远隔节段跳跃型胸椎管狭窄症一期手术与分期手术的临床疗效观察
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摘要
目的 :回顾性研究远隔节段跳跃型胸椎管狭窄症的一期手术和分期手术治疗效果,为远隔节段跳跃型胸椎管狭窄症手术治疗提供依据。方法:回顾性分析2005年1月~2016年6月期间于我院治疗的远隔节段跳跃型胸椎管狭窄症患者34例,其中男18例,女16例,确诊时年龄37~80岁,平均52.8±10.9岁。病程1~120个月,平均22.5±28.1个月。根据患者的手术方案,将患者分为一期手术与分期手术组,比较两组患者术前及末次随访JOA评分及改善情况、手术情况(出血量、手术时间)、术后住院时长及并发症情况。结果:一期手术组15例;分期手术组19例。随访时间为11~113个月,平均40.0±29.7个月。两组JOA评分术前分别为4.7±1.1分、4.3±2.2分,末次随访时分别为8.4±1.1分、7.5±2.0分,平均改善率分别为(57.1±21.6)%、(46.0±25.8)%,两组间上述参数比较差异均无统计学意义。两组平均手术时长分别为166.8±50.3min、326.6±121.8min,手术平均失血量分别为484.0±286.1ml、1694.2±1532.4ml,两组手术时间及手术失血量均有统计学差异(P<0.01)。两组术后平均总住院时间分别为7.5±4.0d、19.9±8.7d,有统计学差异(P<0.01)。根据手术疗效评定标准,一期手术组术后优良率60.0%,分期手术组术后优良率52.6%,两组优良率比较无统计学差异。分期手术组当中,手术间隔1年以内和1年以上,术后效果无明显统计学差异。术后共14例(41.2%)发生脑脊液漏(cerebrospinal fluid leakage,CSFL),其中一期手术组5例,分期手术组9例。共有10例(29.4%)发生其他方面并发症,其中一期手术组4例,分期手术组6例。两组在CSFL及其他并发症发生率方面统计学无明显差异。结论:远隔节段跳跃型胸椎管狭窄症患者可采用一期手术和分期手术。对于涉及的手术复杂程度低和身体状态好者,可选择一期手术;反之,建议分期手术。按上述既定方案,两组术后疗效及并发症发生率均无明显区别。
Objectives: To compare outcomes after one stage decompression of the skip type noncontiguous thoracic spine stenosis versus staged operations. Methods: 34 patients with skip type symptomatic noncontiguous thoracic spine stenosis who underwent surgical decompression in the author′ s hospital between January2005 and June 2016 were retrospectively reviewed. They were grouped by the general physical conditions and complexities of the lesions, and the patient′s preoperative and postoperative JOA score and the JOA improvement ratio, the surgical procedures(operation time, combined estimated blood loss, etc), and complications were evaluated. Results: 15 cases were treated with one stage operation, while 19 patients were accomplished by staged operation. The follow-up time was 11-120 months with an average of 40.0 ±29.7 months. Preoperative JOA scores of these two groups were 4.7 ±1.1 and 4.3±2.2 respectively, while 8.4 ±1.1 and 7.5 ±2.0 at final follow-up respectively, with an average recovery rate of(57.1 ±21.6)% and(46.0±25.8)% respectively, however,there was no statistical significance of the above-mentioned. Combined intraoperative blood loss in staged group and simultaneous group was 484.0±286.1 ml and 1694.2±1532.4 ml, respectively. And total operative time in these two groups was 166.8±50.3 min and 326.6±121.8 min and postoperative hospital stay days was 7.5±4.0 days and 19.9±8.7 days, respectively. There were statistical significances with respect of the total operation time, combined intraoperative blood loss and postoperative hospital stay days. According to the clinical outcome grading for recovery rate, the fine rate of these two groups was 60.0% and 52.6% respectively, however,there was no statistical significance. After statistical analysis, the surgical outcome of those whose operation intervals Iess than 1 year was not significantly better than those of more than 1 year. 11 cases(41.2%) were complicated with cerebrospinal fluid leakage(CSFL), including 5 cases of simultaneous group and 9 cases of staged group, while 10 cases(29.4%) were noted with other complications, including 4 cases of simultaneous group and 6 cases of staged group. However, there is no statistical significance with the respect to the complications. Conclusions: It is suggested that the single stage procedure should be for those patients with simple surgeries and good physical condition, otherwise, the staged procedure is recommended. Once the surgical options were selected, there was no difference in postoperative clinical efficacy and rate of the complications between the two groups.
Objectives: To compare outcomes after one stage decompression of the skip type noncontiguous thoracic spine stenosis versus staged operations. Methods: 34 patients with skip type symptomatic noncontiguous thoracic spine stenosis who underwent surgical decompression in the author′ s hospital between January2005 and June 2016 were retrospectively reviewed. They were grouped by the general physical conditions and complexities of the lesions, and the patient′s preoperative and postoperative JOA score and the JOA improvement ratio, the surgical procedures(operation time, combined estimated blood loss, etc), and complications were evaluated. Results: 15 cases were treated with one stage operation, while 19 patients were accomplished by staged operation. The follow-up time was 11-120 months with an average of 40.0 ±29.7 months. Preoperative JOA scores of these two groups were 4.7 ±1.1 and 4.3±2.2 respectively, while 8.4 ±1.1 and 7.5 ±2.0 at final follow-up respectively, with an average recovery rate of(57.1 ±21.6)% and(46.0±25.8)% respectively, however,there was no statistical significance of the above-mentioned. Combined intraoperative blood loss in staged group and simultaneous group was 484.0±286.1 ml and 1694.2±1532.4 ml, respectively. And total operative time in these two groups was 166.8±50.3 min and 326.6±121.8 min and postoperative hospital stay days was 7.5±4.0 days and 19.9±8.7 days, respectively. There were statistical significances with respect of the total operation time, combined intraoperative blood loss and postoperative hospital stay days. According to the clinical outcome grading for recovery rate, the fine rate of these two groups was 60.0% and 52.6% respectively, however,there was no statistical significance. After statistical analysis, the surgical outcome of those whose operation intervals Iess than 1 year was not significantly better than those of more than 1 year. 11 cases(41.2%) were complicated with cerebrospinal fluid leakage(CSFL), including 5 cases of simultaneous group and 9 cases of staged group, while 10 cases(29.4%) were noted with other complications, including 4 cases of simultaneous group and 6 cases of staged group. However, there is no statistical significance with the respect to the complications. Conclusions: It is suggested that the single stage procedure should be for those patients with simple surgeries and good physical condition, otherwise, the staged procedure is recommended. Once the surgical options were selected, there was no difference in postoperative clinical efficacy and rate of the complications between the two groups.
引文
1.Hou X,Sun C,Liu X,et al.Clinical features of thoracic spinal stenosis-associated myelopathy[J].Clin Spine Surg,2014,29(2):86-89.
2 .Aizawa T,Sato T,Sasaki H,et al.Results of surgical treatment for thoracic myelopathy:minimum 2-year follow-up study in 132 patients[J].J Neurosurg Spine,2007,7(1):13-20.
3 .Ando K,Imagama S,Kobayashi K,et al.Comparative study of surgical treatment and nonsurgical follow up for thoracic ossification of the posterior longitudinal ligament:radiological and clinical evaluation[J].Spine(Phila Pa 1976),2017,42(6):407-410.
4 .Bydon M,Gokaslan Z.Minimally invasive approaches in the treatment of thoracic disk herniation[J].World Neurosurg,2014,81(5-6):717-718.
5 .Chen CF,Chang MC,Liu CL,et al.Acute noncontiguous multiple-level thoracic disc herniations with myelopathy:a case report[J].Spine(Phila Pa 1976),2004,29(8):E157-E160.
6 .Feng F,Sun C,Chen Z.Progress on clinical characteristics and identification of location of thoracic ossification of the ligamentum flavum[J].Orthop Surg,2015,7(2):87-96.
7 .Takenaka S,Kaito T,Hosono N,et al.Neurological manifestations of thoracic myelopathy[J].Arch Orthop Trauma Surg,2014,134(7):903-912.
8 .Wang H,Ma L,Xue R,et al.The incidence and risk factors of postoperative neurological deterioration after posterior decompression with or without instrumented fusion for thoracic myelopathy[J].Medicine(Baltimore),2016,95(49):e5519.
9 .Aizawa T,Sato T,Tanaka Y,et al.Thoracic myelopathy in Japan:epidemiological retrospective study in Miyagi Prefecture during 15 years[J].Tohoku J Exp Med,2006,210(3):199-208.
10 .Gao R,Yuan W,Yang L,et al.Clinical features and surgical outcomes of patients with thoracic myelopathy caused by multilevel ossification of the ligamentum flavum[J].Spine J,2013,13(9):1032-1038.
11 .Guo JJ,Luk KD,Karppinen J,et al.Prevalence,distribution,and morphology of ossification of the ligamentum flavum:a population study of one thousand seven hundred thirty-six magnetic resonance imaging scans[J].Spine,2010,35(1):51-56.
12 .Tong JW,Chan AP,Cheung K.Compressive thoracic myelopathy caused by combined ossification of the posterior longitudinal ligament and ossification of the ligamentumflavum:a report of four cases and a literature review[J].Journal of Orthopaedics Trauma&Rehabilitation,2014,18(1):41-43.
13 .Matsumoto M,Toyama Y,Chikuda H,et al.Outcomes of fusion surgery for ossification of the posterior longitudinal ligament of the thoracic spine:a multicenter retrospective survey[J].J Neurosurg Spine,2011,15(4):380-385.
14 .Onishi E,Yasuda T,Yamamoto H,et al.Outcomes of surgical treatment for thoracic myelopathy:a single-institutional study of 73 patients[J].Spine(Phila Pa 1976),2016,41(22):E1356-E1363.
15 .Li M,Meng H,Du J,et al.Management of thoracic myelopathy caused by ossification of the posterior longitudinal ligament combined with ossification of the ligamentum flavum:a retrospective study[J].Spine J,2012,12(12):1093-1102.
16 .Ting W,Chunyan D,Xiujun Z,et al.Surgical strategies for thoracic myelopathy due to ossification of ligamentumflavum:a technical note based on radiological type[J].Turk Neurosurg,2017,Jun 20.[Epub ahead of print].
17 .Wang H,Wei F,Long H,et al.Surgical outcome of thoracic myelopathy caused by ossification of ligamentum flavum[J].J Clin Neurosci,2017,45:83-88.
18 .Zhong Z,Wu Q,Meng T,et al.Clinical outcomes after decompressive laminectomy for symptomatic ossification of ligamentum flavum at the thoracic spine[J].J Clin Neurosci,2016,28:77-81.
19 .Li F,Chen Q,Xu K.Surgical treatment of 40 patients with thoracic ossification of the ligamentumflavum[J].J Neurosurg Spine,2006,4(3):191-197.
20 .Min JH,Jang JS,Lee SH.Clinical results of ossification of the posterior longitudinal ligament(OPLL)of the thoracic spine treated by anterior decompression[J].J Spinal Disord Tech,2008,21(2):116-119.
21 .Yu S,Wu D,Li F,et al.Surgical results and prognostic factors for thoracic myelopathy caused by ossification of ligamentumflavum:posterior surgery by laminectomy[J].Acta Neurochir(Wien),2013,155(7):1169-1177.
22 .Baaj AA,Smith DA,Vale FL,et al.Surgical approaches to thoracic ossification of the posterior longitudinal ligament[J].J Clin Neurosci,2012,19(3):349-351.
23 .Gay CW,Bishop MD,Beres JL.Clinical presentation of a patient with thoracic myelopathy at a chiropractic clinic[J].J Chiropr Med,2012,11(2):115-120.
24 .Miyakoshi N,Shimada Y,Suzuki T,et al.Factors related to long-term outcome after decompressive surgery for ossification of the ligamentum flavum of the thoracic spine[J].J Neurosurg,2003,99(3 Suppl):251-256.
25 .Hitchon PW,Abode-Iyamah K,Dahdaleh NS,et al.Risk factors and outcomes in thoracic stenosis with myelopathy:a single center experience[J].Clin Neurol Neurosurg,2016,147:84-89.
26 .Chen Y,Chen D,Wang X,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.
27 .Kawaguchi Y,Yasuda T,Seki S,et al.Variables affecting postsurgical prognosis of thoracic myelopathy caused by ossification of the ligamentum flavum[J].Spine J,2013,13(9):1095-1107.
28 .Li WJ,Guo SG,Sun ZJ,et al.Multilevel thoracic ossification of ligamentum flavum coexisted with/without lumbar spinal stenosis:staged surgical strategy and clinical outcomes[J].BMC Musculoskelet Disord,2015,16:206.
29 .Hu P,Yu M,Liu X,et al.Cerebrospinal fluid leakage after surgeries on the thoracic spine:a review of 362 cases[J].Asian Spine J,2016,10(3):472-479.
30 .Yamazaki M,Okawa A,Fujiyoshi T,et al.Posterior decompression with instrumented fusion for thoracic myelopathy caused by ossification of the posterior longitudinal ligament[J].Eur Spine J,2010,19(5):691-698.
31 .Koda M,Furuya T,Okawa A,et al.Mid-to long-term outcomes of posterior decompression with instrumented fusion for thoracic ossification of the posterior longitudinal ligament[J].J Clin Neurosci,2016,27:87-90.
2 .Aizawa T,Sato T,Sasaki H,et al.Results of surgical treatment for thoracic myelopathy:minimum 2-year follow-up study in 132 patients[J].J Neurosurg Spine,2007,7(1):13-20.
3 .Ando K,Imagama S,Kobayashi K,et al.Comparative study of surgical treatment and nonsurgical follow up for thoracic ossification of the posterior longitudinal ligament:radiological and clinical evaluation[J].Spine(Phila Pa 1976),2017,42(6):407-410.
4 .Bydon M,Gokaslan Z.Minimally invasive approaches in the treatment of thoracic disk herniation[J].World Neurosurg,2014,81(5-6):717-718.
5 .Chen CF,Chang MC,Liu CL,et al.Acute noncontiguous multiple-level thoracic disc herniations with myelopathy:a case report[J].Spine(Phila Pa 1976),2004,29(8):E157-E160.
6 .Feng F,Sun C,Chen Z.Progress on clinical characteristics and identification of location of thoracic ossification of the ligamentum flavum[J].Orthop Surg,2015,7(2):87-96.
7 .Takenaka S,Kaito T,Hosono N,et al.Neurological manifestations of thoracic myelopathy[J].Arch Orthop Trauma Surg,2014,134(7):903-912.
8 .Wang H,Ma L,Xue R,et al.The incidence and risk factors of postoperative neurological deterioration after posterior decompression with or without instrumented fusion for thoracic myelopathy[J].Medicine(Baltimore),2016,95(49):e5519.
9 .Aizawa T,Sato T,Tanaka Y,et al.Thoracic myelopathy in Japan:epidemiological retrospective study in Miyagi Prefecture during 15 years[J].Tohoku J Exp Med,2006,210(3):199-208.
10 .Gao R,Yuan W,Yang L,et al.Clinical features and surgical outcomes of patients with thoracic myelopathy caused by multilevel ossification of the ligamentum flavum[J].Spine J,2013,13(9):1032-1038.
11 .Guo JJ,Luk KD,Karppinen J,et al.Prevalence,distribution,and morphology of ossification of the ligamentum flavum:a population study of one thousand seven hundred thirty-six magnetic resonance imaging scans[J].Spine,2010,35(1):51-56.
12 .Tong JW,Chan AP,Cheung K.Compressive thoracic myelopathy caused by combined ossification of the posterior longitudinal ligament and ossification of the ligamentumflavum:a report of four cases and a literature review[J].Journal of Orthopaedics Trauma&Rehabilitation,2014,18(1):41-43.
13 .Matsumoto M,Toyama Y,Chikuda H,et al.Outcomes of fusion surgery for ossification of the posterior longitudinal ligament of the thoracic spine:a multicenter retrospective survey[J].J Neurosurg Spine,2011,15(4):380-385.
14 .Onishi E,Yasuda T,Yamamoto H,et al.Outcomes of surgical treatment for thoracic myelopathy:a single-institutional study of 73 patients[J].Spine(Phila Pa 1976),2016,41(22):E1356-E1363.
15 .Li M,Meng H,Du J,et al.Management of thoracic myelopathy caused by ossification of the posterior longitudinal ligament combined with ossification of the ligamentum flavum:a retrospective study[J].Spine J,2012,12(12):1093-1102.
16 .Ting W,Chunyan D,Xiujun Z,et al.Surgical strategies for thoracic myelopathy due to ossification of ligamentumflavum:a technical note based on radiological type[J].Turk Neurosurg,2017,Jun 20.[Epub ahead of print].
17 .Wang H,Wei F,Long H,et al.Surgical outcome of thoracic myelopathy caused by ossification of ligamentum flavum[J].J Clin Neurosci,2017,45:83-88.
18 .Zhong Z,Wu Q,Meng T,et al.Clinical outcomes after decompressive laminectomy for symptomatic ossification of ligamentum flavum at the thoracic spine[J].J Clin Neurosci,2016,28:77-81.
19 .Li F,Chen Q,Xu K.Surgical treatment of 40 patients with thoracic ossification of the ligamentumflavum[J].J Neurosurg Spine,2006,4(3):191-197.
20 .Min JH,Jang JS,Lee SH.Clinical results of ossification of the posterior longitudinal ligament(OPLL)of the thoracic spine treated by anterior decompression[J].J Spinal Disord Tech,2008,21(2):116-119.
21 .Yu S,Wu D,Li F,et al.Surgical results and prognostic factors for thoracic myelopathy caused by ossification of ligamentumflavum:posterior surgery by laminectomy[J].Acta Neurochir(Wien),2013,155(7):1169-1177.
22 .Baaj AA,Smith DA,Vale FL,et al.Surgical approaches to thoracic ossification of the posterior longitudinal ligament[J].J Clin Neurosci,2012,19(3):349-351.
23 .Gay CW,Bishop MD,Beres JL.Clinical presentation of a patient with thoracic myelopathy at a chiropractic clinic[J].J Chiropr Med,2012,11(2):115-120.
24 .Miyakoshi N,Shimada Y,Suzuki T,et al.Factors related to long-term outcome after decompressive surgery for ossification of the ligamentum flavum of the thoracic spine[J].J Neurosurg,2003,99(3 Suppl):251-256.
25 .Hitchon PW,Abode-Iyamah K,Dahdaleh NS,et al.Risk factors and outcomes in thoracic stenosis with myelopathy:a single center experience[J].Clin Neurol Neurosurg,2016,147:84-89.
26 .Chen Y,Chen D,Wang X,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.
27 .Kawaguchi Y,Yasuda T,Seki S,et al.Variables affecting postsurgical prognosis of thoracic myelopathy caused by ossification of the ligamentum flavum[J].Spine J,2013,13(9):1095-1107.
28 .Li WJ,Guo SG,Sun ZJ,et al.Multilevel thoracic ossification of ligamentum flavum coexisted with/without lumbar spinal stenosis:staged surgical strategy and clinical outcomes[J].BMC Musculoskelet Disord,2015,16:206.
29 .Hu P,Yu M,Liu X,et al.Cerebrospinal fluid leakage after surgeries on the thoracic spine:a review of 362 cases[J].Asian Spine J,2016,10(3):472-479.
30 .Yamazaki M,Okawa A,Fujiyoshi T,et al.Posterior decompression with instrumented fusion for thoracic myelopathy caused by ossification of the posterior longitudinal ligament[J].Eur Spine J,2010,19(5):691-698.
31 .Koda M,Furuya T,Okawa A,et al.Mid-to long-term outcomes of posterior decompression with instrumented fusion for thoracic ossification of the posterior longitudinal ligament[J].J Clin Neurosci,2016,27:87-90.