课件：胸椎黄韧带骨化症.ppt

胸椎黄韧带骨化症,贺石生 侯铁胜 赵杰,文献回顾,1912 LE DOUBLE, Anatole F Trait des variations de la colonne vertbrale de lhomme Paris : Vigot frres 1920 Polgar X线表现 Polgar F. Uber interakuell wirbelverkalking. Forschr Geb Rontgenstr nuklearmed Erganzungsband 1920;40:2928. 1962 Yamaguchi 第一例OLF引起脊髓压迫患者 Yamaguchi M, Tamagake S, Fujita S . A case of ossification of ligamentum flavum causing thoracic myelopathy. J Orthop Surg 1960;11 :951956,胸椎黄韧带附着处骨化是比较常见的现象，但引起脊髓压迫，导致胸椎黄韧带骨化症比较少见 Williams回顾了50例尸体标本及100个CT扫描，发现韧带附着处骨化比较常见。 Radiology. 1984 Feb;150(2):423-6. Maigne 对121例老年人调查发现下胸椎83%附着点骨化，腰椎33%骨化，认为下胸椎尾端附着处骨化是老年人的一种正常现象，受旋转应力的影响 Surg Radiol Anat. 1992;14(2):119-24.,Payer M,et al. Thoracic myelopathy due to enlarged ossified yellow Ligaments. J Neurosurg (Spine 1) 92:105108, 2000,英文比较大数量病例报道，日本6篇、中国台湾1篇、中国大陆1篇、突尼斯1篇，6篇大于20例，3篇15-20例 Ben Hamouda K, Jemel H. J Neurosurg (Spine). 99(2):157-61, 2003. Hanakita J, Suwa H, Ohta F. Neuroradiology 32:3842, 1990 Miyakoshi N, Shimada Y, Suzuki T. J Neurosurg (Spine). 99(3):251-6, 2003. Miyamoto S, Yonenobu K, Ono K. Spine 18:22672270, 1993 Miyasaka K, Kaneda K, Sato S. AJNR 4:629632, 1983 Nishiura I, Isozumi T, Nishihara K. Surg Neurol 51: 368372, 1999 Shiokawa K, Hanakita J, Suwa H. J Neurosurg (Spine 2) 94:221226, 2001,Liao CC, Chen TY, Jung SM, Chen LR. J Neurosurg (Spine). 2005;2(1):34-9. 24例 Shisheng He, Nakazat Hussain, Shaohua Li, Tiesheng Hou. J Neurosurg (Spine). 2005;3(5):348-354. 27例,戴力扬; 戴方义. 中华外科杂志 1989; 27(2): 99-101 倪斌; 贾连顺;戴力扬; 刘洪奎; 侯铁胜; 赵定麟. 中华放射学杂志 1995.12.10; 29(12): 858-861 王全平; 陆裕朴.中华骨科杂志 1993; 13(1): 15-18 倪斌; 贾连顺; 戴力扬; 刘洪奎; 侯铁胜; 赵定麟. 中国脊柱脊髓杂志 1994.04.28; 4(2): 56-59 陈仲强; 党耕町; 刘晓光; 蔡钦林. 中华骨科杂志 1999.04.25; 19(4): 197-200 (72例)。,发病机理,一、慢性损伤和退变 部分患者有外伤、手术等病史 下胸椎（T10-L1)多见，骨化的发生率及骨化的大小均与小关节的旋转活动范围有关，在旋转活动范围最大的T10T11水平，骨化的发生率最高，骨化的体积也最大 患者脊柱有明显退行性改变,二、遗传及种族差异 在年龄超过65岁的亚洲人中韧带骨化的发病率可高达20 而对于欧美人群的发病情况，至今为止，仅有数篇文献近20例报导,三、其它因素 甲状旁腺功能低下、骨软化症等全身性疾病患者的韧带骨化率相应增高。此外糖尿病、氟骨症、肥胖患者的韧带骨化发病率也相对较高。中国、日本人高盐少肉的饮食习惯可导致血清中雌激素水平增高，刺激软骨细胞的生长而导致韧带骨化,临床表现,本临床表现病变化多样，容易误诊和延误诊断 典型表现为上运动神经元损伤，但有时出现上下运动神经元同时受损表现 起病隐匿，进展缓慢,Miyakoshi N, Shimada Y, Suzuki T. Factors related to long-term outcome after decompressive surgery for ossification of the ligamentum flavum of the thoracic spine. J Neurosurg (Spine). 99(3):251-6, 2003.,Shisheng He, Nakazat Hussain, Shaohua Li, Tiesheng Hou. The Clinical and Prognostic analysis of Ossified Ligamentum Flavum in Chinese population。J Neurosurg (Spine). 2005;3(5):348-354.,Shisheng He, Nakazat Hussain, Shaohua Li, Tiesheng Hou. The Clinical and Prognostic analysis of Ossified Ligamentum Flavum in Chinese population。J Neurosurg (Spine). 2005;3(5):348-354.,颈、胸、腰椎均可出现，颈椎少见，而以胸椎和胸腰椎多见,根据其形态可进行X线分型， (1)棘突型； 又可分为上位型， 下位型和上下位型；(2)板状型；(3)结节状型；(4)游离型。,The lateral-type lesion showed ossification only at the facet joint capsule The extended type showed ossification extending to the lamina The enlarged type showed thickened ossification with anteromedial enlargement The fused type showed thickened bilateral ossified ligaments fused at the midline The tuberous type showed fused ossified ligaments growing anteriorly The more advanced the ossified ligamentum flavum from the lateral to the tuberous type, the more stenotic the spinal canal becomes.,可分为三种类型（MRI矢状位扫描） 局灶型：骨化局限在两个节段问 连续型：骨化连续三个节段及以上的 跳跃型：局灶或连续OLF间断地分布在各 段胸椎，之间为无骨化的节段,31 cases Shiokawa K, et al. Clinical analysis and prognostic study of ossified ligamentum flavum of the thoracic spine. J Neurosurg (Spine 2) 94:221226, 2001,Shisheng He, Nakazat Hussain, Shaohua Li, Tiesheng Hou. The Clinical and Prognostic analysis of Ossified Ligamentum Flavum in Chinese population。J Neurosurg (Spine). 2005;3(5):348-354.,治疗方法,后路椎板切除：整块切除 横向减压时必须将椎板、双侧椎间关节内缘12及骨化的韧带一同切除。上、下减压范围应包括骨化上下各一节段, 在合并胸椎OPLL时，则应包括OPLL两端及上、下各加一个椎板。 “双层椎板”样结构，以及肥大增生的关节突及骨化的关节囊韧带挤入椎管内，严重硬膜粘连，常难以做到经典的“揭盖式”的椎板切除。,后路椎板切除：逐渐蚕食 先用磨钻将骨化黄韧带打薄，薄弱处用钩子钩破，从正常及压迫轻部位进入（头侧、尾侧和两侧） 在多于半数病人中发现骨化的黄韧带和硬膜间粘连,牢固的粘连通常发生于椎管最狭窄的部位,钝性分离不能分开 在粘连周围减压,然后把粘连的骨块咬碎,逐个切除 切除骨化块造成的硬膜缺损用局部深筋膜修补 切忌用椎板咬骨钳直接深入椎管内咬,椎板成形 Okada等在4例中应用了椎板成形术,该术式由Hirabayashi的治疗颈椎管狭窄的方法改良而来。椎板切除的结果并不令人满意,因为早期并发症发生率高或由于相同部位黄韧带骨化复发或脊柱后凸畸形加重至晚期病情加重。他们推荐保留后部结构的椎板成形术作为首选方法。 Okada K,et al. Spine,1991,16:280.,2019/8/20,29,可编辑,环形减压：合并有OPLL、胸椎间盘突出症 行椎管后壁切除减压术后，用磨钻或骨刀切除积侧关节突段下一椎体的横突、肋骨与椎体和横突相关连部分及少许后肋，沿椎体侧面行骨膜下剥离，从椎体的后外侧切除椎间盘或骨化的后纵韧带，这样可以避免对脊髓的牵拉与刺激。因后柱的完整性丧失，减压后需行内固定及植骨,预后判断,Miyakoshi N, Shimada Y, Suzuki T. Factors related to long-term outcome after decompressive surgery for ossification of the ligamentum flavum of the thoracic spine. J Neurosurg (Spine). 99(3):251-6, 2003.,FFO: Final follow up outcome; RR: Recovery rate *: Significant difference :OLF Type was scored from small to large as: 1, lateral; 2, extended; 3, enlarged; 4, fused; and 5, tuberous Shisheng He, Nakazat Hussain, Shaohua Li, Tiesheng Hou. The Clinical and Prognostic analysis of Ossified Ligamentum Flavum in Chinese population。J Neurosurg (Spine). 2005;3(5):348-354.,The surgical outcomes classified as Excellent: Nurick Scale Grades 0-2 and JOA improvement more than 1; Fair: Nurick Scale Grades 3-5 or JOA no improvement. Sex: female=0, male=1 The other variables: without=0, with=1 The surgical outcome: