分期后路-前路联合手术治疗颈椎后纵韧带骨化症伴重度脊髓型颈椎病的疗效分析

Clinical efficacy of staged combined posterior-anterior approach for severe ossification of posterior longitudinal ligament

目的:探讨分期后路-前路联合手术治疗颈椎后纵韧带骨化症(ossification of the posteriorl ongitudinal ligament,OPLL)伴重度脊髓型颈椎病患者的疗效。方法:2005年1月至2008年6月共收治颈椎OPLL伴重度脊髓型颈椎病患者35例,均先行后路椎板切除减压植骨内固定术,术后3～6个月,行影像学检查均发现颈髓前方尚有压迫和/或神经根麻痹,再行前路椎体次全切除及骨化物切除减压植骨内固定术。术前及第一、第二次术后(末次随访时)行JOA(17分法)评分,分析比较术前、术后评分并计算改善率。结果:一期后路手术后3例患者出现C5神经根麻痹症状,经保守治疗后1例症状消失,2例有所减轻,二期前路手术后症状消失。2例患者前路术后出现脑脊液漏,经适当加压等保守治疗后愈合。本组平均随访时间21.5±5.0个月,术前JOA评分6.9±2.3分,第一次后路手术后JOA评分11.2±4.2分,改善率为(43±22)%;二期前路手术后JOA评分14.0±3.8分,改善率为(48±20)%,与未治疗之前相比改善率为(70±21)%。第一次后路手术后改善率≤35%的患者(17例),二期前路手术后均取得较好的改善率,54%～68%,平均(60±16)%。结论:对于颈椎OPLL伴重度脊髓型颈椎病患者,后路手术后3～6个月,若前方尚有压迫和/或神经根麻痹者,尤其是后路手术改善率≤35%的患者,二期前路手术可进一步提高手术改善率,达到良好的神经功能恢复效果。

Objective：To investigate the clinical outcome of staged combined posterior-anterior approach for ossification of posterior longitudinal ligament（OPLL） complicated with severe cervical spondylotic myelopathy.Method：35 patients with OPLL accompanied wtih severe cervical spondylotic myelopathy undergoing posterior laminectomy,decompression,bone graft and internal fixation between January 2005 and June 2008 were reviewed retrospectively.Ventral compression nerve roots paralysis still presented on radiograph in 3 to 6 months after surgery in all cases,anterior corpectomy and dissection of OPLL as well as bone graft was then conducted.JOA 17 was used to evaluate the pre-and post-operation score and follow-up outcome.Result：3 cases presented C5 nerve root paralysis after posterior approach,which was resolved in 1 case by conservative treatment,and 2 cases irresponsible to conservative treatment had complete relieved after anterior approach.2 cases were complicated with CSF leakage which resolved by conservative treatment.The mean follow-up time was 21.5±5.0 months.The preoperative mean scores of JOA was 6.9±2.3,and 11.2±4.2 for posterior approach with the mean improvement ratio of（43±22）%.The mean JOA scores after anterior decompression was 14.0± 3.8 with the mean improvement ratio of 70±21% compared with preoperation,and（48±20）% compared with the post-posterior operation.Patients with improvement ratio less than 35% after posterior operation（17 patients） got better improvement ratio of 54%-68%,with the mean value of（60±16）% secondary to anterior approach.Conclusion：Patient with OPLL accompanied with severe cervical spondylotic myelopathy undergoing posterior decompression will respond well to anterior approach if still presenting ventral compression nerve roots paralysis in 3 to 6 months,especially for those with improvement ratio less than 35%.