胸椎黄韧带骨化合并腰椎管狭窄的临床特点及手术疗效影响因素

Clinical characteristics and prognostic factors of thoracic ossification of ligamentum flavum coexisted with lumbar spinal stenosis

目的:分析胸椎黄韧带骨化症(thoracic ossification of ligamentum flavum,TOLF)合并腰椎管狭窄(lumbar spinal stenosis,LSS)的临床表现,探讨手术策略和手术疗效的影响因素。方法:回顾性分析山西医科大学附属第二医院2014年6月至2018年6月收治的47例TOLF合并LSS患者的临床资料,男20例,女27例。16例同期行胸椎后路椎板切除、腰椎后路椎板减压植骨融合内固定术,14例行分阶段手术治疗,其余17例一期部分椎管减压后未行二期手术,其中10例一期行单纯胸椎减压术,7例行单纯腰椎减压术。采用胸椎日本骨科协会(Japanese Orthopaedic Association,JOA)评分和腰椎Oswestry功能障碍指数(Oswestry disability index,ODI)评价患者神经功能,并对相关因素进行二元Logistic回归分析。结果:47例纳入患者得到随访,随访时间9~60个月,平均(31.4±15.3)个月。所有患者的JOA评分均不同程度地提高,16例同期行两部位手术治疗,末次随访JOA改善率为(52.4±18.3)%;14例分期手术治疗,恢复率为(57.7±14.9)%;17例接受单纯胸或腰椎管减压,平均恢复率为(45.6±15.4)%。术前JOA评分、脊髓信号改变以及是否充分解除脊髓的压迫与术后疗效有显著的相关性。结论:TOLF合并LSS的临床表现复杂,诊断需要重视病史采集并进行仔细的体格检查。同期手术创伤较大,需要考虑患者的年龄和身体耐受能力。分期手术的总住院天数更长,因为存在间隔时间将延迟神经功能的恢复。术前的低JOA评分、遗留未手术治疗的椎管狭窄及术前胸段脊髓的异常信号对术后恢复不利。

Objective:To analyze the clinical features of thoracic ossification of ligamentum flavum(TOLF coexisted with lumbar spinal stenosis(LSS)and to discuss the surgical strategy and possible prognostic factors.Methods:From June 2014 to June 2018,47 patients(20 males,27 females)were retrospectively reviewed.16 patients underwent surgical decompression at both levels in one stage,14 patients underwent two-stage surgery.Additionally,remaining 17 patients were merely operated for thoracic or lumbar disorders.Postoperative functional outcomes were evaluated by modified Japanese Orthopedic Association(JOA)score and Oswestry disability index(ODI).Related factors were analyzed by Logistic regression analysis.Results:47 cases were followed up for 9 to60 months,averaged 31.4±15.3 months.After surgery,all of the patients experienced improvement.Sixteen patients underwent one-stage surgery,14 patients underwent two-stage procedure,the others didn’t received the second decompression,the average JOA recovery rates were(52.4±18.3)%,(57.7±14.9)%and(45.6±15.4)%respectively at the final follow-up.Logistic regression analysis showed that preoperative JOA score,intramedullary signal change and complete decompression correlated with postoperative recovery.Conclusion:The clinical features of TOLF accompanied with LSS were complicated,meticulous history taking and physical examination might help to make an accurate diagnosis.Simultaneous operation was invasive,and patients’age and physical endurance need to be considered.While two-stage operation needed longer total hospital stay,and the recovery of neurological function might be delayed due to the interval time.Low preoperative JOA score,incomplete decompression and abnormal intramedullary signal type significantly compromised recovery.