胸椎黄韧带骨化症

胸椎黄韧带骨化症贺石生侯铁胜赵杰文献回顾1912LEDOUBLE,AnatoleFTraitédesvariationsdelacolonnevertébraledel'hommeParis:Vigotfrères1920PolgarX线表现PolgarF.Uberinterakuellwirbelverkalking.ForschrGebRontgenstrnuklearmedErganzungsband1920;40:292–8.1962Yamaguchi第一例OLF引起脊髓压迫患者YamaguchiM,TamagakeS,FujitaS.Acaseofossificationofligamentumflavumcausingthoracicmyelopathy.JOrthopSurg1960;11:951–956胸椎黄韧带附着处骨化是比较常见的现象，但引起脊髓压迫，导致胸椎黄韧带骨化症比较少见Williams回顾了50例尸体标本及100个CT扫描，发现韧带附着处骨化比较常见。Radiology.1984Feb;150(2):423-6.Maigne对121例老年人调查发现下胸椎83%附着点骨化，腰椎33%骨化，认为下胸椎尾端附着处骨化是老年人的一种正常现象，受旋转应力的影响SurgRadiolAnat.1992;14(2):119-24.PayerM,etal.ThoracicmyelopathyduetoenlargedossifiedyellowLigaments.JNeurosurg(Spine1)92:105–108,2000英文比较大数量病例报道，日本6篇、中国台湾1篇、中国大陆1篇、突尼斯1篇，6篇大于20例，3篇15-20例BenHamoudaK,JemelH.JNeurosurg(Spine).99(2):157-61,2003.HanakitaJ,SuwaH,OhtaF.Neuroradiology32:38–42,1990MiyakoshiN,ShimadaY,SuzukiT.JNeurosurg(Spine).99(3):251-6,2003.MiyamotoS,YonenobuK,OnoK.Spine18:2267–2270,1993MiyasakaK,KanedaK,SatoS.AJNR4:629–632,1983NishiuraI,IsozumiT,NishiharaK.SurgNeurol51:368–372,1999ShiokawaK,HanakitaJ,SuwaH.JNeurosurg(Spine2)94:221–226,2001LiaoCC,ChenTY,JungSM,ChenLR.JNeurosurg(Spine).2005;2(1):34-9.24例ShishengHe,NakazatHussain,ShaohuaLi,TieshengHou.JNeurosurg(Spine).2005;3(5):348-354.27例戴力扬;戴方义.中华外科杂志1989;27(2):99-101倪斌;贾连顺;戴力扬;刘洪奎;侯铁胜;赵定麟.中华放射学杂志1995.12.10;29(12):858-861王全平;陆裕朴.中华骨科杂志1993;13(1):15-18倪斌;贾连顺;戴力扬;刘洪奎;侯铁胜;赵定麟.中国脊柱脊髓杂志1994.04.28;4(2):56-59陈仲强;党耕町;刘晓光;蔡钦林.中华骨科杂志1999.04.25;19(4):197-200(72例)。发病机理一、慢性损伤和退变部分患者有外伤、手术等病史下胸椎（T10-L1)多见，骨化的发生率及骨化的大小均与小关节的旋转活动范围有关，在旋转活动范围最大的T10～T11水平，骨化的发生率最高，骨化的体积也最大患者脊柱有明显退行性改变二、遗传及种族差异在年龄超过65岁的亚洲人中韧带骨化的发病率可高达20％而对于欧美人群的发病情况，至今为止，仅有数篇文献近20例报导三、其它因素甲状旁腺功能低下、骨软化症等全身性疾病患者的韧带骨化率相应增高。此外．糖尿病、氟骨症、肥胖患者的韧带骨化发病率也相对较高。中国、日本人高盐少肉的饮食习惯可导致血清中雌激素水平增高，刺激软骨细胞的生长而导致韧带骨化临床表现本临床表现病变化多样，容易误诊和延误诊断典型表现为上运动神经元损伤，但有时出现上下运动神经元同时受损表现起病隐匿，进展缓慢MiyakoshiN,ShimadaY,SuzukiT.Factorsrelatedtolong-termoutcomeafterdecompressivesurgeryforossificationoftheligamentumflavumofthethoracicspine.JNeurosurg(Spine).99(3):251-6,2003.SymptomsNumbersWeaknessinlowerlimbsandgaitdisturbance25NumbnessandSensorydeficit24Lowbackpain13'Squeezingtightband'aroundchestorabdomen10Neurologicalclaudication9Legpain7Fecalandurinaryincontinence11Kneeandanklehyperreflexia22Positivepatellarandankleclonus13PositiveBabinksi14ShishengHe,NakazatHussain,ShaohuaLi,TieshengHou.TheClinicalandPrognosticanalysisofOssifiedLigamentumFlavuminChinesepopulation。JNeurosurg(Spine).2005;3(5):348-354.ShishengHe,NakazatHussain,ShaohuaLi,TieshengHou.TheClinicalandPrognosticanalysisofOssifiedLigamentumFlavuminChinesepopulation。JNeurosurg(Spine).2005;3(5):348-354.LocationofOLFNumbersT10-T118T11-T128T8-T113T6-T102T10-T122T1-T3,T11-T121T1-T71T1-T31T2-T31颈、胸、腰椎均可出现，颈椎少见，而以胸椎和胸腰椎多见根据其形态可进行X线分型，(1)棘突型；又可分为上位型，下位型和上下位型；(2)板状型；(3)结节状型；(4)游离型。Thelateral-typelesionshowedossificationonlyatthefacetjointcapsuleTheextendedtypeshowedossificationextendingtothelaminaTheenlargedtypeshowedthickenedossificationwithanteromedialenlargementThefusedtypeshowedthickenedbilateralossifiedligamentsfusedatthemidlineThetuberoustypeshowedfusedossifiedligamentsgrowinganteriorlyThemoreadvancedtheossifiedligamentumflavumfromthelateraltothetuberoustype,themorestenoticthespinalcanalbecomes.可分为三种类型（MRI矢状位扫描）局灶型：骨化局限在两个节段问连续型：骨化连续三个节段及以上的跳跃型：局灶或连续OLF间断地分布在各段胸椎，之间为无骨化的节段31casesShiokawaK,etal.Clinicalanalysisandprognosticstudyofossifiedligamentumflavumofthethoracicspine.JNeurosurg(Spine2)94:221–226,2001CaseNoSexAge(yrs)OLFCoexistingDiseasesSurgicalProcedures1M46T10-11L3-5canalstenosis,T10/11discherniationT10-11lamimectomy,L3-5laminectomy2M56T11-12C2-3OPLL,T3-5OPLLT11-12laminectomy3F64T10-11C4/5discherniation,T4-6OPLLT10-T11laminectomy,T4-6OPLLremoval4M42T8-11T9/10discherniationT8-11laminectomy,T9/10discectomy5F67T11-12C3-6canalstenosis,T11/12discherniationT11-12,C3-6laminectomy6M63T6-10C2-7OPLL,T6-8OPLLT6-10laminectomy,T6-8OPLLremoval7M70T11-12L4/5discherniationT11-12laminectomy8F44T1-3C4/5,C5/6,T1/2,T2/3ossifieddischerniationT1-3laminectomy,T1/2,2/3discectomy9F71T8-11L4/5canalstenosisT8-11,L4-5lamnectomy10M52T10-12T10/11,11/12discherniationT10-12laminectomy11M47T1-7C3-5canalstenosis;C2-4OPLLC3-5,T1-7laminectomy12M59T1-3,T11-12T9/10discherniation,L4/5stenosisT1-3,T11-12laminectomy13M69T10-12T10/11discherniation,C3-6canalstenosisT10-12laminectomy,C3-6laminectomy14M55T10-11T8/9discherniation,L4/5discherniationT10-11laminectomy15F61T6-10C3-6OPLL,L4-5canalstenosisT6-10laminectomy16M64T8-11C5/6discherniationT8-11laminectomyShishengHe,NakazatHussain,ShaohuaLi,TieshengHou.TheClinicalandPrognosticanalysisofOssifiedLigamentumFlavuminChinesepopulation。JNeurosurg(Spine).2005;3(5):348-354.治疗方法后路椎板切除：整块切除横向减压时必须将椎板、双侧椎间关节内缘1／2及骨化的韧带一同切除。上、下减压范围应包括骨化上下各一节段,在合并胸椎OPLL时，则应包括OPLL两端及上、下各加一个椎板。“双层椎板”样结构，以及肥大增生的关节突及骨化的关节囊韧带挤入椎管内，严重硬膜粘连，常难以做到经典的“揭盖式”的椎板切除。后路椎板切除：逐渐蚕食先用磨钻将骨化黄韧带打薄，薄弱处用钩子钩破，从正常及压迫轻部位进入（头侧、尾侧和两侧）在多于半数病人中发现骨化的黄韧带和硬膜间粘连,牢固的粘连通常发生于椎管最狭窄的部位,钝性分离不能分开在粘连周围减压,然后把粘连的骨块咬碎,逐个切除切除骨化块造成的硬膜缺损用局部深筋膜修补切忌用椎板咬骨钳直接深入椎管内咬椎板成形Okada等在4例中应用了椎板成形术,该术式由Hirabayashi的治疗颈椎管狭窄的方法改良而来。