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. 2022 Mar;36(3):376–379. [Article in Chinese] doi: 10.7507/1002-1892.202111072

颈椎减压术后C5麻痹发生原因研究进展

Research progress of etiologies for C5 palsy after cervical decompression

Chuan GUO 1,2, Xinyue SONG 1, Qingquan KONG 2,*, Yu WANG 2, Ye WU 1,2, Weilong LI 1,2
PMCID: PMC8923932  PMID: 35293181

Abstract

Objective

To review the definition and possible etiologies for C5 palsy.

Methods

The literature on C5 palsy at home and abroad in recent years was extensively reviewed, and the possible etiologies were analyzed based on clinical practice experience.

Results

There are two main theories (nerve root tether and spinal cord injury) accounting for the occurrence of C5 palsy, but both have certain limitations. The former can not explain the occurrence of C5 palsy after anterior cervical spine surgery, and the latter can not explain that the clinical symptoms of C5 palsy is often the motor dysfunction of the upper limb muscles. Based on the previous reports, combining our clinical experience and research, we propose that the occurrence of C5 palsy is mainly due to the instrumental injury of anterior horn of cervical spinal cord during anterior cervical decompression. In addition, the C5 palsy following surgery via posterior approach may be related to the nerve root tether caused by the spinal cord drift after decompression.

Conclusion

In view of the main cause of C5 palsy after cervical decompression, it is recommended to reduce the compression of the spinal cord by surgical instruments to reduce the risk of this complication.

Keywords: Cervical decompression, C5 palsy , nerve root, spinal cord

C5麻痹是颈椎减压术后独特的并发症，据统计发生率为7% [1]。 既往Machino等[2]将其定义为患者出现三角肌瘫痪，伴或不伴肱二头肌受累，不存在其他肌肉力量下降。但随着临床研究深入，学者们发现C5麻痹患者不仅表现为运动障碍，也可以同时表现感觉麻痹症状，因此将其定义为单侧或双侧三角肌或肱二头肌肌力下降，伴或不伴相应神经根支配区域的感觉障碍[3-4]。

目前C5麻痹发生原因尚未明确，神经根拴系和脊髓损伤为两种主流学说[5-7]，目前尚无有效预防措施。因此，深入探讨C5麻痹发生原因，对降低该并发症的发生风险具有重要意义。本文通过回顾近年相关文献，结合本团队临床实践，对C5麻痹发生的可能原因进行系统分析。

1. C5麻痹介绍

1961年，Scoville[8]首次报道颈椎椎板切除术后存在运动障碍发生风险, 但没有对其进行明确定义。1965年，Keegan[9]将该并发症描述为“分离性上肢运动障碍”，分析为神经根受压所致。国内研究大多将该并发症命名为“C5神经根损伤”或“C5神经根麻痹”。但深入研究发现C5神经根受损不是其发生的唯一原因，还可能与脊髓前角运动神经元受损有关[6-7]。因此，我们认为上述命名不准确，本文将其称为“C5麻痹”。

虽然既往研究表明C5麻痹好发于颈椎后路减压术[10]，但近期一项荟萃分析显示前路手术C5麻痹发生率与后路手术相似[11]。C5麻痹患者中，92%为单侧发病，仅8%为双侧同时出现[12]。从发病时间看，大部分患者在颈椎减压术后3 d内出现症状[13]；临床表现往往以1～2个肌群运动障碍为主，严重者可以有感觉障碍。值得注意的是，这种分离性运动障碍不仅会发生在C5节段，还会发生在C6～T1节段。

虽然C5麻痹预后通常较好，一般只需保守治疗，70%以上患者在术后4～5个月即可恢复，但会影响患者术后生活质量和对手术的满意度，因此需要积极研究有效防治方法[14-16]。

2. C5麻痹发生原因研究

2.1. 神经根拴系学说

20世纪70年代，主流观点认为C5麻痹主要发生于颈椎后路减压术，分析与后路减压后脊髓后移导致的神经根拴系有关。这一学说主要是基于C5节段解剖学特点提出。Sakaura等[12]和Kim等[17]研究发现C4、5节段较其他节段前凸，故C5神经根较其他节段神经根短，游离度差。在椎板成形术中，由于C5节段常位于颈椎前弓顶点，减压后该节段脊髓后移距离最大，过度牵张引起神经根拴系，进而导致C5麻痹。Baba等[18]报道脊髓后移距离达3.6 mm时，可引起C5麻痹。

单开门椎管成形术中脊髓后移程度和椎板打开角度相关，角度越大，允许脊髓后移距离越大，发生C5麻痹风险也越高。Zhang等[14]根据椎板打开角度将单开门椎管成形术患者分为>30° 组及15°～30° 组，比较发现15°～30° 组术后C5麻痹发生率明显低于>30° 组。Tsuji等[19]的一项回顾性队列研究也得到了相似结论。

后路手术中椎板切除宽度与减压范围有关，也会影响脊髓后移距离。Radcliff等[20]通过在MRI上测量后路减压后椎板切除宽度，发现术后发生C5麻痹的患者其C5节段椎板切除宽度明显大于未发生C5麻痹患者。分析原因为后路椎板切除宽度越大，减压范围越大，进而脊髓后移距离越大，更容易诱发神经根拴系。因此，控制术中椎板切除宽度和脊髓后移距离，可能有助于降低术后C5麻痹发生风险。

此外，椎间孔减压不充分也容易导致神经根拴系，进而导致C5麻痹的发生。据统计，由于减压不充分导致的C5麻痹发生率为6%～8%[21] 。减压术后脊髓旋转更易导致神经根栓系。Kaneyama等[22]的研究发现，单开门手术后C5麻痹发生风险明显高于双开门手术，分析原因为与双开门手术相比，单开门手术后脊髓两侧压力不对称，导致脊髓旋转和后移，进而导致神经根拴系。

2.2. 脊髓损伤学说

近年有报道颈椎前路减压术后也会发生C5麻痹[23]，而神经根拴系学说不能解释这种C5麻痹的发生，加之术后分离性上肢运动障碍还可以发生在C5节段以外的其他节段，因而应该还有其他原因导致C5麻痹。

有学者提出了脊髓损伤学说，认为脊髓缺血与缺血再灌注损伤在C5麻痹发生中起到重要作用。Hasegawa等[24]进行了一项回顾性研究，共纳入857例颈椎前路减压术患者，结果表明发生C5麻痹患者的脊髓前角均受到压迫。因此，他们认为脊髓慢性压迫解除后，前角细胞血流迅速增加引起的缺血再灌注损伤是造成C5麻痹的原因。Chiba等[25]发现C5麻痹患者术后脊髓节段存在T2WI高信号改变，而该信号改变是脊髓损伤的影像学特征。Ikegami等[26]通过分析C5麻痹患者MRI发现，大部分患者C3～5节段脊髓出现T2WI高信号改变。由此推断脊髓损伤引起的功能障碍可能是C5麻痹发生原因之一。

然而，Tsuzuki等[27]对脊髓缺血再灌注损伤患者的MRI进行分析，发现脊髓高信号大多为对称性分布。这一研究结论无法解释C5麻痹多发生于单侧， 且往往只有1～2个肌群受累的现象。脊髓内毛细血管网十分丰富，如果发生了缺血再灌注损伤，所涉及的区域应非常广泛，理论上单纯C5节段损伤发生概率应低于多节段损伤，因此缺血再灌注损伤也无法解释C5麻痹发生率高于其他节段。故脊髓损伤学说存在较大争议。

脊髓型颈椎病和分离性上肢运动障碍性颈椎病具有相似表现，包括运动障碍，伴或者不伴感觉障碍，也可表现为多根神经根损伤，因而分析C5麻痹的发生原因与该类颈椎病相似。脊髓前角挤压损伤是该类颈椎病发生原因，因此推测C5麻痹发生可能也与脊髓前角的挤压损伤有关。从解剖特点来看，C5～T1节段为脊髓“颈膨大”处，该节段病变可分为中颈髓病变和下颈髓病变。其中，中颈髓病变位于C5～7节段，以C5为中心，常表现为上肢肌肉与肩胛带肌肉无力和萎缩，有时伴神经根系疼痛，严重时会有感觉障碍症状。由于C5节段为脊髓“颈膨大”节段，该节段发生狭窄时，椎管后壁与脊髓腹侧硬膜囊之间的潜在空间较小，因而颈椎减压术中减压器械更容易挤压脊髓前角，诱发C5麻痹。临床中我们发现使用小角度椎板咬骨钳（40°）进行椎间孔区域减压后，更容易发生C5麻痹；而使用大角度椎板咬骨钳（130°），C5麻痹较少发生。近期，我们使用超声骨刀进行前路减压，术后C5麻痹发生率与使用常规手术器械相比进一步降低，分析与超声骨刀可减少减压过程中对脊髓前角的挤压有关。综合上述因素，我们认为颈椎减压术中器械对脊髓前角的挤压损伤可能是引起C5麻痹的主要原因。

3. 小结

综上述，颈椎前路减压术后C5麻痹的发生与术中器械损伤脊髓前角有关，颈椎后路减压术后C5麻痹发生与减压后脊髓后移导致的神经根拴系有关。因此，我们提倡在前路手术中尽量减少器械对脊髓的挤压，尤其在椎间孔区域的减压操作中，推荐采用大角度椎板咬骨钳（130°）或者超声骨刀进行减压，以减少术后C5麻痹的发生。

利益冲突　所有作者声明，在课题研究和论文撰写过程中不存在利益冲突

作者贡献声明　孔清泉、王玉、伍椰负责综述构思及设计、对文章的知识性内容作批评性审阅；郭川、宋心月、李韦龙负责资料收集、文章撰写及修改

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