(jīng)根麻痹的危險(xiǎn)因素,但是并不是所有C5神經(jīng)根麻痹的患者均在術(shù)后即刻發(fā)生,大多數(shù)發(fā)生于術(shù)后1 d至數(shù)周[1-2],因此該發(fā)生機(jī)制也很難給出合理的解釋。

2.4脊髓缺血及再灌注損傷

脊髓缺血及再灌注損傷是脊柱外科近年來(lái)的研究熱點(diǎn),越來(lái)越多的學(xué)者用該假說(shuō)解釋C5神經(jīng)麻痹的發(fā)生機(jī)制。脊髓再灌注損傷可導(dǎo)致脊髓神經(jīng)元細(xì)胞功能短暫或永久喪失。Hasegawa等[31]認(rèn)為脊髓長(zhǎng)期受壓可導(dǎo)致局部脊髓神經(jīng)元受損,這些神經(jīng)元在減壓后更易受到局部血運(yùn)異常的影響,并繼發(fā)缺血再灌注損傷。Chiba等[27]認(rèn)為脊髓白質(zhì)和灰質(zhì)血運(yùn)存在差異,灰質(zhì)區(qū)細(xì)胞、神經(jīng)連接及血運(yùn)更加豐富,這種差異會(huì)導(dǎo)致皮質(zhì)脊髓束和脊髓灰質(zhì)前角細(xì)胞更容易繼發(fā)缺血再灌注損傷。這也進(jìn)一步解釋了一些患者僅表現(xiàn)為C5支配區(qū)運(yùn)動(dòng)功能障礙而無(wú)感覺(jué)障礙這一臨床現(xiàn)象(感覺(jué)運(yùn)動(dòng)分離)。

3危險(xiǎn)因素

C5神經(jīng)根麻痹的危險(xiǎn)因素與其病因、發(fā)生機(jī)制密切相關(guān)。研究表明,C5神經(jīng)根麻痹的危險(xiǎn)因素主要包括：術(shù)前椎間孔狹窄[32]、術(shù)前C4，5水平脊髓高信號(hào)[28]、OPLL[16]、椎板成形并融合術(shù)[20,26]、減壓范圍過(guò)大[9,21]、不對(duì)稱減壓及高齡等[5,27]。 Gu等[32]回顧分析文獻(xiàn),認(rèn)為術(shù)前存在椎間孔狹窄、OPLL、脊髓過(guò)度漂移、后路椎板切除及男性患者是頸椎術(shù)后C5神經(jīng)根麻痹的危險(xiǎn)因素。Seichi等[28]認(rèn)為術(shù)前C3，4和/或C4，5水平脊髓高信號(hào)是C5神經(jīng)根麻痹的危險(xiǎn)因素。Radcliff等[21]發(fā)現(xiàn)頸后路椎板切除的寬度及脊髓漂移的程度與C5神經(jīng)根麻痹的發(fā)生率呈正相關(guān),因此認(rèn)為二者是頸椎術(shù)后C5神經(jīng)根麻痹的危險(xiǎn)因素。Yamanaka等[20]發(fā)現(xiàn)椎板成形術(shù)同期行融合術(shù)后C5神經(jīng)根麻痹的發(fā)生率高于非融合組,因此也認(rèn)為椎板成形術(shù)并內(nèi)固定是術(shù)后C5神經(jīng)根麻痹的危險(xiǎn)因素。Bydon等[5]研究發(fā)現(xiàn),頸前路椎體次全切的節(jié)段越多,術(shù)后C5神經(jīng)根麻痹的發(fā)生率越高,而且高齡也是危險(xiǎn)因素之一。

4防治措施及預(yù)后

4.1評(píng)估方法

應(yīng)用神經(jīng)電生理監(jiān)測(cè)早期發(fā)現(xiàn)C5神經(jīng)根麻痹能夠避免術(shù)后神經(jīng)功能損傷。目前已有多種術(shù)中神經(jīng)監(jiān)測(cè)方法應(yīng)用于臨床,如軀體感覺(jué)誘發(fā)電位(somatosensory-evoked potentials,SEPs)、經(jīng)顱電刺激運(yùn)動(dòng)誘發(fā)電位(transcranial electrical motor-evoked potentials,tceMEPs)和自發(fā)肌電圖(spontaneous electromyography,spEMG)。SEPs是脊髓后索神經(jīng)誘發(fā)的神經(jīng)沖動(dòng),直接評(píng)估脊髓感覺(jué)神經(jīng)纖維。tceMEPs是反映運(yùn)動(dòng)神經(jīng)纖維誘發(fā)的神經(jīng)沖動(dòng),用于評(píng)估運(yùn)動(dòng)神經(jīng)纖維。spEMG則常用于監(jiān)測(cè)某一特定神經(jīng)根的牽拉傷或微損傷。研究認(rèn)為,SEPs雖然特異性較高,但敏感性較低,tceMEPs的敏感性和特異性均較高,而spEMG對(duì)于明確特定的神經(jīng)根的損傷較為敏感；因此tceMEPs和spEMG在臨床上更為常用[30，33]。

影像學(xué)評(píng)估也有助于預(yù)防C5神經(jīng)根麻痹。Lubelski等[34]認(rèn)為C5神經(jīng)根麻痹與脊柱的特殊結(jié)構(gòu)有關(guān),通過(guò) MRI 及 CT 掃描分析 C4，5椎管正中矢狀徑、左右椎間孔徑以及脊髓-椎板角3種解剖參數(shù)能夠預(yù)測(cè)術(shù)后C5神經(jīng)根麻痹,有助于術(shù)者采取相應(yīng)的干預(yù)措施。

4.2手術(shù)治療

手術(shù)治療方法主要包括椎間孔減壓、硬脊膜切開(kāi)。由于硬脊膜切開(kāi)后并發(fā)癥較多,且臨床上支持該方法的資料少,因此不被臨床醫(yī)師廣泛接受。

預(yù)防性椎間孔減壓是防治術(shù)后 C5神經(jīng)根麻痹的重要方法[1,11-12,30,35]。Fan等[30]進(jìn)行的前瞻性隊(duì)列研究,對(duì)術(shù)中電生理監(jiān)測(cè)發(fā)現(xiàn)神經(jīng)異常放電現(xiàn)象的患者進(jìn)行C4，5椎間孔擴(kuò)大減壓,術(shù)后C5神經(jīng)根麻痹癥狀消失。Komagata等[11]研究發(fā)現(xiàn)雙側(cè)椎間孔切開(kāi)術(shù)的患者C5神經(jīng)根麻痹的發(fā)生率明顯低于未切開(kāi)手術(shù)者(0.6%vs. 4.0%)。Katsumi等[12]通過(guò)前瞻性研究發(fā)現(xiàn),頸后路單開(kāi)門椎板成形術(shù)同時(shí)行C4，5椎間孔減壓的患者術(shù)后C5神經(jīng)根麻痹的發(fā)生率為1.4%,而未行椎間孔減壓的患者術(shù)后C5神經(jīng)根麻痹的發(fā)生率為6.4%,提示預(yù)防性C4，5椎間孔減壓可降低C5神經(jīng)根麻痹的發(fā)生率。

根據(jù)C5神經(jīng)根麻痹的危險(xiǎn)因素調(diào)整手術(shù)方案也是避免其發(fā)生的有效方法。Odate等[26]認(rèn)為減壓寬度過(guò)大及不對(duì)稱減壓是術(shù)后C5神經(jīng)根麻痹的危險(xiǎn)因素,其建議在前路手術(shù)時(shí)將開(kāi)槽寬度限制在15 mm以內(nèi)、避免不對(duì)稱減壓。Xia等[9]研究發(fā)現(xiàn),當(dāng)開(kāi)槽位置在側(cè)塊內(nèi)側(cè)緣時(shí),C5神經(jīng)根麻痹的發(fā)生率為 5.3%,而當(dāng)開(kāi)槽位置在椎板外1/3時(shí),其發(fā)生率則為 0%,因此其建議椎板成形術(shù)時(shí)采用窄開(kāi)門的方法。

4.3非手術(shù)治療

術(shù)前擺體位時(shí)使患者頸椎處于中立位、避免頸椎過(guò)伸或過(guò)屈、雙上肢避免過(guò)度向下?tīng)坷瓤梢灶A(yù)防C5神經(jīng)根麻痹。Chen等[16]認(rèn)為采用高壓氧結(jié)合理療的方式是有益的,所有患者在1年內(nèi)均完全康復(fù)。Hasegawa等[31]提出應(yīng)用自由基清除劑和/或地西泮預(yù)防缺血再灌注損傷,從而防止C5神經(jīng)根麻痹的發(fā)生。Takenaka等[36]認(rèn)為在開(kāi)槽時(shí)使用冰鹽水有助于降低術(shù)后C5神經(jīng)根麻痹的發(fā)生。其他治療方式包括應(yīng)用非甾體類抗炎藥物、糖皮質(zhì)激素以及頸托保護(hù)等。

4.4預(yù)后

C5神經(jīng)根麻痹的總體預(yù)后比較好,通?；謴?fù)期為4～5個(gè)月,絕大多數(shù)患者在術(shù)后 2 年內(nèi)恢復(fù),但肌力<2級(jí)的患者可能恢復(fù)較為困難[1-5]。Hashimoto等[4]對(duì)17例頸椎術(shù)后C5神經(jīng)根麻痹的患者進(jìn)行了隨訪,發(fā)現(xiàn)肌力>3級(jí)者(7例)隨訪期內(nèi)完全恢復(fù),而肌力在<2級(jí)者(10例)恢復(fù)較差,甚至不能恢復(fù)(2例)。

5總結(jié)

頸椎術(shù)后C5神經(jīng)根麻痹是脊柱外科醫(yī)師處理頸椎疾患時(shí)所面臨的一個(gè)難題。雖然C5神經(jīng)根麻痹的發(fā)生是多因素的,但是減壓術(shù)后硬膜囊向后漂移對(duì)神經(jīng)根的牽拉是目前最流行的假設(shè)理論。應(yīng)用神經(jīng)電生理監(jiān)測(cè)有助于早期發(fā)現(xiàn)和避免C5神經(jīng)根麻痹,手術(shù)技術(shù)的進(jìn)步有助于外科醫(yī)師避免該類并發(fā)癥的發(fā)生。在對(duì)頸椎退變性疾病進(jìn)行手術(shù)時(shí),除了術(shù)前的充分評(píng)估及術(shù)中監(jiān)測(cè)之外,脊柱外科醫(yī)師必須在有效減壓和可能帶來(lái)的并發(fā)癥之間尋找到一個(gè)平衡點(diǎn),這樣才能有效防止術(shù)后發(fā)生C5神經(jīng)根麻痹。

參 考 文 獻(xiàn)

[1] Guzman JZ, Baird EO, Fields AC, et al. C5 nerve root palsy following decompression of the cervical spine：a systematic evaluation of the literature[J].Bone Joint J, 2014, 96-B(7)：950-955.

[2] Nassr A, Eck JC, Ponnappan RK, et al.The incidence of C5 palsy after multilevel cervical decompression procedures：a review of 750 consecutive cases[J].Spine (Phila Pa 1976), 2012, 37(3)：174-178.

[3] Kim S, Lee SH, Kim ES, et al.Clinical and radiographic analysis of c5 palsy after anterior cervical decompression and fusion for cervical degenerative disease[J].J Spinal Disord Tech, 2014, 27(8)：436-441.

[4] Hashimoto M, Mochizuki M, Aiba A, et al. C5 palsy following anterior decompression and spinal fusion for cervical degenerative diseases[J].Eur Spine J, 2010, 19(10)：1702-1710.

[5] Bydon M, Macki M, Kaloostian P, et al.Incidence and prognostic factors of c5 palsy：a clinical study of 1001 cases and review of the literature[J].Neurosurgery, 2014, 74(6)：595-604.

[6] Eskander MS, Balsis SM, Balinger C, et al.The association between preoperative spinal cord rotation and postoperative C5 nerve palsy[J].J Bone Joint Surg Am, 2012, 94(17)：1605-1609.

[7] Liu Y, Qi M, Chen H, et al.Comparative analysis of complications of different reconstructive techniques following anterior decompression for multilevel cervical spondylotic myelopathy[J].Eur Spine J, 2012, 21(12)：2428-2435.

[8] Odate S, Shikata J, Kimura H, et al. Hybrid Decompression and Fixation Technique Versus Plated Three-Vertebra Corpectomy for Four-Segment Cervical Myelopathy：Analysis of 81 Cases With a Minimum 2-Year Follow-Up[J].J Spinal Disord Tech, 2013 [Epub ahead of print].

[9] Xia Y, Xia Y, Shen Q, et al.Influence of hinge position on the effectiveness of expansive open-door laminoplasty for cervical spondylotic myelopathy[J].J Spinal Disord Tech, 2011, 24(8)：514-520. JZ, Baird EO, Fields AC, et al. C5 nerve root palsy following decompression of the cervical spine：a systematic evaluation of the literature[J].Bone Joint J, 2014, 96-B(7)：950-955.

[2] Nassr A, Eck JC, Ponnappan RK, et al.The incidence of C5 palsy after multilevel cervical decompression procedures：a review of 750 consecutive cases[J].Spine (Phila Pa 1976), 2012, 37(3)：174-178.

[3] Kim S, Lee SH, Kim ES, et al.Clinical and radiographic analysis of c5 palsy after anterior cervical decompression and fusion for cervical degenerative disease[J].J Spinal Disord Tech, 2014, 27(8)：436-441.

[4] Hashimoto M, Mochizuki M, Aiba A, et al. C5 palsy following anterior decompression and spinal fusion for cervical degenerative diseases[J].Eur Spine J, 2010, 19(10)：1702-1710.

[5] Bydon M, Macki M, Kaloostian P, et al.Incidence and prognostic factors of c5 palsy：a clinical study of 1001 cases and review of the literature[J].Neurosurgery, 2014, 74(6)：595-604.

[6] Eskander MS, Balsis SM, Balinger C, et al.The association between preoperative spinal cord rotation and postoperative C5 nerve palsy[J].J Bone Joint Surg Am, 2012, 94(17)：1605-1609.

[7] Liu Y, Qi M, Chen H, et al.Comparative analysis of complications of different reconstructive techniques following anterior decompression for multilevel cervical spondylotic myelopathy[J].Eur Spine J, 2012, 21(12)：2428-2435.

[8] Odate S, Shikata J, Kimura H, et al. Hybrid Decompression and Fixation Technique Versus Plated Three-Vertebra Corpectomy for Four-Segment Cervical Myelopathy：Analysis of 81 Cases With a Minimum 2-Year Follow-Up[J].J Spinal Disord Tech, 2013 [Epub ahead of print].

[9] Xia Y, Xia Y, Shen Q, et al.Influence of hinge position on the effectiveness of expansive open-door laminoplasty for cervical spondylotic myelopathy[J].J Spinal Disord Tech, 2011, 24(8)：514-520.

[10]Liu K, Shi J, Jia L, et al. Surgical technique：Hemilaminectomy and unilateral lateral mass fixation for cervical ossification of the posterior longitudinal ligament[J].Clin Orthop Relat Res, 2013, 471(7)：2219-2224.

[11]Komagata M, Nishiyama M, Endo K, et al. Prophylaxis of C5 palsy after cervical expansive laminoplasty by bilateral partial foraminotomy[J].Spine J, 2004, 4(6)：650-655.

[12]Katsumi K, Yamazaki A, Watanabe K, et al. Can prophylactic bilateral C4/C5 foraminotomy prevent postoperative C5 palsy after open-door laminoplasty?：a prospective study[J].Spine (Phila Pa 1976), 2012, 37(9)：748-754.

[13]Park JH, Roh SW, Rhim SC, et al. Long-term outcomes of 2 cervical laminoplasty methods：midline splitting versus unilateral single door[J].J Spinal Disord Tech, 2012, 25(8)：E224-229.

[14]Chen Y, Chen DY, Wang XW, et al. Single-stage combined decompression for patients with tandem ossification in the cervical and thoracic spine[J].Arch Orthop Trauma Surg, 2012, 132(9)：1219-1226.

[15]Zhao X, Xue Y, Pan F, et al. Extensive laminectomy for the treatment of ossification of the posterior longitudinal ligament in the cervical spine[J].Arch Orthop Trauma Surg, 2012, 132(2)：203-209.

[16]Chen Y, Chen D, Wang X, et al. C5 palsy after laminectomy and posterior cervical fixation for ossification of posterior longitudinal ligament[J].J Spinal Disord Tech, 2007, 20(7)：533-535.

[17]Zhang H, Lu S, Sun T, et al. Effect of Lamina Open Angles in Expansion Open-door Laminoplasty on the Clinical Results in Treating Cervical Spondylotic Myelopathy[J].J Spinal Disord Tech, 2015, 28(3)：89-94.

[18]Currier BL. Neurological complications of cervical spine surgery：C5 palsy and intraoperative monitoring[J].Spine (Phila Pa 1976), 2012, 37(5)：E328-334.

[19]Wu FL, Sun Y, Pan SF, et al.Risk factors associated with upper extremity palsy after expansive open-door laminoplasty for cervical myelopathy[J].Spine J, 2014, 14(6)：909-915.

[20]Yamanaka K, Tachibana T, Moriyama T, et al. C-5 palsy after cervical laminoplasty with instrumented posterior fusion[J].J Neurosurg Spine, 2014, 20(1)：1-4.

[21]Radcliff KE, Limthongkul W, Kepler CK, et al.Cervical laminectomy width and spinal cord drift are risk factors for postoperative C5 palsy[J].J Spinal Disord Tech, 2014, 27(2)：86-92.

[22]Shiozaki T, Otsuka H, Nakata Y, et al.Spinal cord shift on magnetic resonance imaging at 24 hours after cervical laminoplasty[J].Spine (Phila Pa 1976), 2009, 34(3)：274-279.

[23]Bydon M, Macki M, Aygun N, et al.Development of postoperative C5 palsy is associated with wider posterior decompressions：an analysis of 41 patients[J].Spine J, 2014, 14(12)：2861-2867.

[24]Katsumi K, Yamazaki A, Watanabe K, et al. Analysis of C5 palsy after cervical open-door laminoplasty：relationship between C5 palsy and foraminal stenosis[J].J Spinal Disord Tech, 2013, 26(4)：177-182.

[25]Imagama S, Matsuyama Y, Yukawa Y, et al. C5 palsy after cervical laminoplasty：a multicentre study[J].J Bone Joint Surg Br, 2010, 92(3)：393-400.

[26]Odate S, Shikata J, Yamamura S, et al.Extremely wide and asymmetric anterior decompression causes postoperative C5 palsy：an analysis of 32 patients with postoperative C5 palsy after anterior cervical decompression and fusion[J].Spine (Phila Pa 1976), 2013, 38(25)：2184-2189.

[27]Chiba K, Toyama Y, Matsumoto M, et al. Segmental motor paralysis after expansive open-door laminoplasty[J].Spine (Phila Pa 1976), 2002, 27(19)：2108-2115.

[28]Seichi A, Takeshita K, Kawaguchi H, et al. Postoperative expansion of intramedullary high-intensity areas on T2-weighted magnetic resonance imaging after cervical laminoplasty[J]. Spine (Phila Pa 1976), 2004, 29(13)：1478-1482.

[29]Uematsu Y, Tokuhashi Y, Matsuzaki H. Radiculopathy after laminoplasty of the cervical spine[J]. Spine (Phila Pa 1976), 1998, 23(19)：2057-2062.

[30]Fan D, Schwartz DM, Vaccaro AR, et al. Intraoperative neurophysiologic detection of iatrogenic C5 nerve root injury during laminectomy for cervical compression myelopathy[J].Spine (Phila Pa 1976), 2002, 27(22)：2499-2502.

[31]Hasegawa K, Homma T, Chiba Y. Upper extremity palsy following cervical decompression surgery results from a transient spinal cord lesion[J].Spine (Phila Pa 1976), 2007, 32(6)：E197-202.

[32]Gu Y, Cao P, Gao R, et al. Incidence and risk factors of C5 palsy following posterior cervical decompression：a systematic review[J].PLoS One, 2014, 9(8)：e101933.

[33]Nakamae T, Tanaka N, Nakanishi K, et al. Investigation of segmental motor paralysis after cervical laminoplasty using intraoperative spinal cord monitoring with transcranial electric motor-evoked potentials[J].J Spinal Disord Tech, 2012, 25(2)：92-98.

[34]Lubelski D, Derakhshan A, Nowacki AS, et al. Predicting C5 palsy via the use of preoperative anatomic measurements[J]. Spine J, 2014, 14(9)：1895-1901.

[35]Ohashi M, Yamazaki A, Watanabe K, et al. Two-year clinical and radiological outcomes of open-door cervical laminoplasty with prophylactic bilateral C4-C5 foraminotomy in a prospective study[J]. Spine (Phila Pa 1976), 2014, 39(9)：721-727.

[36]Takenaka S, Hosono N, Mukai Y, et al.The use of cooled saline during bone drilling to reduce the incidence of upper-limb palsy after cervical laminoplasty：clinical article[J].J Neurosurg Spine, 2013, 19(4)：420-427. K, Shi J, Jia L, et al. Surgical technique：Hemilaminectomy and unilateral lateral mass fixation for cervical ossification of the posterior longitudinal ligament[J].Clin Orthop Relat Res, 2013, 471(7)：2219-2224.

[11]Komagata M, Nishiyama M, Endo K, et al. Prophylaxis of C5 palsy after cervical expansive laminoplasty by bilateral partial foraminotomy[J].Spine J, 2004, 4(6)：650-655.

[12]Katsumi K, Yamazaki A, Watanabe K, et al. Can prophylactic bilateral C4/C5 foraminotomy prevent postoperative C5 palsy after open-door laminoplasty?：a prospective study[J].Spine (Phila Pa 1976), 2012, 37(9)：748-754.

[13]Park JH, Roh SW, Rhim SC, et al. Long-term outcomes of 2 cervical laminoplasty methods：midline splitting versus unilateral single door[J].J Spinal Disord Tech, 2012, 25(8)：E224-229.

[14]Chen Y, Chen DY, Wang XW, et al. Single-stage combined decompression for patients with tandem ossification in the cervical and thoracic spine[J].Arch Orthop Trauma Surg, 2012, 132(9)：1219-1226.

[15]Zhao X, Xue Y, Pan F, et al. Extensive laminectomy for the treatment of ossification of the posterior longitudinal ligament in the cervical spine[J].Arch Orthop Trauma Surg, 2012, 132(2)：203-209.

[16]Chen Y, Chen D, Wang X, et al. C5 palsy after laminectomy and posterior cervical fixation for ossification of posterior longitudinal ligament[J].J Spinal Disord Tech, 2007, 20(7)：533-535.

[17]Zhang H, Lu S, Sun T, et al. Effect of Lamina Open Angles in Expansion Open-door Laminoplasty on the Clinical Results in Treating Cervical Spondylotic Myelopathy[J].J Spinal Disord Tech, 2015, 28(3)：89-94.

[18]Currier BL. Neurological complications of cervical spine surgery：C5 palsy and intraoperative monitoring[J].Spine (Phila Pa 1976), 2012, 37(5)：E328-334.

[19]Wu FL, Sun Y, Pan SF, et al.Risk factors associated with upper extremity palsy after expansive open-door laminoplasty for cervical myelopathy[J].Spine J, 2014, 14(6)：909-915.

[20]Yamanaka K, Tachibana T, Moriyama T, et al. C-5 palsy after cervical laminoplasty with instrumented posterior fusion[J].J Neurosurg Spine, 2014, 20(1)：1-4.

[21]Radcliff KE, Limthongkul W, Kepler CK, et al.Cervical laminectomy width and spinal cord drift are risk factors for postoperative C5 palsy[J].J Spinal Disord Tech, 2014, 27(2)：86-92.

[22]Shiozaki T, Otsuka H, Nakata Y, et al.Spinal cord shift on magnetic resonance imaging at 24 hours after cervical laminoplasty[J].Spine (Phila Pa 1976), 2009, 34(3)：274-279.

[23]Bydon M, Macki M, Aygun N, et al.Development of postoperative C5 palsy is associated with wider posterior decompressions：an analysis of 41 patients[J].Spine J, 2014, 14(12)：2861-2867.

[24]Katsumi K, Yamazaki A, Watanabe K, et al. Analysis of C5 palsy after cervical open-door laminoplasty：relationship between C5 palsy and foraminal stenosis[J].J Spinal Disord Tech, 2013, 26(4)：177-182.

[25]Imagama S, Matsuyama Y, Yukawa Y, et al. C5 palsy after cervical laminoplasty：a multicentre study[J].J Bone Joint Surg Br, 2010, 92(3)：393-400.

[26]Odate S, Shikata J, Yamamura S, et al.Extremely wide and asymmetric anterior decompression causes postoperative C5 palsy：an analysis of 32 patients with postoperative C5 palsy after anterior cervical decompression and fusion[J].Spine (Phila Pa 1976), 2013, 38(25)：2184-2189.

[27]Chiba K, Toyama Y, Matsumoto M, et al. Segmental motor paralysis after expansive open-door laminoplasty[J].Spine (Phila Pa 1976), 2002, 27(19)：2108-2115.

[28]Seichi A, Takeshita K, Kawaguchi H, et al. Postoperative expansion of intramedullary high-intensity areas on T2-weighted magnetic resonance imaging after cervical laminoplasty[J]. Spine (Phila Pa 1976), 2004, 29(13)：1478-1482.

[29]Uematsu Y, Tokuhashi Y, Matsuzaki H. Radiculopathy after laminoplasty of the cervical spine[J]. Spine (Phila Pa 1976), 1998, 23(19)：2057-2062.

[30]Fan D, Schwartz DM, Vaccaro AR, et al. Intraoperative neurophysiologic detection of iatrogenic C5 nerve root injury during laminectomy for cervical compression myelopathy[J].Spine (Phila Pa 1976), 2002, 27(22)：2499-2502.

[31]Hasegawa K, Homma T, Chiba Y. Upper extremity palsy following cervical decompression surgery results from a transient spinal cord lesion[J].Spine (Phila Pa 1976), 2007, 32(6)：E197-202.

[32]Gu Y, Cao P, Gao R, et al. Incidence and risk factors of C5 palsy following posterior cervical decompression：a systematic review[J].PLoS One, 2014, 9(8)：e101933.

[33]Nakamae T, Tanaka N, Nakanishi K, et al. Investigation of segmental motor paralysis after cervical laminoplasty using intraoperative spinal cord monitoring with transcranial electric motor-evoked potentials[J].J Spinal Disord Tech, 2012, 25(2)：92-98.

[34]Lubelski D, Derakhshan A, Nowacki AS, et al. Predicting C5 palsy via the use of preoperative anatomic measurements[J]. Spine J, 2014, 14(9)：1895-1901.

[35]Ohashi M, Yamazaki A, Watanabe K, et al. Two-year clinical and radiological outcomes of open-door cervical laminoplasty with prophylactic bilateral C4-C5 foraminotomy in a prospective study[J]. Spine (Phila Pa 1976), 2014, 39(9)：721-727.

[36]Takenaka S, Hosono N, Mukai Y, et al.The use of cooled saline during bone drilling to reduce the incidence of upper-limb palsy after cervical laminoplasty：clinical article[J].J Neurosurg Spine, 2013, 19(4)：420-427.

(本文編輯張建芬)