目的 探讨延伸至上颈椎的颈椎后纵韧带骨化的治疗策略.方法 从我院2010年5月至2017年3月收治的460例颈椎后纵韧带骨化症患者中筛选出骨化的后纵韧带向上延伸至颈2/3椎间盘平面以上、资料完整且获得随访的39例患者.其中9例行颈3-7单开门椎管扩大成形术(第①种手术方式),3例行颈3-7单开门+颈2椎板下缘潜行减压椎管扩大术(第②种手术方式),22例行颈3-7单开门+颈2半椎板切除、椎管潜行减压术(第③种手术方式),5例颈2-7或2-6单开门椎管扩大成形术(第④种手术方式).所有患者术前、术后、随访时常规颈椎正侧位片、屈伸功能位片、CT三维重建、MRI检查.测量术前和随访时颈椎活动度、颈椎曲度、JOA评分及缓解率、颈2平面矢状径椎管占位率,在MRI T2加权像上评价颈2/3椎间盘平面和颈2椎体平面脊髓前后脑脊液信号是否存在.结果 39例中后纵韧带骨化范围累及颈2/3椎间盘平面13例,累及颈2椎体后缘26例.术前全部患者颈脊髓前方脑脊液信号消失范围3-6个节段、后方消失范围1-6个节段.术后有8例前方脑脊液信号消失范围0-4个节段、后方消失范围0-5个节段.术前与术后脊髓前方和后方脑脊液信号消失范围的比较差异均有显著性意义(P=0. 000,P=0. 000).采用第种手术方式的9例患者中有4例术后仍有脊髓前和/或后脑脊液信号的消失,采用第②③④种手术方式的30例患者中仅有4例术后仍存在脊髓前和/或后脑脊液信号的消失,术后两类手术方式之间前后脑脊液信号消失范围差异均有统计学意义(P=0. 038;P=0. 042).随访6 ～ 36个月,JOA术前(3 ～ 13)分,平均(6. 85±3. 35)分,JOA末次随访(4 ～ 17)分,JOA改善率0. 07 ～ 1. 00;两类手术方式之间的术前、末次随访JOA评分、JOA缓解率差异均无统计学意义(P>0. 05).结论 颈椎后纵韧带骨化累及颈2/3椎间盘平面以上时减压范围应到颈2椎平面,颈2半椎板切除+潜行减压和颈2椎板成形术是较好的手术方式,减压后脊髓前后脑脊液信号恢复良好.%Objective To explore the surgical strategy of the ossification of posterior longitudinal ligament expansive to the upper cervical spine. Methods A retrospective analysis was performed in 39 patients with ossification expansive to the up over the level of C2/3 disc, with satisfying data and with follow-up from 460 cases who were suffered with ossification of the posterior longitudinal ligament in cervical spine from May 2010 to Mar 2017. In all 39 cases, there were 9 cases be operated by unilateral open-door laminoplasty (1st operative method), 3 cases by unilateral open-door laminoplasty and undermining decompression at C2 laminate inferior margin (2nd operativemathod), 22 cases by unilateral open-door laminoplasty and C2 semi-laminectomy undermining decompression (3rd operative mathod), 5 cases by C2-6 or C2-7 unilateral open-door laminoplasty (4rd operative mathod). All the patients had preoperative, postoperative and followup plain radiographs, computed tomography (CT) scans, and magnetic resonance images (MRI). The cervical lordosis, cervical range of motion (ROM), the ossified mass occupying ratio at the level of C2, presence or absence of images of cerebrospinal fluid (CSF) at the level of C2/3 disc and C2 body inMRI T2WI, JOA and improvement rate(IR) were used to assess clinical outcomes. Results In all 39 cases, there were 13 cases whose OPLL up to C2/3 disc level and 26 cases whose OPLL up to C2 body level. Pre-operatively, all the cases absent the images of CSF in MRI T2WI. The absence segment in the front of spinal cord was 3-6 and the absence segment behind spinal cord was 1-6. Post-operatively, the data was 0-4 and 0-5 in just 8 cases. There was significant difference between pre- and post- operative absent the images of CSF of in the front of and behind the spinal cord (P=0. 000, P=0. 000). In the 1st operative method group, 4 cases still absent the images of CSF in MRI T2WI in 9 cases, however, in the 2nd, 3rd, and 4th operative method groups there were only 4 cases in 30 cases. There was significant difference between the two groups about the range of absence images of CSF in MRI T2WI in the front of or behind the spinal cord post-operatively (P=0. 038;P=0. 042). The follow-up was 4-17 months. The last follow-up JOA score was 12. 03±3. 71 (range 4-17), the pre-operative JOA was 6. 85±3. 35 (3-13), the recovery rate was 57％±27％ (range 7-100％). The three parameters were no significant difference between the two groups. Conclusion The depression should be done to C2 level when a patient's ossification of the posterior longitudinal ligament expansive to up over the level of C2/3 disc. C2 semi-laminectomy undermining decompression and unilateral open-door laminoplasty to C2 level was a good surgical method in which images of CSF in MRI T2WI of in the front of and behind the spinal cord turn better after depression.
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