胸椎黄韧带骨化症.ppt.ppt

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1、胸椎黄韧带附着处骨化是比较常见的现胸椎黄韧带附着处骨化是比较常见的现象，但引起脊髓压迫，导致胸椎黄韧带象，但引起脊髓压迫，导致胸椎黄韧带骨化症比较少见骨化症比较少见Williams回顾了回顾了50例尸体标本及例尸体标本及100个个CT扫描，发现扫描，发现韧带附着处骨化比较常见。韧带附着处骨化比较常见。Radiology.1984 Feb;150(2):423-6.Maigne 对对121例老年人调查发现下胸椎例老年人调查发现下胸椎83%附附着点骨化，腰椎着点骨化，腰椎33%骨化，认为下胸椎尾端附骨化，认为下胸椎尾端附着处骨化是老年人的一种正常现象，受旋转应着处骨化是老年人的一种正常现象，受旋转

2、应力的影响力的影响Surg Radiol Anat.1992;14(2):119-24.Payer M,et al.Thoracic myelopathy due to enlarged ossified yellow Ligaments.J Neurosurg(Spine 1)92:105108,2000在年龄超过65岁的亚洲人中韧带骨化的发病率可高达20而对于欧美人群的发病情况，至今为止，仅有数篇文献近20例报导甲状旁腺功能低下、骨软化症等全身性疾病患者的韧带骨化率相应增高。此外糖尿病、氟骨症、肥胖患者的韧带骨化发病率也相对较高。中国、日本人高盐少肉的饮食习惯可导致血清中雌激素水平增高，刺

3、激软骨细胞的生长而导致韧带骨化Miyakoshi N,Shimada Y,Suzuki T.Factors related to long-term outcome after decompressive surgery for ossification of the ligamentum flavum of the thoracic spine.J Neurosurg(Spine).99(3):251-6,2003.SymptomsNumbersWeakness in lower limbs and gait disturbance25Numbness and Sensory deficit

4、24Low back pain13Squeezing tight band around chest or abdomen10Neurological claudication 9Leg pain7Fecal and urinary incontinence11Knee and ankle hyperreflexia22Positive patellar and ankle clonus13Positive Babinksi14Location of OLFNumbersT10-T118T11-T128T8-T113T6-T102T10-T122T1-T3,T11-T121T1-T71T1-T

5、31T2-T31颈、胸、腰椎均可出现，颈椎少见，而以胸椎和胸腰椎多见颈、胸、腰椎均可出现，颈椎少见，而以胸椎和胸腰椎多见根据其形态可进行根据其形态可进行X线分型，线分型，(1)棘突型；棘突型；又可分为上位型，又可分为上位型，下位型和上下位型；下位型和上下位型；(2)板状型；板状型；(3)结节状型；结节状型；(4)游离型。游离型。The lateral-type lesion showed ossification only at the facet joint capsuleThe extended type showed ossification extending to the lamin

6、aThe enlarged type showed thickened ossification with anteromedial enlargementThe fused type showed thickened bilateral ossified ligaments fused at the midline The tuberous type showed fused ossified ligaments growing anteriorlyThe more advanced the ossified ligamentum flavum from the lateral to the

7、 tuberous type,the more stenotic the spinal canal becomes.可分为三种类型（可分为三种类型（MRI矢状位扫描）矢状位扫描）局灶型：骨化局限在两个节段问连续型：骨化连续三个节段及以上的跳跃型：局灶或连续OLF间断地分布在各 段胸椎，之间为无骨化的节段31 casesShiokawa K,et al.Clinical analysis and prognostic study of ossifiedligamentum flavum of the thoracic spine.J Neurosurg(Spine 2)94:221226,200

8、1Ca se NoSexAge(yrs)OLFCoexisting DiseasesSurgical Procedures1M46T10-11L3-5 canal stenosis,T10/11 disc herniationT10-11 lamimectomy,L3-5 laminectomy2M56T11-12C2-3 OPLL,T3-5 OPLLT11-12 laminectomy3F64T10-11C4/5 disc herniation,T4-6 OPLLT10-T11 laminectomy,T4-6 OPLL removal4M42T8-11T9/10 disc herniati

9、onT8-11 laminectomy,T9/10 discectomy5F67T11-12C3-6 canal stenosis,T11/12 disc herniationT11-12,C3-6 laminectomy6M63T6-10C2-7 OPLL,T6-8 OPLLT6-10 laminectomy,T6-8 OPLL removal7M70T11-12L4/5 disc herniationT11-12 laminectomy8F44T1-3C4/5,C5/6,T1/2,T2/3 ossified disc herniationT1-3 laminectomy,T1/2,2/3

10、discectomy9F71T8-11L4/5 canal stenosisT8-11,L4-5 lamnectomy10M52T10-12T10/11,11/12 disc herniationT10-12 laminectomy11M47T1-7C3-5 canal stenosis;C2-4 OPLLC3-5,T1-7 laminectomy12M59T1-3,T11-12T9/10 disc herniation,L4/5 stenosisT1-3,T11-12 laminectomy13M69T10-12T10/11 disc herniation,C3-6 canal stenos

11、is T10-12 laminectomy,C3-6 laminectomy14M55T10-11T8/9 disc herniation,L4/5 disc herniationT10-11 laminectomy15F61T6-10C3-6 OPLL,L4-5 canal stenosisT6-10 laminectomy16M64T8-11C5/6 disc herniationT8-11 laminectomy横向减压时必须将椎板、双侧椎间关节内缘12及骨化的韧带一同切除。上、下减压范围应包括骨化上下各一节段,在合并胸椎OPLL时，则应包括OPLL两端及上、下各加一个椎板。“双层椎板”

12、样结构，以及肥大增生的关节突及骨化的关节囊韧带挤入椎管内，严重硬膜粘连，常难以做到经典的“揭盖式”的椎板切除。先用磨钻将骨化黄韧带打薄，薄弱处用钩子钩破，从正先用磨钻将骨化黄韧带打薄，薄弱处用钩子钩破，从正常及压迫轻部位进入（头侧、尾侧和两侧）常及压迫轻部位进入（头侧、尾侧和两侧）在多于半数病人中发现骨化的黄韧带和硬膜间粘连在多于半数病人中发现骨化的黄韧带和硬膜间粘连,牢固牢固的粘连通常发生于椎管最狭窄的部位的粘连通常发生于椎管最狭窄的部位,钝性分离不能分开钝性分离不能分开在粘连周围减压在粘连周围减压,然后把粘连的骨块咬碎然后把粘连的骨块咬碎,逐个切除逐个切除切除骨化块造成的硬膜缺损用局部深筋

13、膜修补切除骨化块造成的硬膜缺损用局部深筋膜修补切忌用椎板咬骨钳直接深入椎管内咬切忌用椎板咬骨钳直接深入椎管内咬行椎管后壁切除减压术后，用磨钻或骨刀切除积侧关节突段下一椎体的横突、肋骨与椎体和横突相关连部分及少许后肋，沿椎体侧面行骨膜下剥离，从椎体的后外侧切除椎间盘或骨化的后纵韧带，这样可以避免对脊髓的牵拉与刺激。因后柱的完整性丧失，减压后需行内固定及植骨Miyakoshi N,Shimada Y,Suzuki T.Factors related to long-term outcome after decompressive surgery for ossification of the li

14、gamentum flavum of the thoracic spine.J Neurosurg(Spine).99(3):251-6,2003.FFO:Final follow up outcome;RR:Recovery rate*:Significant difference:OLF Type was scored from small to large as:1,lateral;2,extended;3,enlarged;4,fused;and 5,tuberous VariablesJOA Score at FFORR at FFOCoefficientp ValueCoeffic

15、ientp ValueAge(yrs)-0.6300.120-0.5340.404Preoperative Symptom Duration (Months)-0.2060.003*-2.4920.001*Preoperative JOA Score1.1740.021*1.5490.040*Levels of OFL-0.5870.375-2.0380.674OFL Type-0.5710.088-3.6510.346The surgical outcomes classified as Excellent:Nurick Scale Grades 0-2 and JOA improvemen

16、t more than 1;Fair:Nurick Scale Grades 3-5 or JOA no improvement.Sex:female=0,male=1 The other variables:without=0,with=1 The surgical outcome:Excellent=0,Fair=1.OR:Odds Ratio *:Significant differenceVariablesp ValueORSex0.3471.024Coexisting Spinal Diseases0.0921.251Operation for Coexisting Spinal Diseases0.1031.136Intramedullary High T2 Signal Change0.038*1.478Weakness in Lower Extremities and Gait Disturbance0.3511.269Numbness and Sensory Deficit0.1741.172Low back pain0.5731.042Squeezing Tight