超声骨刀辅助下分区式椎板切除术治疗重度胸椎黄韧带骨化症

The clinical effect of ultrasonic bone curette-assisted"zoning"style laminectomy for the treatment of severe ossification of thoracic ligamentum flavum

目的探讨超声骨刀辅助下“分区式”椎板切除治疗重度胸椎黄韧带骨化症的安全性及临床效果。方法回顾性分析2015年10月至2018年10月于郑州市骨科医院脊柱外科采用超声骨刀辅助下“分区式”椎板切除术治疗的36例重度胸椎黄韧带骨化症患者的临床资料。男性17例,女性19例,年龄(57.3±10.2)岁(范围:43~80岁)。根据胸椎黄韧带解剖特征及骨化病理过程,将每个减压节段划分为椎板上1/3区、骨化黄韧带两侧区、移行区、骨化黄韧带与脊髓紧密接触区,采用不同的手术策略依次进行减压操作。手术前后采用改良日本骨科协会评分系统(mJOA)评估神经功能状态,评价患者的手术效果,并观察手术并发症情况。数据分析采用配对样本t检验。结果36例患者均顺利完成手术,手术时间(88.6±24.6)min(范围:60~150 min);术中出血量(426.7±167.4)ml(范围:250~800 ml)。随访时间(27.2±7.7)个月(范围:12~48个月)。末次随访时mJOA评分(9.0±1.5)分,与术前的(5.4±1.8)分相比,差异有统计学意义(t=13.59,P<0.01);mJOA评分改善率为(65.7±22.1)%,其中痊愈17例(47.2%),显效13例(36.1%),有效4例(11.1%),无效2例(5.6%)。10例患者在分离或切除硬膜骨化时出现脑脊液漏,术后采取综合保守治疗后均痊愈。2例患者出现术后短暂性神经功能恶化,给予提高平均动脉压、神经营养药物等治疗后,神经功能逐渐恢复至术前状态。随访中均未发现神经功能障碍加重、手术节段后凸畸形等情况。结论超声骨刀辅助下“分区式”椎板切除术治疗重度胸椎黄韧带骨化症,可在术中直视骨化黄韧带与椎管内结构的位置关系,准确指导手术减压,具有操作安全、减压彻底等优点,手术效果良好,是临床的一种手术选择。

Objective To investigate the safety and clinical efficacy of"zoning"style laminectomy by ultrasonic bone curette in patients with severe thoracic ossification of the ligamentum flavum(TOLF).Methods The clinical data of 36 patients with severe TOLF treated by"zoning"style laminectomy at Department of Spinal Surgery,Zhengzhou Orthopaedic Hospital from October 2015 to October 2018 were respectively analyzed.There were 17 males and 19 females,aged(57.3±10.2)years(range:43 to 80 years).According to the anatomical characteristics of the thoracic ligamentum flavum and the pathological process of ossionization,each decompression segment was divided into the upper 1/3 area of the lamina,the bilateral area of the ossionum flavum,the transitional area,and the area of close contact between the ossionum flavum and the spinal cord.Different surgical strategies were used for decompression in turn.The modified Japanese Orthopedic Association(mJOA)was used to evaluate the neurological function status before and after surgery,to evaluate the surgical effect of patients,and to observe the surgical complications.Paired sample T test was used for data analysis.Results All 36 patients successfully completed the operation,the operation time was(88.6±24.6)minutes(range:60 to 150 minutes).The intraoperative blood loss was(426.7±167.4)ml(range:250 to 800 ml).Follow-up time was(27.2±7.7)months(range:12 to 48 months).The mJOA score at the last follow-up was 9.0±1.5,which was statistically significant compared with the preoperative score 5.4±1.8(t=13.59,P<0.01).The improvement rate of mJOA score was(65.7±22.1)%,of which 17 cases were excellent(47.2%),13 cases were good(36.1%),4 cases were normal(11.1%),2 cases were ineffective(5.6%).Ten patients had cerebrospinal fluid leakage during the separation or removal of dural ossification and were cured after a series of comprehensive conservative treatment.Two patients showed transient neurological deterioration,and the neurological function gradually recovered to the preoperative state after comprehensive treatment such as increasing the mean arterial pressure and using neurotrophic drugs.During the follow-up,no aggravation of neurological dysfunction and segmental kyphosis were found.Conclusions The ultrasonic bone curette-assisted"zoning"style laminectomy for the treatment of severe TOLF can directly observed the position relationship between ossification of the ligamentum flavum and the spinal canal structure during the operation,and accurately guide the surgical decompression.It has the advantages of safe operation and complete decompression,which provides an important reference for the selection of clinical surgery.