Transcript 骨化物漂浮 - 365骨科网

前路多节段椎体次全切除
治疗严重颈椎后纵韧带骨化症
陈德玉
上海市长征医院骨科
上海市脊柱外科中心
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
OPLL 的流行病学
日本 1.8%-4.1%
中国 1.6%-1.8%
韩国 0.95%
美国 0.12%
德国 0.1%
From OPLL edited by K Yonnenobu, et al
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
OPLL的手术治疗
后路椎板切除
后路椎管成形术
(Hirabayashi 1977)
直接切除减压
(Yamaura 1976)
骨化物漂浮
(Yamaura 1983)
椎间隙融合
(Onari 2001)
前后路联合手术
(Epstein 2004)
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
病例选择
 18例，男性11例，女性7例
 年龄42～75岁，平均53岁
 出现症状时间11月～7年，平均3.7年
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
影像学检查
颈椎生理曲度变化
前凸消失11例
后凸5例
生理前凸2例
骨化物范围2～4个椎体，平均2.8个椎体
椎管狭窄率(CNR): 50%-97%，平均 68.4%
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
手术治疗
纤支镜引导插管、全麻
多椎体次全切除（范围足够）
分离切除骨化后纵韧带
重建颈椎的稳定性
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
Case presentation
男 71岁
四肢麻木无力 5 年
加重半年
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
4
5
CT and sagittal
reformation showing
OPLL at C4-C5
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
Corpectomy of C4-C5 was performed
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
CT and MR showing
complete removal of
OPLL and
decompression
Case presentation
女 51岁
四肢麻木无力伴行
走不稳1年
小便控制困难1周
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
MRI showing spinal cord
was compressed from C4
to C6
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
CT showing OPLL at C4-C6
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
C4-C6 corpectomy was performed.
Dural ossification
floating anteriorly
Pre-op
MRI showing sufficient
decompression of the
spinal cord
Post-op
Case presentation
男 71 岁
肢体麻木乏力4年
行走不稳2年
不能行走7月
X-ray and CT:
C3-C6 OPLL with kyphosis
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
C3
C4
C4
C5
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
Compression of the spinal cord
from C3 to C5
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
C3-5 corpectomy and fusion
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
Pre-op
The change of spinal cord
on pre- and post-operative
MRI
Post-op
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
结果
两椎体次全切除12例，三椎体次全切除6例
25
20
15
10
5
0
C3
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
C4
C5
C6
C7
结果
神经功能JOA评分
 术前平均9.3分，术后平均14.2分，恢复
率22.2％～87.5％，平均63.2％。
优5例，良9例，可3例，差1例。优良
率77.8％。
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
结果
8例颈椎曲度较手术前改善
钛网重建者有轻度下沉
Postoperative Alignment
Preoperative
Alignment
lordotic
Straight
Kyphotic
Total
lordotic
2
0
0
2
Straight
3
8
0
11
Kyphotic
0
5
0
5
Total
5
13
0
18
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
并发症
 6例脑脊液漏
 2例神经根麻痹
 1例血肿压迫
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
讨论 --- 那种手术方法更好?
The A-group had a better JOA score after surgery (13.9vs 10.1 ;
P<0.003) and a higher IR (58% vs 13%; P<0.002) than P-group.
(Tani et al. Spine, 2002)
Surgical outcome of anterior decompression and fusion was superior
to that of laminoplasty in the patients with occupying rate greater
than 60% (54％ vs 14%; P<0.03).
(Iwasaki et al. Spine, 2007)
Excellent or good for 89% were obtained through anterior direct
removal of OPLL.
(Mizuno and Nakagawa, The Spine Journal 2006)
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
Why to choose
anterior approach
2001
2000
女性49岁, 四肢麻木乏力7年，行走不稳2年，不能行走3个月
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
C4/5
Y 2001
C6/7
C5/6
Y 2007
Y 2007
Progression of OPLL
Y 2007
CT scan in 2007 showing multilevel OPLL
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
Y 2000
Y 2007
MRI in year 2000 and 2007
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
X-ray and MRI after corpectomy
The neurological status was significantly improvement
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
Pre-op
Pre-op
MRI pre- and 3 m
post-operation
Post-op
Why to choose
anterior approach
男性51岁, 四肢麻木3年
伴行走困难2月
Lateral X-ray: cervical
alignment was lordotic
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
MRI showing compression of the
spinal cord at C4-C5
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
CT scan showing OPLL at different levels
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
Pre-op
Post-op
Laminoplasty was performed without
function improvement.
X-ray and CT at 2 m postoperatively
The cervical alignment was straight.
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
CT scan showing the spinal canal was not expanded
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
Post-operative CT sagittal reformation
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
MRI showing the
spinal cord was
still compressed.
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
2 level corpectomy in 4 m after Laminoplasty
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
Dural ossification
floating anteriorly
Post-Lami
MRIs after anterior decompression and laminoplasty
骨化后纵韧带直接切除减压
前路手术的安全界限：
骨化物厚度<5mm
椎管狭窄率<45%
骨化物范围<3个椎节
我们认为：
骨化物厚度>5mm、椎管狭窄率>45%并非前路直
接切除之禁忌
颈椎曲度变直或后凸更宜前路减压
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
前路骨化后纵韧带切除的优点
彻底去除致压因素，为直接减压
符合生物力学原理，尤其对颈椎
生理前凸消失或后凸者
更好的临床效果
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
前路骨化后纵韧带切除的缺点
 手术难度较大
 有一定风险
 易并发脑脊液漏
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
合并硬脊膜骨化
手术前CT连续薄扫和
矢状为重建有利于诊断
骨化物呈双层－有分
离可能
Double-layer sign
by Hida
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
合并硬脊膜骨化
手术前CT连续薄扫和
矢状为重建有利于诊断
骨化物不规则呈钩状
或特别厚－常无法分离易
形成硬膜缺损
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
Irregular hook-like angle
by Epstein
合并硬脊膜骨化术中处理
认真解剖仔细分离，保留
骨化硬膜使其漂浮。
硬膜缺损修补困难，生物
蛋白胶加明胶海绵覆盖可防止
或减轻脑脊液漏。
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
合并硬脊膜骨化术后处理
平卧体位或头低脚高位
常压引流保证切口愈合
局部加压酌情反复抽吸
脑脊液引流或分流
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
结论
切除骨化韧带为直接减压，符合生物力
学原理，临床上神经功能回复比较理想。
技术条件要求高，有一定风险，较易并
发脑脊液漏。
前路切除骨化韧带更适合于颈椎生理前
凸消失或后凸的OPLL患者。
Shanghai
Shanghai Changzheng
Changzheng Hospital
Hospital
THANK YOU FOR
YOUR ATTENTION