椎管内韧带串联骨化症的临床特征及手术策略

Clinical characteristics and surgical strategies of tandem ossification of the intraspinal ligaments

后纵韧带骨化(ossification of posterior longitudinal ligament,OPLL)和黄韧带骨化(ossification of ligamentum flavum,OLF)是临床常见的异位骨化疾病,是导致颈胸椎管狭窄及脊髓损害的主要原因。少数情况下,二者可连续累及多个脊柱部位,亦可合并出现,增加了临床诊断和治疗难度。初步尝试以“椎管内韧带串联骨化症(tandem ossification of intraspinal ligaments,TOIL)定义该特殊骨化现象,指由多种因素引起的OPLL和OLF单独或联合出现在颈椎、胸椎或腰椎两处及以上部位且骨化节段数≥5个,进行性压迫脊髓或神经导致一系列复杂临床症状的严重脊柱韧带骨化性疾病。TOIL发病率不明,但临床检出率并不低,其中颈椎OPLL合并胸椎OPLL或(和)OLF最为常见;该病涉及因素较多,具体的发病机制尚不明确,临床症状和体征往往相互干扰,可同时出现上下运动神经元损害表现;TOIL存在形式多样,影像学特征复杂,且无统一的诊断及定位诊断标准,极易导致漏诊和误诊,对于TOIL的临床鉴定,目前仍建议以患者典型症状体征为依据,以CT三维重建及MRI征象为参考,同时结合可能的危险因素及临床经验进行综合判断;对于症状性TOIL患者,责任节段的手术减压是唯一有效的治疗措施,然而国内外学者对其最佳手术策略仍存在较大的分歧,如何定位手术节段及确定减压范围,采用何种手术入路及方式,何时选择分期手术或一期联合手术,尚未达成一致结论。通过检索相关文献,总结并探讨TOIL的临床特征及手术策略选择现状及进展,为临床医生诊断和治疗TOIL提供参考。

Ossification of posterior longitudinal ligament(OPLL)and ossification of ligamentum flavum(OLF)are clinically common heterotopic ossification diseases,which are the main causes of cervical and thoracic spinal stenosis and spinal cord injury.In some cases,OPLL and OLF may involve multiple spinal sites,individually or concurrently,increasing the difficulty of clinical diagnosis and treatment.This review initially attempts to define this specific ossification phenomenon as Tandem ossification of intraspinal ligaments(TOIL).It refers to a kind of severe spinal ligament ossification diseases caused by multiple factors,that OPLL and OLF occur alone or in combination at two or more sites of the cervical,thoracic,or lumbar spine with five or more ossified segments,progressively compressing the spinal cord or nerves,thereby resulting in a series of complex clinical symptoms.The prevalence of TOIL remains unknown,but its clinical detection rate is relatively high,and the most common TOIL is cervical OPLL combined with thoracic OPLL or/and OLF.Moreover,occurrence and development of TOIL involve many factors and its definitepathogenesis is not clear.Damage of upper and lower motor neurons can occur simultaneously in TOIL patients so that their clinical symptoms and signs often interfere with each other.TOIL has various forms,complex imaging features,and no uniform diagnostic and localization diagnostic criteria,which may easily lead to missed diagnosis and misdiagnosis.It is recommended that TOIL is identified by the typical symptoms and signs as the basis,CT three-dimensional reconstruction and MRI signs as the reference,and combination of the possible risk factors and clinical experience.Currently,surgical decompression for responsible lesions is the only effective treatment for symptomatic TOIL.However,domestic and foreign scholars still have great arguments on the optimal surgical strategy of TOIL.No consensus has been reached on how to determine the operating segment and the extent of decompression,which surgical approach and technique to be adopted,and when to select staged or one-stage combined surgery.Therefore,this review summarizes and discusses the current status and progress of the clinical characteristics and surgical strategies of TOIL through searching the relevant literature,to provide a reference for clinicians to diagnose and treat TOIL.