前路多节段椎体次全切除
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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. 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. 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)

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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


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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


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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)


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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


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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%


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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


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Case presentation

男 71岁

四肢麻木无力 5 年加重半年


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4

5


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CT and sagittal reformation showing OPLL at C4-C5


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Corpectomy of C4-C5 was performed


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CT and MR showing complete removal of OPLL and decompression


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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


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MRI showing spinal cord was compressed from C4 to C6


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CT showing OPLL at C4-C6


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C4-C6 corpectomy was performed.


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Dural ossification floating anteriorly


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Pre-op

MRI showing sufficient decompression of the spinal cord

Post-op


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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


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C4

C3

C4

C5


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Compression of the spinal cord from C3 to C5


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C3-5 corpectomy and fusion


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Pre-op

The change of spinal cord on pre- and post-operative MRI

Post-op


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结果

两椎体次全切除12例,三椎体次全切除6例


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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%。


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结果

  • 8例颈椎曲度较手术前改善

  • 钛网重建者有轻度下沉


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并发症

  • 6例脑脊液漏

  • 2例神经根麻痹

  • 1例血肿压迫


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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)


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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


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C4/5

Y 2001

Y 2007

C6/7

C5/6

Progression of OPLL

Y 2007

Y 2007


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CT scan in 2007 showing multilevel OPLL


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Y 2000

Y 2007

MRI in year 2000 and 2007


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X-ray and MRI after corpectomy

The neurological status was significantly improvement


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Pre-op

Pre-op

MRI pre- and 3 m post-operation

Post-op


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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


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MRI showing compression of the spinal cord at C4-C5


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CT scan showing OPLL at different levels


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Pre-op

Post-op

Laminoplasty was performed without function improvement.

X-ray and CT at 2 m postoperatively The cervical alignment was straight.


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CT scan showing the spinal canal was not expanded


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Post-operative CT sagittal reformation


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MRI showing the spinal cord was still compressed.


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2 level corpectomy in 4 m after Laminoplasty


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Dural ossification floating anteriorly


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Post-Lami

MRIs after anterior decompression and laminoplasty


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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


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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


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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


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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


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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

Irregular hook-like angle by Epstein


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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。


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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


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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。


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THANK YOU FOR

YOUR ATTENTION


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