胸椎黃韌帶骨化癥

1、胸椎黃韌帶骨化癥,賀石生 侯鐵勝 趙杰,文獻回顧,1912 LE DOUBLE, Anatole F Traité des variations de la colonne vertébrale de l'homme Paris : Vigot frères1920 Polgar X線表現(xiàn) Polgar F. Uber interakuell wirbelverkalking. Fors

2、chr Geb Rontgenstr nuklearmed Erganzungsband 1920;40:292–8. 1962 Yamaguchi 第一例OLF引起脊髓壓迫患者Yamaguchi M, Tamagake S, Fujita S . A case of ossification of ligamentum flavum causing thoracic myelopathy. J Orthop Surg 19

3、60;11 :951–956,胸椎黃韌帶附著處骨化是比較常見的現(xiàn)象，但引起脊髓壓迫，導致胸椎黃韌帶骨化癥比較少見Williams回顧了50例尸體標本及100個CT掃描，發(fā)現(xiàn)韌帶附著處骨化比較常見。Radiology. 1984 Feb;150(2):423-6.Maigne 對121例老年人調查發(fā)現(xiàn)下胸椎83%附著點骨化，腰椎33%骨化，認為下胸椎尾端附著處骨化是老年人的一種正?，F(xiàn)象，受旋轉應力的影響Surg Radiol

4、Anat. 1992;14(2):119-24.,Payer M,et al. Thoracic myelopathy due to enlarged ossified yellow Ligaments. J Neurosurg (Spine 1) 92:105–108, 2000,英文比較大數(shù)量病例報道，日本6篇、中國臺灣1篇、中國大陸1篇、突尼斯1篇，6篇大于20例，3篇15-20例Ben Hamouda K, Jemel H.

5、 J Neurosurg (Spine). 99(2):157-61, 2003. Hanakita J, Suwa H, Ohta F. Neuroradiology 32:38–42, 1990Miyakoshi N, Shimada Y, Suzuki T. J Neurosurg (Spine). 99(3):251-6, 2003.Miyamoto S, Yonenobu K, Ono K. Spine 18:22

6、67–2270, 1993Miyasaka K, Kaneda K, Sato S. AJNR 4:629–632, 1983Nishiura I, Isozumi T, Nishihara K. Surg Neurol 51: 368–372, 1999Shiokawa K, Hanakita J, Suwa H. J Neurosurg (Spine 2) 94:221–226, 2001,Liao CC, Chen T

7、Y, Jung SM, Chen LR.J Neurosurg (Spine). 2005;2(1):34-9. 24例Shisheng He, Nakazat Hussain, Shaohua Li, Tiesheng Hou. J Neurosurg (Spine). 2005;3(5):348-354. 27例,戴力揚; 戴方義. 中華外科雜志  1989; 27(2): 99-101倪斌; 賈連順

8、;戴力揚; 劉洪奎; 侯鐵勝; 趙定麟. 中華放射學雜志  1995.12.10; 29(12): 858-861王全平; 陸裕樸.中華骨科雜志  1993; 13(1): 15-18倪斌; 賈連順; 戴力揚; 劉洪奎; 侯鐵勝; 趙定麟. 中國脊柱脊髓雜志  1994.04.28; 4(2): 56-59陳仲強; 黨耕町; 劉曉光; 蔡欽林. 中華骨科雜志  1999.04.25;

9、19(4): 197-200 (72例)。,發(fā)病機理,一、慢性損傷和退變部分患者有外傷、手術等病史下胸椎（T10-L1)多見，骨化的發(fā)生率及骨化的大小均與小關節(jié)的旋轉活動范圍有關，在旋轉活動范圍最大的T10～T11水平，骨化的發(fā)生率最高，骨化的體積也最大患者脊柱有明顯退行性改變,二、遺傳及種族差異在年齡超過65歲的亞洲人中韌帶骨化的發(fā)病率可高達20％而對于歐美人群的發(fā)病情況，至今為止，僅有數(shù)篇文獻近20例報導,三、其

10、它因素甲狀旁腺功能低下、骨軟化癥等全身性疾病患者的韌帶骨化率相應增高。此外．糖尿病、氟骨癥、肥胖患者的韌帶骨化發(fā)病率也相對較高。中國、日本人高鹽少肉的飲食習慣可導致血清中雌激素水平增高，刺激軟骨細胞的生長而導致韌帶骨化,臨床表現(xiàn),本臨床表現(xiàn)病變化多樣，容易誤診和延誤診斷典型表現(xiàn)為上運動神經元損傷，但有時出現(xiàn)上下運動神經元同時受損表現(xiàn)起病隱匿，進展緩慢,Miyakoshi N, Shimada Y, Suzuki T. Factor

11、s 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.,,Shisheng He, Nakazat Hussain, Shaohua Li, Tiesheng Hou.

12、 The Clinical and Prognostic analysis of Ossified Ligamentum Flavum in Chinese population。J Neurosurg (Spine). 2005;3(5):348-354.,Shisheng He, Nakazat Hussain, Shaohua Li, Tiesheng Hou. The Clinical and Prognostic analys

13、is of Ossified Ligamentum Flavum in Chinese population。J Neurosurg (Spine). 2005;3(5):348-354.,頸、胸、腰椎均可出現(xiàn)，頸椎少見，而以胸椎和胸腰椎多見,,,根據(jù)其形態(tài)可進行X線分型， (1)棘突型； 又可分為上位型， 下位型和上下位型；(2)板狀型；(3)結節(jié)狀型；(4)游離型。,The lateral-type lesion showed os

14、sification only at the facet joint capsuleThe extended type showed ossification extending to the laminaThe enlarged type showed thickened ossification with anteromedial enlargementThe fused type showed thickened bilat

15、eral 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 tuberous type, the more stenotic

16、 the spinal canal becomes.,,,可分為三種類型（MRI矢狀位掃描）局灶型：骨化局限在兩個節(jié)段問連續(xù)型：骨化連續(xù)三個節(jié)段及以上的跳躍型：局灶或連續(xù)OLF間斷地分布在各 段胸椎，之間為無骨化的節(jié)段,31 casesShiokawa K, et al. Clinical analysis and prognostic study of ossifiedligamentum flavum of t

17、he thoracic spine. J Neurosurg (Spine 2) 94:221–226, 2001,,Shisheng He, Nakazat Hussain, Shaohua Li, Tiesheng Hou. The Clinical and Prognostic analysis of Ossified Ligamentum Flavum in Chinese population。J Neurosurg (Spi

18、ne). 2005;3(5):348-354.,治療方法,后路椎板切除：整塊切除橫向減壓時必須將椎板、雙側椎間關節(jié)內緣1／2及骨化的韌帶一同切除。上、下減壓范圍應包括骨化上下各一節(jié)段, 在合并胸椎OPLL時，則應包括OPLL兩端及上、下各加一個椎板?！半p層椎板”樣結構，以及肥大增生的關節(jié)突及骨化的關節(jié)囊韌帶擠入椎管內，嚴重硬膜粘連，常難以做到經典的“揭蓋式”的椎板切除。,后路椎板切除：逐漸蠶食先用磨鉆將骨化黃韌帶打薄，薄弱處

19、用鉤子鉤破，從正常及壓迫輕部位進入（頭側、尾側和兩側）在多于半數(shù)病人中發(fā)現(xiàn)骨化的黃韌帶和硬膜間粘連,牢固的粘連通常發(fā)生于椎管最狹窄的部位,鈍性分離不能分開在粘連周圍減壓,然后把粘連的骨塊咬碎,逐個切除切除骨化塊造成的硬膜缺損用局部深筋膜修補切忌用椎板咬骨鉗直接深入椎管內咬,椎板成形Okada等在4例中應用了椎板成形術,該術式由Hirabayashi的治療頸椎管狹窄的方法改良而來。椎板切除的結果并不令人滿意,因為早期并

20、發(fā)癥發(fā)生率高或由于相同部位黃韌帶骨化復發(fā)或脊柱后凸畸形加重至晚期病情加重。他們推薦保留后部結構的椎板成形術作為首選方法。Okada K,et al. Spine,1991,16:280.,環(huán)形減壓：合并有OPLL、胸椎間盤突出癥行椎管后壁切除減壓術后，用磨鉆或骨刀切除積側關節(jié)突段下一椎體的橫突、肋骨與椎體和橫突相關連部分及少許后肋，沿椎體側面行骨膜下剝離，從椎體的后外側切除椎間盤或骨化的后縱韌帶，這樣可以避免對脊髓的牽拉與刺激。

21、因后柱的完整性喪失，減壓后需行內固定及植骨,預后判斷,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):25

22、1-6, 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 Shisheng He, Nakazat Hu

23、ssain, Shaohua Li, Tiesheng Hou. The Clinical and Prognostic analysis of Ossified Ligamentum Flavum in Chinese population。J Neurosurg (Spine). 2005;3(5):348-354.,The surgical outcomes classified as Excellent: Nurick Scal

24、e Grades 0-2 and JOA improvement 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 Rat

25、io *: Significant differenceShisheng He, Nakazat Hussain, Shaohua Li, Tiesheng Hou. The Clinical and Prognostic analysis of Ossified Ligamentum Flavum in Chinese population。J Neurosurg (Spine). 2005;3(5):348-354.,病 例