扩大后壁减压术治疗颈椎后纵韧带骨化

目的 介绍扩大后壁减压术(显露根袖起始部)治疗颈椎后纵韧带骨化(ossification of the posterior longitudinal ligament,OPLL)合并脊髓病,并探讨其疗效.方法 1998年1月至2005年12月,采用扩大后壁减压手术治疗颈椎OPLL患者82例.男47例,女35例;年龄39～84岁,平均57岁.节段型31例,连续型40例,混合型11例.手术前后用日本矫形外科学会(JOA)评分判定神经功能;用疼痛视觉模拟评分(VAS)评价颈肩痛程度;用Ishihara法测定颈椎曲率指数(cervical curvature index,CCI);在MRI上测量脊髓扩大和后移程度.结果 手术平均减压5.2(4～6)个节段.全部病例随访13～58个月,平均41个月.术后JOA评分平均为13.9(11～17)分,较术前[10.9(7～15)分]有显著改善(t=14.65,P＜0.01),临床效果优良率为98.7%.仅2例出现C5神经根麻痹,为一过性.术后颈肩痛VAS评分平均为1.4(1～3)分,较术前[5.3(4～6)分]明显缓解(t=15.46,P＜0.01).术后CCI平均为10.5%,较术前(18.8%)下降(t=5.03,P＜0.01),但未发生颈脊髓再次受压.MRI测量:最狭窄处硬膜囊平均横截面积由85.4 mm2增至153.8 mm2,较术前增加80.1%(t=16.33,P＜0.01);颈脊髓较术前所在位置平均向后移动6.2mm(t=15.35,P＜0.01).结论 显露根袖起始部的扩大后壁减压术能使脊髓充分后移,减压彻底,降低脊髓轴位张力,避免C5神经根麻痹,术后无颈椎脱位或半脱位,未出现颈脊髓受压复发情况.

Abstract：

Objective To introduce the surgical strategy of enlarged laminectomy (with partial facet joint dissection to expose the nerve root), and to discuss its benefit for cervical ossification of the posterior longitudinal ligament(OPLL) with myelopathy. Methods Totally 82 patients with cervical OPLL were treated by enlarged laminectomy from January 1998 to December 2005. There were 47 males and 35 females, with an average age of 57 years (ranged, 39-84 years). Among them, there were 31 cases of the solitary type, 40 cases of the continuous type, and 11 cases of the mixed type. JOA scoring system and the visual analogue scale (VAS) scoring were applied to evaluate the neurological function and neck/shoulder pain respectively.Ishihara method was employed to measure cervical curvature index(CCI). The degree of spinal cord backward expanding and displacement were calculated in MR1. Results The mean decompression length was 5.2 (4-6) segments. The mean follow-up duration was 41 months (ranged, 13-58 months). JOA score has improved from 10.9(7-15) preoperatively to 13.9(11-17) postoperatively (t=14.65, P＜0.01). The excellent and good rate was 98.7%. The palsy of C5 nerve root occurred in only 2 patients, both recovered after surgery. Zhe mean postoperative VAS score was 1.4(1-3), comparing with the preoperative score of 5.3 (4-6). The pain in neck/shoulder was alleviated obviously (t=15.46, P＜0.01 ). CCI decreased from 18.8% to 10.5%(t=5.03, P＜0.01 ),but did not follow by neuron function deterioration. MRI indicated that the cross-sectional area at the level of maximum compression of the dural sac increased from 85.4 mm2 preoperatively to 153.8 mm2 postoperatively (t=16.33, P＜0.01), and the mean spinal cord posterior shift was 6.2 mm (t=15.35, P＜0.01). Conclusion The enlarged laminectomy is proved to be effective in treating cervical OPLL, in terms of significant posterior shift of the spinal cord, relief of cervical/shoulder pain, lower rate of the palsy of C5 nerve root, with no recurrence of spinal cord compression symptom.     

Surgical strategy for ossification of the posterior longitudinal ligament in the cervical spine

Ossification of the posterior longitudinal ligament is a common cause of cervical myelopathy, and controversy remains regarding surgical options. Between January 2004 and December 2007, a total of 164 patients with ossification of the posterior longitudinal ligament in the cervical spine who underwent surgical treatment at the authors' institution were included in this study. The choice of surgical option was based on pathological extent and cervical alignment. Short-segment pathology was treated via the anterior approach and long-segment pathology via the posterior approach. When the posterior approach was selected, laminoplasty was performed for the patients with cervical lordosis and laminectomy with fusion for those with cervical kyphosis. Consequently, anterior corpectomy and fusion was performed in 91 patients, laminoplasty in 41 patients, and laminectomy and instrumented fusion in 32 patients. The Japanese Orthopedic Association scoring system was used to evaluate patients' neurological status, and related complications were also recorded. Clinical results between different approaches and techniques were compared at mid-term follow-up.Based on the results of this study and a review of previous literature, no significant differences existed between different approaches and techniques for patients with mild ossification of the posterior longitudinal ligament, but anterior corpectomy and fusion had significantly better results in patients with severe ossification of the posterior longitudinal ligament. With respect to the posterior approach, laminectomy and instrumented fusion improved the surgical results of patients with cervical kyphosis, but a high incidence of C5 palsy existed simultaneously.     

Prevalence of ossification of the posterior longitudinal ligament of the cervical spine

ObjectivesTo determine the prevalence of ossification of the posterior longitudinal ligament (OPLL) in cervical spines in Koreans.MethodsWe reviewed the reports of the radiologic examination of cervical spines from January 2002 to September 2005 in Hanyang University Hospital, Seoul, Korea. OPLL was indicated by the presence of heterotopic ossification in the posterior longitudinal ligament on lateral cervical radiograph.ResultsAmong 11,774 adults aged 16 years or more, 71 cases of OPLL were found (0.60%). The male to female ratio was 42:29 (1.45:1). The highest prevalence was in patients aged 50–59 years. In terms of the types of OPLL, the continuous type was noted in 32.0% of the patients, the segmental type in 31.0%, the mixed type in 31.0%, and the localized type in 5.6%. C4, C5, and C3 were most commonly involved, in that order of frequency. Diffuse idiopathic skeletal hyperostosis, which is another common hyperostotic disorder, was also found in eight male patients.ConclusionsThe prevalence of cervical OPLL in Koreans was 0.60%, which was lower than that of Japanese and some previous western reports.     

脊髓型颈椎后纵韧带骨化症的手术治疗

[目的]比较分析不同手术入路治疗脊髓型颈椎后纵韧带骨化症的疗效及并发症.[方法]回顾性分析本院自2005年1月～2009年3月56例脊髓型颈椎后纵韧带骨化症患者的手术人路、手术方式、手术时间、出血量、手术疗效及其并发症.[结果]56例患者随访20个月～6年,平均3.8年;前路手术25例,手术时间为(220.00±35.82)min,术中出血量为(280.00±127.48)ml,术前JOA评分8.36±1.41,术后JOA评分13.52±2.00,改善率为61.92％±16.46％,并发症发生7例;后路手术21例,手术时间为(118.57±22.20)min,术中出血量为(414.29±200.71)ml,术前JOA评分8.23±1.67,术后JOA评分13.19±1.97,改善率为58.57％±15.36％,并发症发生5例;前后联合手术10例,手术时间为(309.00±51.09)min,术中出血量为(760.00±337.30)ml,术前JOA评分7.40±1.07,术后JOA评分13.70±1.64,改善率为66.60％±13.29％,并发症发生3例;三组病例术中出血量、手术时间行组间比较有显著性差异(P＜0.05),但三组术前JOA评分、术后JOA评分、术后改善率、手术并发症发生例数行组间比较无显著性差异(P＞0.05).[结论]脊髓型颈椎后纵韧带骨化症前、后路或前后联合入路手术疗效均良好,手术并发症发生率均比较高,因此脊髓型颈椎后纵韧带骨化症的手术入路选择,除了要全面考虑患者病情,同时必须兼顾自身技术特点及条件,只要能够安全地对脊髓进行充分减压,维持或重建颈椎的稳定性,三种治疗方案均是可以选择的治疗手段,但前后联合人路手术时间长、出血量大,宜慎重.     

颈椎后纵韧带骨化的病因学研究进展

颈椎后纵韧带骨化(Ossification of the Posterior Longitudinal Ligament of the Cervical Spine C-OPLL),是一种发病原因复杂、发病机制尚未明确的病理现象,是指颈椎椎体的后纵韧带发生病理变化,导致后纵韧带异位骨化,并由此引发颈椎椎管狭窄以及颈脊髓、神经根受压等损害的一种起病隐匿、慢性进展性疾病。近年来,随着科学技术的发展,有关C-OPLL的实验性研究等报道逐渐增多,人们对其认识得到更进一步加深,本文将结合目前研究成果对C-OPLL病因学作简要综述。     

Tetraparesis associated with ossification of the posterior longitudinal ligament of the cervical spine

This is a case report of tetraparesis associated with extraordinarily severe ossification of the posterior longitudinal ligament (OPLL) of the cervical spine. There was no history of trauma. The object of this paper is to show that OPLL can progress relentlessly to a nearly complete quadriplegia even without trauma, but that adequate decompression can produce almost complete recovery.

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Résumé  Il s’agit d’un cas de tétraplégie pour une OPLL (Ossification du Ligamentum Flavum) extrêmement sévère du rachis cervical, sans traumatisme. L’objectif de cette étude est de montrer qu’un cas de OPPL peut évoluer de facon critique vers une quadriplegie même sans traumatisme, mais avec une décompression adéquate le patient peut recouvrir pratiquement toutes ses fonctions.

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Accepted: 29 May 1999     

Micturitional disturbance in ossification of the posterior longitudinal ligament in the cervical spine

Neurourological studies were performed on 39 patients with cervical myelopathy due to ossification of the posterior longitudinal ligament. Micturitional history revealed that 30 patients (77%) had voiding symptoms: obstructive in 8, irritative in 11, and both obstructive and irritative symptoms in 11. Ten patients had urge incontinence and 4 had urinary retention. Urodynamic studies revealed that 7 of 19 had abnormal uroflowmetrogram, 16 of 35 had residual urine, 18 of 39 had detrusor hyperreflexia, and 10 of 39 had detrusor-sphincter dyssynergia. There were no statistical differences in lower extremity neurological signs in patients with incontinence, and patients with residual urine or urinary retention.     

Atlantoaxial subluxation associated with ossification of posterior longitudinal ligament of the cervical spine

STUDY DESIGN: Two case reports. OBJECTIVE: To demonstrate two rare cases of atlantoaxial subluxation associated with ossification of the posterior longitudinal ligament of the cervical spine, in which spastic quadriplegia developed. SUMMARY OF BACKGROUND DATA: There are only two reports of an association of diffuse idiopathic skeletal hyperostosis with atlantoaxial subluxation. This condition often accompanies ossification of the posterior longitudinal ligament of the cervical spine, but there is nothing in the literature about the association of ossification of the posterior longitudinal ligament with atlantoaxial subluxation. METHODS: Clinical and radiographic findings of these two cases were demonstrated. In both cases laminoplasty of the cervical spine was performed with occipitoaxial arthrodesis. RESULTS: The spastic quadriplegia of these two patients caused by myelocompression improved after surgical intervention. CONCLUSION: Ossification of the posterior longitudinal ligament of the cervical spine may cause atlantoaxial subluxation.     

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。     

Anterior corpectomy and fusion for severe ossification of posterior longitudinal ligament in the cervical spine

Between May 2002 and October 2006, 19 patients (17 men and 2 women; average age 57.2; range 47-71 years) received anterior corpectomy and fusion for severe ossification of the posterior longitudinal ligament (OPLL) in our department. Preoperative radiological evaluation showed the narrowing by the OPLL exceeded 50% in all cases, and OPLL extended from one to three vertebrae. We followed-up all patients for 12-36 months (mean 18 months). The Japanese Orthopaedic Association (JOA) score before surgery was 9.3 +/- 1.8 (range 5-12) which significantly increased to 14.2 +/- 1.3 (range 11-16) points at the last follow-up (P < 0.01). The improvement rate (IR) of neurological function ranged from 22.2-87.5%, with a mean of 63.2% +/- 15.2%. The operation also provided a significant increase in the cervical lordosis and the cord flatting rate (P < 0.01). No severe neurological complication developed. We therefore concluded that anterior decompression and fusion was effective and safe in the treatment of the selected patients, although OPLL exceeded 50% diameter of the spinal canal.     

后纵韧带钩辅助下颈椎后纵韧带骨化物切除减压术

目的探讨后纵韧带钩辅助下颈椎后纵韧带骨化物前路切除的适应证、方法及其临床效果。方法患者19例,男14例,女5例;年龄51-71岁,平均59岁。术前影像学检查结果示后纵韧带骨化物局限型6例,分节型13例;椎管狭窄率32％-75％,平均54％。术前神经功能JOA评分4-14分,平均9．6分。行颈前路常规手术入路,椎体开槽切骨达椎体后壁,范围超过后纵韧带骨化灶。利用后纵韧带钩插入后纵韧带下,钩起后纵韧带及骨化物,在后纵韧带与硬膜间形成一间隙,直视下用超薄型枪状咬骨钳切除后纵韧带及骨化物,而后植骨固定,恢复颈椎稳定性。结果随访6-36个月,平均16个月。术后JOA评分8～16分,平均12．8分,恢复率42％＇-92％,其中疗效优9例,良7例,可3例,优良率84．2％。4例患者术后并发脑脊液漏,保守治疗后均获得痊愈。术后CT和MR检查显示骨化后纵韧带切除完全,脊髓和硬膜囊形态恢复良好。结论后纵韧带钩可提高颈椎前路手术切除后纵韧带骨化物的安全性和有效性,适用于局限型和分节型、切除范围在两个椎节之间的颈椎后纵韧带骨化症患者。     

颈椎后纵韧带骨化症手术治疗研究进展

脊柱韧带骨化性疾病是一类临床常见的多因素迟发性疾病,进展缓慢,不可逆转,常引起脊髓和神经根病变,以多种脊柱韧带骨化为特征。颈椎后纵韧带骨化症（OPLL）为颈部后纵韧带中的异位骨化,因其压迫脊髓和神经根而导致一系列临床症状,病因复杂。由于OPLL具有不可逆性,及时治疗及选择合适的治疗方法尤为重要,手术治疗是目前较为有效的治疗方法之一。临床上广泛应用于治疗颈椎OPLL的术式包括颈前路、颈后路、前后联合入路及微创等。本文就近年来相关文献中颈椎OPLL手术治疗术式作如下综述。     

前路根治性减压治疗严重颈椎后纵韧带骨化症

目的 报告前路后纵韧带根治性切除治疗椎管占位率＞50%的严重颈椎后纵韧带骨化症(OPLL)的手术疗效.方法 2002年7月至2006年2月,采用前路切除骨化韧带减压术治疗椎管占位率＞50%的严重OPLL患者26例.男性18例,女性8例;年龄43～73岁,平均59岁;骨化物形态均为基底开放型.术前骨化率50%～85%,平均(65±20)%;脊髓矢状径相对值(25±7)%;JOA评分(8.7±2.8)分.采用前路减压直接切除骨化物,行钛网或自体髂骨植骨,带锁钢板固定.26例患者中,行一个椎体次全切除+单节段椎间隙减压10例,2个椎体次全切除术3例,单节段椎体次全切除13例.所有患者均行脑诱发电位(ECP)监护,CT横断面测量骨化率,MRI T2 加权测量脊髓矢状径相对值;记录患者并发症、JOA评分,计算改善率.结果 26例患者均顺利实施前路手术,随访6个月至4年(平均2年8个月).术后骨化率平均(10±5)%,脊髓矢状径相对值(75±15)%,JOA评分(14.2±2.5)分,改善率(61±24)%.3例合并糖尿病患者出现短暂神经症状恶化,其中1例行二次血肿清除术,患者神经症状均在8周内恢复;2例出现脑脊液漏(包括1例合并糖尿病者),经保守治疗2周后痊愈;无内固定失败.结论 前路手术直接减压治疗严重OPLL,神经功能恢复更彻底,但对技术要求较高.     

Experimental studies on the ossification of the posterior longitudinal ligament of the cervical spine

Fluor, which is a natural substance contained in rice, vegetables, marine products and some seasonings, is assimilated into the body through ingestion. Approximately 60% of the total amount of this fluor intake would be based on rice. A histological study of cervical spine, knee ligaments, Achilles tendon and viscera of rabbits (approx. 12-16 weeks old) was made after injection with sodium fluoride in this study. The rabbits were divided into three groups: Group A (administered NaF 86.2 mg/kg, 5.7 mg/ml, 7 rabbits); Group B (administered NaF 31.5 mg/kg, 2.85 mg/ml, 6 rabbits) and a Control Group of 3 rabbits. Five rabbits in Group A (71.4%) and all six rabbits in Group B (100%) developed ossification of the posterior longitudinal ligament. Ossification of the yellow ligament was also found in two rabbits in Group A and one in Group B. No ossification was found in the Control Group. Both enchondral and intramembranous ossification were found in ossification of posterior longitudinal ossification in the rabbits.     

颈椎后纵韧带骨化症的前路骨化灶悬切减压治疗

目的 探讨颈椎后纵韧带骨化症采取颈前路骨化灶悬切减压治疗效果.方法 颈椎后纵韧带骨化症42例136个骨化节段.颈前路椎体开槽,深至椎体后缘,与硬膜严重粘连不宜切除的骨化灶可用丝线缝穿骨化灶一侧残余的后纵韧带或骨化灶周围的纤维组织,轻轻提起系在植骨块或颈长肌上,使骨化灶完全缩入骨槽内;对体积较小、与硬膜粘连轻的骨化灶予以...     

Diagnosis and surgery of ossification of posterior longitudinal ligament associated with dural ossification in the cervical spine

Direct removal of the ossified mass via anterior approach carries good decompression to ossification of the posterior longitudinal ligament (OPLL) in the cervical spine. Ossification occasionally involves not only the posterior longitudinal ligament but also the underlying dura mater, which increased the opportunity of the cerebrospinal fluid (CSF) leakage or neurological damage. The surgeon was required to recognize the dural ossification (DO) and need more cautious manipulation. Hida et al. first described the computed tomography (CT) findings that indicated the association with DO, and suggest the double-layer sign appeared more specific for DO. This study reviewed 138 patients who received anterior cervical corpectomy and fusion (ACCF) for OPLL, and 40 patients were found in the association with DO during anterior procedure. Radiological studies revealed that the patients with severe OPLL (higher occupying rate and larger extent) have increasing opportunity of association with DO. The double-layer sign, as a specific indicator for association with DO was sensitive in the patients with mild OPLL, but less frequent in those with severe OPLL with DO. Two surgical techniques were used for the patients with DO in anterior decompression procedure. When the double-layer sign was observed on CT scans, the OPLL could be separated from DO through a thin layer consisting a nonossified degenerated PLL to avoid CSF leakage. Otherwise, the entire ossified mass including OPLL and DO was removed completely. In this technique, the arachnoid membrane needed to be persevered with the aid of microscope to avoid a large area of membrane defect, resulting in uncontrolled CSF leakage. There was no significant difference in clinical results between the patients with DO and those without DO. Therefore, ACCF is meritorious for the patient with OPLL associated with DO, although more difficult manipulation and higher risk of CSF leakage.     

Spinal canal size in ossification of the posterior longitudinal ligament of the cervical spine

BACKGROUND: The size of the spinal canal is a factor that contributes to the neurologic deficits associated with cervical ossification of the posterior longitudinal ligament (OPLL). METHODS: Bone-window computed tomography (CT) examinations of the cervical spine in 64 patients with cervical OPLL were reviewed. Forty-two patients underwent surgical treatment (anterior decompression: 16 patients, posterior decompression: 26 patients). The remaining 22 patients were managed conservatively. Selection of the surgical approach, anterior or posterior, was based on the longitudinal extent of cord compression. RESULTS: The mean developmental size of the spinal canal in the posterior decompression group (10.7 mm at C4) was significantly smaller than the other 2 groups. The spinal canal was narrowed by OPLL to 2.9 to 10.0 mm. The proportion of the patients showing motor deficits of the lower extremities significantly increased when the sagittal canal diameter was narrowed to less than 8 mm. CONCLUSIONS: This study demonstrates critical values of CT-determined spinal canal stenosis. Developmental size of the spinal canal and the residual anterior-posterior canal diameters resulting from OPLL spinal cord compression are important factors influencing clinical management and the neurologic state.