节段性椎管后壁整块切除术治疗结节型黄韧带骨化症所致胸椎脊髓病效果
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摘要
目的探讨节段性椎管后壁整块切除术治疗结节型黄韧带骨化症所致胸椎脊髓病的效果和安全性。方法收集2009年1月—2014年12月采用节段性椎管后壁整块切除术治疗结节性黄韧带骨化所致胸椎脊髓病病人28例。术中对每个病变节段行椎板、部分关节突关节、骨化黄韧带的整块切除,硬膜发生骨化时,则以尖刀片进行锐性分离。术后随访观察病人的手术效果和并发症发生情况。结果本组病人均顺利完成手术,手术时间(225.9±93.6)min,术中出血量(571.3±443.3)mL。28例病人共切除48个骨化节段,其中单节段11例,双节段14例,三节段3例。除2例病人于术后21d症状改善、1例病人术后出现短暂脊髓病症状加重外,余25例病人术后即刻症状得到改善。本组4例病人发生脑脊液漏,经对症治疗后痊愈。本组病人术后随访时间24~42个月,平均30.6个月,随访结束时病人的改良日本骨科学会(mJOA)评分为(7.9±1.2)分,与术前mJOA评分(3.8±1.2)分比较,差异有统计学意义(t=12.926,P<0.01)。随访结束时疗效为优2例,良20例,可6例,优良率为78.6%。结论节段性椎管后壁整块切除术治疗结节型黄韧带骨化症所致胸椎脊髓病安全有效。
Objective To determine the efficacy and safety of segmental en bloc resection of the posterior wall of the spinal canal for treating severe thoracic myelopathy caused by tuberous ossification of the ligamentum flavum(OLF). Methods Twenty-eight patients who underwent segmental en bloc resection of the posterior wall of the spinal canal for severe thoracic myelopathy caused by tuberous OLF between January 2009 and December 2014 were included in this study.The laminae,partial facet joint,and ossified ligamentum flavum from each affected vertebral segment were resected en bloc.Ossified dura mater was removed by a sharp blade if present.All patients were followed up to determine the efficacy of surgery and incidence of complications.Results All patients had successful surgery,with a duration of(225.9±93.6)min and blood loss of(571.3±443.3)mL.A total of 48 ossified vertebral segments were resected from the 28 patients,including 11 cases of single segments,14 cases of double segments,and 3cases of triple segments.All patients had immediate postoperative neurological improvement except 2who remained unchanged for 21 days,and 1who experienced transient postoperative neurological deterioration for 5days.Four of the patients experienced transient postoperative cerebrospinal fluid(CSF)leakage,which subsequently went away after conservative treatment.Patients were followed up for 24-42 months(mean 30.6 months),and the mean modified Japanese Orthopaedic Association(mJOA)score was significantly higher after surgery(7.9±1.2vs 3.8±1.2,t=12.926,P<0.01).The surgical outcome was excellent in 2patients,good in 20 patients,and fair in 6patients.The rate of excellent and good surgical outcomes was 78.6%. Conclusion Segmental en bloc resection of the posterior wall of the spinal canal is a safe and effective treatment for tuberous OLF.
Objective To determine the efficacy and safety of segmental en bloc resection of the posterior wall of the spinal canal for treating severe thoracic myelopathy caused by tuberous ossification of the ligamentum flavum(OLF). Methods Twenty-eight patients who underwent segmental en bloc resection of the posterior wall of the spinal canal for severe thoracic myelopathy caused by tuberous OLF between January 2009 and December 2014 were included in this study.The laminae,partial facet joint,and ossified ligamentum flavum from each affected vertebral segment were resected en bloc.Ossified dura mater was removed by a sharp blade if present.All patients were followed up to determine the efficacy of surgery and incidence of complications.Results All patients had successful surgery,with a duration of(225.9±93.6)min and blood loss of(571.3±443.3)mL.A total of 48 ossified vertebral segments were resected from the 28 patients,including 11 cases of single segments,14 cases of double segments,and 3cases of triple segments.All patients had immediate postoperative neurological improvement except 2who remained unchanged for 21 days,and 1who experienced transient postoperative neurological deterioration for 5days.Four of the patients experienced transient postoperative cerebrospinal fluid(CSF)leakage,which subsequently went away after conservative treatment.Patients were followed up for 24-42 months(mean 30.6 months),and the mean modified Japanese Orthopaedic Association(mJOA)score was significantly higher after surgery(7.9±1.2vs 3.8±1.2,t=12.926,P<0.01).The surgical outcome was excellent in 2patients,good in 20 patients,and fair in 6patients.The rate of excellent and good surgical outcomes was 78.6%. Conclusion Segmental en bloc resection of the posterior wall of the spinal canal is a safe and effective treatment for tuberous OLF.
引文
[1]INAMASU J,GUIOT B H.A review of factors predictive of surgical outcome for ossification of the ligamentum flavum of the thoracic spine[J].J Neurosurg Spine,2006,5(2):133-139.
[2]LI K K,CHUNG O M,CHANG Y P,et al.Myelopathy caused by ossification of ligamentum flavum[J].Spine(Phila Pa 1976),2002,27(12):E308-E312.
[3]LI F,CHEN Q,XU K.Surgical treatment of 40patients with thoracic ossification of the ligamentum flavum[J].J Neurosurg Spine,2006,4(3):191-197.
[4]OKADA K,OKA S,TOHGE K,et al.Thoracic myelopathy caused by ossification of the ligamentum flavum.Clinicopathologic study and surgical treatment[J].Spine(Phila Pa 1976),1991,16(3):280-287.
[5]XU R,SCIUBBA D M,GOKASLAN Z L,et al.Ossification of the ligamentum flavum in a Caucasian man[J].J Neurosurg Spine,2008,9(5):427-437.
[6]VAN OOSTENBRUGGE R J,HERPERS M J,DE KRUIJK JR.Spinal cord compression caused by unusual location and extension of ossified ligamenta flava in a Caucasian male.A case report and literature review[J].Spine(Phila Pa 1976),1999,24(5):486-488.
[7]PASCAL-MOUSSELARD H,SMADJA D,CABRE P,et al.Ossification of the ligamenta flava with severe myelopathy in a black patient.A case report[J].Spine(Phila Pa 1976),1998,23(14):1607-1608.
[8]AL-ORAINY I A,KOLAWOLE T.Ossification of the ligament flavum[J].Eur J Radiol,1998,29(1):76-82.
[9]JIA L S,CHEN X S,ZHOU S Y,et al.En bloc resection of lamina and ossified ligamentum flavum in the treatment of thoracic ossification of the ligamentum flavum[J].Neurosurgery,2010,66(6):1181-1186.
[10]冯法博,孙垂国,陈仲强,等.“揭盖式”胸椎管后壁切除术治疗单节段胸椎黄韧带骨化症的疗效及其影响因素[J].中国脊柱脊髓杂志,2014,24(7):585-592.
[11]NISHIURA I,ISOZUMI T,NISHIHARA K,et al.Surgical approach to ossification of the thoracic yellow ligament[J].Surg Neurol,1999,51(4):368-372.
[12]YOUNG W F,BARON E.Acute neurologic deterioration after surgical treatment for thoracic spinal stenosis[J].J Clin Neurosci,2001,8(2):129-132.
[13]YANG Z,XUE Y,DAI Q,et al.Upper facet joint en bloc resection for the treatment of thoracic myelopathy caused by ossification of the ligamentum flavum[J].J Neurosurg Spine,2013,19(1):81-89.
[14]ZHAO Y,XUE Y,SHI N,et al.The CT and intraoperative observation of pedicel-ossification tunnel in 151cases of thoracic spinal stenosis from ossification of ligamentum flavum[J].Eur Spine J,2014,23(6):1325-1331.
[15]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.
[16]SMITH D E,GODERSKY J C.Thoracic spondylosis:an unusual cause of myelopathy[J].Neurosurgery,1987,20(4):589-593.
[17]赵华健,雪原,李建鹏,等.胸椎黄韧带骨化的病理单元及分层八边手术法[J].中华骨科杂志,2010,30(11):1053-1058.
[18]赵莹,史念珂,雪原,等.经根黄通道减压手术治疗连续型胸椎黄韧带骨化症[J].中国脊柱脊髓杂志,2014,24(7):593-598.
[19]雪原,王沛,姜建新,等.利用根黄通道减压治疗胸椎黄韧带骨化合并脊髓病[J].中华骨科杂志,2007,27(1):10-14.
[20]李文菁,赵宇.胸椎黄韧带骨化症合并硬脊膜骨化的研究进展[J].中华骨科杂志,2013,33(6):670-673.
[21]孙景城,王沛,马信龙,等.胸椎管狭窄症硬膜骨化的手术策略[J].中华骨科杂志,2011,31(1):39-43.
[22]ANDO K,IMAGAMA S,ITO Z,et al.Predictive factors for a poor surgical outcome with thoracic ossification of the ligamentum flavum by multivariate analysis:a multicenter study[J].Spine(Phila Pa 1976),2013,38(12):E748-E754.
[23]SUN X,SUN C,LIU X,et al.The frequency and treatment of dural tears and cerebrospinal fluid leakage in 266patients with thoracic myelopathy caused by ossification of the ligamentum flavum[J].Spine(Phila Pa 1976),2012,37(12):E702-E707.
[24]MUTHUKUMAR N.Dural ossification in ossification of the ligamentum flavum:apreliminary report[J].Spine(Phila Pa1976),2009,34(24):2654-2661.
[25]AIZAWA T,SATO T,SASAKI H,et al.Thoracic myelopathy caused by ossification of the ligamentum flavum:clinical features and surgical results in the Japanese population[J].J Neurosurg Spine,2006,5(6):514-519.
[2]LI K K,CHUNG O M,CHANG Y P,et al.Myelopathy caused by ossification of ligamentum flavum[J].Spine(Phila Pa 1976),2002,27(12):E308-E312.
[3]LI F,CHEN Q,XU K.Surgical treatment of 40patients with thoracic ossification of the ligamentum flavum[J].J Neurosurg Spine,2006,4(3):191-197.
[4]OKADA K,OKA S,TOHGE K,et al.Thoracic myelopathy caused by ossification of the ligamentum flavum.Clinicopathologic study and surgical treatment[J].Spine(Phila Pa 1976),1991,16(3):280-287.
[5]XU R,SCIUBBA D M,GOKASLAN Z L,et al.Ossification of the ligamentum flavum in a Caucasian man[J].J Neurosurg Spine,2008,9(5):427-437.
[6]VAN OOSTENBRUGGE R J,HERPERS M J,DE KRUIJK JR.Spinal cord compression caused by unusual location and extension of ossified ligamenta flava in a Caucasian male.A case report and literature review[J].Spine(Phila Pa 1976),1999,24(5):486-488.
[7]PASCAL-MOUSSELARD H,SMADJA D,CABRE P,et al.Ossification of the ligamenta flava with severe myelopathy in a black patient.A case report[J].Spine(Phila Pa 1976),1998,23(14):1607-1608.
[8]AL-ORAINY I A,KOLAWOLE T.Ossification of the ligament flavum[J].Eur J Radiol,1998,29(1):76-82.
[9]JIA L S,CHEN X S,ZHOU S Y,et al.En bloc resection of lamina and ossified ligamentum flavum in the treatment of thoracic ossification of the ligamentum flavum[J].Neurosurgery,2010,66(6):1181-1186.
[10]冯法博,孙垂国,陈仲强,等.“揭盖式”胸椎管后壁切除术治疗单节段胸椎黄韧带骨化症的疗效及其影响因素[J].中国脊柱脊髓杂志,2014,24(7):585-592.
[11]NISHIURA I,ISOZUMI T,NISHIHARA K,et al.Surgical approach to ossification of the thoracic yellow ligament[J].Surg Neurol,1999,51(4):368-372.
[12]YOUNG W F,BARON E.Acute neurologic deterioration after surgical treatment for thoracic spinal stenosis[J].J Clin Neurosci,2001,8(2):129-132.
[13]YANG Z,XUE Y,DAI Q,et al.Upper facet joint en bloc resection for the treatment of thoracic myelopathy caused by ossification of the ligamentum flavum[J].J Neurosurg Spine,2013,19(1):81-89.
[14]ZHAO Y,XUE Y,SHI N,et al.The CT and intraoperative observation of pedicel-ossification tunnel in 151cases of thoracic spinal stenosis from ossification of ligamentum flavum[J].Eur Spine J,2014,23(6):1325-1331.
[15]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.
[16]SMITH D E,GODERSKY J C.Thoracic spondylosis:an unusual cause of myelopathy[J].Neurosurgery,1987,20(4):589-593.
[17]赵华健,雪原,李建鹏,等.胸椎黄韧带骨化的病理单元及分层八边手术法[J].中华骨科杂志,2010,30(11):1053-1058.
[18]赵莹,史念珂,雪原,等.经根黄通道减压手术治疗连续型胸椎黄韧带骨化症[J].中国脊柱脊髓杂志,2014,24(7):593-598.
[19]雪原,王沛,姜建新,等.利用根黄通道减压治疗胸椎黄韧带骨化合并脊髓病[J].中华骨科杂志,2007,27(1):10-14.
[20]李文菁,赵宇.胸椎黄韧带骨化症合并硬脊膜骨化的研究进展[J].中华骨科杂志,2013,33(6):670-673.
[21]孙景城,王沛,马信龙,等.胸椎管狭窄症硬膜骨化的手术策略[J].中华骨科杂志,2011,31(1):39-43.
[22]ANDO K,IMAGAMA S,ITO Z,et al.Predictive factors for a poor surgical outcome with thoracic ossification of the ligamentum flavum by multivariate analysis:a multicenter study[J].Spine(Phila Pa 1976),2013,38(12):E748-E754.
[23]SUN X,SUN C,LIU X,et al.The frequency and treatment of dural tears and cerebrospinal fluid leakage in 266patients with thoracic myelopathy caused by ossification of the ligamentum flavum[J].Spine(Phila Pa 1976),2012,37(12):E702-E707.
[24]MUTHUKUMAR N.Dural ossification in ossification of the ligamentum flavum:apreliminary report[J].Spine(Phila Pa1976),2009,34(24):2654-2661.
[25]AIZAWA T,SATO T,SASAKI H,et al.Thoracic myelopathy caused by ossification of the ligamentum flavum:clinical features and surgical results in the Japanese population[J].J Neurosurg Spine,2006,5(6):514-519.