前路根治性减压治疗严重颈椎后纵韧带骨化症

Anterior radical decompression for severe ossification of the posterior longitudinal ligament in the cervical spine

目的报告前路后纵韧带根治性切除治疗椎管占位率〉50％的严重颈椎后纵韧带骨化症（OPLL）的手术疗效。方法2002年7月至2006年2月，采用前路切除骨化韧带减压术治疗椎管占位率〉50％的严重OPLL患者26例。男性18例，女性8例；年龄43～73岁，平均59岁；骨化物形态均为基底开放型。术前骨化率50％～85％，平均（65±20）％；脊髓矢状径相对值（25±7）％；JOA评分（8．7±2．8）分。采用前路减压直接切除骨化物，行钛网或自体髂骨植骨，带锁钢板固定。26例患者中，行一个椎体次全切除＋单节段椎间隙减压10例，2个椎体次全切除术3例，单节段椎体次全切除13例。所有患者均行脑诱发电位（ECP）监护，CT横断面测量骨化率，MRI T2加权测量脊髓矢状径相对值；记录患者并发症、JOA评分，计算改善率。结果26例患者均顺利实施前路手术，随访6个月至4年（平均2年8个月）。术后骨化率平均（10±5）％，脊髓矢状径相对值（75±15）％，JOA评分（14．2±2．5）分，改善率（61±24）％。3例合并糖尿病患者出现短暂神经症状恶化，其中1例行二次血肿清除术，患者神经症状均在8周内恢复；2例出现脑脊液漏（包括1例合并糖尿病者），经保守治疗2周后痊愈；无内固定失败。结论前路手术直接减压治疗严重OPLL，神经功能恢复更彻底，但对技术要求较高。

Objective To report the outcome of anterior radical decompression for the treatment of severe ossification of the posterior longitudinal ligament （OPLL） with an average occupying ratio exceeding 50% in the cervical spine. Methods From July 2002 to February 2006, 26 patients with cervical OPLL occupying ratio of the spinal cord exceeding 50% underwent anterior decompression and fusion. There were 18 males and 8 females. The average age was 59 years （ranged from 43 to 73 years） and the mean occupying ratio was （65 ± 20） % ; Before operation, the JOA score was 8. 7 ± 2. 8, and the saggital diameter of spinal cord was （ 25 ± 7 ） %. The ossified ligament was classified into two groups, the base-open group and the base-closed group. The occupying ratio was measured on 3-D CT scans, and the sagital diameter of the deformed spinal cord was measured at the narrowest level on sagittal T2-weighted MRI. All patients received anterior decompression with the ossified ligament removed completely. Among them, 10 cases underwent one level corpectomy combined with one level disectomy, 3 cases underwent 2 level corpectomy, and the other 13 patients underwent one level corpectomy. The decompressed segments were reconstructed either with a tricortical iliac crest strut or a titanium cage, and an anterior locking plate was implanted to prevent graft extrusion in every patient. All patients were monitored with ECP during decompression. Results The occupying ratio decreased to （ 10 ± 5 ） %, the saggital diameter of spinal cord increased to （ 75 ± 15） %, and the average diameter of spinal cord at the narrowest site increased 3 times after operation. The JOA score was 14. 2 ±2. 5, with an average improvement ratio of （61 ±24） %. Three patients accompanied with diabetes presented with temporarily neurological deterioration. There were two cases complicated with cerebrospinal fluid leaks but cured within 2 weeks after surgery. One case acccompanied with diabetes underwent a second emergency reexploration for hematoma in the spinal canal which caused a dyspnea. Conclusions Anterior radical decompression is an optimal method for the management of severe OPLL in the cervical spine . Higher rate of neurofunction recovery can be anticipated.