胸椎黄韧带骨化症的临床特点及手术治疗

摘要

Background:Thoracic ossification of ligamentum flavum (TOLF) is the thoracic spinal stenosis characterized with compression of dorsal spinal cord. Surgical decompression is the major treatment and operation methods are varied. Objective:To explore the clinical characteristics and clinical outcomes and surgical techniques of TOLF.Methods:Totally 48 TOLF patients underwent spinal canal posterior wall resection decompression with slotting the inner side of facet joint between November 2009 and June 2016.There were 23 males and 25 females with an average age of 52 years(range,34-69 years).The lesions presented in short segments(≤3 segments)in 32 patients and in long segments(>3 segments)in 16 pa-tients.Dural ossification occurred in 10 patients.Clinical features,visual analog scale(VAS)and modified Japanese Ortho-paedic Association(mJOA)score before surgery and at the final follow-up,and nerve function were evaluated.Results:All the patients were followed up for 34.8 months on average(range,6-87 months).The VAS scores of low back and lower ex-tremities at the final follow-up were significantly lower than preoperative ones(0.71±1.07 vs 2.31±2.67,0.56±0.89 vs 1.75± 2.25),while mJOA score significantly increased at the final follow-up(9.15±1.18 vs 6.33±1.89,P<0.05).The mean nerve function recovery rate and the rate of excellent or good were 60.0% and 64.8%,respectively.Dural tears were found during decompression process in 10 patients while postoperative cerebrospinal fluid leakage occurred in 4 patients.No kyphosis ap-peared at the final follow-up.No patients needed secondary surgery and had neurologic deterioration except one undergoing reoperation due to the aggravation of adjacent segment of TOLF.Conclusions:TOLF mainly involve in short segments.It is important to identify the involved sections through sensory plane and other locating signs with image data.Dural ossifica-tion is a common finding in TOLF patients.There is a high incidence of surgical complications.Slotting the inner side of facet joint in lamina resection decompression process seems to be more reasonable.Correct use of high-speed grinding drill and vertebral plate clamp is the key to avoid aggravating neurology.%背景:胸椎黄韧带骨化症是以脊髓背侧受压为特征的胸椎管狭窄症,治疗以手术减压为主,且手术方式多样.目的:探讨胸椎黄韧带骨化症的临床特点及手术治疗的疗效和技术要点.方法:回顾性分析2009年11月至2016年6月接受小关节内侧开槽椎管后壁切除减压治疗的48例胸椎黄韧带骨化症患者.男23例,女25例;年龄34~69岁,平均52岁,短节段(≤3个)32例,多节段(>3个)16例.10例合并硬脊膜骨化.分析患者临床特点并比较术前和末次随访的疼痛视觉模拟评分(VAS)及改良日本骨科协会评分(mJOA),评价神经功能改善情况.结果:所有患者随访6~87个月,平均34.8个月.术前、末次随访腰背部VAS评分分别为2.31±2.67、0.71±1.07,下肢VAS评分分别为1.75±2.25、0.56±0.89,mJOA评分分别为6.33±1.89、9.15±1.18,差异均有统计学意义(P<0.05).手术疗效方面:优15例,良16例,优良率为64.8%.根据JOA评分计算平均改善率为60.0%.术中硬脊膜撕裂10例,术后脑脊液漏4例,末次随访未见明显脊柱后凸畸形.除1例因邻椎出现黄韧带骨化加重再次手术,其他患者均无二次手术及神经功能恶化.结论:胸椎黄韧带骨化症以短节段受累为主,通过感觉平面等定位体征结合影像学明确责任病灶尤为重要.合并硬脊膜骨化的病例并不少见,手术治疗并发症发生率高.在椎板切除减压过程中,小关节内侧开槽更为合理,正确使用高速磨钻和椎板钳是避免神经症状加重的关键.