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胸椎黄韧带骨化合并腰椎管狭窄的临床特点及手术疗效影响因素
作者:黄维军  韩来春  李承罡  梁冬牧  丁壮志  关海山 
单位:山西医科大学附属第二医院 脊柱外科, 山西 太原 030000
关键词:胸椎黄韧带骨化 腰椎管狭窄 手术疗效 影响因素 
分类号:R681.53
出版年·卷·期(页码):2021·49·第二期(134-143)
摘要:

目的:分析胸椎黄韧带骨化症(thoracic ossification of ligamentum flavum,TOLF)合并腰椎管狭窄(lumbar spinal stenosis,LSS)的临床表现,探讨手术策略和手术疗效的影响因素。方法:回顾性分析山西医科大学附属第二医院2014年6月至2018年6月收治的47例TOLF合并LSS患者的临床资料,男20例,女27例。16例同期行胸椎后路椎板切除、腰椎后路椎板减压植骨融合内固定术,14例行分阶段手术治疗,其余17例一期部分椎管减压后未行二期手术,其中10例一期行单纯胸椎减压术,7例行单纯腰椎减压术。采用胸椎日本骨科协会(Japanese Orthopaedic Association,JOA)评分和腰椎Oswestry功能障碍指数(Oswestry disability index,ODI)评价患者神经功能,并对相关因素进行二元Logistic回归分析。结果:47例纳入患者得到随访,随访时间9~60个月,平均(31.4±15.3)个月。所有患者的JOA评分均不同程度地提高,16例同期行两部位手术治疗,末次随访JOA改善率为(52.4±18.3)%;14例分期手术治疗,恢复率为(57.7±14.9)%;17例接受单纯胸或腰椎管减压,平均恢复率为(45.6±15.4)%。术前JOA评分、脊髓信号改变以及是否充分解除脊髓的压迫与术后疗效有显著的相关性。结论:TOLF合并LSS的临床表现复杂,诊断需要重视病史采集并进行仔细的体格检查。同期手术创伤较大,需要考虑患者的年龄和身体耐受能力。分期手术的总住院天数更长,因为存在间隔时间将延迟神经功能的恢复。术前的低JOA评分、遗留未手术治疗的椎管狭窄及术前胸段脊髓的异常信号对术后恢复不利。

Objective:To analyze the clinical features of thoracic ossification of ligamentum flavum (TOLF) coexisted with lumbar spinal stenosis(LSS) and to discuss the surgical strategy and possible prognostic factors.Methods: From June 2014 to June 2018, 47 patients (20 males, 27 females)were retrospectively reviewed.16 patients underwent surgical decompression at both levels in one stage,14 patients underwent two-stage surgery. Additionally, remaining 17 patients were merely operated for thoracic or lumbar disorders. Postoperative functional outcomes were evaluated by modified Japanese Orthopedic Association(JOA) score and Oswestry disability index (ODI). Related factors were analyzed by Logistic regression analysis. Results: 47 cases were followed up for 9 to 60 months,averaged 31.4±15.3 months. After surgery, all of the patients experienced improvement. Sixteen patients underwent one-stage surgery,14 patients underwent two-stage procedure, the others didn't received the second decompression, the average JOA recovery rates were (52.4±18.3)%,(57.7±14.9)% and (45.6±15.4)% respectively at the final follow-up. Logistic regression analysis showed that preoperative JOA score, intramedullary signal change and complete decompression correlated with postoperative recovery. Conclusion: The clinical features of TOLF accompanied with LSS were complicated, meticulous history taking and physical examination might help to make an accurate diagnosis. Simultaneous operation was invasive, and patients' age and physical endurance need to be considered. While two-stage operation needed longer total hospital stay, and the recovery of neurological function might be delayed due to the interval time. Low preoperative JOA score, incomplete decompression and abnormal intramedullary signal type significantly compromised recovery.

参考文献:

[1] MORI K,IMAI S,KASAHARA T,et al.Prevalence, distribution,and morphology of thoracic ossification of the posterior longitudinal ligament in Japanese:results of CT-based cross-sectional study[J].Spine (Phila Pa 1976),2014,39(5):394-399.
[2] 孙垂国,陈仲强,刘忠军,等.胸椎黄韧带骨化症术后远期疗效分析[J].中华外科杂志,2012,50(5):426-429.
[3] MATSUMOTO Y,HARIMAYA K,DOI T,et al.Clinical characteristics and surgical outcome of the symptomatic ossification of ligamentum flavum at the thoracic level with combined lumbar spinal stenosis[J].Arch Orthop Trauma Surg,2012,132(4):465-470.
[4] HOU X,SUN C,LIU X,et al.Clinical features of thoracic spinal stenosis-associated myelopathy:A retrospective analysis of 427 cases[J].Clin Spine Surg,2016,29(2):86-89.
[5] UEHARA M,TSUMIMOTO T,YUI M,et al.Single-stage surgery for compressive thoracic myelopathy associated with compressive cervical myelopathy and/or lumbar spinal canal stenosis[J].Eur Spine J,2016,25(6):1904-1911.
[6] GAO R,YUAN W,YANG L L,et al.Clinical features and surgical outcomes of patients with thoracic myelopathy caused by multilevel ossification of the ligamentum flavum[J].Spine J,2013,13(9):1032-1038.
[7] 刘克骏,米明珊,白海明,等.胸椎黄韧带骨化患者伴腰椎管狭窄行椎板切除术的预后[J].实用医学杂志,2016,32(1):164-165.
[8] 王哲,罗卓荆,胡慧敏,等.下胸椎黄韧带骨化症合并腰椎管狭窄症的诊断与一期外科治疗[J].中华骨科杂志,2010,30(11):1096-1100.
[9] SUDARSHAN M,FARSCHID M,JOHN P M.Multilevel spinal stenosis at cervical,thoracic and lumbar spine:a clinical report[J].Joint Bone Spine,2012,79(4):417-418.
[10] 宁尚龙,陈仲强,马信龙,等.胸椎黄韧带骨化基础与临床研究进展[J].中国矫形外科杂志,2017,25(11):999-1004
[11] LI W, GUO S,SUN Z,et al.Multilevel thoracic ossification of ligamentum flavum coexisted with/without lumbar spinal stenosis:staged surgical strategy and clinical outcomes[J].BMC Musculoskelet Disord,2015,16(1):206-216.
[12] HIOKI A,MIYAMOTO K,HOSOE H,et al.Two-stage decompression for combined epiconus and cauda equina syndrome due to multilevel spinal canal stenosis of the thoracolumbar spine:a case report[J].Arch Orthop Trauma Surg,2008,128(9):955-958.
[13] ESKANDER M S,AUBIN M E,DREW J M,et al.Is there a difference between simultaneous or staged decompressions for combined cervical and lumbar stenosis?[J].JSpinal Disord Tech,2011,24(6):409-413.
[14] 任红伟,李磊.后路减压内固定手术治疗胸椎黄韧带骨化症的预后影响因素分析[J].颈腰痛杂志,2019,40(2):153-156.
[15] 万勇,梁堂钊,龙光华,等.手术治疗胸椎管狭窄症的效果分析[J].中国脊柱脊髓杂志,2010,20(80):664-668.
[16] 刘晓明,张锐光,李小强.胸椎管狭窄症后路手术疗效及相关影响因素分析[J].临床医药文献电子杂志,2018,5(62):16-18.
[17] SANGHVI A V,CHHABRA H S,MASCARENHAS A A,et al.Thoracic myelopathy due to ossification of ligamentum flavum:a retrospective analysis of predictors of surgical outcome and factors affecting preoperative neurological status[J].Eur Spine J,2011,20(2):205-215.
[18] GUPTA A, DAVE B,NANDA A,et al. Concomitant noncontiguous level (thoracic & lumbar) spinal stenosis[J].Int Orthop,2009,33(2):483-488.
[19] OVERLEY S C,KIM J S,GOGEL B A,et al.Tandem spinal stenosis:a systematic review[J].JBJS Rev,2017,5(9):e2.
[20] SCHAFFER J C,RAUDENBUSH B L,MOLINARI C,et al.Symptomatic triple-region spinal stenosis treated with simultaneous surgery:case report and review of the literature[J].Global Spine J,2015,5(6):513-521.
[21] BAKER J F.Evaluation and treatment of tandem spinal stenosis[J].J Am Acad Orthop Surg,2020,28(6):229-239.
[22] CHEN Y,CHEN D Y,WANG X W,et al.Single-stage combined decompression for patients with tandem ossification in the cervical and thoracic spine[J].Arch Orthop Trauma Surg,2012,132(9):1219-1226.
[23] HU P,MIAO Y,LIU X,et al. Surgeries for patients with tandem spinal stenosis in cervical and thoracic spine:combined or staged surgeries?[J].World Neurosurge,2017,107:115-123.
[24] 雷涛,高显达,曹俊明,等.同期或分期手术治疗颈腰综合征的疗效观察与比较[J].中国脊柱脊髓杂志,2019,29(11):969-976.
[25] LUO C A,KALIYA-PERUMAL A K,LU M L,et al.Staged surgery for tandem cervical and lumbar spinal stenosis:which should be treated first?[J].Eur Spine J,2018,28(1):61-68.
[26] 中华医学会骨科学分会脊柱外科学组.胸椎管狭窄症诊疗指南[J].中华骨科杂志,2015,35(1):1-5.
[27] FUSHIMI K,MIYAMOTO K,HIOKI A,et al.Neurological deterioration due to missed thoracic spinal stenosis after decompressive lumbar surgery:a report of six cases of tandem thoracic and lumbar spinal stenosis[J].Bone Joint J,2013,95-B(10):1388-1391.
[28] TAKEUCHI A,MIYAMOTO K,HOSOE H,et al.Thoracic paraplegia due to missed thoracic compressive lesions after lumbar spinal decompression surgery.Report of three cases[J].J Neurosurg,2004,100(1 Suppl Sp):71-74.
[29] KO S B,LEE S W,SHIM J H.Paraplegia due to missed Thoracic meningioma after laminotomy for lumbar spinal stenosis:Report of two cases[J].Asian Spine J,2011,5(4):253-257.
[30] KNAFO S,LONJON G,VASSAL M, et al. Spinal cord compression due to undiagnosed thoracic meningioma following lumbar surgery in an elderly patient:a case report[J].Orthop Traumatol Surg Res,2013,99(8):983-986.
[31] 李宏,李淳德,邑晓东,等.一期颈腰椎联合手术治疗脊髓型颈椎病合并腰椎管狭窄症的临床疗效观察[J].中华骨与关节外科杂志,2018,11(3):197-201.
[32] 刘晓光.胸椎管狭窄症患者MRI髓内高信号的原因及对预后的影响[J].中国脊柱脊髓杂志,2014,24(7):581-582.
[33] 贺宝荣,许正伟,郝定均,等.胸椎黄韧带骨化症患者髓内MRI高信号与手术疗效的关系[J].中国脊柱脊髓杂志,2014,24(10):928-932.
[34] MITSURU Y,KEN N,MICHIYA K,et al.Long-term surgical outcome and risk factors in patients with cervical myelopathy and a change in signal intensity of intramedullary spinal cord on magnetic resonance imaging[J].J Neurosurg,2010,12(1):59-65.
[35] 王德训,王亭,郭建伟,等.黄韧带骨化所致胸椎管狭窄症脊髓MRI信号改变与手术效果关系[J].青岛大学学报(医学版),2019,55(2):159-163.
[36] 刘法敬,丁晓坤,曹俊明,等.胸椎管狭窄程度与脊髓内高信号及临床症状的相关性研究[J].现代中西医结合杂志,2014,23(33):3664-3666.
[37] VEDANTAM A,JONATHAN A,RAJSHEKHAR V,et al.Associationof magnetic resonance imaging signal changes and outcome prediction after surgery for cervical spondyloticmyelopathy[J].J Neurosurg Spine,2011,15(6):660-666.
[38] 申沧海,冯永健,宋彦澄,等.MRI T2WI量化指标评估胸椎黄韧带骨化症手术预后的价值[J].中国组织工程研究,2020,24(18):2893-2899.
[39] 李乐鹏,李高磊,崔艳萍,等.后路椎板减压内固定术治疗胸椎黄韧带骨化症的预后因素[J].中国矫形外科杂志,2017,25(13):1168-1172.

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