颈椎前路手术治疗后纵韧带骨化症行后纵韧带切除的疗效评价
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摘要
目的：探讨颈椎前路椎体次全切除减压手术中行后纵韧带切除的临床意义。
方法：回顾性分析了近6年(2005年1月-2010年10月)山东中医药大学附属医院脊柱骨科,因颈椎后纵韧带骨化症行前路椎体次全切除治疗的患者,术后通过电话、信件、门诊等方式进行随访,符合纳入标准且有完整资料者共44例。其中A组共21例,行颈椎前路椎体次全切除加钛网植骨融合内固定术；B组共23例,行颈椎前路椎体次全切除加后纵韧带切除加钛网植骨融合内固定术。术后随访6-72个月,根据日本骨科学会JOA[1] (Japanese Orthopedics Association)评分对手术前后脊髓功能评分,对两组术式术后的改善率进行比较及疗效评价。
结果：对后纵韧带保留组与切除组病例的性别、年龄、病程、病变程度、住院时间、手术时间、术前JOA评分进行比较,均无显著性差异,而两组手术所有病例术后脊髓功能或神经症状均得到了一定程度的改善,但两组间改善率的比较却存在显著性差异,后纵韧带切除组患者的术后JOA评分、优良率、改善率较保留组高。
结论：在严格掌握手术适应症及科学、准确操作的基础上,切除骨化增生的后纵韧带比采用”漂浮法”保留后纵韧带能得到更充分的减压,神经功能改善率更佳,远期疗效也明显优于后者。
Objective:to discuss the clinic significance of treament for Ossification of posterior Longitudinal Ligament by anterior surgery with anterior cervical vertebral subtotal vertebrectomy and posterior longitudinal ligament excision.
Method:Analysing the cases of cervical ossification of the posterior longitudinal ligament during six years (from Junary,2005 to October,2010) treated by anterior cervical vertebral subtotal vertebrectomy in Spine Department, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, the author collected 44 patients with complete date and meeting the criteria after the surgery by means of telephone, mail and out-patient and then divided them into group A and group B. Group A includes 21 cases of anterior cervical vertebral subtotal vertebrectomy with synmesh fixation implanted under the bone, and group B includes 23 cases of anterior cervical vertebral subtotal vertebrectomy and posterior longitudinal ligament excision with synmesh fixation implanted under the bone. The follow-up period was 6-72 months, in which the author compared the improvement rate of the both groups and evaluated the two curative effect according to pre- and postoperative spinal cord JOA scores. Meanwhile, the patients' age, the course of disease, the degree of pathologicalprocess were also analysed in the article.
Result:comparison of sex, age, courseofdisease, pathologicalprocess, length of stay,number of treatment and preoperative JOA scores shows no difference between longitudinal ligament reainment and excision. However, the spinal cord function and neurological symptoms of the both two groups after surgery were improved to some extent. Moreover, there exists marked difference of improvement rate between two group:after surgery,the JOA score,goodness and improvement rate of patients with posterior longitudinal ligament excision (group A) are higher than the retained ones (groupB).Conclusion:Under the premise of the scientific and accurate operating with strictly mastering indications, to treat the patient with cervical vertebra whose spinal cord is compressed because of proliferation of hypertrophic posterior longitudinal ligament with anterior cervical vertebral subtotal vertebrectomy and posterior longitudinal ligament excision, and complete decompression, may receive a better clinical efficacy.
方法：回顾性分析了近6年(2005年1月-2010年10月)山东中医药大学附属医院脊柱骨科,因颈椎后纵韧带骨化症行前路椎体次全切除治疗的患者,术后通过电话、信件、门诊等方式进行随访,符合纳入标准且有完整资料者共44例。其中A组共21例,行颈椎前路椎体次全切除加钛网植骨融合内固定术；B组共23例,行颈椎前路椎体次全切除加后纵韧带切除加钛网植骨融合内固定术。术后随访6-72个月,根据日本骨科学会JOA[1] (Japanese Orthopedics Association)评分对手术前后脊髓功能评分,对两组术式术后的改善率进行比较及疗效评价。
结果：对后纵韧带保留组与切除组病例的性别、年龄、病程、病变程度、住院时间、手术时间、术前JOA评分进行比较,均无显著性差异,而两组手术所有病例术后脊髓功能或神经症状均得到了一定程度的改善,但两组间改善率的比较却存在显著性差异,后纵韧带切除组患者的术后JOA评分、优良率、改善率较保留组高。
结论：在严格掌握手术适应症及科学、准确操作的基础上,切除骨化增生的后纵韧带比采用”漂浮法”保留后纵韧带能得到更充分的减压,神经功能改善率更佳,远期疗效也明显优于后者。
Objective:to discuss the clinic significance of treament for Ossification of posterior Longitudinal Ligament by anterior surgery with anterior cervical vertebral subtotal vertebrectomy and posterior longitudinal ligament excision.
Method:Analysing the cases of cervical ossification of the posterior longitudinal ligament during six years (from Junary,2005 to October,2010) treated by anterior cervical vertebral subtotal vertebrectomy in Spine Department, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, the author collected 44 patients with complete date and meeting the criteria after the surgery by means of telephone, mail and out-patient and then divided them into group A and group B. Group A includes 21 cases of anterior cervical vertebral subtotal vertebrectomy with synmesh fixation implanted under the bone, and group B includes 23 cases of anterior cervical vertebral subtotal vertebrectomy and posterior longitudinal ligament excision with synmesh fixation implanted under the bone. The follow-up period was 6-72 months, in which the author compared the improvement rate of the both groups and evaluated the two curative effect according to pre- and postoperative spinal cord JOA scores. Meanwhile, the patients' age, the course of disease, the degree of pathologicalprocess were also analysed in the article.
Result:comparison of sex, age, courseofdisease, pathologicalprocess, length of stay,number of treatment and preoperative JOA scores shows no difference between longitudinal ligament reainment and excision. However, the spinal cord function and neurological symptoms of the both two groups after surgery were improved to some extent. Moreover, there exists marked difference of improvement rate between two group:after surgery,the JOA score,goodness and improvement rate of patients with posterior longitudinal ligament excision (group A) are higher than the retained ones (groupB).Conclusion:Under the premise of the scientific and accurate operating with strictly mastering indications, to treat the patient with cervical vertebra whose spinal cord is compressed because of proliferation of hypertrophic posterior longitudinal ligament with anterior cervical vertebral subtotal vertebrectomy and posterior longitudinal ligament excision, and complete decompression, may receive a better clinical efficacy.
引文
[1]日本骨科学会.颈部脊椎病性脊髓症治疗成绩判定基准[J].日本整形外科学会杂志,1975；(99)：122.
[2]袁泽农,张佐伦,刘立成等,脊髓型颈椎病合并后纵韧带退变的病因和病理变化.中国矫形外科杂志,2001,8(10)：941.
[3]Go to S, Kita T. Long term follow up evaluation of surgery for ossification of the posterior longitudinal ligament [J]. Spine,1995,20:2247-2511.
[4]Iwasakim, Sakaura H, Fujimori T, et al. Updates of ossification of posterior longitudinal ligament. Surgical cutcome of anterior decomp ression and fusion for the ossification of posterior longitudinal ligament of the cervical spine:a comparison with that of laminoplasty [J]. Clin Calcium,2009,10:1486-1492.
[5]Fraser JF,Hartl R. Anterior approaches to fusion of the cervical spine:a meta analysis of fusion rates[J]. J Neurosurg Spine,2007.4:298-303.
[6]Hwang SL,Lee KS,Su YF,et al. Anterior corpectomy with iliac bone fusion or discectomy with interbody titanium cage fusion for multilevel cervical degenerated disc disease [J]. J Spinal Disord Tech,2007,8:565-570.
[7]第二届颈椎病专题座谈会纪要[J].中华外科杂志,1993；31(8)：472-476
[8]陈德玉,陈宇,王新伟,等1颈椎后纵韧带骨化症的手术治疗及疗效分析[J].中国矫形外科杂志,2006,1：9-111.
[9]金大地.现代脊柱外科手术学[M].第2版.北京：人民军医出版社,2001：386-387.
[10]秦海江,聂新富等,脊髓型颈椎病手术疗效分析,实用骨科杂志,2007,13(5)：302—303.
[11]刘建波,吕会强等,后纵韧带切除与保留在脊髓型颈椎病前路减压术中的疗效比较,宁夏医学杂志,2010,32(9),784-785.
[12]王新伟,陈德玉,赵定麟等.切除与不切除后纵韧带颈椎减压术后的MRI观察.中国脊柱脊髓杂志,2003,12(10)：597.
[13]李智钢,侯铁胜等,脊髓型颈椎病肥厚后纵韧带的病理学观察及临床意义,颈腰痛杂志,2005,26(6)：417—420.
[14]韩德韬,张昌茂,汤发强,等.颈后纵韧带张力性压迫症及手术治疗(附50例析).骨与 关节损伤杂志,2002,17：89-90.
[15]Herkow itz HH, Garfin SR, Balderston RA, et al. The Spine[M].4th ed. Philadelphia: Saunders,1999.29-74.
[16]陈德玉,贾连顺等,增生后纵韧带切除扩大减压治疗脊髓型颈椎病,中国矫形外科杂志.2001,8(8)：738—739.
[17蒋振松,张佐伦等,后纵韧带切除在脊髓型颈椎病前路手术中的应用,中国矫形外科杂志,2003,11(2)：77—80.
[18]Smith MD,Bp;esta MJ et,Postopeative cerebrospinal fluid fi stula associated with erosion of the dura[J],BONE JOINT SURG(AM),1992,74(2):270-277.
[1]Choi S,Lee,SH,Lee JY,et al. Factors affecting prognosis of patients who underwent corpectomy and fusion for treatment of cervical ossification of the posterior longitudinal ligament:analysis of 47 patients[J]. Spinal Disord Tech,2005, 18(4):309-314.
[2]Chen Y,Chen DY,Wang XW,et al.Anterior corpectomy and fusion for severe ossification of posterior longitudinal ligament in the cervical spine[J]. International Orthopaedics(SICOT),2009,33(2):477-482.
[3]贾连顺.脊柱外科学[M].北京：人民军医出版社,2007：757-811.
[4]Matsunaga S, Sakou T, Taketomi E, et al.The natural conuse of myelopathy by ossification of the posterior longitudinal ligament in the cervical spine[J].Clin Orthop,1994,305:168-177.
[5]Yamaura I, Fuji K, Saitoh S, et al.Clinical study of ossification of the posterior longitudinal ligament (in Japanese) [J].Seikeigeka,1974,25 (6):253-267.
[6]Fujiyoshi T,Yamazaki M,Kawabe J,et al.A new concept for making decisions regarding the surgical approach for cervical ossification of the posterior longitudinal ligament:the K-line[J].Spine,2008,33 (26):990-993.
[7]Mizuno J,Nakagawa H.Ossified posterior longitudinal ligament:management strategies and outcomes[J].Spine,2006;6(6)282-288.
[8]Yukawa. compression myelopathy:predictor of surgical outcomes[J].Spin e,2007, 32(15):1675-1679.
[9]Motoki I,Shin ya O,Akira M.Surgical strategy for cervical myelopathy due to ossification of the posterior longitudinal ligament[J]. Spine,2007,32(6):647-653.
[10]侯树勋.脊柱外科学[M].北京：人民军医出版社,2005：722-723.
[11]Motoki I.Surgical strategy for cervical myelopathy due to OPLL[J].Spine, 2007(32):654-660.
[12]陈德玉,陈宇,王新伟,等.颈椎后纵韧带骨化症的手术治疗及疗效分析[J].中国矫形外科杂志,2006,14(1)：9-11.
[13]陈德玉,陈宇,卢旭华等.前路多节段椎体次全切除治疗严重颈椎后纵韧带骨化症[J].中华医学杂志,2009,89(31)：2163-2167.
[14]陈宇,陈德玉,王新伟,等.严重颈椎后纵韧带骨化症前路和后路手术比较[J].中华骨科杂志,2008,28(9)：705-709.
[15]Nakase H,Park YS,Kimura H,et al.Complications and long-term follow-up results in titanium mesh cage reconstruction after cervical corpectomy[J].Spinal Disord Tech,2006; 19(5):353-357.
[16]赵定麟,主编.脊柱外科学.第1版.上海：上海科学技术文献出版社,1996.280。
[17]袁文,王新伟,贾连顺等,颈椎病手术治疗的相关问题探讨,中国脊柱脊髓杂志,2006,16(5)：325-329.
[18]Smith MD,Emery SE,Dudley A,et al.Vertebral artery.injury during anterior decompression of the cervical spine.J Bone JointsurgBr,1993;75(3):410-413.
[19]刘郑生,王岩,等.前路漂浮法治疗颈椎后纵韧带骨化症初步报告[J].中国外科矫形杂志,2004；11：822-824.
[20]史峰军,刘长胜,张勇,等.骨化灶游离前移治疗颈椎后纵韧带骨化症[J].中华骨科杂志.2004；24(12)：723-727.
[21]侯勇,聂林,等.人工颈椎间盘置换术在后纵韧带骨化症中的应用[J].中国矫形外科杂志,2008；16(23)：1771-1773.
[22]Lu JJ.Cervical laminectomy:technique[J].Neurosurgery,2007;60(1) 149-153.
[23]Jain SK,Salunke PS,Vyas KH,et al.Multisegmental cervical ossification of the posterior longitudinal ligament:anterior vs posterior approach [J].Neurol India,2005,53(3):283-285.
[24]顾宇彤,贾连顺.颈椎后纵韧带骨化症手术治疗的进展[J].脊柱外科杂志,2003；1(6)：354-357.
[25]元虎,陈继良,等.改良Z形椎板成形术治疗颈椎后纵韧带骨化症[J].中国矫形外科杂志,2008,16(7)：504-506.
[26]Iwasaki M,Okuda S,Miyauchi A,et al.Surgical strategy for cervical myelopathy due to ossification of the posterior longitudinal ligament. Part 1:Clinical results and limitations of laminoplasty [J]. Spine,2007; 32(6):647-653.
[27]Noboru H,Hironobu S,Katsumasa M,et al.Prospective trial of C3-6 laminoplasty for multisegmental cord compression[J]. Clin Orthop Surg.2004;39(5):659-665.
[28]Masaki Y,Yamazaki M,Okawa A,et al.An analysis of factors causing poor surgical outcome in patients with cervical myelopathy due to ossification of the posterior longitudinal ligament:anterior decompression with spinal fusion versus laminoplasty[J]. Spinal Disord Tech,2007,20(1):7-13.
[29]Iwasaki M,Okuda S,Miyauchi A.et al.Surgical strategy for cervical myelopathy due to ossification of the posterior ligament:part 1:clinical results and limitations of laminoplasty[J].Spine.2007,32:647.
[30]李永军,于俊叶,张宇晨,等.后前路联合手术治疗重型颈椎后纵韧带骨化症[J].中国脊柱脊髓杂志,2008,18(2)：103-107.
[31]徐展望,张建新.Ⅰ期前后路联合入路脊髓减压病灶切除内固定治疗颈椎后纵韧带骨化症[J].中华创伤杂志,2005；21(8)：595-597.
[32]吕振木,申勇,徐英进,等.后前路联合入路治疗重症脊髓型颈椎病[J].中国矫形外科杂志.2007；15(5)：344-346.
[2]袁泽农,张佐伦,刘立成等,脊髓型颈椎病合并后纵韧带退变的病因和病理变化.中国矫形外科杂志,2001,8(10)：941.
[3]Go to S, Kita T. Long term follow up evaluation of surgery for ossification of the posterior longitudinal ligament [J]. Spine,1995,20:2247-2511.
[4]Iwasakim, Sakaura H, Fujimori T, et al. Updates of ossification of posterior longitudinal ligament. Surgical cutcome of anterior decomp ression and fusion for the ossification of posterior longitudinal ligament of the cervical spine:a comparison with that of laminoplasty [J]. Clin Calcium,2009,10:1486-1492.
[5]Fraser JF,Hartl R. Anterior approaches to fusion of the cervical spine:a meta analysis of fusion rates[J]. J Neurosurg Spine,2007.4:298-303.
[6]Hwang SL,Lee KS,Su YF,et al. Anterior corpectomy with iliac bone fusion or discectomy with interbody titanium cage fusion for multilevel cervical degenerated disc disease [J]. J Spinal Disord Tech,2007,8:565-570.
[7]第二届颈椎病专题座谈会纪要[J].中华外科杂志,1993；31(8)：472-476
[8]陈德玉,陈宇,王新伟,等1颈椎后纵韧带骨化症的手术治疗及疗效分析[J].中国矫形外科杂志,2006,1：9-111.
[9]金大地.现代脊柱外科手术学[M].第2版.北京：人民军医出版社,2001：386-387.
[10]秦海江,聂新富等,脊髓型颈椎病手术疗效分析,实用骨科杂志,2007,13(5)：302—303.
[11]刘建波,吕会强等,后纵韧带切除与保留在脊髓型颈椎病前路减压术中的疗效比较,宁夏医学杂志,2010,32(9),784-785.
[12]王新伟,陈德玉,赵定麟等.切除与不切除后纵韧带颈椎减压术后的MRI观察.中国脊柱脊髓杂志,2003,12(10)：597.
[13]李智钢,侯铁胜等,脊髓型颈椎病肥厚后纵韧带的病理学观察及临床意义,颈腰痛杂志,2005,26(6)：417—420.
[14]韩德韬,张昌茂,汤发强,等.颈后纵韧带张力性压迫症及手术治疗(附50例析).骨与 关节损伤杂志,2002,17：89-90.
[15]Herkow itz HH, Garfin SR, Balderston RA, et al. The Spine[M].4th ed. Philadelphia: Saunders,1999.29-74.
[16]陈德玉,贾连顺等,增生后纵韧带切除扩大减压治疗脊髓型颈椎病,中国矫形外科杂志.2001,8(8)：738—739.
[17蒋振松,张佐伦等,后纵韧带切除在脊髓型颈椎病前路手术中的应用,中国矫形外科杂志,2003,11(2)：77—80.
[18]Smith MD,Bp;esta MJ et,Postopeative cerebrospinal fluid fi stula associated with erosion of the dura[J],BONE JOINT SURG(AM),1992,74(2):270-277.
[1]Choi S,Lee,SH,Lee JY,et al. Factors affecting prognosis of patients who underwent corpectomy and fusion for treatment of cervical ossification of the posterior longitudinal ligament:analysis of 47 patients[J]. Spinal Disord Tech,2005, 18(4):309-314.
[2]Chen Y,Chen DY,Wang XW,et al.Anterior corpectomy and fusion for severe ossification of posterior longitudinal ligament in the cervical spine[J]. International Orthopaedics(SICOT),2009,33(2):477-482.
[3]贾连顺.脊柱外科学[M].北京：人民军医出版社,2007：757-811.
[4]Matsunaga S, Sakou T, Taketomi E, et al.The natural conuse of myelopathy by ossification of the posterior longitudinal ligament in the cervical spine[J].Clin Orthop,1994,305:168-177.
[5]Yamaura I, Fuji K, Saitoh S, et al.Clinical study of ossification of the posterior longitudinal ligament (in Japanese) [J].Seikeigeka,1974,25 (6):253-267.
[6]Fujiyoshi T,Yamazaki M,Kawabe J,et al.A new concept for making decisions regarding the surgical approach for cervical ossification of the posterior longitudinal ligament:the K-line[J].Spine,2008,33 (26):990-993.
[7]Mizuno J,Nakagawa H.Ossified posterior longitudinal ligament:management strategies and outcomes[J].Spine,2006;6(6)282-288.
[8]Yukawa. compression myelopathy:predictor of surgical outcomes[J].Spin e,2007, 32(15):1675-1679.
[9]Motoki I,Shin ya O,Akira M.Surgical strategy for cervical myelopathy due to ossification of the posterior longitudinal ligament[J]. Spine,2007,32(6):647-653.
[10]侯树勋.脊柱外科学[M].北京：人民军医出版社,2005：722-723.
[11]Motoki I.Surgical strategy for cervical myelopathy due to OPLL[J].Spine, 2007(32):654-660.
[12]陈德玉,陈宇,王新伟,等.颈椎后纵韧带骨化症的手术治疗及疗效分析[J].中国矫形外科杂志,2006,14(1)：9-11.
[13]陈德玉,陈宇,卢旭华等.前路多节段椎体次全切除治疗严重颈椎后纵韧带骨化症[J].中华医学杂志,2009,89(31)：2163-2167.
[14]陈宇,陈德玉,王新伟,等.严重颈椎后纵韧带骨化症前路和后路手术比较[J].中华骨科杂志,2008,28(9)：705-709.
[15]Nakase H,Park YS,Kimura H,et al.Complications and long-term follow-up results in titanium mesh cage reconstruction after cervical corpectomy[J].Spinal Disord Tech,2006; 19(5):353-357.
[16]赵定麟,主编.脊柱外科学.第1版.上海：上海科学技术文献出版社,1996.280。
[17]袁文,王新伟,贾连顺等,颈椎病手术治疗的相关问题探讨,中国脊柱脊髓杂志,2006,16(5)：325-329.
[18]Smith MD,Emery SE,Dudley A,et al.Vertebral artery.injury during anterior decompression of the cervical spine.J Bone JointsurgBr,1993;75(3):410-413.
[19]刘郑生,王岩,等.前路漂浮法治疗颈椎后纵韧带骨化症初步报告[J].中国外科矫形杂志,2004；11：822-824.
[20]史峰军,刘长胜,张勇,等.骨化灶游离前移治疗颈椎后纵韧带骨化症[J].中华骨科杂志.2004；24(12)：723-727.
[21]侯勇,聂林,等.人工颈椎间盘置换术在后纵韧带骨化症中的应用[J].中国矫形外科杂志,2008；16(23)：1771-1773.
[22]Lu JJ.Cervical laminectomy:technique[J].Neurosurgery,2007;60(1) 149-153.
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