Spine：颈椎前路减压融合术（ACDF）是否应常规切除后纵韧带？

    通常而言，颈椎前路椎间盘切除融合术（ACDF）治疗颈椎间盘突出症具有较好的手术效果，只有少量患者出现疾病的复发。因此有学者建议在颈椎前路手术过程中切除后纵韧带，以减少后期后纵韧带对脊髓压迫的可能性，达到彻底的减压，同时可从一定程度上缓解交感神经症状，如颈椎性头晕。但也有学者对此持反对意见，认为手术保留后纵韧带可以从一定程度上保留临近颈椎节段的生物力学稳定性，同时在放置椎间融合器时可以起保护作用。是否需要切除纵说纷纭，焦点主要集中在后纵韧带后期是否会产生脊髓压迫症状。

    近期有美国学者对颈椎椎间融合术后再次出现神经根症状的患者进行了MRI影像学研究，研究发现颈椎间盘突出患者行ACDF治疗后再次出现神经症状和后纵韧带无显著相关性，相关结论发表在近期出版的spine杂志上。

    研究共纳入33例因颈椎病进行颈椎前路减压融合术的患者（女性66%，平均年龄51.6岁），这些患者术后存在持续或反复发作的颈椎症状，术后进行MRI检查以明确原因，平均术后MRI检查时间点为7月（0.3月-53月）。术后患者存在颈椎后纵韧带骨化或椎间盘突出的患者除外。33例患者中，12例多节段椎体次全切除术，19例前路减压融合术，1例节段椎体切除术，1例颈椎假关节切除融合术，所有患者均保存后纵韧带。颈椎后纵韧带脊髓压迫定义为：2位独立观察者确认颈椎后纵韧带接触或者损伤脊髓。

研究结果提示：所有患者中未发现颈椎残余疼痛症状和脊髓压迫相关（p<0.05），2个独立研究者评估的组间一致性较高。4例患者进行了再次翻修手术（2例C3-C4翻修，1例C6-C7翻修，1例行C4-C5-C6后进行C6-C7翻修），但和后纵韧带的压迫无关。

    研究者分析：颈椎后纵韧带作为颈椎稳定装置的一部分，保留后纵韧带的完整性有较多好处，如作为拉伸装置预防颈椎过度屈曲，作为屏障阻止椎间盘向后突出等。研究者认为，对颈椎后纵韧带无明显病变的患者，保留后纵韧带并不会在后期对颈椎产生压迫等，建议手术医生在手术过程中尽可能完整的保留正常的后纵韧带。但作者同时提醒在应用MRI进行影像学评估时需要注意由此而产生的假阴性结果，需特别警惕在后纵韧带后方突出的的组织造成的脊髓压迫有可能在MRI上没有清楚显示。

与ACDF相关的拓展阅读：

• 颈椎病治疗中 Hybird手术并不优于ACDF
更多信息请点击：有关ACDF更多资讯

Postoperative magnetic resonance imaging assessment for potential compressive effects of retained posterior longitudinal ligament after anterior cervical fusions: a cross-sectional study.
STUDY DESIGN
A cross-sectional study.
OBJECTIVE
To assess using postoperative magnetic resonance imaging whether the posterior longitudinal ligament (PLL) caused residual cord compression after anterior cervical decompression and fusion (ACDF) in a series of patients in whom the PLL was retained.
SUMMARY OF BACKGROUND DATA
There is a lack of data evaluating the postoperative compressive effects of the PLL in patients undergoing ACDF providing guidance as to whether to remove or retain the PLL during discectomy to facilitate adequate decompression.
METHODS
Postoperative gadolinium enhanced magnetic resonance images were reviewed in a series of 33 patients who underwent ACDF for cervical radiculomyelopathy and who had persistent or recurrent postoperative symptoms. Patients with ossification of the posterior longitudinal ligament or with a herniated disc behind the PLL were excluded from this study.
RESULTS
There were no cases of discernible compression by the retained PLL identified on the magnetic resonance image (P < 0.001) as assessed by 2 independent reviewers. Four patients underwent subsequent revision surgery unrelated to the PLL.
CONCLUSION
We were unable to demonstrate magnetic resonance imaging evidence to suggest that the retained PLL caused compression after ACDF in this patient cohort. Therefore we suggest that removing the PLL should be considered for reasons other than concern about residual compression.