无症状严重颈椎病的减压手术
对于无明显神经症状或体征的患者,可考虑在其发生神经功能异常之前进行手术治疗,所依据的理念为,早期积极治疗可能预防神经系统并发症(但出现此类神经系统并发症的风险极低,即<0.1%)。[12]Rao RD, Gourab K, David KS. Operative treatment of cervical spondylotic myelopathy. J Bone Surg Am. 2006 Jul;88(7):1619-40.
http://www.ncbi.nlm.nih.gov/pubmed/16818991?tool=bestpractice.com
例如,有先前椎管狭窄的患者可能因甚至轻微外伤就会出现严重的脊髓型颈椎病。早期手术可能防止此类情况发生。相反,许多患者是无症状的。关于疾病的自然病史,没有研究提示哪一部分患者可能变得有症状,而所有手术有已知的即刻风险,而有些手术可能导致颈椎机械功能障碍。由于没有关于无症状患者随后自发发展为颈脊髓病的可能性的数据,因此目前的共识是,对于大多数无症状患者而言,手术风险通常大于发展为神经损伤的自发风险。
颈椎关节成形术
颈椎关节置换目前已得到美国 FDA 的批准,用于针对神经根型颈椎的颈椎前路手术。[8]Rao RD, Currier BL, Albert TJ, et al. Degenerative cervical spondylosis: clinical syndromes, pathogenesis and management. J Bone Joint Surg Am. 2007 Jun;89(6):1360-78.
http://www.ncbi.nlm.nih.gov/pubmed/17575617?tool=bestpractice.com
[20]Bono CM, Ghiselli G, Gilbert TJ, et al; North American Spine Society. An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders. Spine J. 2011 Jan;11(1):64-72.
http://www.ncbi.nlm.nih.gov/pubmed/21168100?tool=bestpractice.com
[43]Burkus JK, Haid RW, Traynelis VC, et al. Long-term clinical and radiographic outcomes of cervical disc replacement with the Prestige disc: results from a prospective randomized controlled clinical trial. J Neurosurg Spine. 2010 Sep;13(3):308-18.
http://thejns.org/doi/pdf/10.3171/2010.3.SPINE09513
http://www.ncbi.nlm.nih.gov/pubmed/20809722?tool=bestpractice.com
然而,与腰椎关节成形术和腰椎前路椎体间融合一致的是,这些器械在治疗由颈椎退行性变引起的轴向颈痛方面也可能有疗效。[44]Boselie TF, Willems PC, van Mameren H, et al. Arthroplasty versus fusion in single-level cervical degenerative disc disease: a Cochrane review. Spine (Phila Pa 1976). 2013 Aug 1;38(17):E1096-107.
http://www.ncbi.nlm.nih.gov/pubmed/23656959?tool=bestpractice.com
[48]Gao F, Mao T, Sun W, et al. An updated meta-analysis comparing artificial cervical disc arthroplasty (CDA) versus anterior cervical discectomy and fusion (ACDF) for the treatment of cervical degenerative disc disease (CDDD). Spine (Phila Pa 1976). 2015 Dec;40(23):1816-23.
http://www.ncbi.nlm.nih.gov/pubmed/26571063?tool=bestpractice.com
[53]Vaccaro A, Beutler W, Peppelman W, et al. Clinical outcomes with selectively constrained SECURE-C cervical disc arthroplasty: two-year results from a prospective, randomized, controlled, multicenter investigational device exemption study. Spine (Phila Pa 1976). 2013 Dec 15;38(26):2227-39.
http://www.ncbi.nlm.nih.gov/pubmed/24335629?tool=bestpractice.com
两项针对随机对照试验的为期 7 年的研究显示,在颈部失能结局方面,关节成形术显示出优越性,并且与颈椎前路椎间盘切除术和融合术相比,关节成形术减少了二次手术。[54]Janssen ME, Zigler JE, Spivak JM, et al. ProDisc-C total disc replacement versus anterior cervical discectomy and fusion for single-level symptomatic cervical disc disease: Seven-year follow-up of the prospective randomized U.S. Food and Drug Administration investigational device exemption study. J Bone Joint Surg Am. 2015 Nov 4;97(21):1738-47.
http://www.ncbi.nlm.nih.gov/pubmed/26537161?tool=bestpractice.com
[55]Radcliff K, Davis RJ, Hisey MS, et al. Long-term evaluation of cervical disc arthroplasty with the Mobi-C© cervical disc: A randomized, prospective, multicenter clinical trial with seven-year follow-up. Int J Spine Surg. 2017 Nov 28;11:31.
http://www.ncbi.nlm.nih.gov/pubmed/29372135?tool=bestpractice.com