1 / 53

陈德玉

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)

makya
Download Presentation

陈德玉

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. 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

  2. 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

  3. 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)

  4. 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

  5. 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%

  6. 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

  7. Case presentation 男 71岁 四肢麻木无力 5 年加重半年

  8. 4 5

  9. CT and sagittal reformation showing OPLL at C4-C5

  10. Corpectomy of C4-C5 was performed

  11. CT and MR showing complete removal of OPLL and decompression

  12. 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

  13. MRI showing spinal cord was compressed from C4 to C6

  14. CT showing OPLL at C4-C6

  15. C4-C6 corpectomy was performed.

  16. Dural ossification floating anteriorly

  17. Pre-op MRI showing sufficient decompression of the spinal cord Post-op

  18. 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

  19. C4 C3 C4 C5

  20. Compression of the spinal cord from C3 to C5

  21. C3-5 corpectomy and fusion

  22. Pre-op The change of spinal cord on pre- and post-operative MRI Post-op

  23. 结果 两椎体次全切除12例，三椎体次全切除6例

  24. 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％。

  25. 结果 • 8例颈椎曲度较手术前改善 • 钛网重建者有轻度下沉

  26. 并发症 • 6例脑脊液漏 • 2例神经根麻痹 • 1例血肿压迫

  27. 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)

  28. 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

  29. C4/5 Y 2001 Y 2007 C6/7 C5/6 Progression of OPLL Y 2007 Y 2007

  30. CT scan in 2007 showing multilevel OPLL

  31. Y 2000 Y 2007 MRI in year 2000 and 2007

  32. X-ray and MRI after corpectomy The neurological status was significantly improvement

  33. Pre-op Pre-op MRI pre- and 3 m post-operation Post-op

  34. 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

  35. MRI showing compression of the spinal cord at C4-C5

  36. CT scan showing OPLL at different levels

  37. Pre-op Post-op Laminoplasty was performed without function improvement. X-ray and CT at 2 m postoperatively The cervical alignment was straight.

  38. CT scan showing the spinal canal was not expanded

  39. Post-operative CT sagittal reformation

  40. MRI showing the spinal cord was still compressed.

  41. 2 level corpectomy in 4 m after Laminoplasty

  42. Dural ossification floating anteriorly

  43. Post-Lami MRIs after anterior decompression and laminoplasty

  44. 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

  45. 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

  46. 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

  47. 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

  48. 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

  49. 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。

More Related