胸椎管狭窄的诊断和治疗

胸椎管狭窄症的诊断与治疗原则,冯世庆,天津医科大学总医院,Tianjin, 10/7/2013,A Typical Case,A 50-year-old manChief illness: slight numbness of the lower extremities and back pain persisting for 10 years, the numbness of his right leg had deteriorated for 6monthsPast history: a volleyball player at school and had played volleyball until recentlyPhysical examination: Romberg signs (+); Deep tendon reflexs of lower extremities exaggerated; Below T12 bilaterally: vibration, position, pain and temperature sensation diminished,A Typical Case,Arai A, Aihara H, Miyake S, Hanada Y, Kohmura E. Syringomyelia due to thoracic spinal stenosis with ossified ligamentum flavum-case report. Neurol Med Chir (Tokyo). 2011;51(2):157-9.,概念,胸椎管狭窄症是由发育性因素或由椎间盘退变突出、椎体后缘骨赘及小关节增生、韧带骨化等因素导致胸椎管或神经根管狭窄引起相应脊髓、神经根受压的疾病,胸椎黄韧带骨化症（OLF）胸椎间盘突出症(TDH）后纵韧带骨化症（OPLL）硬膜骨化,其他少见原因：弥漫性骨肥厚症、强直性脊柱炎、氟骨症、胸椎椎体后缘骨软骨结节、关节突内聚,病因,流行病学,Aizawa T, Sato T, Sasaki H, Matsumoto F, Morozumi N, Kusakabe T, Itoi E,Kokubun S. Results of surgical treatment for thoracic myelopathy: minimum 2-year follow-up study in 132 patients. J Neurosurg Spine. 2007 Jul;7(1):13-20.,OLF: 胸椎黄韧带骨化症OPLL: 后纵韧带骨化症SP：胸椎椎体后缘骨软骨结节HE：胸椎间盘突出,下胸椎（T9-T12)最多见 ，好发于4060岁成年人,病理机制,应力刺激可诱发黄韧带细胞向骨化方向转化【1】成骨蛋白（Bone morphogenetic protein） 和 转化生长因子-b（transforming growth factor-b）【1,2】,【1】Li M, Wang Z, Du J, Luo Z, Wang Z. Thoracic myelopathy caused by ossification of the ligamentum flavum: a retrospective study in Chinese patients. J Spinal Disord Tech. 2013 Feb;26(1):E35-40.【2】Hoshi K, Amizuka N, Sakou T, et al. Fibroblasts of spinal ligamentspathologically differentiate into chondrocytes induced by recombinanthuman bone morphogenetic protein-2: morphological examinations for ossification of spinal ligaments. Bone. 1997;21:155162,临床表现,症状,胸脊髓或神经根受累的相应症状和体征，相互间并无显著区别,OLF和OPLL：胸背部疼痛症状不突出,TDH：胸背部疼痛,脊髓源性间歇性跛行: 早期仅感觉行走一段距离后,下肢无力、发僵、发沉、不灵活等，休息片刻又可继续行走。,临床表现,体征,典型表现：脊髓上运动神经元性损害为主的表现,即躯干、下肢感觉障碍,下肢肌力减弱,肌张力升高,膝反射、跟腱反射亢进,病理征阳性等,但当胸腰段椎管狭窄致脊髓圆锥损害时，临床表现可为上、下运动神经元混合性损害或者广泛的下运动神经元性损害，易与腰椎管狭窄症相混淆,影像学表现,CT检查：可以清晰显示骨性椎管及骨化韧带的结构MRI检查：可清楚显示整个胸椎病变及部位、病因、压迫程度、脊髓损害情况，是确诊胸椎管狭窄症最为有效的辅助检查方法,影像学表现,黄韧带骨化的CT分型,Zhou Jian,Chen Nong,Dong Jian,Li Xi-lei,Zhou Xiao-gang,Fang Tao-lin,Lin Hong,Ma Yi-qun. Surgical treatment of ossification of thoracic ligamentum flavum and analysis of the factors related to outcome.FuDan University Journal of Medical Sciences .2010-04,影像学表现,逗号征comma sign,轨道征（tram track sign）双椎板,胸椎黄韧带骨化症合并硬脊膜骨化的影像学特点,诊断,需要注意的是：胸椎椎管狭窄症病例中的40合并有脊髓型颈椎病，10合并腰椎椎管狭窄症，容易误诊误治或漏诊漏治,鉴别诊断,JOA评分,当颈椎病患者的上肢功能评分构成比(上肢功能评分总分100)36时，需警惕合并胸椎管狭窄症的可能；当上肢评分构成比43时则肯定合并胸椎椎管狭窄症。,对于那些颈椎、胸椎椎管狭窄并存，但上肢感觉运动功能正常，仅表现为下肢症状者，应把胸椎椎管狭窄症作为首要诊断,治疗,保守治疗 轻度时可用，包括按摩、热敷、理疗，意义不大,手术治疗 唯一有效 可分为： 后路减压术 前路减压术 前后联合入路环形减压术 侧前方入路减压术 Ohtsuka 法,Aizawa T, Sato T, Sasaki H, Matsumoto F, Morozumi N,Kusakabe T, et al. Results of surgical treatment for thoracicmyelopathy: minimum 2-year follow-up study in 132 patients. J Neurosurg Spine 2007; 7: 13-20,后路减压融合术,回顾性研究51名OPLL患者A组：后路减压B组：后路减压+OPLL切除C组：后路减压+融合随访 1年/最后检查结果：JOA评分 术后改善率 group A 41.9% ， group B 62.1%， group C 59.3%,推荐后路减压融合术应用于术前脊髓严重受损和/或应用前入路减压术风险较大的患者中,Yamazaki M, Mochizuki M, Ikeda Y, Sodeyama T, Okawa A, Koda M, Moriya H.Clinical results of surgery for thoracic myelopathy caused by ossification of the posterior longitudinal ligament: operative indication of posterior decompression with instrumented fusion. Spine (Phila Pa 1976). 2006 Jun 1;31(13):1452-60.,后路360脊椎减压内固定术,11名OPLL和OLF患者后路减压联合内固定术JOA评分 术后改善率68%无对照,【1】Zhang HQ, Chen LQ, Liu SH, Zhao D, Guo CF. Posterior decompression with kyphosis correction for thoracic myelopathy due to ossification of the ligamentum flavum and ossification of the posterior longitudinal ligament at the same level. J Neurosurg Spine 2010; 13: 116-122【2】Kawahara N, Tomita K, Murakami H, Hato T, Demura S,Sekino Y, et al. Circumspinal decompression with dekyphosis stabilization for thoracic myelopathy due to ossification ofthe posterior longitudinal ligament. Spine 2008; 33: 39-46,15名患者OPLL360脊椎减压联合内固定术JOA评分 术后改善率66.3%无对照,前入路减压术,Ohnishi K, Miyamoto K, Hosoe H, Shimizu K. Anterior decompression and fusion for ossification of the posterior longitudinal ligament of the thoracic spine: procedure and clinical outcomes of transthoracic and transsternal approaches. In: Yonenobu K, Nakahara K, Toyama Y, eds. Ossification ofthe Posterior Longitudinal Ligament. Tokyo: Springer-Verlag;2006: 231-234,9名OPLL患者随访 平均37.3月结果虽无显著的统计学差异，但有强烈的改善倾向术后并发症 1例切口肿胀，2例反复喉神经麻痹，1例脊柱后凸异常,Ohtsuka 法,1988年，由Ohtsuka提出，在23名TDH患者上施行，故又称Ohtsuka method,Otani K, Yoshida M, Fujii E, Nakai S, Shibasaki K: Thoracic disc herniation. Surgical treatment in 23 patients. Spine 13: 12621267, 1988,手术方法：首先行椎板切除术，然后通过后入路切除椎体的后半部，最后尽可能切除骨化的后纵韧带的前部,后路椎板成形术,回顾性研究21名OPLL患者7名连续型OPLL：前路减压融合术1人， Ohtsuka 法 3人， 椎管扩大成形术3人14名间断型OPLL：前路减压融合术2人， Ohtsuka 法 6人，椎管扩大成形术6人,Matsuyama Y, Yoshihara H, Tsuji T, Sakai Y, Yukawa Y, Nakamura H, Ito K,Ishiguro N. Surgical outcome of ossification of the posterior longitudinal ligament (OPLL) of the thoracic spine: implication of the type of ossification and surgical options. J Spinal Disord Tech. 2005 Dec;18(6):492-7; discussion 498,后路椎板成形术,Matsuyama Y, Yoshihara H, Tsuji T, Sakai Y, Yukawa Y, Nakamura H, Ito K,Ishiguro N. Surgical outcome of ossification of the posterior longitudinal ligament (OPLL) of the thoracic spine: implication of the type of ossification and surgical options. J Spinal Disord Tech. 2005 Dec;18(6):492-7; discussion 498,后路椎板成形术,Matsuyama Y, Yoshihara H, Tsuji T, Sakai Y, Yukawa Y, Nakamura H, Ito K,Ishiguro N. Surgical outcome of ossification of the posterior longitudinal ligament (OPLL) of the thoracic spine: implication of the type of ossification and surgical options. J Spinal Disord Tech. 2005 Dec;18(6):492-7; discussion 498,48岁女性主要表现：共济失调，需要轮椅辅助诊断：C3到T7的OPLL，C7到T2的严重的椎管狭窄,后路椎板成形术,术式：C2到T9的椎管成形术术后三年，病人恢复行走能力。,Matsuyama Y, Yoshihara H, Tsuji T, Sakai Y, Yukawa Y, Nakamura H, Ito K,Ishiguro N. Surgical outcome of ossification of the posterior longitudinal ligament (OPL