摘要
目的探讨后路一期胸椎管后壁切除、局限性后纵韧带骨化块切除联合去后凸治疗胸椎多节段后纵韧带骨化症(ossification of the posterior longitudinal ligament,OPLL)的安全性与有效性。方法自2012年08月至2016年08月共采用此技术治疗胸椎多节段OPLL患者31例,其中获得2年以上随访的29例患者纳入研究。男9例,女20例;年龄32-65岁,平均(48.5±7.1)岁。后纵韧带骨化节段数量为3-11节段,平均(6.5±2.2)节段;切除椎板节段数量为4-13节段,平均(7.9±2.5)节段。其中26例合并胸椎黄韧带骨化症。采用"揭盖法"将OPLL对应节段椎管后壁切除,在靠近后凸顶点及对脊髓压迫最重部位的OPLL骨化块进行限局性切除;然后经椎间隙楔形截骨减轻后凸畸形程度。术后随访主要观察指标为脊髓功能改善情况及影像学参数测量,统计学分析采用配对设计t检验。结果27例患者采用单节段局限性切除,2例采用双节段局限性切除。手术时间131-423 min,平均(245.2±75.1)min;术中出血量300-6 000 ml,平均(1 307.9±1 457.7)ml。术后随访时间25-69个月,平均(40.2±14.9)个月。术前胸椎管狭窄节段范围内后凸Cobb角平均28.7°±9.6°,术后即刻平均17.3°±8.6°,与术前比较差异有统计学意义,后凸角度平均减少11.4°±3.5°;末次随访时平均22.3°±10.3°,与术后即刻比较差异有统计学意义,平均减少7.4°±3.1°。切除后纵韧带骨化块长度平均(11.3±3.9)mm,后纵韧带骨化块切除部位的相邻椎体后缘短缩长度平均(5.0±3.0)mm(0.4-13. 8 mm)。术前平均日本骨科协会(Japanese Orthopaedic Association Scores,JOA)评分(11分法)为(4.3±2.2)分(1-9分),末次随访时为(9.3±2.3)分(3-11分),与术前比较差异有统计学意义。症状缓解率中位数为85.7% (-100%-100%),优良率为89.7%。术后6例患者术后出现一过性神经症状加重,最终均恢复至优于术前;1例患者发生持续性截瘫;19例发生脑脊液漏,均经保守治疗后痊愈。结论对于胸椎多节段后纵韧带骨化患者,一期后路胸椎椎管后壁切除、局限性后纵韧带骨化块切除联合去后凸手术可获得明显的脊髓功能改善,且术后并发截瘫的风险低,是一种安全、有效的手术方式。
Objective To investigate the safety and effectiveness of posterior approach laminectomy combined with localized resection of ossified posterior longitudinal ligament and dekyphosis for multilevel ossification of the posterior longitudinal ligament (OPLL) in the thoracic spine.Methods Thirty-one cases of thoracic multilevel OPLL was treated with this new technique between August of 2012 and August of 2016. Twenty-nine among the 31 cases were successfully followed up more than two years. Among these 29 cases, 9 were male and the other 20 were female, with an average age of 48.5±7.1 years. The average segment number of OPLL was 6.5±2.2 (range, 3-11). The average segment number of laminectomy was 7.9±2.5 (range, 4-13). There were 26 cases combined with ossification of the ligamentum flavum (OLF). Posterior approach laminectomy combined with localized resection of OPLL and dekyphosis for multilevel OPLL in the thoracic spine was applied to all cases. Firstly, en-bloc laminectomy was performed to all the segments of OPLL. Then the nearest segment of ossification to the kyphotic apex and the most stenotic level was selected and limitedly resected. Finally, wedge-shaped osteotomy was conducted to decrease the kyphosis. The outcomes including recovery rate of myelopathy and the radiological changes were recorded during the post-operative follow-up. Single group pre and post analysis was conducted by using paired t-test.Results Twenty-seven cases underwent one-level circumferential decompression, and the other two case underwent two-level localized resection of the ossified posterior longitudinal ligament. The average operation time was 245.2±75.1 min (range, 131-423 min). The average blood loss was 1 307.9±1 457.7 ml(range, 300-6 000 ml). The average follow-up time was 40.2±14.9 months (range, 25-69 months). The kyphotic angle of the stenotic segments decreased 11.4°±3.5° averagely after the surgery, from pre-operative 28.7°±9.6° to post-operative 17.3°±8.6°. The decreased kyphotic angle was 7.4°±3.1° at the final follow-up with an average kyphotic angel of 22.3°±10.3°. The average length of the resected ossified posterior longitudinal ligament was 11.3±3.9 mm, and the average shortening length of the spinal column was 5.0±3.0 mm (range, 0.4-13.8 mm). The pre-operative Japanese Orthopedic Association (JOA) score was 4.3±2.2 averagely (range, 1-9), and the final JOA score increased to 9.3±2.3 (rang, 3-11). The average recover rate was 85.7% (range, -100% to 100%), and the rate of excellent or good was 89.7%. Among the 29 cases, 6 cases occurred post-operative transient deterioration and regained a satisfactory recovery eventually;one case occurred post-operative paraplegia and never recovered;19 cases occurred post-operative cerebrospinal fluid leakage and healed under conservative treatment.Conclusion For the thoracic multilevel OPLL, one-stage posterior approach laminectomy combined with localized resection of the ossified posterior longitudinal ligament and dekyphosis can significantly improve the outcomes of the myelopathy with low rate of post-operative paraplegia. Therefore, this new surgery technique is a safe and effective treatment for multilevel OPLL in thoracic spine.
作者
孙垂国
陈仲强
李危石
侯晓飞
郭昭庆
齐强
曾岩
钟沃权
Sun Chuiguo;Chen Zhongqiang;Li Weishi;Hou Xiaofei;Guo Zhaoqing;Qi Qiang;Zeng Yan;Zhong Woquan(Department of Orthopaedics,Peking University Third Hospital,100191 China;Department of Orthopaedics,Xuanwu Hospital, Capital Medical University,100053 China)
出处
《中华骨科杂志》
CAS
CSCD
北大核心
2019年第4期193-200,共8页
Chinese Journal of Orthopaedics
基金
国家自然科学基金(81572101).
关键词
胸椎
后纵韧带骨化
椎管狭窄
减压术
外科
Thoracic vertebrae
Ossification of posterior longitudinal ligament
Spinal stenosis
Decompression, surgical
