胸椎黄韧带骨化症合并脊髓型颈椎病手术方案选择

Selection of the surgical methods for the thoracic ossification of ligamentum flavum combined with cervical spondylotic myelopathy

目的 探讨胸椎黄韧带骨化（ossification of ligamentum flavum,OLF）合并脊髓型颈椎病（cervical spondylotic myelopathy,CSM）手术方案的选择.方法 1991年1月至2003年1月,手术治疗胸椎OLF合并CMS患者56例,其中40例获得2年以上随访,男22例,女18例;确诊时年龄27～70岁,平均58岁;病程1～120个月,平均16.5个月.其中OLF 25例,OLF合并后纵韧带骨化（ossification of posterior longitudjnal ligament,OPLL）12例,OLF合并胸椎间盘突出3例;同时合并颈椎OPLL 23例,退变性颈椎管狭窄17例.18例一期行颈后路＂单开门＂椎板成形术＋上胸椎椎管后壁切除术,9例一期行胸椎管后壁切除术,13例分期行颈后路和胸椎管后壁切除术.结果 40例患者的随访时间为24～227个月,平均67.5个月.根据改良Epstein手术疗效评定标准评价优良率,18例一期行颈后路＂单开门＂椎板成形术＋上胸椎椎管后壁切除术者为88.9%（16/18）,9例行胸椎管后壁切除术者为66.7%（6/9）;13例分期行颈后路和胸椎管后壁切除术者为53.8%（7/13）.结果 显示分期手术者术后优良率低于一期手术者,手术间隔时间在1年以内者的优良率高于间隔1年以上者.结论 上胸椎OLF合并CSM者应一期行颈椎和上胸椎脊髓减压术;下肢症状严重而上肢症状轻微者应先行胸脊髓减压术;上、下肢症状均重者应一期或分期行颈脊髓减压术和胸脊髓减压术,而分期手术者的手术间隔时间不宜过长.

Objective To investigate the difference between the different surgical methods for thoracic ossification of ligamentum flavum（OLF）combined with cervical spondylotic myelopathy（CSM）.Methods From January 1991 to January 2003,56 cases with thoracic OLF combined with CSM were reviewed retrospectively.Forty of 56 cases had been followed up for more than two years.There were 22 males and 18 females with an average of 58 years（range,27-70 years）.The course of the diseases were 1 to 120 months,with an average of 16.5 months.The pathological factors for thoracic myelopathy included：OLF for 25 cases,OLF combined with ossification of posterior longitudinal ligament（OPLL）for 12 cases,OLF combined with thoracic disc herniation for 3 cases.There were 23 cases combined with cervical OPLL and 17 cases combined with cervical stenosis.Eighteen cases underwent cervical laminoplasty and thoracic laminectomy,9 cases underwent only thoracic laminectomy,and 13 cases underwent both cervical and thoracic posterior decompression in multiple stages.Results Forty cases were followed up for 24 to 227 months,with an average of 67.5 months.According to Epstein standard,the excellent and good rate was 88.9% for 18 cases who underwent cervical laminaplasty and thoracic laminectomy（16/18）,66.7% for 9 cases who underwent only thoracic laminectomy（6/9）,and 53.8% for 13 cases who underwent both cervical and thoracic posterior decompression（7/13）.Statistics analysis showed that the outcome of one-stage surgery was better than multiple stages surgeries,and outcome of those whose operation intervals less than 1 year was better than those of more than 1 year.Conclusion Thoracic and cervical decompression should be performed at one stage for those with upper thoracic OLF combined with CSM.Thoracic decompression should be performed firstly for those with severe lower extremities syndrome and few upper extremities syndrome.Thoracic and cervical decompression in one or multiple stages should be performed for those with severe upper and lower extremities syndrome,and operation interval should be less than one year.