胸椎黄韧带骨化的外科治疗及其疗效分析

目的:根据CT分型分别采取不同手术方法治疗胸椎黄韧带骨化合并脊髓病,并探讨其疗效。方法:对2001年1月至2010年6月收治的胸椎黄韧带骨化合并脊髓病30例患者进行回顾性分析,男22例,女8例;年龄37～68岁,平均52.8岁;病程2个月～6年。单节段孤立性黄韧带骨化11例;多节段黄韧带骨化19例,其中2例合并颈椎黄韧带骨化,1例合并后纵韧带骨化。上胸段(T1,2-T4,5)5例,中胸段(T5,6-T8,9)7例,下胸段(T9,10-T11,12)12例,上中胸段联合2例,中下胸段联合4例。根据骨化节段CT表现将其分为两种类型:单纯型18个节段,骨化黄韧带单侧,骨化较薄或双侧均较薄,未融合;复杂型42个节段,骨化黄韧带弥漫性融合,或呈结节型。21例表现为上运动神经元瘫,9例表现为上下运动神经元混合瘫;括约肌功能障碍26例,JOA括约肌功能评分为1.97±0.56。改良JOA下肢运动功能评分为1.20±0.76。单纯型行"揭盖法"切除,复杂型行"薄化法"切除。对于减压范围较大者减压后行内固定、后外侧植骨融合。结果:减压2～6个椎板,平均3.1个。3例出现脑脊液漏,1例出现切口处血肿。全部病例获随访,时间12～96个月,平均26个月。22例束带感均消失;28例感觉障碍及下肢麻木、疼痛者中,完全恢复18例,部分恢复10例。术后括约肌功能JOA评分为2.73±0.45,与术前比较差异有统计学意义(P<0.01)。术后JOA下肢运动功能评分为3.57±0.77,与术前比较差异有统计学意义(P<0.01),改善率平均为86.1%,优24例,良3例,可2例,差1例。结论:根据不同CT分型采取不同手术方式治疗胸椎黄韧带骨化能提高手术安全性,降低风险。

Surgical treatment of ossification of ligamentum flavum in thoracic spine and its therapeutic effect analysis

Objective: To explore the correlation between CT classification and operative method and to discuss its therapeutic effect. Methods: From January of 2001 to June of 2010,30 patients with thoracic ossification of ligamentum flavum were reviewed retrospectively,including 22 males and 8 females with an average age of 52.8 years old(ranged from 37 to 68 years old). The course of duration ranged from 2 months to 6 years. Single segment lesion was in 11 cases and multiple segments were in 19 cases. Two patients were accompanied by cervical ossification of ligamentum flavum and 1 was accompanied by ossification of posterior longitudinal ligament. The ossified lesions were located at T_1,2 to T_4,5 in 5 cases,T_5,6 to T_8,9 in 7 cases,T_9,10 to T_11,12 in 12 cases,at the upper and middle thoracic levels in 2 cases,at the middle and lower thoracic levels in 4 cases. They were divided into 2 types according to the morphologic features of the CT scan:simple type,18 segments with lateral,slice or unfused type; complex type,42 segments with thickened,fused or nodular type. The clinical manifestation was paralysis of upper motor neuron in 21 cases,and of upper and lower motor neuron in other 9 cases. Sphincter dysfunction was found in 26 cases. Preoperative JOA sphincter function score was 1.97±0.56. Preoperative modified JOA motor function score of lower limb was 1.20±0.76. Different surgical procedure was applied to one of the 2 types. For the simple type,an en bloc laminectomy was performed. However,for the complex type,a laminar shelling decompression was done. Laminectomy combined with internal fixation and lateral fusion was performed in patients whose decompressive areas were wider. Results: The mean decompression length was 3.1 lamina(2 to 6 lamina). Cerebrospinal fluid leakage was found in 3 cases and hematoma in incision was found in 1 case. The mean follow-up duration was 26 months(12 to 96 months). Twenty-two patients with the feel of constriction of trunk or lower limbs were completely recovered; 18 cases with sensation disturbance,numbness and pain of the lower limb were totally recovered,and relived in 10 cases. Postoperative JOA sphincter function score was 2.73±0.45,comparing with the preoperative score,and the difference was significant(P<0.01). Postoperative JOA motor function score was 3.57±0.77,comparing with the preoperative score,and the difference was significant(P<0.01). The lower limb function relief rate was 86.1%,24 patients got an excellent results,3 good,2 poor and 1 bad. Conclusion: Different surgical procedures will be safely and effectively applied to treat thoracic ossification of ligamentum flavum according to CT classification.