胸椎黄韧带骨化症课件

胸椎黄胸椎黄韧带韧带骨化症骨化症贺贺石生石生 侯侯铁胜铁胜 赵赵杰杰1.胸椎黄韧带骨化症贺石生侯铁胜赵杰1.文献回文献回顾顾2.文献回顾2.1912LEDOUBLE,AnatoleFTrait des variations de la colonne vertbrale de lhomme Trait des variations de la colonne vertbrale de lhomme Paris:Vigot frresParis:Vigot frres1920PolgarX线线表表现现PolgarF.Uberinterakuellwirbelverkalking.PolgarF.Uberinterakuellwirbelverkalking.Forschr Geb Forschr Geb Rontgenstr nuklearmed ErganzungsbandRontgenstr nuklearmed Erganzungsband1920;40:2928.1920;40:2928.1962Yamaguchi第一例第一例OLF引起脊髓引起脊髓压压迫患者迫患者Yamaguchi M,Tamagake S,Fujita S.A case of ossification of Yamaguchi M,Tamagake S,Fujita S.A case of ossification of ligamentum flavum causing thoracic myelopathy.J Orthop Surg ligamentum flavum causing thoracic myelopathy.J Orthop Surg 1960;11:9519561960;11:9519563.1912LEDOUBLE,AnatoleFTra胸椎黄胸椎黄韧带韧带附着附着处处骨化是比骨化是比较较常常见见的的现现象，但引起脊髓象，但引起脊髓压压迫，迫，导导致胸椎黄致胸椎黄韧带韧带骨化症比骨化症比较较少少见见Williams回回顾顾了了50例尸体例尸体标标本及本及100个个CT扫扫描，描，发现发现韧带韧带附着附着处处骨化比骨化比较较常常见见。Radiology.1984 Feb;150(2):423-6.Maigne 对对121例老年人例老年人调查发现调查发现下胸椎下胸椎83%附附着点骨化，腰椎着点骨化，腰椎33%骨化，骨化，认为认为下胸椎尾端附下胸椎尾端附着着处处骨化是老年人的一种正常骨化是老年人的一种正常现现象，受旋象，受旋转应转应力的影响力的影响Surg Radiol Anat.1992;14(2):119-24.4.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Payer M,et al.Thoracic myelopathy due to enlarged ossified yellow Ligaments.J Neurosurg(Spine 1)92:105108,20005.PayerM,etal.Thoracicmyelop英文比英文比英文比英文比较较较较大数量病例大数量病例大数量病例大数量病例报报报报道，日本道，日本道，日本道，日本6 6篇、中国台湾篇、中国台湾篇、中国台湾篇、中国台湾1 1篇、中国大篇、中国大篇、中国大篇、中国大陆陆陆陆1 1篇、突尼斯篇、突尼斯篇、突尼斯篇、突尼斯1 1篇，篇，篇，篇，6 6篇大于篇大于篇大于篇大于2020例，例，例，例，3 3篇篇篇篇15-2015-20例例例例BenHamoudaK,JemelH.JNeurosurg(Spine).99(2):157-61,2003.BenHamoudaK,JemelH.JNeurosurg(Spine).99(2):157-61,2003.HanakitaJ,SuwaH,OhtaF.Neuroradiology32:3842,1990HanakitaJ,SuwaH,OhtaF.Neuroradiology32:3842,1990MiyakoshiN,ShimadaY,SuzukiT.JNeurosurg(Spine).99(3):251-6,MiyakoshiN,ShimadaY,SuzukiT.JNeurosurg(Spine).99(3):251-6,2003.2003.MiyamotoS,YonenobuK,OnoK.Spine18:22672270,1993MiyamotoS,YonenobuK,OnoK.Spine18:22672270,1993MiyasakaK,KanedaK,SatoS.AJNR4:629632,1983MiyasakaK,KanedaK,SatoS.AJNR4:629632,1983NishiuraI,IsozumiT,NishiharaK.SurgNeurol51:368372,1999NishiuraI,IsozumiT,NishiharaK.SurgNeurol51:368372,1999ShiokawaK,HanakitaJ,SuwaH.JNeurosurg(Spine2)94:221226,ShiokawaK,HanakitaJ,SuwaH.JNeurosurg(Spine2)94:221226,200120016.英文比较大数量病例报道，日本6篇、中国台湾1篇、中国大陆1篇LiaoCC,ChenTY,JungSM,ChenLR.JNeurosurg(Spine).2005;2(1):34-9.24例例ShishengHe,NakazatHussain,ShaohuaLi,TieshengHou.JNeurosurg(Spine).2005;3(5):348-354.27例例7.LiaoCC,ChenTY,JungSM,Che戴力戴力戴力戴力扬扬扬扬;戴方戴方戴方戴方义义义义.中中中中华华华华外科外科外科外科杂杂杂杂志志志志1989;27(2):99-1011989;27(2):99-101倪斌倪斌倪斌倪斌;贾连顺贾连顺贾连顺贾连顺;戴力戴力戴力戴力扬扬扬扬;刘洪奎刘洪奎刘洪奎刘洪奎;侯侯侯侯铁胜铁胜铁胜铁胜;赵赵赵赵定麟定麟定麟定麟.中中中中华华华华放放放放射学射学射学射学杂杂杂杂志志志志1995.12.10;29(12):858-8611995.12.10;29(12):858-861王全平王全平王全平王全平;陆陆陆陆裕朴裕朴裕朴裕朴.中中中中华华华华骨科骨科骨科骨科杂杂杂杂志志志志1993;13(1):15-181993;13(1):15-18倪斌倪斌倪斌倪斌;贾连顺贾连顺贾连顺贾连顺;戴力戴力戴力戴力扬扬扬扬;刘洪奎刘洪奎刘洪奎刘洪奎;侯侯侯侯铁胜铁胜铁胜铁胜;赵赵赵赵定麟定麟定麟定麟.中国脊中国脊中国脊中国脊柱脊髓柱脊髓柱脊髓柱脊髓杂杂杂杂志志志志1994.04.28;4(2):56-591994.04.28;4(2):56-59陈陈陈陈仲仲仲仲强强强强;党耕町党耕町党耕町党耕町;刘刘刘刘晓晓晓晓光光光光;蔡蔡蔡蔡钦钦钦钦林林林林.中中中中华华华华骨科骨科骨科骨科杂杂杂杂志志志志 1999.04.25;19(4):197-200(721999.04.25;19(4):197-200(72例例例例)。8.戴力扬;戴方义.中华外科杂志1989;27(2):发发病机理病机理9.发病机理9.一、慢性损伤和退变部分患者有外伤、手术等病史下胸椎（T10-L1)多见，骨化的发生率及骨化的大小均与小关节的旋转活动范围有关，在旋转活动范围最大的T10T11水平，骨化的发生率最高，骨化的体积也最大患者脊柱有明显退行性改变10.一、慢性损伤和退变部分患者有外伤、手术等病史下胸椎（二、遗传及种族差异在年龄超过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11.二、遗传及种族差异在年龄超过65岁的亚洲人中韧带骨化的发三、其它因素甲状旁腺功能低下、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，刺激软骨细胞的生长而导致韧带骨化12.三、其它因素甲状旁腺功能低下、骨软化症等全身性疾病患者的韧临临床表床表现现13.临床表现13.本临床表现病变化多样，容易误诊和延误诊断典型表现为上运动神经元损伤，但有时出现上下运动神经元同时受损表现起病隐匿，进展缓慢14.本临床表现病变化多样，容易误诊和延误诊断典型表现为上运动神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):251-6,2003.15.MiyakoshiN,ShimadaY,SuzukiSymptomsNumbersWeakness in lower limbs and gait disturbance25Numbness and Sensory deficit24Low back pain13Squeezing tight band around chest or abdomen10Neurological claudication 9Leg pain7Fecal and urinary incontinence11Knee and ankle hyperreflexia22Positive patellar and ankle clonus13Positive Babinksi14ShishengHe,NakazatHussain,ShaohuaLi,TieshengHou.TheShishengHe,NakazatHussain,ShaohuaLi,TieshengHou.TheClinicalandPrognosticanalysisofOssifiedLigamentumFlavuminClinicalandPrognosticanalysisofOssifiedLigamentumFlavuminChinesepopulationChinesepopulation。JNeurosurg(Spine).2005;3(5):348-354.JNeurosurg(Spine).2005;3(5):348-354.16.SymptomsNumbersWeaknessinlowShishengHe,NakazatHussain,ShaohuaLi,TieshengHou.TheShishengHe,NakazatHussain,ShaohuaLi,TieshengHou.TheClinicalandPrognosticanalysisofOssifiedLigamentumFlavuminClinicalandPrognosticanalysisofOssifiedLigamentumFlavuminChinesepopulationChinesepopulation。JNeurosurg(Spine).2005;3(5):348-354.JNeurosurg(Spine).2005;3(5):348-354.Location of OLFNumbersT10-T118T11-T128T8-T113T6-T102T10-T122T1-T3,T11-T121T1-T71T1-T31T2-T31颈颈、胸、腰椎均可出、胸、腰椎均可出现现，颈颈椎少椎少见见，而以胸椎和胸腰椎多，而以胸椎和胸腰椎多见见17.ShishengHe,NakazatHussain,根据其形根据其形态态可可进进行行X线线分型，分型，(1)棘突型；棘突型；又可分又可分为为上位型，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)结节结节状型；状型；(4)游离型。游离型。18.根据其形态可进行X线分型，(1)棘突型；又可分为上位型，The lateral-type lesion showed ossification 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 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 tuberous type,the more stenotic the spinal canal becomes.19.Thelateral-typelesionshowed20.20.可分可分为为三种三种类类型（型（MRI矢状位矢状位扫扫描）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21.可分为三种类型（MRI矢状位扫描）21.31 casesShiokawa K,et al.Clinical analysis and prognostic study of ossifiedligamentum flavum of the thoracic spine.J Neurosurg(Spine 2)94:221226,200122.31cases22.Case 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 herniationT8-11 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 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 stenosis 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 laminectomyShishengHe,NakazatHussain,ShaohuaLi,TieshengHou.TheClinicalandPrognosticanalysisofShishengHe,NakazatHussain,ShaohuaLi,TieshengHou.TheClinicalandPrognosticanalysisofOssifiedLigamentumFlavuminChinesepopulationOssifiedLigamentumFlavuminChinesepopulation。JNeurosurg(Spine).2005;3(5):348-354.JNeurosurg(Spine).2005;3(5):348-354.23.CaseNoSexAgeOLFCoexistingDis治治疗疗方法方法24.治疗方法24.后路椎板切除：整块切除横向减横向减压时压时必必须须将椎板、双将椎板、双侧侧椎椎间间关关节节内内缘缘1 12 2及骨化及骨化的的韧带韧带一同切除。上、下减一同切除。上、下减压压范范围应围应包括骨化上下各一包括骨化上下各一节节段段,在合并胸椎在合并胸椎OPLLOPLL时时，则应则应包括包括OPLLOPLL两端及上、下两端及上、下各加一个椎板。各加一个椎板。“双双层层椎板椎板”样结样结构，以及肥大增生的关构，以及肥大增生的关节节突及骨化的关突及骨化的关节节囊囊韧带挤韧带挤入椎管内，入椎管内，严严重硬膜粘重硬膜粘连连，常，常难难以做到以做到经经典的典的“揭盖式揭盖式”的椎板切除。的椎板切除。25.后路椎板切除：整块切除横向减压时必须将椎板、双侧椎间关节26.26.后路椎板切除：逐渐蚕食先用磨先用磨先用磨先用磨钻钻钻钻将骨化黄将骨化黄将骨化黄将骨化黄韧带韧带韧带韧带打薄，薄弱打薄，薄弱打薄，薄弱打薄，薄弱处处处处用用用用钩钩钩钩子子子子钩钩钩钩破，从正破，从正破，从正破，从正常及常及常及常及压压压压迫迫迫迫轻轻轻轻部位部位部位部位进进进进入（入（入（入（头侧头侧头侧头侧、尾、尾、尾、尾侧侧侧侧和两和两和两和两侧侧侧侧）在多于半数病人中在多于半数病人中在多于半数病人中在多于半数病人中发现发现发现发现骨化的黄骨化的黄骨化的黄骨化的黄韧带韧带韧带韧带和硬膜和硬膜和硬膜和硬膜间间间间粘粘粘粘连连连连,牢固牢固牢固牢固的粘的粘的粘的粘连连连连通常通常通常通常发发发发生于椎管最狭窄的部位生于椎管最狭窄的部位生于椎管最狭窄的部位生于椎管最狭窄的部位,钝钝钝钝性分离不能分开性分离不能分开性分离不能分开性分离不能分开在粘在粘在粘在粘连连连连周周周周围围围围减减减减压压压压,然后把粘然后把粘然后把粘然后把粘连连连连的骨的骨的骨的骨块块块块咬碎咬碎咬碎咬碎,逐个切除逐个切除逐个切除逐个切除切除骨化切除骨化切除骨化切除骨化块块块块造成的硬膜缺造成的硬膜缺造成的硬膜缺造成的硬膜缺损损损损用局部深筋膜修用局部深筋膜修用局部深筋膜修用局部深筋膜修补补补补切忌用椎板咬骨切忌用椎板咬骨切忌用椎板咬骨切忌用椎板咬骨钳钳钳钳直接深入椎管内咬直接深入椎管内咬直接深入椎管内咬直接深入椎管内咬27.后路椎板切除：逐渐蚕食先用磨钻将骨化黄韧带打薄，薄弱处用椎板成形Okada等在4例中应用了椎板成形术,该术式由Hirabayashi的治疗颈椎管狭窄的方法改良而来。椎板切除的结果并不令人满意,因为早期并发症发生率高或由于相同部位黄韧带骨化复发或脊柱后凸畸形加重至晚期病情加重。他们推荐保留后部结构的椎板成形术作为首选方法。OkadaK,etal.Spine,1991,16:280.28.椎板成形Okada等在4例中应用了椎板成形术,该术式由H环形减压：合并有OPLL、胸椎间盘突出症行椎管后壁切除减行椎管后壁切除减压术压术后，用磨后，用磨钻钻或骨刀切除或骨刀切除积积侧侧关关节节突段下一椎体的横突、肋骨与椎体和横突突段下一椎体的横突、肋骨与椎体和横突相关相关连连部分及少部分及少许许后肋，沿椎体后肋，沿椎体侧侧面行骨膜下剥面行骨膜下剥离，从椎体的后外离，从椎体的后外侧侧切除椎切除椎间盘间盘或骨化的后或骨化的后纵韧纵韧带带，这样这样可以避免可以避免对对脊髓的脊髓的牵牵拉与刺激。因后柱拉与刺激。因后柱的完整性的完整性丧丧失，减失，减压压后需行内固定及植骨后需行内固定及植骨29.环形减压：合并有OPLL、胸椎间盘突出症行椎管后壁切除减预预后判断后判断30.预后判断30.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):251-6,2003.31.MiyakoshiN,ShimadaY,SuzukiFFO: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 ShishengHe,NakazatHussain,ShaohuaLi,TieshengHou.TheClinicalandPrognosticanalysisofShishengHe,NakazatHussain,ShaohuaLi,TieshengHou.TheClinicalandPrognosticanalysisofOssifiedLigamentumFlavuminChinesepopulationOssifiedLigamentumFlavuminChinesepopulation。JNeurosurg(Spine).2005;3(5):348-354.JNeurosurg(Spine).2005;3(5):348-354.VariablesJOA Score at FFORR at FFOCoefficientp ValueCoefficientp 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-0.5710.088-3.6510.34632.FFO:Finalfollowupoutcome;The surgical outcomes classified as Excellent:Nurick Scale 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 Ratio *:Significant differenceShishengHe,NakazatHussain,ShaohuaLi,TieshengHou.TheClinicalandPrognosticanalysisofShishengHe,NakazatHussain,ShaohuaLi,TieshengHou.TheClinicalandPrognosticanalysisofOssifiedLigamentumFlavuminChinesepopulationOssifiedLigamentumFlavuminChinesepopulation。JNeurosurg(Spine).2005;3(5):348-354.JNeurosurg(Spine).2005;3(5):348-354.Variablesp 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 Band Around Chest or Abdomen0.3781.329Neurological Claudication 0.2721.196Leg Pain0.7251.182Fecal and/or Urinary Incontinence0.002*3.274Knee and/or Ankle Hyperreflexia0.2171.312Positive Patellar and/or Ankle Clonus0.016*2.531Positive Babinksi Sign0.0792.13733.Thesurgicaloutcomesclassifi病病例例34.病例34.35.35.36.36.37.37.38.38.39.39.40.40.41.41.42.42.43.43.44.44.45.45.46.46.47.47.48.48.49.49.50.50.51.51.52.52.53.53.54.54.