胸椎黄韧带骨化症髓内高信号的临床研究与手术治疗策略
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摘要
第一部分胸椎黄韧带骨化症脊髓压迫程度与髓内高信号的相关研究
目的：近年来，随着医学检查技术及设备的更新与发展，特别是MRI和CT的广泛应用，越来越多的胸椎黄韧带骨化症患者得以明确诊断。由于黄韧带骨化程度较轻的患者可无临床症状，而随着骨化物的逐步增大，脊髓受压程度超过其最大耐受时就会出现神经受损症状。MRI成像尤其是全脊柱MRI为胸椎黄韧带骨化的定位和定性提供了可靠依据，同时也可清楚显示胸髓内是否存在信号变化。
该研究借助MRI成像技术，在矢状径位下比较不同胸髓受压程度下脊髓高信号（Intramedullary increased signal intensity, ISI）的发生情况，明确两者是否存在一定的相关关系。
方法：2010年10月～2012年9月，共92例患者在我院门诊经MRI检查明确诊断为胸椎黄韧带骨化症（ossification of the ligamentum flavum,OLF），按脊髓受压程度将其分为：A组（椎管矢状径残余率≥66.7%）29例，其中男13例，女16例，年龄43～67岁，平均55.2岁；B组（33.3%≤椎管矢状径残余率﹤66.7%）36例，男19例，女17例，年龄45～69岁，平均56.6岁；C组（椎管矢状径残余率﹤33.3%）27例，男12例，女15例，年龄42～71岁，平均56.9岁。采用日本骨科协会(Japanese OrthopedicAssociation,JOA)评分评定患者神经功能状况，同时观察胸髓内高信号发生情况。
结果：A组29例患者中有6例出现ISI（20.7%），B组36例患者中17例出现ISI（47.2%），C组27例患者中有19例出现ISI（70.4%），差异具有统计学意义（P <0.05)；A组JOA评分为7.1±2.1，B组为6.0±1.8，C组为5.6±2.0，组间比较差异有显著性（P <0.05)。进一步比较，A组与B组、A组与C组差异具有统计学意义（P＜0.05），而B组与C组差异均无统计学意义（P＞0.05）。ISI患者JOA评分为5.4±1.8，无ISI者JOA评分为7.5±2.3，差异有统计学意义（P＜0.05）。同时，ISI患者的平均病程较无ISI患者更长（P＜0.05）。
结论：OLF患者脊髓压迫程度越重，脊髓内越容易出现高信号；同
时，伴有髓内高信号的患者JOA评分低，病程长，故脊髓内高信号的出现预示着神经受损症状严重。
第二部分胸椎板逐节切除植骨内固定术治疗多节段胸椎黄韧带骨化症的疗效分析
目的：多节段胸椎黄韧带骨化症（multi-level of ossification of theligamentum flavum, M-OLF）的手术治疗以后路椎板切除脊髓减压为主，较经典的术式为胸椎后路椎板蚕食法脊髓减压术。近年来，随着高速磨钻、薄刃骨刀及脊柱内固定器械的广泛推广与应用，后路全椎板薄化层揭法、后路多椎板整块切除法及多椎板截骨原位回植内固定等术式应运而生，各术式均有其自身特点，同时亦伴有各种不足之处。如多椎板整块切除术容易发生硬膜撕裂、脑脊液漏及神经症状加重，单纯多节椎板切除后易出现减压节段不稳及后凸畸形发生，而椎板截骨原位回植手术操作相对复杂，且目前尚未出现理想的回植椎板固定器械，随访发现内植物容易发生松动。
针对上述问题，我们对M-OLF患者多采用胸椎板逐节切除减压植骨内固定术，此术式可借助椎弓根钉的固定和横突间植骨来维持减压区域的稳定性，同时，椎板的逐节切除可降低硬膜囊撕裂进而发生脑脊液漏的风险。
方法：2008年10月～2011年6月共15例M-OLF患者在我院采用胸椎板逐节切除减压植骨内固定术治疗，其中男6例，女9例，年龄41～69岁，平均55.7岁，两节段黄韧带骨化者2例，三节段10例，四节段3例。记录手术时间、出血量及并发症发生情况，随访过程中观察患者神经功能恢复情况及手术节段曲度变化。
结果：平均手术时间213.5min，平均出血量为760ml，所有患者均无脊髓及神经根损伤等情况发生。随访时间23～46个月，未出现内固定物松动、脱出及椎板移位。JOA评分（11分法）由术前的5.8±1.7分提高
至术后3个月的8.9±2.4分和末次随访时的9.3±2.5分，差异具有统计学
意义（P <0.01)），神经功能改善率为67.3%±15.2%。Cobb角由术前的15.9°±4.1°降低至术后3个月的13.3°±3.7°及末次随访的14.0°±3.8°，术后与术前比较均无显著性差异（P＞0.05），局部Cobb平均降低1.9°±0.7°。术中共发生脑脊液漏4例，经缝合及人工硬脊膜覆盖后愈合良好；术后1例出现下肢深静脉血栓，1例发生肺部感染，经积极治疗后均好转出院。
结论：胸椎板逐节切除减压植骨内固定术是治疗M-OLF的一种有效术式，它可使脊髓获得充分减压的同时有效降低脑脊液漏的发生率，而椎弓根钉的置入和横突间植骨能维持减压区域的稳定性，有助于避免术后出现后凸畸形和神经症状加重的发生。
第三部分后路经关节突减压植骨融合内固定术治疗黄韧带伴后纵韧带骨化型胸椎管狭窄症
目的：胸椎黄韧带骨化（ossification of the ligamentum flavum,OLF）合并后纵韧带骨化（ossification of the posterior longitudinal ligament,OPLL）型胸椎管狭窄症的外科治疗难度较大，且对术者的操作技巧要求很高，同时治疗效果往往不佳。到目前为止，国内外脊柱专家逐步探索出样式各异的手术方法和治疗策略来试图攻克这一难题，比较常用的有一期或分期前后路联合环形减压内固定术、后路椎板切除脊髓减压植骨内固定术、一期经后路环形减压内固定术等。上述术式均有各自的优缺点。而本研究中所应用的后路经关节突减压植骨融合内固定术（posterior decompression withtransforaminal thoracic interbody fusion, PTTIF），是在腰椎经关节突入路减压植骨内固定术（transforaminal lumbar interbody fusion, TLIF）的基础上加以改进，从而成为治疗这一钳夹型胸椎管狭窄症的一种新术式，它具有创伤小、出血少，并发症相对少、可一期完成前后路减压等优点，不失为治疗OLF合并OPLL型胸椎管狭窄症的理想术式。
方法：回顾性分析2005年1月至2008年12月在我院接受PTTIF手术的16例同节段黄韧带伴后纵韧带骨化型胸椎管狭窄症患者，其中男7例，女9例，年龄39～72岁，平均55.6岁，所有手术均由同一组医师完成，记录手术时间、出血量、术中及术后并发症发生情况，以日本骨科协会(JapaneseOrthopedic Association,JOA)评分评定患者手术前后神经功能状况，随访过程中观察手术节段局部后凸角（Cobb角）的变化。
结果：平均手术时间275min，平均出血量为1031ml，术中共3例患者发生脑脊液漏，经缝合及修补后均一期愈合；1例患者术后即可出现下肢神经功能恶化，经甲泼尼龙冲击治疗后恢复至术前水平。所有患者均获得临床随访，随访时间28～47个月，JOA评分由术前的4.3±1.2恢复至术后3个月时的7.3±1.7及末次随访时的8.5±1.5，手术前后比较差异具有统计学意义（P<0.05)，末次随访时神经功能恢复率达到63.6%±20.0%。Cobb角由术前的9.2o±2.1o恢复至术后的8.3o±2.0o及末次随访时的8.4o±2.1o，手术前后比较差异具有统计学意义（P<0.05)。术前共8例（68.8%）患者脊髓内出现高信号，至末次随访时，其中5例患者髓内高信号完全消失，经统计分析发现，脊髓内持续高信号的患者较术前无信号变化或术后高信号消失者神经功能恢复的差（P<0.05)。
结论：PTTIF作为治疗黄韧带伴后纵韧带骨化型胸椎管狭窄症的有效术式，只需一期后路减压即可显著促进患者神经功能的恢复，内固定物的植入可效维持减压节段的稳定性；同时，术前髓内高信号的出现并非预示患者预后不佳，只有术后持续高信号才预示患者将获得较差的临床疗效。
Part1Correlation study of the degree of spinal cord compression andintramedullary increased signal intensity on ossification of theligamentum flavum patients
Objective: With the development of medical examination technology andequipment, magnetic resonance imaging (MRI) and computerized tomography(CT) have been used in clinical examination in recent years. So more andmore patients who had ossification of the ligamentum flavum (OLF) could bediagnosed clearly. In slight stenosis cases, patients usually without any clinicalsymptoms. However, after the ossified tissues increased gradually, theneurological condition could become deteriorate when it can not tolerate theserious compression. The MRI, especially the whole spine MRI, given aaccuracy position for the thoracic ossification of the ligamentum flavum, andthe intramedullary increased signal intensity (ISI) can also be detect in th T2weighted image.
In our study, we want to analysis the correlation between the degree ofspinal cord compression and the occurrence of ISI in the sagittal image, and toexplore if certain correlation was exist between them.
Methods: From October2010to September2012, a total of92cases ofOLF patients were clearly diagnosed by the1.5T MR image, and they weredivided into3groups (group A, B and C) according to the degree of spinalcord compression. The neurological condition and intramedullary ISI wererecorded and analyzed respectively.
Results: six patients who with ISI were in group A (20.7%),17cases werein group B (47.2%) and19cases were in group C (70.4%), there was significant statistical difference between the three group (P <0.05). TheJapanese Orthopedic Association (JOA) scale was7.1±2.1in group A,6.0±1.8
in group B and5.6±2.0in group C, the difference being significant (P<0.05).After a further comparison, group A had significant difference with the groupB and C(P<0.05). However, no significant difference exist between group Band C (P＞0.05). The JOA score was5.4±1.8in the ISI patients and7.5±2.3inthe normal intensity patients, there was significant statistical differencebetween the two group (P <0.05).
Conclusion: In OLF patients, the more severe the spinal cord beingcompressed, the more likely the ISI appeared. Moreover, the ISI patients havea lower JOA score and a longer disease course, which indicate a severe nervedamage.
Part2The clinical effective of substep laminectomy and internal fixationin the treatment of multi-level of ossification of the ligamentum flavum
Objective: The posterior laminectomy and spinal decompression as oneof the most prevalent methods has significant effect in the treatment ofmulti-level of ossification of the ligamentum flavum(M-OLF). In recent years,accompanied with the clinical application of high speed burr and thin bladeosteotome, laminar shelling decompression and Lamina osteotomy andreplantation with miniplate fixation as the new surgical technical had appliedin clinical to treat M-OLF. Each surgical procedure has its own characteristicsand accompanied by a variety of inadequacies. The en bloc resection oflaminae usually has the complications of dural tear, cerebrospinal fluidleakage and neurological deterioration. The multi-level laminectomy tends tooccurring segmental instability and local kyphosis. Lamina osteotomy andreplantation with miniplate fixation is relative complex, and has no ideal devices to fixation the replanted laminae, so the mini-plate is prone to loosingin the long term follow-up.
In response to these problems, we attempted to treat M-OLF by theprocedure of substep laminectomy and internal fixation. The pedicle screwfixation combined bone graft between the transverse process could maintainthe stability for the decompression area. Besides, substep laminectomy couldreduce the risk of cerebrospinal fluid leakage.
Methods: A retrospective study was performed in15patients who hadmulti-level of ossification of the ligamentum flavum received the procedure ofsubstep laminectomy and internal fixation, in which the laminae weredecompressed step by step until the spinal cord was fully smooth, and then thepedicle screw fixation combined bone graft between the transverse processwas done. There were6male and9female patients ranging from41-69years(mean,55.7years). The ossified ligamentum flavum involved two segments in2patients, three segments in10cases and four segments in3cases. Theneurological improvement and sagittal alignment changes postoperativelywere recorded and analyzed.
Results: All patients were successfully being operated. After a average34.4-month follow-up, the mean score according to the Japanese OrthopedicAssociation (JOA) scale improved from5.8±1.7preoperatively to8.9±2.4at3months after the operation and9.3±2.5at the final follow-up (P＜0.01), with amean recovery rate of67.3%±15.2%. The Cobb angle decreased from15.9°±4.1°preoperatively to13.3°±3.7°at3months after the operation and14.0°±3.8°at the final follow-up (P＜0.05), the local kyphotic in the treatedarea decreased by1.9°±0.7°. No patient required additional surgery due tospinal canal re-obstruction and progressive spinal deformity. Cerebrospinalfluid leakage occurred in4patients, and healed well after being repaired. Alung infection and a deep vein thrombosis occurred in1patient respectively,and they were safely discharged after a regular treatment.
Conclusion: substep laminectomy and internal fixation is an effectivetherapeutic option for thoracic myelopathy due to multilevel OLF compression, it not only provide an adequate decompression and a stabilized sagittalalignment, but also reduce the incidence of cerebrospinal fluid leakage.
Part3Clinical Results and intramedullary signal changes of posteriordecompression with transforaminal interbody fusion for thoracicmyelopathy caused by combined ossification of the posterior longitudinalligament and ligamentum flavum
Objective: Surgical treatment for thoracic myelopathy caused byossification of the posterior longitudinal ligament (OPLL) and ossification ofthe ligamentum flavum (OLF) has been recognized as technically demandingand results tend to be unfavorable. Until now, various operative approachesand treatment strategies have been attempted to conquer this problem, and theprocedure of posterior decompression with transforaminal thoracic interbodyfusion (PTTIF) may be the optimal tactic to treat the anterior–posteriorcompression in one step. It is comparatively less traumatic and with lessserious complications.
Methods: Sixteen patients (seven men and nine women) with thoracicmyelopathy due to concurrent OLF and OPLL at the same level underwentPTTIF. We investigated the clinical outcomes and neurological improvement.Magnetic resonance imaging (MRI) was performed on all patientspreoperatively and postoperatively, and the intramedullary signal changeswere observed and evaluated..
Results: The mean operating time was275minutes, and the meanoperating bleeding amount was1031mL. Cerebrospinal fluid leakage occurredin three patients, and healed well after being repaired. Neurological symptomdeterioration occurred in one patient, but the patient recovered nearly to thepre-operative level after methylprednisolone ictus treatment. The follow-up period ranged from28to47months. The mean score according to theJapanese Orthopedic Association (JOA) scale improved from4.3±1.2preoperatively to7.3±1.7at3months postoperation to8.5±1.5at the finalfollow-up (P <0.01), with a recovery rate of63.6%±20.0%. Postoperativeimages showed a significant improvement in the local kyphosis (P <0.01).Eleven patients (68.8%) showed increased signal intensity (ISI) onT2-weighted MRI preoperatively. At the final follow-up, the intramedullaryISI totally recovered in five patients. Neurological improvement was worse inpatients who had persistent ISI than the other patients (P <0.05).
Conclusion: PTTIF is an effective therapeutic option for combinedOPLL and OLF, which provides satisfactory neurological recovery andstabilized thoracic fusion through a single posterior approach. Theintramedullary signal change does not always indicate a poor prognosis; onlythe irreversible ISI correlates with a poor clinical result.
目的：近年来，随着医学检查技术及设备的更新与发展，特别是MRI和CT的广泛应用，越来越多的胸椎黄韧带骨化症患者得以明确诊断。由于黄韧带骨化程度较轻的患者可无临床症状，而随着骨化物的逐步增大，脊髓受压程度超过其最大耐受时就会出现神经受损症状。MRI成像尤其是全脊柱MRI为胸椎黄韧带骨化的定位和定性提供了可靠依据，同时也可清楚显示胸髓内是否存在信号变化。
该研究借助MRI成像技术，在矢状径位下比较不同胸髓受压程度下脊髓高信号（Intramedullary increased signal intensity, ISI）的发生情况，明确两者是否存在一定的相关关系。
方法：2010年10月～2012年9月，共92例患者在我院门诊经MRI检查明确诊断为胸椎黄韧带骨化症（ossification of the ligamentum flavum,OLF），按脊髓受压程度将其分为：A组（椎管矢状径残余率≥66.7%）29例，其中男13例，女16例，年龄43～67岁，平均55.2岁；B组（33.3%≤椎管矢状径残余率﹤66.7%）36例，男19例，女17例，年龄45～69岁，平均56.6岁；C组（椎管矢状径残余率﹤33.3%）27例，男12例，女15例，年龄42～71岁，平均56.9岁。采用日本骨科协会(Japanese OrthopedicAssociation,JOA)评分评定患者神经功能状况，同时观察胸髓内高信号发生情况。
结果：A组29例患者中有6例出现ISI（20.7%），B组36例患者中17例出现ISI（47.2%），C组27例患者中有19例出现ISI（70.4%），差异具有统计学意义（P <0.05)；A组JOA评分为7.1±2.1，B组为6.0±1.8，C组为5.6±2.0，组间比较差异有显著性（P <0.05)。进一步比较，A组与B组、A组与C组差异具有统计学意义（P＜0.05），而B组与C组差异均无统计学意义（P＞0.05）。ISI患者JOA评分为5.4±1.8，无ISI者JOA评分为7.5±2.3，差异有统计学意义（P＜0.05）。同时，ISI患者的平均病程较无ISI患者更长（P＜0.05）。
结论：OLF患者脊髓压迫程度越重，脊髓内越容易出现高信号；同
时，伴有髓内高信号的患者JOA评分低，病程长，故脊髓内高信号的出现预示着神经受损症状严重。
第二部分胸椎板逐节切除植骨内固定术治疗多节段胸椎黄韧带骨化症的疗效分析
目的：多节段胸椎黄韧带骨化症（multi-level of ossification of theligamentum flavum, M-OLF）的手术治疗以后路椎板切除脊髓减压为主，较经典的术式为胸椎后路椎板蚕食法脊髓减压术。近年来，随着高速磨钻、薄刃骨刀及脊柱内固定器械的广泛推广与应用，后路全椎板薄化层揭法、后路多椎板整块切除法及多椎板截骨原位回植内固定等术式应运而生，各术式均有其自身特点，同时亦伴有各种不足之处。如多椎板整块切除术容易发生硬膜撕裂、脑脊液漏及神经症状加重，单纯多节椎板切除后易出现减压节段不稳及后凸畸形发生，而椎板截骨原位回植手术操作相对复杂，且目前尚未出现理想的回植椎板固定器械，随访发现内植物容易发生松动。
针对上述问题，我们对M-OLF患者多采用胸椎板逐节切除减压植骨内固定术，此术式可借助椎弓根钉的固定和横突间植骨来维持减压区域的稳定性，同时，椎板的逐节切除可降低硬膜囊撕裂进而发生脑脊液漏的风险。
方法：2008年10月～2011年6月共15例M-OLF患者在我院采用胸椎板逐节切除减压植骨内固定术治疗，其中男6例，女9例，年龄41～69岁，平均55.7岁，两节段黄韧带骨化者2例，三节段10例，四节段3例。记录手术时间、出血量及并发症发生情况，随访过程中观察患者神经功能恢复情况及手术节段曲度变化。
结果：平均手术时间213.5min，平均出血量为760ml，所有患者均无脊髓及神经根损伤等情况发生。随访时间23～46个月，未出现内固定物松动、脱出及椎板移位。JOA评分（11分法）由术前的5.8±1.7分提高
至术后3个月的8.9±2.4分和末次随访时的9.3±2.5分，差异具有统计学
意义（P <0.01)），神经功能改善率为67.3%±15.2%。Cobb角由术前的15.9°±4.1°降低至术后3个月的13.3°±3.7°及末次随访的14.0°±3.8°，术后与术前比较均无显著性差异（P＞0.05），局部Cobb平均降低1.9°±0.7°。术中共发生脑脊液漏4例，经缝合及人工硬脊膜覆盖后愈合良好；术后1例出现下肢深静脉血栓，1例发生肺部感染，经积极治疗后均好转出院。
结论：胸椎板逐节切除减压植骨内固定术是治疗M-OLF的一种有效术式，它可使脊髓获得充分减压的同时有效降低脑脊液漏的发生率，而椎弓根钉的置入和横突间植骨能维持减压区域的稳定性，有助于避免术后出现后凸畸形和神经症状加重的发生。
第三部分后路经关节突减压植骨融合内固定术治疗黄韧带伴后纵韧带骨化型胸椎管狭窄症
目的：胸椎黄韧带骨化（ossification of the ligamentum flavum,OLF）合并后纵韧带骨化（ossification of the posterior longitudinal ligament,OPLL）型胸椎管狭窄症的外科治疗难度较大，且对术者的操作技巧要求很高，同时治疗效果往往不佳。到目前为止，国内外脊柱专家逐步探索出样式各异的手术方法和治疗策略来试图攻克这一难题，比较常用的有一期或分期前后路联合环形减压内固定术、后路椎板切除脊髓减压植骨内固定术、一期经后路环形减压内固定术等。上述术式均有各自的优缺点。而本研究中所应用的后路经关节突减压植骨融合内固定术（posterior decompression withtransforaminal thoracic interbody fusion, PTTIF），是在腰椎经关节突入路减压植骨内固定术（transforaminal lumbar interbody fusion, TLIF）的基础上加以改进，从而成为治疗这一钳夹型胸椎管狭窄症的一种新术式，它具有创伤小、出血少，并发症相对少、可一期完成前后路减压等优点，不失为治疗OLF合并OPLL型胸椎管狭窄症的理想术式。
方法：回顾性分析2005年1月至2008年12月在我院接受PTTIF手术的16例同节段黄韧带伴后纵韧带骨化型胸椎管狭窄症患者，其中男7例，女9例，年龄39～72岁，平均55.6岁，所有手术均由同一组医师完成，记录手术时间、出血量、术中及术后并发症发生情况，以日本骨科协会(JapaneseOrthopedic Association,JOA)评分评定患者手术前后神经功能状况，随访过程中观察手术节段局部后凸角（Cobb角）的变化。
结果：平均手术时间275min，平均出血量为1031ml，术中共3例患者发生脑脊液漏，经缝合及修补后均一期愈合；1例患者术后即可出现下肢神经功能恶化，经甲泼尼龙冲击治疗后恢复至术前水平。所有患者均获得临床随访，随访时间28～47个月，JOA评分由术前的4.3±1.2恢复至术后3个月时的7.3±1.7及末次随访时的8.5±1.5，手术前后比较差异具有统计学意义（P<0.05)，末次随访时神经功能恢复率达到63.6%±20.0%。Cobb角由术前的9.2o±2.1o恢复至术后的8.3o±2.0o及末次随访时的8.4o±2.1o，手术前后比较差异具有统计学意义（P<0.05)。术前共8例（68.8%）患者脊髓内出现高信号，至末次随访时，其中5例患者髓内高信号完全消失，经统计分析发现，脊髓内持续高信号的患者较术前无信号变化或术后高信号消失者神经功能恢复的差（P<0.05)。
结论：PTTIF作为治疗黄韧带伴后纵韧带骨化型胸椎管狭窄症的有效术式，只需一期后路减压即可显著促进患者神经功能的恢复，内固定物的植入可效维持减压节段的稳定性；同时，术前髓内高信号的出现并非预示患者预后不佳，只有术后持续高信号才预示患者将获得较差的临床疗效。
Part1Correlation study of the degree of spinal cord compression andintramedullary increased signal intensity on ossification of theligamentum flavum patients
Objective: With the development of medical examination technology andequipment, magnetic resonance imaging (MRI) and computerized tomography(CT) have been used in clinical examination in recent years. So more andmore patients who had ossification of the ligamentum flavum (OLF) could bediagnosed clearly. In slight stenosis cases, patients usually without any clinicalsymptoms. However, after the ossified tissues increased gradually, theneurological condition could become deteriorate when it can not tolerate theserious compression. The MRI, especially the whole spine MRI, given aaccuracy position for the thoracic ossification of the ligamentum flavum, andthe intramedullary increased signal intensity (ISI) can also be detect in th T2weighted image.
In our study, we want to analysis the correlation between the degree ofspinal cord compression and the occurrence of ISI in the sagittal image, and toexplore if certain correlation was exist between them.
Methods: From October2010to September2012, a total of92cases ofOLF patients were clearly diagnosed by the1.5T MR image, and they weredivided into3groups (group A, B and C) according to the degree of spinalcord compression. The neurological condition and intramedullary ISI wererecorded and analyzed respectively.
Results: six patients who with ISI were in group A (20.7%),17cases werein group B (47.2%) and19cases were in group C (70.4%), there was significant statistical difference between the three group (P <0.05). TheJapanese Orthopedic Association (JOA) scale was7.1±2.1in group A,6.0±1.8
in group B and5.6±2.0in group C, the difference being significant (P<0.05).After a further comparison, group A had significant difference with the groupB and C(P<0.05). However, no significant difference exist between group Band C (P＞0.05). The JOA score was5.4±1.8in the ISI patients and7.5±2.3inthe normal intensity patients, there was significant statistical differencebetween the two group (P <0.05).
Conclusion: In OLF patients, the more severe the spinal cord beingcompressed, the more likely the ISI appeared. Moreover, the ISI patients havea lower JOA score and a longer disease course, which indicate a severe nervedamage.
Part2The clinical effective of substep laminectomy and internal fixationin the treatment of multi-level of ossification of the ligamentum flavum
Objective: The posterior laminectomy and spinal decompression as oneof the most prevalent methods has significant effect in the treatment ofmulti-level of ossification of the ligamentum flavum(M-OLF). In recent years,accompanied with the clinical application of high speed burr and thin bladeosteotome, laminar shelling decompression and Lamina osteotomy andreplantation with miniplate fixation as the new surgical technical had appliedin clinical to treat M-OLF. Each surgical procedure has its own characteristicsand accompanied by a variety of inadequacies. The en bloc resection oflaminae usually has the complications of dural tear, cerebrospinal fluidleakage and neurological deterioration. The multi-level laminectomy tends tooccurring segmental instability and local kyphosis. Lamina osteotomy andreplantation with miniplate fixation is relative complex, and has no ideal devices to fixation the replanted laminae, so the mini-plate is prone to loosingin the long term follow-up.
In response to these problems, we attempted to treat M-OLF by theprocedure of substep laminectomy and internal fixation. The pedicle screwfixation combined bone graft between the transverse process could maintainthe stability for the decompression area. Besides, substep laminectomy couldreduce the risk of cerebrospinal fluid leakage.
Methods: A retrospective study was performed in15patients who hadmulti-level of ossification of the ligamentum flavum received the procedure ofsubstep laminectomy and internal fixation, in which the laminae weredecompressed step by step until the spinal cord was fully smooth, and then thepedicle screw fixation combined bone graft between the transverse processwas done. There were6male and9female patients ranging from41-69years(mean,55.7years). The ossified ligamentum flavum involved two segments in2patients, three segments in10cases and four segments in3cases. Theneurological improvement and sagittal alignment changes postoperativelywere recorded and analyzed.
Results: All patients were successfully being operated. After a average34.4-month follow-up, the mean score according to the Japanese OrthopedicAssociation (JOA) scale improved from5.8±1.7preoperatively to8.9±2.4at3months after the operation and9.3±2.5at the final follow-up (P＜0.01), with amean recovery rate of67.3%±15.2%. The Cobb angle decreased from15.9°±4.1°preoperatively to13.3°±3.7°at3months after the operation and14.0°±3.8°at the final follow-up (P＜0.05), the local kyphotic in the treatedarea decreased by1.9°±0.7°. No patient required additional surgery due tospinal canal re-obstruction and progressive spinal deformity. Cerebrospinalfluid leakage occurred in4patients, and healed well after being repaired. Alung infection and a deep vein thrombosis occurred in1patient respectively,and they were safely discharged after a regular treatment.
Conclusion: substep laminectomy and internal fixation is an effectivetherapeutic option for thoracic myelopathy due to multilevel OLF compression, it not only provide an adequate decompression and a stabilized sagittalalignment, but also reduce the incidence of cerebrospinal fluid leakage.
Part3Clinical Results and intramedullary signal changes of posteriordecompression with transforaminal interbody fusion for thoracicmyelopathy caused by combined ossification of the posterior longitudinalligament and ligamentum flavum
Objective: Surgical treatment for thoracic myelopathy caused byossification of the posterior longitudinal ligament (OPLL) and ossification ofthe ligamentum flavum (OLF) has been recognized as technically demandingand results tend to be unfavorable. Until now, various operative approachesand treatment strategies have been attempted to conquer this problem, and theprocedure of posterior decompression with transforaminal thoracic interbodyfusion (PTTIF) may be the optimal tactic to treat the anterior–posteriorcompression in one step. It is comparatively less traumatic and with lessserious complications.
Methods: Sixteen patients (seven men and nine women) with thoracicmyelopathy due to concurrent OLF and OPLL at the same level underwentPTTIF. We investigated the clinical outcomes and neurological improvement.Magnetic resonance imaging (MRI) was performed on all patientspreoperatively and postoperatively, and the intramedullary signal changeswere observed and evaluated..
Results: The mean operating time was275minutes, and the meanoperating bleeding amount was1031mL. Cerebrospinal fluid leakage occurredin three patients, and healed well after being repaired. Neurological symptomdeterioration occurred in one patient, but the patient recovered nearly to thepre-operative level after methylprednisolone ictus treatment. The follow-up period ranged from28to47months. The mean score according to theJapanese Orthopedic Association (JOA) scale improved from4.3±1.2preoperatively to7.3±1.7at3months postoperation to8.5±1.5at the finalfollow-up (P <0.01), with a recovery rate of63.6%±20.0%. Postoperativeimages showed a significant improvement in the local kyphosis (P <0.01).Eleven patients (68.8%) showed increased signal intensity (ISI) onT2-weighted MRI preoperatively. At the final follow-up, the intramedullaryISI totally recovered in five patients. Neurological improvement was worse inpatients who had persistent ISI than the other patients (P <0.05).
Conclusion: PTTIF is an effective therapeutic option for combinedOPLL and OLF, which provides satisfactory neurological recovery andstabilized thoracic fusion through a single posterior approach. Theintramedullary signal change does not always indicate a poor prognosis; onlythe irreversible ISI correlates with a poor clinical result.
引文
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