背景：脊髓型颈椎病是脊柱外科常见的颈椎退行性疾病，具有较高的致残率；手术减压是阻止疾病继续发展的最有效方法，然而患者术后常伴有感觉和运动功能障碍等残余神经症状，目前临床上对于脊髓型颈椎病患者术后神经功能恢复的药物治疗方案仍不明确。

目的：探讨甲钴胺联合鼠神经生长因子对脊髓型颈椎病术后神经功能恢复的疗效。

方法：2017年6月至2018年9月徐州医科大学附属医院收治的脊髓型颈椎病患者82例，随机分为研究组41例和对照组41例；对照组患者给予鼠神经生长因子注射液，研究组患者在对照组基础上加用甲钴胺注射液，所有患者治疗2周，分别记录2组患者术前及术后的症状和体征，利用颈椎功能障碍指数评分(Neck Disability Index，NDI)和日本骨科协会评估治疗分数量表(Japanese Orthopedic Association，JOA)进行术后神经功能评估。

结果与结论：在术后1，3，6个月及1年时，两组患者的NDI评分均较术前降低(P＜ 0.05)，JOA评分均较术前升高(P＜ 0.05)；治疗6个月和1年时，研究组NDI评分显著低于对照组(P＜ 0.05)，JOA评分显著高于对照组(P＜ 0.05)。结果表明甲钴胺联合鼠神经生长因子有助于脊髓型颈椎病患者术后神经功能的恢复，且效果优于单用鼠神经生长因子治疗。

BACKGROUND:Cervical spondylotic myelopathy is a common degenerative disease of the cervical spine in spinal surgery. Surgical decompression is the most effective method to prevent the further development of the disease. However, patients are often accompanied by residual neurological symptoms such as sensory and motor dysfunction after surgery. Currently, the drug treatment for postoperative neurological recovery of patients is still unclear clinically.

OBJECTIVE:To investigate the effect of mecobalamine combined with mouse nerve growth factor on the recovery of nerve function after cervical spondylotic myelopathy surgery.

METHODS:A total of 82 cases of cervical spondylotic myelopathy from June 2017 to September 2018 in the Affiliated Hospital of Xuzhou Medical University were enrolled in this study. All the patients were randomly divided into observation group and control group with 41 cases in each. Mouse nerve growth factor injection was applied to the control group, and mecobalamine injection was added to the research group. All the patients were treated for 2 symptoms and signs in both groups were respectively recorded before and after the treatment, and postoperative residual neurological symptoms were evaluated by Neck Disability Index (NDI) scores and Japanese Orthopedic Association scores.

RESULTS AND CONCLUSION:At 1 month, 3 months, 6 months and 1 year after the operation, the NDI scores of the two groups were lower than those before the treatment, and the JOA scores were both getting higher than those before the treatment. The NDI scores in the observation group at 6 months and 1 year after the operation were significantly lower than those in the control group, and as well, the Japanese Orthopedic Association scores were significantly higher than those in the control group. These findings indicate that the combination of mecobalamine and mouse nerve growth factor is helpful to the recovery of nerve function in patients after cervical spondylotic myelopathy surgery, and the effect is better than that of mouse nerve growth factor alone.

0 引言 Introduction

脊髓型颈椎病是一种由于颈椎慢性退行性病变导致颈椎椎管进行性狭窄，从而引起脊髓受压、感觉系统和运动系统功能紊乱的临床综合征[1-2]，通常表现为感觉异常、精细运动功能逐渐丧失、运动无力等[3]。前路、后路或前后入路联合的手术干预可以给脊髓减压，重建颈椎的稳定性，尽可能挽救并保存患者的神经功能[4]，但部分患者术后仍伴有残余神经症状，常表现为术前症状未完全缓解，如肢体麻木、疼痛和感觉异常[5]，极大影响患者术后的生存质量。颈椎功能障碍指数评分(Neck Disability Index，NDI)可以全面评估患者颈部疼痛及相关症状，分析对患者日常生活的影响，具有较好的重复性和综合性[6]；日本骨科协会评估治疗分数量表(Japanese Orthopedic Association，JOA)在脊髓型颈椎病患者普遍受累的上肢运动、下肢运动、感觉和膀胱功能4个方面进行综合评定，目前在临床上广泛应用于评估和量化脊髓型颈椎病患者功能残疾等级[7]。

甲钴胺是维生素B12的活性形式，1962年GUEST等[8]首次发现其含有生物活性的烷基钴胺；作为一种四配位辅酶，其中心的钴原子在β位上连接的是甲基，见图1。通过甲基转换反应促进核酸代谢，参与胸腺嘧啶的合成过程，促进轴索再生及髓鞘的形成，修复被损害的神经组织[9]。甲钴胺的缺乏与重要的神经病理特别是周围神经病变密切相关[10]，会抑制维生素B12依赖的蛋氨酸合成酶导致S-腺苷蛋氨酸/S-腺苷同型半胱氨酸比值下降，从而损害蛋氨酸循环中的蛋氨酸保护酶，影响髓鞘中的甲基化反应，阻碍神经正常生理功能[11]；在临床上，甲钴胺通过促进损伤神经的再生和拮抗谷氨酸诱导的神经毒性，发挥神经保护作用[12]，已被广泛用于治疗各种原因引起的周围神经病变。鼠神经生长因子是目前发现最早的神经生长因子类型[13]，它是从小鼠颌下腺中提取的一种生物活性蛋白，与人类的神经生长因子有着极高的同源性，两者的生物学效应相似，通过对靶细胞基因表达进行调控，加速损伤神经的再生[14]，同时通过调控内源性神经生长因子的合成，促进轴突再生和髓鞘形成[15]，目前在临床上被广泛应用于周围神经损伤的治疗。