How to treat cervical spondylotic myelopathy with spinal stenosis?

Mild cases can be treated with physical therapy, immobilization and symptomatic treatment. The symptoms of most patients are often relieved by non-surgical treatment. Patients with rapid development and severe symptoms of spinal cord injury should be treated by surgery as soon as possible. According to the different surgical approaches, the surgical methods can be divided into anterior surgery, anterolateral surgery and posterior surgery. The choice of surgical approach should make full use of modern imaging techniques such as CT and MRI on the basis of clinic. It is a principle to determine the location of spinal stenosis and cervical spinal cord compression before operation, where to compress and where to decompress, and to decompress the compressed segments in a targeted manner. Under normal circumstances, those who have pressure on the anterior and posterior sides of the spinal canal should undergo anterior surgery, which can effectively remove the direct or main pressure-causing substances in front of the spinal cord, and bone grafting and fusion can stabilize the cervical spine and achieve therapeutic effects. If it is ineffective or the symptoms are not obviously improved, posterior decompression surgery will be performed after 3 ~ 6 months. Anterior approach and posterior approach have their own indications and cannot replace each other, so they should be chosen reasonably. 1. Non-surgical treatment of cervical spinal stenosis The treatment of mild cervical spinal stenosis can adopt physical therapy, immobilization and symptomatic treatment. Most patients with cervical spinal stenosis can often relieve their symptoms through non-surgical treatment. Generally speaking, the self-made Chinese patent medicine Zhenggu Shenjin Capsule is taken orally to relax muscles and promote blood circulation, dredge collaterals and relieve pain, combined with sodium aescinate, Mailuoning and energy mixture intravenous drip, external treatment with occipital and maxillofacial traction, and oral administration of western medicine 654-2, nimodipine, aspirin and vitamin E as appropriate, which can quickly relieve the condition of patients with cervical spinal stenosis. 2. Surgical treatment of cervical spinal stenosis Because patients with this type of cervical spinal stenosis are prone to fall, sometimes minor neck trauma can lead to irreparable neurological damage. Patients with rapid development of spinal cord injury and severe symptoms should be operated as soon as possible, and anterior surgery, anterolateral surgery and posterior surgery can be used. The choice of surgical approach should make full use of modern imaging techniques such as CT and MRI on the basis of clinic.

Anterior surgery

Anterior decompression can be divided into two types: one is to remove the protruding intervertebral disc and completely scrape the nucleus pulposus and fibrous ring protruding into the spinal canal; The other is to remove the hard protrusion and decompress, take out the intervertebral disc protruding into the spinal canal or root canal together with the osteophyte, or open a bone groove in the vertebral body and bone grafting at the same time.

Posterior operation

Total laminectomy and spinal cord decompression can be divided into localized laminectomy and extensive laminectomy and decompression. 1. Local laminectomy and decompression of spinal canal: generally, laminectomy does not exceed spinous process suspension.

[3] Three dentate ligaments were cut off during the operation. When the spinal cord is obviously compressed, the dura mater can form a smooth and relaxed spinal cord capsule without suture. 2. Extensive laminectomy and decompression: It is suitable for patients with developmental or secondary cervical spinal stenosis. The sagittal diameter of cervical spinal canal is less than 10mm, or the osteophyte at the posterior edge of vertebral body is more than 3mm between 10mm ~ 12mm, or myelography shows obvious impression behind the cervical spinal cord, with a large range. Generally, 5 laminae of neck 3 ~ 7 are removed, and the removal range can be expanded if necessary. If the articular process hyperplasia obviously compresses the nerve root, the articular process should be partially removed. This operation can directly relieve the compression of the posterior wall of spinal canal, and the backward movement of cervical spinal cord after decompression can indirectly relieve the compression of the anterior part of cervical spinal cord. However, due to the extensive formation and contraction of postoperative scars, the early postoperative functional recovery is satisfactory, but the symptoms can often be aggravated in the long term, and the cervical spine is unstable or even lordosis or kyphosis due to extensive resection of the posterior structure of the cervical spine. Unilateral laminectomy and decompression of spinal cord The purpose of this operation is not only to relieve the compression of cervical spinal cord and enlarge the spinal canal, but also to retain most of the stable structures at the back of cervical spine. Key points of operation: the range of laminectomy is from the base of spinous process to the base of lateral articular process to preserve articular process. The length of longitudinal resection was 2 ~ 7 necks. This operation can ensure the static and dynamic stability of cervical spine after operation. Effectively and permanently maintain the enlarged spinal canal volume. CT examination confirmed that the dural sac moved backward from the posterior edge of vertebral body after operation and separated from the anterior spinal canal pressurizer. The scar formed after operation is only 1/4 of the circumference of the new spinal canal. Posterior laminoplasty In view of the many disadvantages of total laminectomy to prognosis, scholars all over the world have carried out various laminoplasties. Because of the high incidence of ossification of the posterior longitudinal ligament in Japan, the adult X-ray survey is 1.5% ~ 2%, so Japanese scholars have done a lot of work in this field. 1980, Yamazaki proposed an improved laminectomy called double-door laminoplasty. On this basis, Miyazaki proposed a double-door laminectomy and lateral posterior bone grafting in 1984. The experimental study shows that the sagittal diameter of spinal canal increases and becomes oval after opening the door, and the scar tissue adheres less to the dura mater and does not compress the spinal cord. Because the lamina is preserved, bone transplantation and fusion can be carried out to increase the stability of the spinal canal. 1. One-door method: turn the lamina to one side and suspend it at the tip of the inferior spinous process, which is called "one-door method". The direction of opening the door depends on the symptoms. Usually, an incision is made in the middle of the back of the neck to expose 3-7 cervical vertebrae, cut off two spinous processes, drill a hole at the root of each spinous process, and make a longitudinal bone groove with a grinding drill (or pointed duckbill pliers) at the lamina of the inner edge of the facet joint at the hinge side, leaving a bone with a thickness of about 2mm at the bottom. Bite open the lamina at the corresponding position of the opposite lamina, open the door to the hinge side for about 10mm, fix each spinous process on the muscle and joint capsule at the hinge side with silk thread suspension suture, and cover the bone window with fat sheet. 2. Double-door method: remove the spinous process of cervical vertebra to be decompressed, and then cut off the lamina from the middle. At the inner edge of the two joints, the outer cortex was removed by grinding drill or pointed duckbill pliers as the osteogenic groove, and the thickness of the bone at the bottom was about 2mm, and the inner plates of the laminae were retained on both sides to make them loose-leaf on both sides. Split the middle of spinous process to open to both sides, enlarge the spinal canal, and fix the bitten spinous process or iliac bone in the middle of both sides with steel wire. The exposure method of spinous process suspension is the same as before First, bite off part of spinous process to make the spinous mutation short, and do bilateral full-thickness laminotomy at the inner edge of facet joint to remove the lowest supraspinous and interspinous ligaments, as well as the ligamentum flavum. A bone groove is formed on the adjacent spinous process near the lowest end. Suture the bottommost spinous process with the bone groove on the adjacent spinous process with steel wire or silk thread to fuse the bones, and put fat on both sides.

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