颈椎减压术后C5神经根麻痹

·综述·

颈椎减压术后C5神经根麻痹

李俊宽,黄稳定,严望军

作者单位:125000辽宁,海军92493部队医院门诊部(李俊宽)；上海,解放军第411医院骨科(黄稳定)；第二军医大学长征医院骨科(严望军)

通信作者:严望军spinetumor@163.com

【关键词】颈椎； 减压术,外科； 神经根病； 综述文献

作者简介:李俊宽(1971—),本科,副主任医师

【中图分类号】R 681.531【文献标志码】 A

DOI【】

收稿日期：(2014-11-28)

C5神经根麻痹是颈椎术后较为常见的严重并发症,严重影响患者生活质量。其发生机制复杂,已成为脊柱外科领域关注的一项重要课题。目前该并发症的特点及如何预防等方面取得了一定的成果[1-2]。本文对近年C5神经根麻痹流行病学、病因学及如何预防该并发症的发生等进行了文献回顾、分析。现综述如下。

1C5神经根麻痹临床特点及发生率

颈前路及颈后路减压术后均会导致C5神经根麻痹,通常发生于术后24 h～2个月,大部分患者于术后1周内出现症状,以单侧症状最为常见。患者主要表现为三角肌和/或肱二头肌麻痹、肌力减退,可同时伴有C5神经支配区感觉障碍和/或顽固性疼痛[1-2]。

术后C5神经根麻痹的发生率与手术方式、疾病类型有关。不同术式的发生率不同,颈前路减压术后C5神经根麻痹的发生率为0%～26.4%[1,3-6],平均为7.7%[1]。Liu等[7]报道多节段颈前路椎间盘切除融合术后的发生率为3.8%,混合式减压(椎体次全切除并椎间盘切除植骨融合术)术后的发生率为8.3%,双节段椎体次全切术后的发生率为26.4%。Odate等[8]报道前路混合式减压术后其发生率为 3.0%。

颈后路减压术后C5神经根麻痹的发生率为 0%～50.0%[9-14],平均为 7.8%[1]。其中颈椎椎板切除术后C5神经根麻痹的发生率为2.4%～40.0%[1,14-15],椎板成形术后发生率为0%～50.0%[1,13]。Komagata等[11]报道单开门椎板扩大成形术后其发生率为4.0%。Katsumi等[12]报道单开门椎板成形术同时行预防性C4/C5椎间孔切开术后其发生率为 1.4%。Park等[13]报道单开门椎板成形术后其发生率为8.9%,双开门术后其发生率为0%。颈椎前后联合入路术后C5神经根麻痹的研究报道较少。Nassr等[2]报道该术式减压后其发生率为8.4%。

疾病类型也与术后C5神经根麻痹的发生率有关[1]。Kim等[3]对颈椎退变性疾病前路减压后C5神经根麻痹的发生率进行了对比,在神经根型颈椎病、脊髓型颈椎病、混合型颈椎病及颈椎后纵韧带骨化(ossification of posterior longitudinal ligament, OPLL)中其发生率分别为0、3.9%、16.7%、9.0%。Chen等[16]报道椎板切除融合术治疗OPLL术后C5神经根麻痹的发生率为18.0%。

2C5神经根麻痹病因学及发生机制

迄今为止仍然没有明确颈椎术后C5神经根麻痹的发生机制,目前认为是多种因素作用的结果,主要存在5种可能因素[1-2,5]：①颈椎椎管减压后脊髓漂移牵拉神经根；②节段性脊髓功能障碍；③术中神经根损伤；④根动脉血供减少引起脊髓缺血；⑤脊髓缺血再灌注损伤。

2.1脊髓漂移引起的神经根栓系效应

颈椎减压术后脊髓向后漂移所导致的神经根栓系继发C5神经根麻痹是目前公认的假设理论。其解剖学基础是[3,17-20]：①C5是颈椎生理曲度的顶点,也是减压区的中心点,减压后C5神经根漂移的距离更大；②C5神经根及其分支较其他神经根短；③其他肌肉为双重神经支配,而三角肌仅有1支神经根支配，更易受神经根功能障碍的影响；④C4，5关节突增生退变或颈椎序列改变引起C4，5椎间孔狭窄。

Xia等[9]发现宽开门组C5神经根麻痹的发生率为 5.3%,窄开门组的发生率则为 0%,其认为窄开门可以减少脊髓漂移的空间,降低C5神经根麻痹的发生率。Zhang等[17]通过术前及术后 CT 影像对脊髓漂移的程度进行了评估,椎板扩大成形术后出现C5神经根麻痹的患者脊髓向后漂移平均增加了4.11 mm,而没有 C5神经根麻痹的患者脊髓向后漂移平均增加了2.79 mm,两者差异有统计学意义。Radcliff等[21]认为椎板切除的宽度和脊髓漂移的程度是颈椎术后C5神经根麻痹的危险因素。Shiozaki等[22]通过MRI对椎板成形术后的脊髓状态进行了评估,与术后2周相比,术后24 h脊髓向后漂移程度明显增加。Bydon等[23]研究发现C5神经根麻痹组脊髓漂移程度及C4，5椎间孔狭窄程度均较非麻痹组大。Katsumi等[24]对椎板成形术后C5神经根麻痹和非麻痹患者的影像资料进行了分析,发现麻痹组椎间孔平均直径为1.99 mm,非麻痹组平均为2.76 mm,两者差异有统计学意义。Imagama等[25]发现C5神经根麻痹患者C4，5椎间孔明显狭窄、C5上关节突更大、C4，5脊髓漂移更加明显。

颈椎减压术后脊髓漂移引起的神经根栓系效应这一理论虽然被广泛接受,但仍然无法合理解释颈前路术后C5神经根麻痹[26],因而该假说还存在一定的局限性。

2.2脊髓病变导致功能障碍

研究[3-4，27-28]报道颈椎术后MRI T2像上出现脊髓高信号或高信号区域的异常扩大,提示术后C5神经根麻痹与脊髓灰质病变存在一定的相关性[3-4,27-28]。Chiba等[27]认为C5神经根麻痹与MRI T2像脊髓中央灰质的高信号区有关,所有患者均出现上述影像学改变。Seichi等[28]对椎板成形术后MRI T2像脊髓高信号区域改变现象进行了分析,发现上肢远端和弥散性麻痹与T2高信号区域扩大有关,认为可能是脊髓功能障碍或病变所致。

然而,并不是所有具有该影像特点的患者都会出现C5神经根麻痹。Chen等[16]对OPLL术前及术后脊髓状态进行了研究,发现术前MRI T2像C4，5水平脊髓高信号的患者术后并不都出现C5神经根麻痹,而术后颈髓MRI T2像高信号也不是引起C5神经根麻痹的因素。Katsumi等[24]认为术前MRI T2像脊髓高信号改变与术后C5神经根麻痹并无明显相关性。脊髓高信号区域通常位于脊髓中央,而C5神经根麻痹往往是单侧表现。因此,节段性脊髓功能改变也不能合理解释C5神经根麻痹的发生机制。

2.3术中神经根直接损伤

理论上讲,术中神经根直接损伤能够解释术中或术后即刻发生的C5神经根麻痹。Uematsu等[29]发现术后即刻发生C5神经根麻痹的患者多见于单开门椎板成形术开门一侧,提示可能是术中直接损伤神经根所致。Fan等[30]报道术中电生理监测发现医源性神经根损伤引起C5神经根麻痹,同期行C4，5椎间孔减压治疗后恢复。

虽然术中神经根直接损伤被视为C5神经根麻痹的危险因素,但是并不是所有C5神经根麻痹的患者均在术后即刻发生,大多数发生于术后1 d至数周[1-2],因此该发生机制也很难给出合理的解释。

2.4脊髓缺血及再灌注损伤

脊髓缺血及再灌注损伤是脊柱外科近年来的研究热点,越来越多的学者用该假说解释C5神经麻痹的发生机制。脊髓再灌注损伤可导致脊髓神经元细胞功能短暂或永久丧失。Hasegawa等[31]认为脊髓长期受压可导致局部脊髓神经元受损,这些神经元在减压后更易受到局部血运异常的影响,并继发缺血再灌注损伤。Chiba等[27]认为脊髓白质和灰质血运存在差异,灰质区细胞、神经连接及血运更加丰富,这种差异会导致皮质脊髓束和脊髓灰质前角细胞更容易继发缺血再灌注损伤。这也进一步解释了一些患者仅表现为C5支配区运动功能障碍而无感觉障碍这一临床现象(感觉运动分离)。

3危险因素

C5神经根麻痹的危险因素与其病因、发生机制密切相关。研究表明,C5神经根麻痹的危险因素主要包括：术前椎间孔狭窄[32]、术前C4，5水平脊髓高信号[28]、OPLL[16]、椎板成形并融合术[20,26]、减压范围过大[9,21]、不对称减压及高龄等[5,27]。 Gu等[32]回顾分析文献,认为术前存在椎间孔狭窄、OPLL、脊髓过度漂移、后路椎板切除及男性患者是颈椎术后C5神经根麻痹的危险因素。Seichi等[28]认为术前C3，4和/或C4，5水平脊髓高信号是C5神经根麻痹的危险因素。Radcliff等[21]发现颈后路椎板切除的宽度及脊髓漂移的程度与C5神经根麻痹的发生率呈正相关,因此认为二者是颈椎术后C5神经根麻痹的危险因素。Yamanaka等[20]发现椎板成形术同期行融合术后C5神经根麻痹的发生率高于非融合组,因此也认为椎板成形术并内固定是术后C5神经根麻痹的危险因素。Bydon等[5]研究发现,颈前路椎体次全切的节段越多,术后C5神经根麻痹的发生率越高,而且高龄也是危险因素之一。

4防治措施及预后

4.1评估方法

应用神经电生理监测早期发现C5神经根麻痹能够避免术后神经功能损伤。目前已有多种术中神经监测方法应用于临床,如躯体感觉诱发电位(somatosensory-evoked potentials,SEPs)、经颅电刺激运动诱发电位(transcranial electrical motor-evoked potentials,tceMEPs)和自发肌电图(spontaneous electromyography,spEMG)。SEPs是脊髓后索神经诱发的神经冲动,直接评估脊髓感觉神经纤维。tceMEPs是反映运动神经纤维诱发的神经冲动,用于评估运动神经纤维。spEMG则常用于监测某一特定神经根的牵拉伤或微损伤。研究认为,SEPs虽然特异性较高,但敏感性较低,tceMEPs的敏感性和特异性均较高,而spEMG对于明确特定的神经根的损伤较为敏感；因此tceMEPs和spEMG在临床上更为常用[30，33]。

影像学评估也有助于预防C5神经根麻痹。Lubelski等[34]认为C5神经根麻痹与脊柱的特殊结构有关,通过 MRI 及 CT 扫描分析 C4，5椎管正中矢状径、左右椎间孔径以及脊髓-椎板角3种解剖参数能够预测术后C5神经根麻痹,有助于术者采取相应的干预措施。

4.2手术治疗

手术治疗方法主要包括椎间孔减压、硬脊膜切开。由于硬脊膜切开后并发症较多,且临床上支持该方法的资料少,因此不被临床医师广泛接受。

预防性椎间孔减压是防治术后 C5神经根麻痹的重要方法[1,11-12,30,35]。Fan等[30]进行的前瞻性队列研究,对术中电生理监测发现神经异常放电现象的患者进行C4，5椎间孔扩大减压,术后C5神经根麻痹症状消失。Komagata等[11]研究发现双侧椎间孔切开术的患者C5神经根麻痹的发生率明显低于未切开手术者(0.6%vs. 4.0%)。Katsumi等[12]通过前瞻性研究发现,颈后路单开门椎板成形术同时行C4，5椎间孔减压的患者术后C5神经根麻痹的发生率为1.4%,而未行椎间孔减压的患者术后C5神经根麻痹的发生率为6.4%,提示预防性C4，5椎间孔减压可降低C5神经根麻痹的发生率。

根据C5神经根麻痹的危险因素调整手术方案也是避免其发生的有效方法。Odate等[26]认为减压宽度过大及不对称减压是术后C5神经根麻痹的危险因素,其建议在前路手术时将开槽宽度限制在15 mm以内、避免不对称减压。Xia等[9]研究发现,当开槽位置在侧块内侧缘时,C5神经根麻痹的发生率为 5.3%,而当开槽位置在椎板外1/3时,其发生率则为 0%,因此其建议椎板成形术时采用窄开门的方法。

4.3非手术治疗

术前摆体位时使患者颈椎处于中立位、避免颈椎过伸或过屈、双上肢避免过度向下牵拉等可以预防C5神经根麻痹。Chen等[16]认为采用高压氧结合理疗的方式是有益的,所有患者在1年内均完全康复。Hasegawa等[31]提出应用自由基清除剂和/或地西泮预防缺血再灌注损伤,从而防止C5神经根麻痹的发生。Takenaka等[36]认为在开槽时使用冰盐水有助于降低术后C5神经根麻痹的发生。其他治疗方式包括应用非甾体类抗炎药物、糖皮质激素以及颈托保护等。

4.4预后

C5神经根麻痹的总体预后比较好,通常恢复期为4～5个月,绝大多数患者在术后 2 年内恢复,但肌力<2级的患者可能恢复较为困难[1-5]。Hashimoto等[4]对17例颈椎术后C5神经根麻痹的患者进行了随访,发现肌力>3级者(7例)随访期内完全恢复,而肌力在<2级者(10例)恢复较差,甚至不能恢复(2例)。

5总结

颈椎术后C5神经根麻痹是脊柱外科医师处理颈椎疾患时所面临的一个难题。虽然C5神经根麻痹的发生是多因素的,但是减压术后硬膜囊向后漂移对神经根的牵拉是目前最流行的假设理论。应用神经电生理监测有助于早期发现和避免C5神经根麻痹,手术技术的进步有助于外科医师避免该类并发症的发生。在对颈椎退变性疾病进行手术时,除了术前的充分评估及术中监测之外,脊柱外科医师必须在有效减压和可能带来的并发症之间寻找到一个平衡点,这样才能有效防止术后发生C5神经根麻痹。

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[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.

(本文编辑张建芬)