经皮微通道单侧入路双侧显微减压治疗胸椎黄韧带骨化症

Microsurgical decompression of thoracic spinal ossification of ligamentum flavum through paruspinal approach using percutaneous tubular retractor system

目的分析经皮微通道单侧椎旁入路双侧显微减压治疗胸椎椎管内黄韧带骨化症(OLF)的临床疗效。方法自2009年8月至2016年12月收治胸椎黄韧带骨化症共11例,气管插管全麻后在神经电生理监测下采用经皮微通道单侧椎旁入路,显微镜下先显露胸椎椎管对侧硬脊膜后方,高速磨钻小心磨除钙化黄韧带,再行同侧椎管减压,达到双侧显微减压目的;分析手术时间、出血量和住院时间,记录术前1 d和术后1、3、7 d肌酸磷酸激酶(CPK-MM)水平;于手术前后采用日本骨科学会(JOA)评分和疼痛视觉模拟量表(VAS)评分评估临床疗效;术前和术后1周行胸椎CT三维重建;术前、术后1 w、术后6个月胸椎MRI平扫。结果本组胸椎椎管减压充分,无神经损伤和脑脊液漏等并发症;MRI复查椎管减压效果好,CT三维重建检查示微创入路椎板切口未影响脊柱的稳定性;VAS及JOA评分在术后1 w、3个月和6个月均较术前明显改善(P<0.05)。CPK-MM水平于术后1 d达到高峰,随后逐渐降低,于术后7 d恢复至接近术前水平。随访6~23个月,所有病例症状改善,随访期间未见脊柱畸形发生。结论显微镜下经皮微通道单侧椎旁入路双侧减压治疗胸椎黄韧带骨化症,充分应用神经电生理监测技术和高速磨钻,术后神经功能恢复良好,既能最大程度避免损伤椎旁肌肉、关节突、棘突和韧带,也能达到椎管减压的目的,具有创伤小、恢复快、并发症少和椎体稳定性好等特点。

Objective The clinical outcomes of microsurgical deconrpression of ossification of ligamentum flavum （OLF） in the thoracic spine throngh paruspinal approach using percutaneous tubular reactor system were analyzed. Methods A total of 11 patients with OLF admitted in the hospital between August 2309 and December 2016 were enrolled in the study. General anesthesia was performed by tracheal intubafian, under the nerve electrophysiological monitoring, through the pereutaneous micro channel unilateral vertebral approach. Under the microscope, firstly the opposite side of the spinal was exposed, the high speed grinding was carefttlly grinding and removing the calcified yellow ligament, and then the same side of the spinal was decompressed to achieve the bilateral decorrrpression of spinal canal. Operative duration, blood loss volume, post-operative wound pain duration and hospital stay were analyzed. Creatine phosphokinase （CPK-MM） level was recorded at 1 d pre-operatively, and post-operatively at 1 d, 3 d and 5 d. The pre-operative and post-operative scores of Japanese Orthopedic Association （JOA） and visual analogue scale （VAS） were analyzed respectively to evaluate the function status of spinal cord. CT three-dimensional reconstruction of thoracic spine was performed at 1 w post-operatively. Magnetic resonance imaging （MRI） plain scan of thoracic spine was conducted before operation, and at 1 w and 6 months after operation. Results Thoracic spinal decompression was achieved in all patients without the injuries of spinal cord or nerve root. The CT three-dimensional reconstruction showed that the minirmlly invasive incision did not affect the stability of the spine, and no deformity of the spine occurred during the follow-up period. No post-operative spinal instability was identified by CT three-dimensional reconstruction. Level of CPK-MM increased at post-operative 1 d and declined gradually, reached the pre-operafive level at 7 d post-operatively. Post- operative scores of JOA and VAS were improved compared with those of pre-operation （P 〈0.05）. All the patients were followed up for 6 to 23 months. The symptoms of all patients were improved. Condusion Microsurgical resection of OLF using pereutaneous tubular retractorsystem through paraspinal approach can achieve a better recovery of neural functional and minimize the injuries of operation. This technique offers the advantages of mini-invasiveness, shorter hospital stay, rapid recovery and good post-operative spinal stability.