骨化物漂浮 - 365骨科网
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前路多节段椎体次全切除 治疗严重颈椎后纵韧带骨化症 陈德玉 上海市长征医院骨科 上海市脊柱外科中心 Shanghai Shanghai Changzheng Changzheng Hospital Hospital OPLL 的流行病学 日本 1.8%-4.1% 中国 1.6%-1.8% 韩国 0.95% 美国 0.12% 德国 0.1% From OPLL edited by K Yonnenobu, et al Shanghai Shanghai Changzheng Changzheng Hospital Hospital OPLL的手术治疗 后路椎板切除 后路椎管成形术 (Hirabayashi 1977) 直接切除减压 (Yamaura 1976) 骨化物漂浮 (Yamaura 1983) 椎间隙融合 (Onari 2001) 前后路联合手术 (Epstein 2004) Shanghai Shanghai Changzheng Changzheng Hospital Hospital 病例选择 18例，男性11例，女性7例 年龄42～75岁，平均53岁 出现症状时间11月～7年，平均3.7年 Shanghai Shanghai Changzheng Changzheng Hospital Hospital 影像学检查 颈椎生理曲度变化 前凸消失11例 后凸5例 生理前凸2例 骨化物范围2～4个椎体，平均2.8个椎体 椎管狭窄率(CNR): 50%-97%，平均 68.4% Shanghai Shanghai Changzheng Changzheng Hospital Hospital 手术治疗 纤支镜引导插管、全麻 多椎体次全切除（范围足够） 分离切除骨化后纵韧带 重建颈椎的稳定性 Shanghai Shanghai Changzheng Changzheng Hospital Hospital Case presentation 男 71岁 四肢麻木无力 5 年 加重半年 Shanghai Shanghai Changzheng Changzheng Hospital Hospital 4 5 CT and sagittal reformation showing OPLL at C4-C5 Shanghai Shanghai Changzheng Changzheng Hospital Hospital Corpectomy of C4-C5 was performed Shanghai Shanghai Changzheng Changzheng Hospital Hospital CT and MR showing complete removal of OPLL and decompression Case presentation 女 51岁 四肢麻木无力伴行 走不稳1年 小便控制困难1周 Shanghai Shanghai Changzheng Changzheng Hospital Hospital MRI showing spinal cord was compressed from C4 to C6 Shanghai Shanghai Changzheng Changzheng Hospital Hospital CT showing OPLL at C4-C6 Shanghai Shanghai Changzheng Changzheng Hospital Hospital C4-C6 corpectomy was performed. Dural ossification floating anteriorly Pre-op MRI showing sufficient decompression of the spinal cord Post-op Case presentation 男 71 岁 肢体麻木乏力4年 行走不稳2年 不能行走7月 X-ray and CT: C3-C6 OPLL with kyphosis Shanghai Shanghai Changzheng Changzheng Hospital Hospital C3 C4 C4 C5 Shanghai Shanghai Changzheng Changzheng Hospital Hospital Compression of the spinal cord from C3 to C5 Shanghai Shanghai Changzheng Changzheng Hospital Hospital C3-5 corpectomy and fusion Shanghai Shanghai Changzheng Changzheng Hospital Hospital Pre-op The change of spinal cord on pre- and post-operative MRI Post-op Shanghai Shanghai Changzheng Changzheng Hospital Hospital 结果 两椎体次全切除12例，三椎体次全切除6例 25 20 15 10 5 0 C3 Shanghai Shanghai Changzheng Changzheng Hospital Hospital C4 C5 C6 C7 结果 神经功能JOA评分 术前平均9.3分，术后平均14.2分，恢复 率22.2％～87.5％，平均63.2％。 优5例，良9例，可3例，差1例。优良 率77.8％。 Shanghai Shanghai Changzheng Changzheng Hospital Hospital 结果 8例颈椎曲度较手术前改善 钛网重建者有轻度下沉 Postoperative Alignment Preoperative Alignment lordotic Straight Kyphotic Total lordotic 2 0 0 2 Straight 3 8 0 11 Kyphotic 0 5 0 5 Total 5 13 0 18 Shanghai Shanghai Changzheng Changzheng Hospital Hospital 并发症 6例脑脊液漏 2例神经根麻痹 1例血肿压迫 Shanghai Shanghai Changzheng Changzheng Hospital Hospital 讨论 --- 那种手术方法更好? The A-group had a better JOA score after surgery (13.9vs 10.1 ; P<0.003) and a higher IR (58% vs 13%; P<0.002) than P-group. (Tani et al. Spine, 2002) Surgical outcome of anterior decompression and fusion was superior to that of laminoplasty in the patients with occupying rate greater than 60% (54％ vs 14%; P<0.03). (Iwasaki et al. Spine, 2007) Excellent or good for 89% were obtained through anterior direct removal of OPLL. (Mizuno and Nakagawa, The Spine Journal 2006) Shanghai Shanghai Changzheng Changzheng Hospital Hospital Why to choose anterior approach 2001 2000 女性49岁, 四肢麻木乏力7年，行走不稳2年，不能行走3个月 Shanghai Shanghai Changzheng Changzheng Hospital Hospital C4/5 Y 2001 C6/7 C5/6 Y 2007 Y 2007 Progression of OPLL Y 2007 CT scan in 2007 showing multilevel OPLL Shanghai Shanghai Changzheng Changzheng Hospital Hospital Y 2000 Y 2007 MRI in year 2000 and 2007 Shanghai Shanghai Changzheng Changzheng Hospital Hospital X-ray and MRI after corpectomy The neurological status was significantly improvement Shanghai Shanghai Changzheng Changzheng Hospital Hospital Pre-op Pre-op MRI pre- and 3 m post-operation Post-op Why to choose anterior approach 男性51岁, 四肢麻木3年 伴行走困难2月 Lateral X-ray: cervical alignment was lordotic Shanghai Shanghai Changzheng Changzheng Hospital Hospital MRI showing compression of the spinal cord at C4-C5 Shanghai Shanghai Changzheng Changzheng Hospital Hospital CT scan showing OPLL at different levels Shanghai Shanghai Changzheng Changzheng Hospital Hospital Pre-op Post-op Laminoplasty was performed without function improvement. X-ray and CT at 2 m postoperatively The cervical alignment was straight. Shanghai Shanghai Changzheng Changzheng Hospital Hospital CT scan showing the spinal canal was not expanded Shanghai Shanghai Changzheng Changzheng Hospital Hospital Post-operative CT sagittal reformation Shanghai Shanghai Changzheng Changzheng Hospital Hospital MRI showing the spinal cord was still compressed. Shanghai Shanghai Changzheng Changzheng Hospital Hospital 2 level corpectomy in 4 m after Laminoplasty Shanghai Shanghai Changzheng Changzheng Hospital Hospital Dural ossification floating anteriorly Post-Lami MRIs after anterior decompression and laminoplasty 骨化后纵韧带直接切除减压 前路手术的安全界限： 骨化物厚度<5mm 椎管狭窄率<45% 骨化物范围<3个椎节 我们认为： 骨化物厚度>5mm、椎管狭窄率>45%并非前路直 接切除之禁忌 颈椎曲度变直或后凸更宜前路减压 Shanghai Shanghai Changzheng Changzheng Hospital Hospital 前路骨化后纵韧带切除的优点 彻底去除致压因素，为直接减压 符合生物力学原理，尤其对颈椎 生理前凸消失或后凸者 更好的临床效果 Shanghai Shanghai Changzheng Changzheng Hospital Hospital 前路骨化后纵韧带切除的缺点 手术难度较大 有一定风险 易并发脑脊液漏 Shanghai Shanghai Changzheng Changzheng Hospital Hospital 合并硬脊膜骨化 手术前CT连续薄扫和 矢状为重建有利于诊断 骨化物呈双层－有分 离可能 Double-layer sign by Hida Shanghai Shanghai Changzheng Changzheng Hospital Hospital 合并硬脊膜骨化 手术前CT连续薄扫和 矢状为重建有利于诊断 骨化物不规则呈钩状 或特别厚－常无法分离易 形成硬膜缺损 Shanghai Shanghai Changzheng Changzheng Hospital Hospital Irregular hook-like angle by Epstein 合并硬脊膜骨化术中处理 认真解剖仔细分离，保留 骨化硬膜使其漂浮。 硬膜缺损修补困难，生物 蛋白胶加明胶海绵覆盖可防止 或减轻脑脊液漏。 Shanghai Shanghai Changzheng Changzheng Hospital Hospital 合并硬脊膜骨化术后处理 平卧体位或头低脚高位 常压引流保证切口愈合 局部加压酌情反复抽吸 脑脊液引流或分流 Shanghai Shanghai Changzheng Changzheng Hospital Hospital 结论 切除骨化韧带为直接减压，符合生物力 学原理，临床上神经功能回复比较理想。 技术条件要求高，有一定风险，较易并 发脑脊液漏。 前路切除骨化韧带更适合于颈椎生理前 凸消失或后凸的OPLL患者。 Shanghai Shanghai Changzheng Changzheng Hospital Hospital THANK YOU FOR YOUR ATTENTION
