OPLL颈椎后纵韧带骨化PPT课件

-,1,OPLL经典综述讲读,王雪鹏杭州市骨科研究所杭州市第一人民医院骨科,-,2,-,3,-,4,-,5,-,6,Ossificationoftheposteriorlongitudinalligament(OPLL)resultsfrompathologicreplacementofthePLLwithlamellarbone,potentiallycausingspinalcordcompressionandneurologicdeteriorationOPLLwasfirstdescribedinJapanesepatientsandhasclassicallybeenconsideredacauseofmyelopathyinpatientsofEastAsianorigin,-,7,spondylosismyelopathyradiculopathystenosisdischerniation,-,8,-,9,AmongpatientsinJapanwithcervicalspinedisorders,theincidencehasbeenestimatedat1.9%to4.3%and,inotherAsiancountries,upto3.0%OPLLhasbeenrecognizedasanetiologyofmyelopathyregardlessofethnicity,withanestimatedincidencerateof0.1%to1.7%amongNorthAmericansandEuropeans,-,10,Pathoanatomy,ThePLLrunsalongthedorsalsurfaceoftheC1anteriorarchandcervicalvertebralbodiesandconsistsoflongitudinalfibersconfluentwiththetectorialmembranecraniallyandendingatthesacrumcaudallyfunctionally,thePLLresistsspinehyperflexion,-,11,Pathophysiology,ThepathologicprocessleadingtoOPLLbeginswithchondroblast-andfibroblast-likespindlecellproliferation,alongwithvascularinfiltrationleadingtoPLLdegenerationandhypertrophy.Endochondralossificationfollows,resultinginitsreplacementwithmaturelamellarboneGenetics,localtissuecharacteristics,andassociatedmedicalcomorbiditieshaveallbeenimplicatedinthisfinalcommonpathway,-,12,-,13,MedicalcomorbiditiesarealsoassociatedwiththedevelopmentofOPLLUpto50%ofCaucasianpatientswithOPLLalsohavediffuseidiopathicskeletalhyperostosisHypoparathyroidism,hypophosphatemicrickets,hyperinsulinemia,andobesityhavebeenidentifiedasriskfactors,-,14,NaturalHistory,PatientswithOPLLcommonlypresentintheirfifthandsixthdecades,withmenaffectedtwiceasoftenaswomen.Mostpatientshavesomeneurologicsymptomsatdiagnosis,with28%to39%fulfillingdiagnosticcriteriaformyelopathy,-,15,-,16,Inpatientswithmyelopathy,64%haddeteriorated,however,and89%ofpatientswithNurickgrade3or4myelopathywhorefusedsurgeryhadprogressedtoawheelchair-orbed-boundstate,-,17,Riskfactorsforthedevelopmentofmyelopathyinclude60%spinalcanalstenosis,6mmofspaceavailableforthecord,increasedcervicalrangeofmotion,andOPLLthatislaterallydeviatedwithinthespinalcanalAge,gender,andthenumberoflevelsaffectedbyOPLLdonotaffecttheprognosis,-,18,ClinicalPresentation,Changesingaitorbalance,lossoffinemotorcontrol,andupperextremityweakness,numbness,orparesthesiasaresuggestiveofmyelopathyEarlymuscularfatigueorworseningsymptomsattheextremesofcervicalmotionarealsoconcerning,-,19,PatientswithOPLLareatanincreasedriskofacutespinalcordinjurywithtrauma,andrapidneurologicdeteriorationinassociationassociationwithevenaminortraumaorwhiplashinjuryshouldraiseconcernforthedevelopmentofcentralcordsyndrome,-,20,PhysicalExamination,-,21,RadiologicEvaluation,-,22,ThelateralradiographisalsousedtodeterminetherelationshipoftheOPLLtothekyphosisline(K-line),whichisdrawnfromthecenterofthecanalatC2tothecenterofthecanalatC7AlargeOPLLmassorlossofcervicallordosiscausestheOPLLtoprotrudeposteriortotheK-line(referredtoasK-linenegative).Thisisanegativeprognosticfactorforposteriorsurgeryalone,-,23,-,24,CTwithsagittalandcoronalreformattinghasemergedasthebenchmarkforradiographicevaluationofOPLLandisnecessarytoreliablycharacterizeit,-,25,Greaterthan60%canaloccupancyatanylevelandalaterallydeviatedmassareassociatedwithhighratesofmyelopathyThis“doublelayersign”onaxialorsagittalCTimagesisassociatedwithduraltearrates50%withanteriordecompressionversus13%whenthesignisabsent,-,26,-,27,NonsurgicalManagement,ProphylacticsurgeryisneithernecessarynorrecommendedManagementincludestemporaryimmobilizationwithaneckbrace,steroidalornonsteroidalanti-inflammatorymedications,activitymodification,andphysicaltherapy,-,28,patientsshouldbeadvisedtoavoidactivitiesthatmayresultinsuddenorexcessivecervicalspinemotionbecauseOPLLisassociatedwithahighrateofacutespinalcordinjury,eveninpatientswhodonotmeetsurgicalcriteria,-,29,SurgicalTreatment,SurgicaldecompressionisthetreatmentofchoiceforpatientswithNurickgrade3or4myelopathyorsevereradiculopathycausedbyOPLLviaeitherananteriororposteriorapproach,-,30,AnteriorDecompressionandFusion,Proponentsarguethatitallowsforasuperiordecompressionandismoreeffectiveatmaintainingorrestoringcervicallordosisthanisposteriorsurgery.Associatedanteriorpathology,suchasdiskherniations,canalsobeaddressed,-,31,Disadvantagesincludetechnicaldifficulty,inabilitytodecompresscranialtoC2,andhighratesofpseudarthrosisanddysphagiawhenthreeormorelevelsrequiretreatmentDuraltearsarealsomuchmorecommonwithananteriorapproach,giventhatanteriorduralossificationoccursin13%to15%,-,32,ExposureisprovidedbythestandardSmith-Robinsonapproach,anddiskectomy,hemicorpectomy,orsubtotalcorpectomysufficienttoallowexposureoftheunderlyingOPLLmassisperformedCorpectomiesofuptofivelevelshavebeenperformedwithsuccess,butremovalofthreeormorecontiguouslevelsisassociatedwithincreasedcomplicationandreoperationrates,-,33,Complicationsoccuraspartoftheapproach(eg,dysphagia,dysphonia),thedecompression(eg,C5palsy,duraltears),orthefusion(eg,graftsubsidence,pseudarthrosis),-,34,Nerverootpalsiesoccurin4%to17%ofpatientsthrougheitherdirecttraumaortraction.Patientspresentwithweakness,numbness,pain,orparesthesias,mostcommonlyintheC5distribution,-,35,Duraltearsoccurin4%to20%ofpatients,oftenbecauseofduralossificationorattenuation.Cerebrospinalfluidleakagemayresultinpseudomeningoceleorfistulaformation,leadingtoneuraldamage,airwaycompression,meningitis,orwoundcomplications,-,36,Tearsrecognizedintraoperativelyaretreatedbydirectrepairorbyapplicationofautogenousfascialorsyntheticcollagengrafts.Closureofpinholedefectsoraugmentationofrepairsisdonewiththrombogenicsealants,suchasfibringlueorgelatinfoam.Postoperatively,divertinglumbardrainsandbedrestcanbeused,-,37,Inanefforttoreduceduraltearrates,Yamauraetalintroducedthe“anteriorfloatingmethod”forcervicaldecompression,consistingofsubtotalvertebralbodyresectionandthinning,butnotremoval,oftheOPLL.Theposteriorvertebralbodyisnotreconstructed,allowingtheOPLLto“float”anteriorlyandawayfromthespinalcanal.At5-yearfollow-up,theauthorsachievedameanrecoveryrateof68.5%andimprovementinJapaneseOrthopaedicAssociationscoresfrom8.3to14.2.Noleaksofcerebrospinalfluidoccurred,but14%ofpatientswereleftwithaninadequatedecompression.Inthesepatients,orwithOPLLprogression,theauthorsrecommendedsubsequentposteriordecompression.,-,38,Whenaddressingmorethantwoorthreelevels,fibularstrutgraftsarepreferredfortheirstructuralsupport.Foroneortwolevels,structuralgraftsoftricorticaliliaccrest,fibula,andvertebralbodieshaveallbeendescribed.Morerecently,interbodycageswithnonstructuralbonegraftorbonegraftsubstituteshavebeenused.Overallratesofpseudarthrosisvaryfrom3%to15%,withthehighestratesoccurringinpatientsundergoingfusionofthreeormorelevels.,-,39,-,40,-,41,-,42,-,43,-,44,PosteriorDecompression,WhenmorethantwoorthreecervicallevelsareaffectedbyOPLL,posteriorsurgery(ie,laminoplasty,orlaminectomyandfusion)ispreferredbecauseofthetechnicaleaseandlowerrateofcomplications.Disadvantagesincludetheriskofpostoperativediseaseprogression,inabilitytocorrectcervicalkyphosis,andpoorresultsinK-linenegativepatients.,-,45,Laminoplastyaccomplishesthisbyhingingopenthelaminaewitheitheran“opendoor”or“Frenchdoor”technique,resultingina30%to40%increaseinthesizeofthespinalcanalLaminectomyandfusionentailsremovalofthelaminaefollowedbyinstrumentedposterolateralfusion,resultingina70%to80%increaseincanalvolume,-,46,-,47,-,48,-,49,-,50,-,51,-,52,-,53,AfullanalysisoftheadvantagesanddisadvantagesbetweenlaminoplastycomparedwithlaminectomyandfusionhasbeendiscussedelsewhereOurpreferenceistouselaminectomyandfusionforOPLLbecausetheretainedcervicalmotionwithlaminoplastymayallowdiseaseprogression,andtheriskforprogressiontokyphosisattheaffectedlevelsiseliminatedwithfusion,-,54,Forseveredisease,recoveryratesafterposteriordecompressionappeartobelowerthanthosefollowinganteriordecompression,butwithalowercomplicationrate,-,55,Iwasakietalretrospectivelycomparedtheresultsofanteriordecompressionandfusionwiththoseoflaminoplasty;theyreportedbetteroutcomesafteranteriorsurgeryinpatientswithanOPLLmassoccupying60%ofthecanal;however,itresultsinareoperationrateof26%versus2%inthelaminoplastygroup.With60%canaloccupancy,recoveryrateswereequivalent.,-,56,Aprospectivecomparisonofanteriordecompressionandfusionversuslaminoplastyfoundsimilarresults.Patientswith50%canaloccupancyhadsuperiorrecoveryrateswithanteriorsurgerybutequivalentrateswith50%involvementPatientswith5ofcervicallordosisalsohadsignificantlyworseoutcomesfromlaminoplasty,and50%lostlordosisversusnoneinthefusiongroup.HalfofthelaminoplastypatientsexperiencedOPLLprogressionversusonlyoneafteranteriorsurgeryHowever,surgicalcomplicationsheavilyfavoredlaminoplasty,witha23%complicationrateanda14%reoperationrateintheanteriorgroupandnoneinthelaminoplastypatients,-,57,OnlyonestudytodatehasexaminedtheresultsoflaminectomyandfusionforOPLL.,-,58,Chenetalreportedameanrecoveryrateof62%at5yearsamong83patientswhounderwentinstrumentedlaminectomyandfusionfromC2orC3toC7.Patientswithagoodoutcomehadsignificantlymorepostoperativelordosis(16.1versus10.4).Nootherfactors,includingoccupyingratio,weresignificantbetweengroups.Thereoperationratewas4%,alltheresultofepiduralhematomaformation.Whetherposteriorfusionhadaneffectondiseaseprogressionwasnotevaluated,althoughtheauthorsnotednolongtermdeclineinneurologicrecovery,asisc