后纵韧带骨化症患者术前颈椎矢状位参数对术后疗效的影响

目的:分析后纵韧带骨化症(ossification of posterior longitudinal ligament,OPLL)患者术前颈椎矢状位参数对行单开门椎管扩大成形术患者术后疗效的影响.方法:回顾性分析2015年1月～2017年12月间,于我院诊断为OPLL并行颈后路单开门椎管扩大成形术的患者共181例.统...     

颈椎后路单开门联合椎间孔切开术治疗颈椎后纵韧带骨化的疗效分析

目的 :探讨颈椎后路单开门联合椎间孔切开术在治疗颈椎后纵韧带骨化中临床疗效。方法 :对2011年9月至2015年9月收治的45例颈椎后纵韧带骨化症患者进行回顾性研究,其中男26例,女19例;年龄28~71岁,平均53.6岁;24例采用后路单开门椎管扩大成形联合椎间孔切开术治疗(联合椎间孔切开组),21例采用单纯后路单开门椎管扩大成形术治疗(单纯单开门组)。比较两组患者的手术时间、术中出血、C_5神经麻痹及轴性症状发生情况;观察两组患者手术前后的JOA评分并计算神经功能改善率;分析两组患者的NDI评分及颈椎Cobb角的变化。结果:两组患者术后均获得随访,时间12~24个月,其中联合椎间孔切开组平均随访时间为(14.3±2.8)个月,单纯单开门组为(13.7±3.1)个月,两组比较差异无统计学意义(P0.05)。两组患者在手术时间、术中出血方面差异均无统计学意义(P0.05)。两组患者术后JOA评分较术前均明显提高(P0.05),但两组改善率比较差异无统计学意义(P0.05)。末次随访时联合椎间孔切开组和单纯单开门组的NDI评分分别为13.6±1.8和16.1±2.4,两组比较差异有统计学意义(P0.05);C_5神经麻痹发生率分别为4.2%(1/24),28.6%(6/21),两组差异有统计学意义(P0.05);轴性症状发生率分别为8.3%(2/24),9.5%(2/21),两组差异无统计学意义(P0.05)。末次随访时两组患者的颈椎Cobb角与术前比较差异无统计学意义(P0.05),组间比较差异也无统计学意义(P0.05)。结论:颈椎后路单开门扩大椎管成形联合椎间孔切开术不仅能够充分的解除脊髓压迫,亦可扩大椎间孔,松解受压神经根,缓解根性症状,同时在预防C_5神经根麻痹等并发症的出现亦取得了良好的效果,是一种治疗伴有神经根症状的颈椎后纵韧带骨化症有效方法。     

Anterior surgery in selective patients with massive ossification of posterior longitudinal ligament of cervical spine: technical note

Study design  

The study includes case series, technical note and review of literature.     

Cervical ossification of the posterior longitudinal ligament: Anterior versus posterior approach

Background:

The optimal approach to provide satisfactory decompression and minimize complications for ossification of the posterior longitudinal ligament (OPLL) involving multiple levels (3 levels or more) remains controversial. The purpose of this study was to compare the results of two surgical approaches for cervical OPLL involving multiple levels; anterior direct decompression and fixation, and posterior indirect decompression and fixation. We present a retrospective review of 56 cases followed at a single Institution.

Materials and Methods:

We compared patients of multiple levels cervical OPLL that were treated at a single institution either with anterior direct decompression and fixation or with posterior indirect decompression and fixation. The clinical records of the patients with a minimum duration of follow-up of 2 years were reviewed. The associated complications were recorded.

Results:

Fifty-six patients constitute the clinical material. 26 cases were treated by anterior corpectomy and fixation and 30 cases received posterior laminectomy and fixation. The two populations were similar. It was found that both anterior and posterior decompression and fixation can achieve satisfactory outcomes, and posterior surgery was accomplished in a shorter period of time with lesser blood loss. Although patients had comparable preoperative Japanese Orthopaedics Association (JOA) scores, those with a canal occupancy by OPLL more than 50% and managed anteriorly had better outcomes. However, for those with more severe stenosis, anterior approach was more difficult and associated with higher risks and complications. Despite its limitations in patients with high occupancy OPLLs, through the multiple level laminectomy, posterior fixation can achieve effective decompression, maintaining or restoring stability of the cervical spine, and thereby improving neural outcome and preventing the progression of OPLL.

Conclusions:

The posterior indirect decompression and fixation has now been adopted as the primary treatment for cervical OPLL involving multiple levels with the canal occupancy by OPLL <50% at our institution because this approach leads to significantly less implant failures. Those patients with the occupancy ≥50% managed with anterior approach surgeries had better outcomes, but approach was more difficult and associated with higher risk and complications.     

Anterior approaches to cervical spondylosis and ossification of the posterior longitudinal ligament: review of operative technique and assessment of 65 multilevel circumferential procedures

BACKGROUND

Multilevel anterior cervical corpectomy with fusion (ACF) offers direct resection of spondylostenosis and ossification of the posterior longitudinal ligament (OPLL) with immediate stabilization. Ideal candidates for multilevel ACF include younger patients (<65 years of age), or older individuals (>65 years of age) with loss or reversal of the cervical lordosis (kyphosis).

METHODS

Sixty-five patients, averaging 56 years of age and including 40 males and 25 females, with multilevel MR- and CT-documented spondylostenosis and OPLL were studied. Preoperatively, patients exhibited moderate to severe myelopathy (average Nurick grade 3.8), and were managed with 2- to 4-level ACF with posterior wiring and fusion (PWF) procedures with halo application. The first 22 patients had no plate instrumentation, the next 22 had constrained (Orion) plates applied followed sequentially by the application of 13 semi-constrained (Atlantis) plates, and finally, 8 dynamic (ABC Aesculap) plates.

RESULTS

Patients improved an average of three postoperative Nurick grades. None exhibited new cord injuries, whereas three had transient C5 root paresis. Graft/plate or vertebral fracture with extrusion were observed in 3/22 nonplated patients, 2/22 constrained-plated patients, 3/13 semi-constrained-plated patients, and 0/8 dynamic-plated patients. Fusion was documented on dynamic radiographs and 2D-CT or 3D-CT studies obtained 3 and 6 months postoperatively, or later where indicated.

CONCLUSIONS

Multilevel ACF/PWF offers direct resection of spondylostenosis and OPLL with immediate maximal stabilization. Thus far, no graft/plate or vertebral body fracture or extrusions have been seen with dynamic plates, whereas the absence of plating and constrained and semi-constrained plating systems have failed.     

颈椎病合并颈椎后纵韧带骨化症的前路手术治疗

目的 探讨颈椎病合并颈椎后纵韧带骨化症(OPLL)前路切除减压的方法及其临床效果.方法采用颈椎前路减压治疗颈椎病合并颈椎OPLL患者61例,其中男42例,女19例,平均57岁(45～74岁).术前明确诊断颈椎病合并OPLL者49例,术中发现合并有OPLL者12例.OPLL椎管狭窄率32%～70%,平均52%.神经功能JOA评分术前4～14分,平均9.6分.手术在常规颈前路经椎间隙或椎体次全切除减压的基础上,切除骨化后纵韧带彻底减压.结果 本组41例患者采用前路椎体次全切除减压,6例经椎间隙扩大减压,14例采用椎体次全切除结合经椎间隙减压的手术方式.所有患者随访6个月～3年,平均16个月.术后JOA评分8～16分,平均12.8分,神经功能恢复率25.0%～87.5%,平均65.2%.5例患者术后并发脑脊液漏,经保守治疗后均获得痊愈,无1例出现脊髓功能损害加重.结论 颈椎病合并颈椎OPLL增加了手术难度和风险,在颈椎前路常规减压的基础上再将骨化的后纵韧带切除,保证了前路减压的彻底性,可提高手术治疗效果.     

A systematic review of complications in cervical spine surgery for ossification of the posterior longitudinal ligament

Background context

Surgical management of ossification of the posterior longitudinal ligament (OPLL) is associated with complications. However, surgical complications for OPLL have not been clearly documented.

Purpose

To review and summarize the incidence of surgical complications of OPLL in the cervical spine and evaluate the impact of surgical approach (anterior or posterior), year of study publication, follow-up duration, and the surgical outcome on complication incidence.

Study design

Systematic review.

Methods

An English literature review was conducted especially on surgical complications of cervical OPLL. The incidence of complications was statistically summarized, with its correlation to surgical approaches, year of study publications, follow-up duration, and the surgical outcome was statistically evaluated.

Results

Twenty-seven retrospective studies, including a total of 1,558 patients, were reviewed. The overall incidence of surgical complications of cervical OPLL was 21.8%. Neurologic deficit (8.3%, overall rate), cerebrospinal fluid leakage (CFL) (5.1%), axial pain (3.5%), and implant complications (3.5%) were relatively common. The incidence of complications for posterior approach was not statistically different from those for anterior procedures. However, with regard to individual complication, C5 palsy and axial pain occurred more frequently in patients approached posteriorly, whereas CFL, implant complications, hoarseness, dysphagia, and dyspnea appeared more common in anterior cases.

Conclusions

There is a relatively high incidence of surgical complications for cervical OPLL compared with other cervical degeneration diseases. It is, therefore, necessary for surgeons to take into consideration the risk of surgical complications when communicating with patients for decision making and to alert complications during or after surgical procedures.     

颈椎后纵韧带骨化症合并硬膜囊骨化的前路手术治疗

目的 探讨颈椎后纵韧带骨化症合并硬膜囊骨化的影像学表现、前路手术方法 及疗效.方法 2005年1月至2008年3月,前路手术治疗颈椎后纵韧带骨化症合并硬膜囊骨化患者13例.男11例,女2例;年龄43～72岁,平均53.6岁.骨化物分型:局限型3例,分节型2例,连续型5例,混合型3例;骨化物范围涉及1～5椎,平均2.8椎.患者均通过前路椎体次全切除术,切除骨化后纵韧带减压,术中6例患者后纵韧带骨化和硬膜囊骨化得以完全分离,硬膜囊保留完整,另7例患者硬膜囊出现不同程度撕裂或缺损.结果 8例患者术前CT横断面成像上表现为典型的"双影征",2例患者表现为整块骨化物存在中心低密度影,余3例患者表现为椎管狭窄率超过90%的严重后纵韧带骨化.术后5例患者并发脑脊液漏,其中3例经卧床休息、局部加压治疗3～5 d后愈合,另2例患者皮肤愈合后形成间歇性脑脊液囊肿,经反复穿刺抽液治疗1个月后痊愈.随访6个月～2年,平均1年,所有患者JOA评分从术前平均8.1分提高至术后平均13.2分,神经功能恢复率平均57.3%.骨化硬膜囊切除和未切除两组患者的神经功能恢复率差异无统计学意义.结论 CT三维重建检查有助于术前诊断后纵韧带骨化合并硬膜囊骨化,合并硬膜囊骨化并非前路手术的禁忌证,前路手术切除骨化后纵韧带、彻底减压是提高此类患者手术疗效的关键.     

颈椎前路减压分段融合术和后路椎管扩大成形术治疗多节段脊髓型颈椎病的病例对照研究

目的 :比较颈椎前路减压分段融合术和后路椎管扩大成形术治疗多节段脊髓型颈椎病的临床疗效。方法:对2009年7月至2012年6月收治的56例多节段脊髓型颈椎病病例进行回顾性分析,男32例,女24例;年龄42~79岁,平均(56.9±12.8)岁,病程2个月~16年,平均(10.6±3.2)年。所有患者术前经影像学检查显示有多节段颈椎间盘突出,并具有脊髓型颈椎病的临床表现。其中34例采用颈椎前路减压分段融合术(前路组),22例采用后路椎管扩大成形术(后路组)。通过影像学资料对两组患者手术前后的病变节段前柱高度和颈椎前曲度进行比较,并采用JOA评分评价手术效果。结果:两组患者无神经血管并发症发生,并获得24~36个月的随访(平均28.6个月)。前路组,术后2周时颈椎病变节段前柱高度较术前明显增高(P0.05),颈椎前曲度较术前明显降低(P0.05)。后路组,术后2周及末次随访时,病变节段前柱高度和颈椎前曲度较术前差异均无统计学意义(P0.05)。两组间在术后2周及末次随访时颈椎前曲度差异有统计学意义(P0.05)。术后两组JOA评分均出现了明显恢复,术后3个月及末次随访时,前路组明显高于后路组(P0.05),且JOA评分改善率前路组也优于后路组(P0.05)。结论:这种分段式前路融合手术可以有效地恢复颈椎前柱高度,并且与颈椎后路椎管扩大成形术相比,可以显著地改善脊髓功能,是治疗多节段脊髓型颈椎病的有效方案。     

Radiological risk factors for progression of ossification of posterior longitudinal ligament following laminoplasty

Background Context

Research shows the progression of ossification of the posterior longitudinal ligament (OPLL) following decompressive surgery for cervical myelopathy, particularly in cases presenting with continuous or mixed radiographic types. To date, no study has investigated OPLL progression within each motion segment.

前路减压植骨融合治疗胸椎后纵韧带骨化症

目的：探讨前路减压植骨融合治疗胸椎后纵韧带骨化症(OPLL)的临床疗效和适用范围。方法：1994年6月--2002年11月对20例OPLL患者采用前路减压植骨融合治疗，中胸段9例，下胸段11例；1个节段8例，2个节段6例，3个节段3例，4、5、6个节段各1例。结果：术后5例出现脑脊液漏，14例随访3个月--5年8个月，JOA评分由术前的平均3.4分提高到7．6分，植骨块无塌陷，内固定无松动。结论：前路减压植骨融合治疗胸椎后纵韧带骨化症可以取得满意的治疗结果，但对于广泛的胸椎OPLL或合并其它脊椎韧带骨化时该术式有其局限性。     

选择性颈后路单开门椎管扩大椎板成形术治疗孤立型颈椎后纵韧带骨化症的临床疗效

目的 :探讨选择性颈后路单开门椎管扩大椎板成形术治疗孤立型颈椎后纵韧带骨化症(ossification of the posterior longitudinal ligament,OPLL)的临床疗效,并与颈前路椎体次全切手术(anterior cervical corpectomy and fusion,ACCF)临床疗效进行比较。方法:回顾性分析2017年1月～2019年1月接受手术治疗且符合入组标准的40例孤立型颈椎OPLL患者的临床资料,其中行ACCF手术22例(ACCF组),行选择性颈后路单开门椎管扩大椎板成形术18例(LP组)。均获得12～24个月随访(ACCF组18.50±4.20个月,LP组18.60±4.50个月)。比较两组患者术前、术后3个月、末次随访时日本骨科协会(Japanese Orthopaedic Association,JOA)评分及颈痛视觉模拟评分(visual analogue score,VAS),比较两组患者末次随访时的神经功能改善率;比较两组患者术前、末次随访时颈椎曲度、颈椎活动度;比较两组患者手术出血量、手术时间、术后住院时间及术后并发症发...     

颈椎前路手术治疗食管型颈椎病伴后纵韧带骨化症1例报告

食管型颈椎病（ECS）是一种以进行性吞咽困难为主要症状,易误诊、漏诊的罕见疾病。多见于弥漫性特发性骨肥厚症（DISH）、强直性脊柱炎（AS）患者。60岁以上中老年人群中20% ~ 30%可出现椎前骨赘的影像学表现,但仅有1% ~ 2%可能出现颈痛、吞咽困难、呼吸困难等症状^[1]。后纵韧带骨化症（OPLL）是一种板层骨沉积的病理过程,由于后纵韧带骨化物压迫脊髓和神经根产生神经功能损伤症候群。CT检查中OPLL的发生率为18.22%;在东亚地区OPLL发生率为0.4% ~ 3.0%^[2-3]。目前,国内外对ECS合并OPLL的报道甚少,本研究对海军军医大学长征医院收治的1例采用颈椎前路手术治疗的ECS伴OPLL病例的诊治过程进行总结,报告如下。     

Bone mineral density in patients with ossification of the posterior longitudinal ligament in the cervical spine

Bone mineral density (BMD) has not been clearly determined in patients with ossification of the posterior longitudinal ligament (OPLL) in the cervical spine. BMD in patients with OPLL was measured in the third vertebral body in the lateral projection and in the distal part of the radius in the anteroposterior projection using dual-energy X-ray absorptiometry (DXA). Patients with OPLL had significantly higher BMD than healthy controls in both the lumbar spine and radius. Observing BMD by gender and age group, high BMD was recognized especially in female patients over 60 years of age. Significantly increased BMD was observed in patients with ankylosing spinal hyperostosis (ASH) in addition to OPLL. These findings suggest that patients with OPLL may tend to develop systemic hyperostosis, leading to the pathological ectopic ossification observed in OPLL. Received: July 7, 1998 / Accepted: March 17, 1999     

Anterior corpectomy versus posterior laminoplasty for multilevel cervical myelopathy: a systematic review and meta-analysis

Background

Surgical strategy for multilevel cervical myelopathy resulting from cervical spondylotic myelopathy (CSM) or ossification of posterior longitudinal ligament (OPLL) still remains controversial. There are still questions about the relative benefit and safety of direct decompression by anterior corpectomy (CORP) versus indirect decompression by posterior laminoplasty (LAMP).

Objective

To perform a systematic review and meta-analysis evaluating the results of anterior CORP compared with posterior LAMP for patients with multilevel cervical myelopathy.

Methods

Systematic review and meta-analysis of cohort studies comparing anterior CORP with posterior LAMP for the treatment of multilevel cervical myelopathy due to CSM or OPLL from 1990 to December 2012. An extensive search of literature was performed in Pubmed, Embase, and the Cochrane library. The quality of the studies was assessed according to GRADE. The following outcome measures were extracted: pre- and postoperative Japanese orthopedic association (JOA) score, neurological recovery rate (RR), surgical complications, reoperation rate, operation time and blood loss. Two reviewers independently assessed each study for quality and extracted data. Subgroup analysis was conducted according to the mean number of surgical segments.

Results

A total of 12 studies were included in this review, all of which were prospective or retrospective cohort studies with relatively low quality. The results indicated that the mean JOA score system for cervical myelopathy and the neurological RR in the CORP group were superior to those in the LAMP group when the mean surgical segments were <3, but were similar between the two groups in the case of the mean surgical segments equal to 3 or more. There was no statistical difference in the surgical complication rate between the two groups when the mean surgical segments <3, but were significantly higher incidences of surgical complications and complication-related reoperation in the CORP group compared with the LAMP group in the case of the mean surgical segments equal to 3 or more. Besides, the operation time in the CORP group was longer than that in the LAMP group, and the average blood loss was significantly more in the CORP group compared with the LAMP group.

Conclusion

Based on the results above, anterior CORP and fusion is recommended for the treatment of multilevel cervical myelopathy when the involved surgical segments were <3. Given the higher rates of surgical complications and complication-related reoperation and the higher surgical trauma associated with multilevel CORP, however, it is suggested that posterior LAMP may be the preferred method of treatment for multilevel cervical myelopathy when the involved surgical segments were equal to 3 or more. In addition, taking the limitations of this study into consideration, it was still not appropriate to draw a strong conclusion claiming superiority for CORP or LAMP. A well-designed, prospective, randomized controlled trial is necessary to provide objective data on the clinical results of both procedures.     

颈椎后纵韧带骨化症的手术治疗及疗效分析

[目的] 探讨颈椎后纵韧带骨化症（OPLL）手术治疗方法、疗效及其并发症。[方法] 对本组自2000年以来手术治疗的48例OPLL患者的临床资料进行回顾性总结分析。其中前路手术18例，后路手术30例，按照JOA评分标准判定其术后改善率，对患者术前术后X线、CT及MRI影像学资料进行比较分析，并统计手术并发症。[结果] 48例患者中合并原发性椎管狭窄23例，平均椎管狭窄率41．4％，术前MRI示脊髓信号改变者19例；前路手术平均改善率68．3％，后路手术平均改善率51．3％；术后并发脑脊液漏2例，节段性神经根麻痹5例，血肿2例。[结论] 应根据后纵韧带骨化部位、范围及椎管狭窄率选择合适手术方法，方能减少并发症，提高手术疗效。     

Spinal cord cross-sectional area during flexion and extension in the patients with cervical ossification of posterior longitudinal ligament

Purpose

The pathomechanism of cervical myelopathy due to cervical ossification of posterior longitudinal ligament (C-OPLL) remains unclear. No previous literature has quantified the influence of dynamic factors on cervical myelopathy due to C-OPLL. The purpose was to investigate the influence of dynamic factors on the spinal column in the patients with C-OPLL using CT scan after myelography (MCT).

Methods

The study included 41 patients with cervical myelopathy due to C-OPLL. An MCT was done during neck flexion and extension, and spinal cord cross-sectional areas (SCCSA) were measured at each disc level between C2/3 and C7/T1. Ossification morphology at each segment was divided into three groups, connection department, coating part, and non-connection department of OPLL group. Dynamic changes of SCCSA in each group of ossification morphology were calculated. The relationship between clinical results and SCCSA at the narrowest level was investigated.

Results

MCT showed SCCSA changes during neck extension; 7.4 ± 5.1 mm² in the connection department, 5.8 ± 6.0 mm² in the coating part, and 6.7 ± 6.4 mm² in the non-connection department of OPLL group. There difference was not statistically significant. There was a weak correlation between the JOA score and SCCSA at the narrowest level (R = 0.49). There was no significant correlation between the recovery rate of JOA score and SCCSA at the narrowest level (R = 0.37).

Conclusion

Dynamic factors are seen both in cervical myelopathy patients with the continuous type of OPLL and others. Deterioration of myelopathy could be induced by motion effects even in the connection department of OPLL.     

前路或后路手术治疗颈椎后纵韧带骨化症的中期疗效观察

目的:观察颈椎前路椎体次全切减压融合术(ACCF)和颈椎后路单开门椎管扩大成形术在治疗颈椎后纵韧带骨化症(OPLL)的中期临床疗效和影像学改善情况。方法:2010年1月~2012年12月我院收治33例颈椎OPLL患者,男17例,女16例;年龄41~78岁(58.6±8.8岁)。其中16例骨化块累及2个节段及以内者通过ACCF切除骨化块减压(A组);17例骨化块累及2个节段以上、前路切除有困难者采用后路单开门椎管扩大成形术(B组)。所有患者术前、术后3个月、1年、2年、3年和末次随访时进行JOA评分。通过配对样本t检验分析两组患者术前、术后和末次时的JOA评分、颈椎曲度及椎管狭窄率的变化情况。结果:A组1例术后发生吞咽困难;B组1例发生脑脊液漏,1例发生切口感染。均经对症处理后痊愈。A组随访48.56±8.02个月,B组随访52.59±8.88个月。两组患者术后JOA评分均较术前有显著性改善(P0.05);术后和末次随访时颈椎曲度较术前无明显差异(P0.05);A组末次随访骨化块面积明显大于术后(P0.05),B组末次随访骨化块面积较术后无明显差异(P0.05)。结论:对于颈椎OPLL,ACCF和后路单开门椎管成形术均为有效且安全的术式,中期随访疗效满意。前者通过切除或"漂浮"骨化块达到有效减压;后者能够扩大椎管缓解脊髓压迫,中期随访椎管狭窄率维持稳定。     

Development of ossification of the posterior longitudinal ligament of the cervical spine after atlanto-axial fusion

We report three cases of the development of ossification of the posterior longitudinal ligament (OPLL) after atlanto-axial fusion. This fusion should be recognized as a causative factor in the development of OPLL. The pathological mechanism is suggested to be increased mechanical stress. Received: December 8, 2000 / Accepted: July 10, 2001     

Walking ability following hybrid assistive limb treatment for a patient with chronic myelopathy after surgery for cervical ossification of the posterior longitudinal ligament

Context: The hybrid assistive limb (HAL) (the wearable robot) can assist kinesis during voluntary control of hip and knee joint motion by detecting the wearer's bioelectric signals on the surface of their skin. The purpose of this study was to report on walking ability following the wearable robot treatment in a patient with chronic myelopathy after surgery for cervical ossification of the posterior longitudinal ligament (OPLL).

Findings: The patient was a 66-year-old woman with cervical OPLL who was able to ambulate independently with the aid of bilateral crutches. The wearable robot treatment was received once every 2 weeks for ten sessions beginning approximately 14 years after surgery. Improvements were observed in gait speed (BL 22.5; post 46.7?m/min), step length (BL 0.36; post 0.57?m), and cadence (BL 61.9; post 81.6?m/min) based on a 10-m walk test and a 2-minute walk test (BL 63.4; post 103.7?m) assessing total walking distance. The improvements in walking ability were maintained after the wearable robot treatment for 6 months.

Conclusion: We report the functional recovery in the walking ability of a patient with chronic cervical myelopathy following the wearable robot treatment, suggesting that as a rehabilitation tool, the wearable robot has the potential to effectively improve functional ambulation in chronic cervical myelopathy patients whose walking ability has plateaued, even many years after surgery.