CAJ | 학술논문

目的：探讨基于CT、MRI影像学特征及病理改变部位、范围所制定的胸椎后纵韧带骨化（TOPLL）新的综合分型及其对治疗的指导价值。方法：纳入2007年5月～2013年6月入院诊治的胸椎后纵韧带骨化症患者49例，其中男8例，女41例，平均年龄51.8±8.7岁（36～71岁），平均病程15.2±21.9个月（1～120个月）。根据术前CT及MRI矢状位和轴位影像将TOPLL分为四型：Ⅰ型为上胸椎（T1～T4）局灶压迫型（1～2节段）；Ⅱ型为中下胸椎（T5～T12）局灶压迫（1～2节段），ⅡA型为不合并同节段黄韧带骨化（OLF）者，ⅡB型为合并OLF者；Ⅲ型为连续腹侧压迫（≥3个节段）；Ⅳ型为跳跃型TOPLL，ⅣA型为间隔≥3个节段者，ⅣB型为间隔＜3个节段者。将此分型应用于临床实践，记录患者的分型、手术相关数据、手术前后JOA评分及改善率，记录Frankel分级变化情况。结果：本组Ⅰ型6例，手术方案为经后路的环形减压（360°涵洞塌陷法）；ⅡA型2例，采用侧前方经胸/腹膜外入路减压，ⅡB型3例，采用经后路的环形减压；Ⅲ型30例，13例后纵韧带为平坦型，行单纯后壁切除术，余17例行广泛后壁切除联合局部环形减压；ⅣA型7例，采用经后路的环形减压术，ⅣB型1例，采用单纯后壁切除术。1例术后26个月死于脑干出血，余48例获得大于12个月随访，随访时间12～85个月，平均47±24个月。48例术前JOA评分4.6±1.8分（0～9分），术后JOA评分为8.8±2.1分（4～11分），平均改善率为69%±28%（14%～100%）。依据Hirabayashi法对改善率进行分级，优23例、良9例、中16例。术前1例Frankel A级患者末次随访时改善为B级，22例Frankel B级患者中17例改善为C级，26例Frankel C级中2例改善为D级，余无变化。术后共11（22%）例发生脑脊液漏，其中单纯后壁切除1例，环形减压10例；均等引流液清亮后拔管，深缝伤口后沙袋加压包扎，俯卧位卧床2d，末次随访仅1例（T8～T12后壁切除、T8/9环形减压者） MRI提示T8/9水平筋膜外脑脊液囊肿存在（无症状），余10例MRI提示脑脊液已吸收。49例中无脊髓损伤及感染发生。结论：根据CT、MRI的影像形态学特征及病变所处位置、范围制定的胸椎OPLL临床实用分型方法，初步临床应用显示其对制定合理、安全的手术方案具有良好的指导作用。目的：探討基于CT、MRI影像學特徵及病理改變部位、範圍所製定的胸椎後縱韌帶骨化（TOPLL）新的綜閤分型及其對治療的指導價值。方法：納入2007年5月～2013年6月入院診治的胸椎後縱韌帶骨化癥患者49例，其中男8例，女41例，平均年齡51.8±8.7歲（36～71歲），平均病程15.2±21.9箇月（1～120箇月）。根據術前CT及MRI矢狀位和軸位影像將TOPLL分為四型：Ⅰ型為上胸椎（T1～T4）跼竈壓迫型（1～2節段）；Ⅱ型為中下胸椎（T5～T12）跼竈壓迫（1～2節段），ⅡA型為不閤併同節段黃韌帶骨化（OLF）者，ⅡB型為閤併OLF者；Ⅲ型為連續腹側壓迫（≥3箇節段）；Ⅳ型為跳躍型TOPLL，ⅣA型為間隔≥3箇節段者，ⅣB型為間隔＜3箇節段者。將此分型應用于臨床實踐，記錄患者的分型、手術相關數據、手術前後JOA評分及改善率，記錄Frankel分級變化情況。結果：本組Ⅰ型6例，手術方案為經後路的環形減壓（360°涵洞塌陷法）；ⅡA型2例，採用側前方經胸/腹膜外入路減壓，ⅡB型3例，採用經後路的環形減壓；Ⅲ型30例，13例後縱韌帶為平坦型，行單純後壁切除術，餘17例行廣汎後壁切除聯閤跼部環形減壓；ⅣA型7例，採用經後路的環形減壓術，ⅣB型1例，採用單純後壁切除術。1例術後26箇月死于腦榦齣血，餘48例穫得大于12箇月隨訪，隨訪時間12～85箇月，平均47±24箇月。48例術前JOA評分4.6±1.8分（0～9分），術後JOA評分為8.8±2.1分（4～11分），平均改善率為69%±28%（14%～100%）。依據Hirabayashi法對改善率進行分級，優23例、良9例、中16例。術前1例Frankel A級患者末次隨訪時改善為B級，22例Frankel B級患者中17例改善為C級，26例Frankel C級中2例改善為D級，餘無變化。術後共11（22%）例髮生腦脊液漏，其中單純後壁切除1例，環形減壓10例；均等引流液清亮後拔管，深縫傷口後沙袋加壓包扎，俯臥位臥床2d，末次隨訪僅1例（T8～T12後壁切除、T8/9環形減壓者） MRI提示T8/9水平觔膜外腦脊液囊腫存在（無癥狀），餘10例MRI提示腦脊液已吸收。49例中無脊髓損傷及感染髮生。結論：根據CT、MRI的影像形態學特徵及病變所處位置、範圍製定的胸椎OPLL臨床實用分型方法，初步臨床應用顯示其對製定閤理、安全的手術方案具有良好的指導作用。
목적：탐토기우CT、MRI영상학특정급병리개변부위、범위소제정적흉추후종인대골화（TOPLL）신적종합분형급기대치료적지도개치。방법：납입2007년5월～2013년6월입원진치적흉추후종인대골화증환자49례，기중남8례，녀41례，평균년령51.8±8.7세（36～71세），평균병정15.2±21.9개월（1～120개월）。근거술전CT급MRI시상위화축위영상장TOPLL분위사형：Ⅰ형위상흉추（T1～T4）국조압박형（1～2절단）；Ⅱ형위중하흉추（T5～T12）국조압박（1～2절단），ⅡA형위불합병동절단황인대골화（OLF）자，ⅡB형위합병OLF자；Ⅲ형위련속복측압박（≥3개절단）；Ⅳ형위도약형TOPLL，ⅣA형위간격≥3개절단자，ⅣB형위간격＜3개절단자。장차분형응용우림상실천，기록환자적분형、수술상관수거、수술전후JOA평분급개선솔，기록Frankel분급변화정황。결과：본조Ⅰ형6례，수술방안위경후로적배형감압（360°함동탑함법）；ⅡA형2례，채용측전방경흉/복막외입로감압，ⅡB형3례，채용경후로적배형감압；Ⅲ형30례，13례후종인대위평탄형，행단순후벽절제술，여17례행엄범후벽절제연합국부배형감압；ⅣA형7례，채용경후로적배형감압술，ⅣB형1례，채용단순후벽절제술。1례술후26개월사우뇌간출혈，여48례획득대우12개월수방，수방시간12～85개월，평균47±24개월。48례술전JOA평분4.6±1.8분（0～9분），술후JOA평분위8.8±2.1분（4～11분），평균개선솔위69%±28%（14%～100%）。의거Hirabayashi법대개선솔진행분급，우23례、량9례、중16례。술전1례Frankel A급환자말차수방시개선위B급，22례Frankel B급환자중17례개선위C급，26례Frankel C급중2례개선위D급，여무변화。술후공11（22%）례발생뇌척액루，기중단순후벽절제1례，배형감압10례；균등인류액청량후발관，심봉상구후사대가압포찰，부와위와상2d，말차수방부1례（T8～T12후벽절제、T8/9배형감압자） MRI제시T8/9수평근막외뇌척액낭종존재（무증상），여10례MRI제시뇌척액이흡수。49례중무척수손상급감염발생。결론：근거CT、MRI적영상형태학특정급병변소처위치、범위제정적흉추OPLL림상실용분형방법，초보림상응용현시기대제정합리、안전적수술방안구유량호적지도작용。
Objectives: To investigate a new compositive classification of thoracic posterior longitudinal liga-ment(TOPLL) based on the imaging features of CT, MRI and the position and range of pathological changes and its role in clinical practice. Methods: 49 patients, including 8 males and 41 females, diagnosed as TOPLL from May 2007 to June 2013 were collected in this series. The mean age was 51.8 ±8.7 years(36-71 years), and the average duration of disease was 15.2±21.9 months(1-120 months). According to pre-operative information on both sagittal and axial planes of CT and MRI, 4 types of TOPLL were classified in practice:Ⅰ, regional compression(1-2 segments) in proximal thoracic spine(T1-T4); Ⅱ, regional compression(1-2 seg-ments) in middle and distal thoracic (T5-T12); ⅡA, without ossification of ligamentum flavum (OLF) at the same segment; ⅡB, with OLF at the same segment; Ⅲ, continuous ventral compressions(≥3 segments); Ⅳ, discontinuous type of TOPLL; ⅣA, discontinuous type of TOPLL (interval≥3 segments); ⅣB, discontinuous type of TOPLL(interval<3 segments). This classification was applied into clinical practice, the types of TOPLL, operative data, JOA scores at pre- and post-operation and recovery rates and Frankel classification were recorded. Results: A total of 49 patients was recruited in this study, 6 cases were classified as type Ⅰ, and the treatment strategy was 360° circumferential decompression(PCD), named "cave in" technique; 2 as ⅡA, and the treatment strategy was anterior decompression(AD); 3 as ⅡB, the treatment strategy was circumferen-tial decompression(PD); 30 as Ⅲ, among them, 13 received PD and 17 received PCD; 8 as Ⅳ, among them, 7 ⅣA received PCD and 1 ⅣB received PD. One patient died from brainstem hemorrhage 26 months after surgery. The remaining 48 cases were followed up for 12-85 months with an average of 47 ±24 months. Pre-operative JOA scores of these 48 patients were 4.6±1.8(0-9), while 8.8±2.1(4-11) at final follow-up, with an average recovery rate of 69%±28%(14%-100%). According to the Hirabayashi grading for recovery rate, 23 patients were ranked as excellent, 9 as good, 16 as middle, none as unchange or worse. 1 patient with Frankel A pre-operatively improved to B at final follow-up. Among 22 cases with Frankel B, 17 improved to C, and 2 Frankel C improved to D at final follow-up. 11 cases(22%) were complicated with cerebrospinal flu-id leakage, including 1 case of PD and 10 cases of PCD. The interventions included removal of drainage, stressful dressing and delayed off bed 2 days later. At final follow-up, only 1 case(T8-T12 PD combined with T8/9 PCD) was still found presence of cerebrospinal fluid at T8/9 on MRI, and in other 10 cases, the CSF completely disappeared. None developed injury of spinal cord or infection. Conculsions: This article proposes a novel classification of TOPLL, which takes the sites, distribution and sources of compression into account, and also proposes surgical strategies respectively. Primary application of this classification in clinical practice suggests its value.