颈脊髓损伤

患者男性，24岁，因“车祸伤致四肢麻木乏力11小时”入院。查体：剑突以下皮肤感觉减退，双手腕关节以下皮肤感觉减退，双三角肌、肱二头肌肌力4级，双肱三头肌肌力3级，双手握力0级，双下肢肌力5-级，四肢生理反射活跃，病理反射未引出，踝阵挛、髌阵挛（-），腹壁反射、提睾反射存在，伤后小便难解，留置尿管，大便未解。颈椎X线片未见骨折脱位，颈椎MRI如下图。请教各位老师，该患者是手术治疗，还是保守治疗？如果行手术治疗，手术治疗的最佳时间是？手术是？ HYPERLINK "http://img.dxycdn.com/upload/2011/10/23/36/52418967.jpg" HYPERLINK "http://img.dxycdn.com/upload/2011/10/23/36/52418967.jpg" HYPERLINK "http://img.dxycdn.com/upload/2011/10/23/41/90702378.jpg" HYPERLINK "http://img.dxycdn.com/upload/2011/10/23/45/81891949.jpg" HYPERLINK "http://img.dxycdn.com/upload/2011/10/23/45/77480646.jpg" 敬阅病史、阅片。 患者，男性，24岁。 病史：车祸伤致四肢麻木乏力11小时。伤后小便难解,留置尿管，大便未解。（缺少过程、细节描述） LZ查体：剑突以下皮肤感觉减退，双手腕关节以下皮肤感觉减退，双三角肌、肱二头肌肌力4级，双肱三头肌肌力3级，双手握力0级，双下肢肌力5-级，四肢生理反射活跃，病理反射未引出，踝阵挛、髌阵挛（-），腹壁反射、提睾反射存在。（括约肌功能？） LZ述：颈椎X线片未见骨折脱位。 MRI：颈4 /5椎间盘向后突出改变，后部纤维环受损，椎间盘前方可见小片T2高信号，后部骨韧带复合体T2高信号，该节段可见颈脊髓内片状T2高信号。颈椎管矢状径稍偏小，椎管矢状中径/椎体矢状中径=比值<75%。 请看C4/5节段MRI ，包括DLC ： 受伤机制： 考虑是车祸时颈部屈曲牵张所致的C4/5椎间盘——后方韧带复合体（DLC）损伤（C4/5椎间盘主要是后部的纤维环损伤，DLC损伤较重，需明确有无附件骨折。），加之发育性颈椎管狭窄的病理特点，导致出现了颈脊髓损伤。 目前初步诊断： 1.屈曲牵张型颈椎、颈脊髓损伤： a.颈4/5椎间盘——后方韧带复合体（DLC）损伤。 b.颈脊髓不完全性损伤（脊髓中央损伤综合征）。 c.颈椎附件骨折待排。（如颈椎CT检查，包括二维、三维重建没有发现骨折，才能确定无骨折脱位型脊髓损伤诊断） 2.发育性颈椎管狭窄。 目前可参考以下依据，确定手术指征： 1.颈脊髓不完全性损伤（脊髓中央损伤综合征），脊髓仍有压迫存在。 2.下颈椎损伤分类评分系统（Subaxial Injury Classification SLIC）：椎间盘韧带复合体——仅仅棘突间隙增宽或MRI信号异常（1分），神经功能状态——不完全脊髓损伤（3分）、持续脊髓受压（1），合计5分。 3.较轻的发育性颈椎管狭窄。 提供建议： 1.暂颈围制动。 2.完善病史、查体。 3.颈椎CT检查，包括二维、三维重建。 4.肾上腺皮质激素使用。 5.脱水、利尿治疗。 6.使用神经节苷脂：前三周100mg/日静点，三周后40mg/日静点。 术后甲钴胺片剂：0.5mg，口服，3次/天。 7.该病例手术应以减压、稳定为目的。稳定颈椎的力学作用应与受伤机制的力学作用相反，明确有无附件骨折、对手术实施有无影响，故提供以下手术方案选择： A.如无附件骨折，根据后方PLC损伤不同可选择： a.如后方PLC损伤较轻、无断裂，可行单纯后路棘突悬吊式单开门颈椎管扩大术，并加术后外固定。 b.如后方PLC完全性断裂，可行后路单开门颈椎管扩大术加DLC断裂节段椎弓根或侧块钉棒固定植骨融合术。 c.如后方PLC不全性断裂，尚有一定的强度，可行单纯后路棘突悬吊式单开门颈椎管扩大术，是否内固定由术者根据损伤和稳定性后具体情况决定。 B.如有附件骨折，可选择： a.如附件骨折和PLC损伤较轻，骨折部位不影响开门，可根据PLC损伤情况选择行后路棘突悬吊式或经典单开门颈椎管扩大术，加不稳定节段椎弓根或侧块钉棒固定植骨融合术。 b.如附件骨折和PLC损伤较严重，影响后路部分节段不能实施开门，可部分节段可做椎板减压，其它需要减压节段行单开门，不稳定节段节段行椎弓根或侧块钉棒固定植骨融合术。 颈椎稳定性评估：a.术前的影像学资料。 b.术中观察到的骨折和PLC损伤的情况。 c.术中椎管扩大、临时固定妥善后，全面监护下，C—臂X机下，动态观察颈椎（小幅度屈伸）。 8.预防并发症。 9.高压氧治疗。 10.头颈胸支具外固定。 11.长期项背肌锻炼。 12.术后长期的康复训练、治疗，如功能电刺激治疗等。 个人浅见，请战友批评指正。 请看以下 丁香园yibotian 战友 2010-12-18 的介绍文章 ： Alexander R. Vacarro, MD, FACS 亚历山大.瓦卡罗 Co-Associate Director for Acute Care, Regional Spinal Cord Injury Center of the Delaware Valley; Co-Director of Reconstruction Spine Services Thomas Jefferson University Hospital Address: 925 Chestnut Street, Fifth Floor Philadelphia, PA 19107, Telephone: (267) 339-3500 Vaccaro等领导的脊柱创伤研究小组（ Spine Trauma Study Group ，2004 ），先后提出了著名的胸腰段损伤TLICS（2005年）和The Subaxial Cervical Spine Injury Classification，SLIC（2007年），对脊柱胸腰段骨折及下颈椎损伤的分类与评估起到了巨大的推动作用，为脊柱损伤的临床治疗选择提供了较好的参考。 脊柱创伤是骨科医师师经常诊治的疾患之一，目前北美地区每年发生脊柱损伤约为150,000例，其中约11,000例发生脊髓损伤；其中约1/3-1/2的脊柱损伤和绝大多数的脊髓损伤发生在下颈椎；颈椎损伤约占所有创伤患者的3%，下颈椎损伤约占颈椎骨折65%和脱位75%。众所周知，脊柱损伤分类系统对其诊断、治疗以及预后的判断都具有重要的指导意义；而下颈椎损伤的评估与治疗中存在大量的各不相同临床，这也注定了同时存在较多的争论。 存在的下颈椎损伤分类系统： 1. Holdsworth 分类 2. Aellen-Ferguson 分类 3. Harris 分类 4. AO 分类 5. Magerl 分类 6. Anderson-Steinmann 分类 7. 形态学分类 8. 脱位分类 …… 以上数种下颈椎损伤分类系统，其中的任何一种都没有明显的优势；其分类主要依据为X线所提示的损伤机制或（和）骨折的形态特点，忽视了韧带结构的完整性，未考虑潜在的神经损伤；这些分型系统繁杂多样、难于记忆、实用性较差；目前尚无一种分型能够在临床广泛应用，很大程度上是因为其临床相关性不强；上述大多数分类系统试图通过单纯的描述性术语来阐明具体的骨折类型，效果欠佳。Mirza、vacarro等众多学者认为理想的分类系统需满足以下要求：全面反映患者受伤当时的状态；有效的结合影像学和临床现；能够客观系统的指导临床诊疗；对损伤的预后具有较好的判断；简单易记、临床应用方便可行。 近年来在下颈椎损伤的分类系统中存在较为明显的进展，其中主要包括Moore等提出的下颈椎损伤修正分类 和 Vaccaro等提出的下颈椎损伤分类评分系统The Subaxial Cervical Spine Injury Classification System and Severity Scale （SLIC）。 1. 2006年，Moore等对下颈椎损伤进行新的分类，此分类系统将颈椎分为前柱、后柱和左、右侧柱四个部分，每个部分又分为单一损伤和复合损伤两种，这样可以更加全面地描述①下颈椎损伤的状态。与②颈椎损伤严重程度（稳定性）量化评分相结合，理论上可以准确判断预后并指导治疗，较为有限的临床应用显示该新型分类系统优于传统的分类方法。该分类系统包含了对韧带等软组织损伤的评估，且引入了量化概念进行稳定性的评估，较以往的分类系统具有一定的先进性。但该分类方法仍然仅从影像学方面对损伤进行评估，未进行神经功能的评估；四柱理论貌似先进，但也一定程度上导致了该分类系统的繁杂。文献复习亦发现该分类系统未引起各国脊柱外科医师的广泛关注。 2.继2005年提出胸腰段损伤TLICS，Vaccaro等领导的脊柱创伤研究小组（ Spine Trauma Study Group ，2004 ）2007年提出了The Subaxial Cervical Spine Injury Classification System and Severity Scale （SLIC）. 该评分系统包括损伤形态、椎间盘韧带复合体、神经功能状态三部分。 具体评分如下： 若总评分 ≤3，建议保守治疗； 若总评分 ≥5，建议手术治疗； 若总评分 = 4，可结合患者具体情况采取保守或手术治疗。 SLIC通过损伤形态、DLC与神经功能对下颈椎损伤提供一个直接而客观的评估，而不是根据那些推测的受力机制而进行评估；其有效的结合了影像学资料和患者的临床表现，对损伤评估较为全面，对临床诊疗决策和预后的判断 具有较好的指导作用；该分类系统并不复杂，容易记忆，临床应用方便；目前引起了各国脊柱外科医师的广泛关注，并获得了初步的肯定。但该分类系统毕竟诞生时间尚短，需要进行大规模的临床应用验证后方能做出最好的判断。 本人根据文献资料初步总结，如有不妥之处，敬请战友们予以指征，大家相互交流，意在共同提高。感兴趣的战友，可以参阅一下文献资料： 1.Kwon BK, Vaccaro AR, Grauer JN, et al. Sub-axial cervical spine trauma. J Am Acad Orthop Surg 2006;14:78–89. 2.Hadley MN. Guidelines for management of acute cervical injuries. Neurosurgery 2002;50(suppl):1– 6. 3.Lowery DW, Wald MM, Browne BJ, et al. Epidemiology of cervical spine Injury victims. Ann Emerg Med 2001;38:12–6. 4.Holdsworth F. Fractures, dislocations, and fracture-dislocations of the spine.J Bone Joint Surg Am 1970;52:1534–51. 5.Allen BL Jr, Ferguson RL, Lehmann T. A mechanistic classification of closed,indirect fractures and dislocations of the lower cervical spine. Spine 1982;7: 1–27. 6.Harris JH, Edeiken-Monroe B, Kopansiky DR. A practical classification of acute cervical spine injuries. Orthop Clin North Am 1986;1:15–30. 7.Aebi M,Nazarian S (1987) Classification of injuries of the cervical spine. Orthopaede 16:27–36 8.BlauthM, KathreinA,MairG, SchmidR, ReinholdM, RiegerM(2007)Classificationof injuriesof the subaxial cervical spine. In: Aebi M, ArletV,Webb JK (eds)AOSpineManual: clinical applications, vol 2. Thieme, Stuttgart, pp 21–38 9. Mirza SK, Mirza AJ, Chapman JR, et al. Classifications of thoracic and lumbar fractures: rationale and supporting data. J Am Acad Orthop Surg 2002;10:364–77. 10. Moore TA, Vaccaro AR, Anderson PA. Classification of Lower Cervical Spine Injuries. Spine, 2006,31（11S）: pp S37–S43 11. Alexander R. Vaccaro, MD, et al. The Subaxial Cervical Spine Injury Classification System: A Novel Approach to Recognize the Importance of Morphology, Neurology, and Integrity of the Disco-Ligamentous Complex. Spine 2007;32:2365–2374 12.The Surgical Approach to Subaxial Cervical Spine Injuries: An Evidence-Based Algorithm Based on the SLIC Classification System. Dvorak, Marcel F. MD, Aarabi, Bizhan MD; Vaccaro, Alexander R. MD .Spine. 32(23):2620-2629, November 1, 2007. 13. Subaxial injury classification system to determine the surgical approach for subaxial cervical spine injuries. Dvorak, Marcel F Current Orthopaedic Practice. 19(4):407-410, August 2008. 14. Subaxial Cervical Trauma: Evaluation, Classification, and Treatment. Alpesh A. Patel MD. Contemporary Spine Surgery , VOLUME 10 NUMBER 2 FEBRUARY 2009. 请阅读以下丁香园战友 冰焰教授 2007-11-07 的译文： 2620The Surgical Approach to Subaxial Cervical Spine Injuries: An Evidence-Based Algorithm Based on the SLIC Classification System. Marcel F. Dvorak, MD, FRCSC; Charles G. Fisher, MD, MHSc, FRCSC; Michael G. Fehlings, MD, PhD; Y Raja Rampersaud, MD, FRCSC; F C. ?ner, MD, PhD; Bizhan Aarabi, MD; Alexander R. Vaccaro, MD Literature Review 下颈椎损伤手术入路的选择: 基于SLIC评分系统的循证医学指南 Abstract Study Design. Systematic review of literature and expert clinical opinions of the members of the Spine Trauma Study Group were combined to develop and refine this algorithm. Obejctive. To develop an evidence-based algorithm for surgical approaches to manage subaxial cervical injuries using a systematic review of the literature, expert opinion, and anticipated patient preferences. Summary of Background Data. There is lack of consensus in the management of subaxial cervical spine trauma, in part, because of the lack of a clinically relevant system for classifying these injuries. The newly developed Subaxial Injury Classification scoring system categorizes injury morphology into 3 broad groups, includes an assessment of the integrity of the discoligamentous soft tissue structures and the patient's neurologic status, and thus guides surgical or nonsurgical treatment. The choice of a specific surgical technique and approach is currently not evidence based, and this gap in knowledge is one which the current article seeks to address. Methods. A literature review followed by a consensus of experts approach was used to develop the algorithm and to ensure face and content validity. Results. An algorithm is presented to guide the choice of surgical approach in cervical subaxial burst fractures, distraction injuries, and translation or rotation injuries. The burst or compression injuries and distraction injuries are more likely to be treated with a single anterior approach, whereas the more severe translation or rotation injuries may more commonly be approached posteriorly or with combined anterior and posterior surgery. Conclusion. This algorithm; derived from the Subaxial Injury Classification scoring system, will assist surgeons in answering the 2 most common questions they face when managing subaxial cervical spine trauma: “Should I operate?” and “Which surgical approach should I select?” 研究设计:系统的复习文献和参考脊柱创伤研究小组临床专家成员的意见来共同制定和修正此指南。 目标：通过系统的复习文献、专家意见和病人偏好来制定下颈椎损伤手术治疗入路选择的循证医学指南。 背景信息摘要：目前关于下颈椎创伤的治疗还没有达成共识，部分原因是由于缺乏此类损伤的临床相关分型系统。最新制定的下颈椎损伤分类评分系统将损伤形态分为三种，并包括评价间盘韧带软组织的完整和患者的神经系统情况。此评分系统能给手术或者非手术治疗提供建议，然而究竟采用何种手术方式和入路目前还没有得到循证医学证实，这正是本文要试图解决的问。 方法：几位观点一致的专家通过复习文献来制定此指南以保证表面和内容的有效性。 结果：制定了下颈椎爆裂骨折、分离损伤、平移或旋转损伤的手术入路选择指南。单纯的爆裂或压缩损伤，或分离损伤大多采取前方入路，严重的平移或旋转损伤则需要后路或者前后路联合的手术方式。 结论：这个来源于下颈椎损伤分类评分系统的指南，能够帮助外科医生回答在诊治下颈椎创伤时两个最常面临的问题：“是否需要手术？”和“选择哪种手术入路？” 关键词：颈椎创伤，手术入路，文献复习 The management of patients with subaxial cervical trauma has lacked consensus among the surgeons who treat these patients, particularly in regard to the decision to operate and which surgical approach or combination of surgical approaches to use.1 One of the shortcomings in identifying optimal treatment for these injuries is the lack of standardized nomenclature or a scoring system. The literature is replete with reports of surgical techniques and approaches for subaxial cervical trauma.2–10 However, no one, to date, has been able to systematically review and consolidate the literature and then blend the results with expert opinion and patient preference to produce an evidence-based treatment algorithm. The development of evidence-based management recommendations for subaxial cervical injuries has been facilitated by the development of the Subaxial Injury Classification (SLIC) scoring system.11 This scoring system proposes 3 major injury characteristics as indicators, which would direct the treatment of subaxial injuries. These 3 characteristics are: (1) injury morphology as determined by the pattern of spinal column disruption on available imaging studies, (2) integrity of the disco-ligamentous soft tissue complex (DLC) represented by both anterior and posterior ligamentous structures as well as the intervertebral disc, and (3) neurologic status of the patient. These 3 injury characteristics are widely recognized as predictors of clinical outcome and influence treatment recommendations. Within each of the 3 categories, subgroups have been identified and graded from least to most severe (Table 1). 外科医生在处理下颈椎创伤患者时还没有一致的意见，尤其是对是否需要手术以及采取什么样的手术入路。不能确定理想手术方式的原因之一在于没有的命名或评分系统。尽管有很多文献报导了手术治疗下颈椎创伤的技术和手术途径，目前尚缺乏系统的回顾和整理文献，并将其结果综合考虑专家意见和病人偏好，来制定循证医学基础的治疗指南。 下颈椎损伤分类评分系统（Subaxial Injury Classification SLIC）的建立促进了颈椎损伤治疗指南的发展。该系统提出将3个主要的损伤特征作为诊治下颈椎损伤的指征,包括:（1）脊柱影像学上的损伤形态，（2）以前纵韧带、后纵韧带和椎间盘为代表的间盘韧带软组织复合体（discoligamentous soft tissue complex DLC)的完整性，（3）患者的神经系统状态。这3个损伤特征目前已经被广泛的应用于预测临床效果和改变治疗方案，并且由轻到重再被分成多个亚组（表1）。 表1.下颈椎损伤评分表 评分 形态学 正常 0 压缩 + 爆裂 1+1=2 分离（小关节半脱位，伸展过度） 3 旋转或平移（小关节脱位，不稳定的泪滴状骨折或陈旧性的屈曲压缩损伤） 4 间盘韧带复合体 完整 0 不确定的（仅仅棘突间隙增宽或MRI信号异常） 1 破裂（前方椎间隙增宽，小关节半脱位或脱位） 2 神经系统状态 完整 0 根性损伤 1 完全性脊髓损伤 2 不完全脊髓损伤 3 持续的脊髓压迫症状（神经功能进行性改变） +1 The SLIC classification divides injury morphology into 3 main categories referenced to the relationship of the vertebral bodies with each other (anterior support structures): (1) compression, (2) distraction, and (3) translation or rotation. The components of the DLC include the intervertebral disc, anterior and posterior longitudinal ligaments, interspinous ligaments, facet capsules, and ligamentum flavum. The integrity of these soft tissue constraints is thought directly proportional to spinal stability and is classified within the SLIC system as disrupted, intact, or indeterminate. Neurologic injury is the third component of the SLIC system and is inherently an important indicator of the severity of spinal column injury and may be the single most influential predictor of treatment. The presence of an incomplete neurologic injury, particularly in the presence of ongoing root or cord compression leads to the highest point score (Table 1). The SLIC scoring system can be used to direct treatment into the broad categories of either surgical or nonsurgical by summing the points in each of the 3 categories outlined in Table 1. Injuries which score 5 or more points on SLIC are all treated surgically, whereas those scoring 3 or less are treated nonsurgically. A score of 4 is considered equivocal. Once the SLIC scoring system suggests that a specific injury should be treated surgically, the surgeon must decide which single or combination of surgical approaches to use. Although the SLIC classification guides the physician to either operative or nonoperative treatment, it does not assist in the choice of surgical approach. Currently, there is no evidence-based algorithm that would provide surgical treatment options and specify which approach should be used. This article focuses on the choice of surgical approach once the decision to operate has already been made. SLIC评分系统根据椎体之间的相对关系（前柱支撑结构）将损伤形态分为3类：（1）压缩（2）分离（3）平移或旋转。DLC的结构包括椎间盘、前后纵韧带、棘突间韧带、关节囊和黄韧带，这些软组织结构的完整性直接影响了脊柱的稳定。SLIC系统将其分为完全断裂、完整或受损的。神经系统状态是SLIC评分的第三个指标，在严重脊柱脊髓损伤中，它是最重要的一个指标，甚至是影响治疗方案的唯一决定因素。不完全性神经损伤，尤其是表现为进行性的神经根或脊髓压迫症状将是很高的评分（表1）。 根据表1，SLIC评分的总和可以直接用来指导非手术或手术治疗。5分或5分以上就需要手术治疗，3分或3分以下可以采取保守治疗，4分则意味着介于两者之间。一旦通过SLIC评分确定了需要手术治疗，外科医生要首先决定的就是采取单一或者联合的手术入路。尽管SLIC评分系统能够为医生提供手术或非手术治疗的建议，但它还不能为手术入路的选择提供帮助。目前，还没有关于手术方式选择尤其是手术入路选择的循证医学指南，本文讨论的焦点在于一旦决定需要手术，采取哪种手术入路更为合适。 Clinical experts can use their experience and knowledge to strengthen and optimize research-generated guidelines. The Spine Trauma Study Group (STSG) is such a group of experts. It is composed of 48 spine surgeons (neurosurgical and orthopaedic) who have committed a substantial portion of their clinical practices and research to the provision of care to spine trauma patients. Finally, and increasingly more importantly, surgeons are relying on patient preference to guide management recommendations and decisions. Patient acceptance of devices such as the halo-thoracic-vest are an example of this.12 Patients have been empowered in the treatment decision armed with information around probabilities of outcome, health-related quality of life, complications, and care paths. Although there is a limited amount of published literature that recommends specific surgical approaches for certain injuries, the published articles to date each have 1 or more significant limitations: exclusive reliance on local experience; lack of consideration of the global experience in the literature; and failure to use well-described nomenclature to define the study population. There were 2 principle objectives of the present study: (1) to undertake a qualitative systematic review of the literature on surgical treatment approaches for various subaxial cervical spine injuries; and (2) to integrate this literature review with the consensus opinion of experts from the STSG and the SLIC scoring system to propose an evidence-based algorithm to manage these injuries. This algorithm would be based on the 3 principal morphologic categories, while incorporating the other 2 interrelated SLIC categories, namely, neurology and discoligamentous complex integrity. By building on the foundation of the SLIC scoring system and by adding an evidence-based treatment algorithm which specifically addresses the optimal surgical approach for subaxial cervical injuries, we intend to improve patient outcomes and facilitate education and clinical research. 单纯的循证医学并不是最好的系统研究方式，其必须结合临床专家意见和病人的偏好。一个系统的文献复习是对前面已有的研究进行详细而客观的回顾，这种方式已经被认为是复习文献的最佳方法。 临床专家能够根据他们自身的经验和知识来加强和优化已经制定的方针，脊柱创伤研究小组（Spine Trauma Study Group STSG)就是一个这样的组织。他由48位专门研究脊柱创伤的脊柱外科医生（包括神经外科和骨科医生）组成。更重要的是，这些医生都是根据病人的偏好来制定治疗建议和决定的。病人接受使用胸部Halo支具就是很好的例子。通过告知其可能取得的效果、带来的与健康相关的生活质量问题、并发症和治疗途径，病人拥有了决定治疗方式的权力。 尽管已经有少量的文献对一些特定的颈椎损伤提供治疗建议，但这些文章含有不同的局限性：过多的依赖地方经验；对其它地区已经发表文章里介绍的经验缺乏考虑；研究中没有采用统一的令名方式。 本次研究的目标是：（1）高质量而又系统地复习手术治疗下颈椎损伤的文献（2）将文献信息，STSG专家的一致意见和SLIC评分系统整合起来提出治疗下颈椎损伤的循证医学指南。该指南以3个主要的形态学分类为基础，并加入了另外两个SLIC相关的分类——神经系统状态和间盘韧带复合体的完整性。通过建立这样一个基于SLIC评分系统的循证医学指南，来为下颈椎损伤手术入路提供依据，我们希望能改进病人的疗效和方便交流和临床研究。 Methods Systematic Review For a given question, it is generally accepted that when homogeneous level 1 studies are not available, quantitative systematic review or meta-analysis cannot be done and a qualitative systematic review becomes the design of choice. This particular study lends itself well to a qualitative review as we are able to apply the various levels of evidence to our broader question around appropriate surgical approaches. Therefore, we categorized these studies according to their level of evidence and their appropriateness to the research question. Unique to this qualitative review is the inclusion of biomechanical studies that are particularly relevant to the question being asked 方法 系统综述 一般来说可信度I级的同质性研究文章比较难得到，无法进行定量的文献回顾或统计学分析，定性的文献回顾成为了设计的选择。我们能够将不同可信度水平的文献应用于关于手术入路选择的问题，使得能够进行很好的定性回顾。为此，我们将根据文献的可信度和它们与本研究的合适度进行分类。 这个定性回顾的独特性在于将与问题相关的生物力学研究包含了进来。 Inclusion or Exclusion Criteria. The criteria used to include studies in this review were determined a priori and considered the following factors: (1) the population that was studied in the article; (2) the intervention that was being reported on; and (3) the outcome measures that were reported in the article. To be included in this literature review the study had to have adult patients (age >16 years) with subaxial cervical traumatic injuries from C3 to T1 inclusive treated surgically with anterior, posterior, or combined anterior and posterior surgical approaches. The study had to measure the radiographic and/or clinical success of the treatment using validated outcome measures and/or radiographic measures and must have described the surgical approach used. The most common reasons for exclusion of what appeared to be appropriate studies were; failure to specify the surgical approach used in treating a cohort of patients, the use of outdated surgical techniques, which are no longer used or relevant (Cloward Procedure in cervical trauma, sublaminar wires, etc.), failure to adequately describe the injury patterns treated, and the inclusion of a heterogeneous population, i.e., nontraumatic conditions or injuries beyond the subaxial cervical spine. Literature Review. A comprehensive literature search was performed to identify potential studies including any article with an English language abstract. Electronic database searches of MEDLINE (1966 to November 2006) and EMBASE (1980 to November 2006) were performed using both medical subject headings and text word searching. Terms used included fracture, cervical, spine fractures, fracture fixation—internal, cervical vertebra. A search of the electronic database of CINAHL (1982 to November 2006) was conducted using the same text word search. Both the Database of Abstracts of Reviews of Effects and the Cochrane Database of Systematic Reviews were searched using text words. Reference lists from relevant articles were hand searched for additional citations. Content experts from the STSG were sought and questioned as to possible additional references. 包含或排除的标准。首先制定是否将文献包含进研究范围的标准，需要考虑下列因素：（1）文献研究的对象（2）文献中报导的治疗方法（3）治疗的结果。因此被纳入此综述的文章必须是介绍成人（年龄>16岁）C3到T1的下颈椎创伤，经过前路、后路或者前后路联合的手术治疗途径。除了描述采用的手术入路，文章中还必须使用相应的评价工具对治疗前后影像学或者临床效果进行比较。 一些文章表面上看起来合适却最终被排除在外，常见原因是在治疗一系列患者时，没有详细说明采用的手术入路；使用了已经过时的手术技术（如椎板下钢丝）；对损伤的类型缺乏详细描述；或者包含了不同的研究群体，如非创伤性的情况或者是下颈椎以外的损伤。 文献检索。通过广泛综合的文献检索来挑选出任何具有英文摘要的文章里可能包含的研究。采用的检索词包括：颈椎，脊柱骨折，骨折内固定，颈椎椎体。分别对MEDLINE (1966到2006年11月) 和 EMBASE (1980到2006年11月)电子数据库同时进行医学主题词和关键词的检索，对CINAH