CAJ | 학술논문

目的：探讨“揭盖式”胸椎管后壁切除术治疗单节段胸椎黄韧带骨化症（OLF）的疗效，并分析其影响因素。方法：回顾性分析2005年2月~2013年5月因确诊单节段胸椎OLF于我院接受“揭盖式”胸椎管后壁切除术并获得随访的44例患者，排除合并其他脊柱疾病、超过1个节段分布以及外伤致病者。其中男23例，女21例；手术时年龄24~76岁，平均56.8岁。节段分布： T10/1120例，T11/1214例，T9/104例，T8/92例，T2/32例，T4/51例，T1/21例。术前JOA脊髓功能评分（11分法）为2~9分，平均6.68±1.76分。末次随访时按JOA评分改善率进行疗效分级，并计算疗效优良率。按术前MRI横断面上骨化黄韧带对脊髓的压迫程度分度，观察T2WI脊髓内有无高信号及矢状位骨化形态。利用术前CT测量并计算横断面椎管中央、侧界及二者中点部位（旁正中）的椎管前后径残余率，矢状位椎管前后径残余率，椎管面积残余率，观察Sato′s 分型及骨化生长位置。采用单因素线性相关分析检验年龄、性别、术前病程、术前JOA评分、单侧/双侧骨化、硬膜骨化、脑脊液漏、骨化生长位置、手术节段、T2WI脊髓内高信号、MRI矢状位骨化形态、Sato′s分型以及各椎管侵占测量参数与JOA评分改善率的相关性，对有统计学意义的影响因素与JOA评分改善率采用多元线性回归分析进行检验。结果：随访10~99个月，平均40个月。末次随访时，JOA评分为5~11分，平均8.84±1.83分；改善率为-20%~100%，平均58.17%；疗效判定：优13例，良20例，一般9例，差2例，优良率为75.0%（33/44）。单因素相关分析显示，术前JOA评分、单侧/双侧骨化、硬膜骨化、骨化生长位置、T2WI脊髓内高信号、Sato′s分型、MRI脊髓受压分度及CT横断面椎管前后径残余率（椎管侧界和旁正中）、矢状位椎管前后径残余率、椎管面积残余率与JOA评分改善率有相关性（P＜0.05），年龄、性别、术前病程、脑脊液漏、OLF手术节段、MRI骨化形态、CT横断面椎管前后径残余率（中央）与JOA评分改善率无相关性（P＞0.05）。多元回归分析显示，术前JOA评分与CT横断面椎管前后径残余率（旁正中）对手术疗效的影响有统计学意义（P＜0.05），而单侧/双侧骨化、硬膜骨化、骨化生长位置、T2WI脊髓内高信号、Sato′s分型、MRI脊髓受压分度、CT横断面椎管前后径残余率（侧界）、矢状位椎管前后径残余率及椎管面积残余率对手术疗效的影响无统计学意义（P＞0.05）。结论：“揭盖式”胸椎管后壁切除术治疗单节段胸椎OLF疗效相对较好，CT横断面椎管前后径残余率（旁正中）与术前JOA评分是影响手术疗效的重要因素。目的：探討“揭蓋式”胸椎管後壁切除術治療單節段胸椎黃韌帶骨化癥（OLF）的療效，併分析其影響因素。方法：迴顧性分析2005年2月~2013年5月因確診單節段胸椎OLF于我院接受“揭蓋式”胸椎管後壁切除術併穫得隨訪的44例患者，排除閤併其他脊柱疾病、超過1箇節段分佈以及外傷緻病者。其中男23例，女21例；手術時年齡24~76歲，平均56.8歲。節段分佈： T10/1120例，T11/1214例，T9/104例，T8/92例，T2/32例，T4/51例，T1/21例。術前JOA脊髓功能評分（11分法）為2~9分，平均6.68±1.76分。末次隨訪時按JOA評分改善率進行療效分級，併計算療效優良率。按術前MRI橫斷麵上骨化黃韌帶對脊髓的壓迫程度分度，觀察T2WI脊髓內有無高信號及矢狀位骨化形態。利用術前CT測量併計算橫斷麵椎管中央、側界及二者中點部位（徬正中）的椎管前後徑殘餘率，矢狀位椎管前後徑殘餘率，椎管麵積殘餘率，觀察Sato′s 分型及骨化生長位置。採用單因素線性相關分析檢驗年齡、性彆、術前病程、術前JOA評分、單側/雙側骨化、硬膜骨化、腦脊液漏、骨化生長位置、手術節段、T2WI脊髓內高信號、MRI矢狀位骨化形態、Sato′s分型以及各椎管侵佔測量參數與JOA評分改善率的相關性，對有統計學意義的影響因素與JOA評分改善率採用多元線性迴歸分析進行檢驗。結果：隨訪10~99箇月，平均40箇月。末次隨訪時，JOA評分為5~11分，平均8.84±1.83分；改善率為-20%~100%，平均58.17%；療效判定：優13例，良20例，一般9例，差2例，優良率為75.0%（33/44）。單因素相關分析顯示，術前JOA評分、單側/雙側骨化、硬膜骨化、骨化生長位置、T2WI脊髓內高信號、Sato′s分型、MRI脊髓受壓分度及CT橫斷麵椎管前後徑殘餘率（椎管側界和徬正中）、矢狀位椎管前後徑殘餘率、椎管麵積殘餘率與JOA評分改善率有相關性（P＜0.05），年齡、性彆、術前病程、腦脊液漏、OLF手術節段、MRI骨化形態、CT橫斷麵椎管前後徑殘餘率（中央）與JOA評分改善率無相關性（P＞0.05）。多元迴歸分析顯示，術前JOA評分與CT橫斷麵椎管前後徑殘餘率（徬正中）對手術療效的影響有統計學意義（P＜0.05），而單側/雙側骨化、硬膜骨化、骨化生長位置、T2WI脊髓內高信號、Sato′s分型、MRI脊髓受壓分度、CT橫斷麵椎管前後徑殘餘率（側界）、矢狀位椎管前後徑殘餘率及椎管麵積殘餘率對手術療效的影響無統計學意義（P＞0.05）。結論：“揭蓋式”胸椎管後壁切除術治療單節段胸椎OLF療效相對較好，CT橫斷麵椎管前後徑殘餘率（徬正中）與術前JOA評分是影響手術療效的重要因素。
목적：탐토“게개식”흉추관후벽절제술치료단절단흉추황인대골화증（OLF）적료효，병분석기영향인소。방법：회고성분석2005년2월~2013년5월인학진단절단흉추OLF우아원접수“게개식”흉추관후벽절제술병획득수방적44례환자，배제합병기타척주질병、초과1개절단분포이급외상치병자。기중남23례，녀21례；수술시년령24~76세，평균56.8세。절단분포： T10/1120례，T11/1214례，T9/104례，T8/92례，T2/32례，T4/51례，T1/21례。술전JOA척수공능평분（11분법）위2~9분，평균6.68±1.76분。말차수방시안JOA평분개선솔진행료효분급，병계산료효우량솔。안술전MRI횡단면상골화황인대대척수적압박정도분도，관찰T2WI척수내유무고신호급시상위골화형태。이용술전CT측량병계산횡단면추관중앙、측계급이자중점부위（방정중）적추관전후경잔여솔，시상위추관전후경잔여솔，추관면적잔여솔，관찰Sato′s 분형급골화생장위치。채용단인소선성상관분석검험년령、성별、술전병정、술전JOA평분、단측/쌍측골화、경막골화、뇌척액루、골화생장위치、수술절단、T2WI척수내고신호、MRI시상위골화형태、Sato′s분형이급각추관침점측량삼수여JOA평분개선솔적상관성，대유통계학의의적영향인소여JOA평분개선솔채용다원선성회귀분석진행검험。결과：수방10~99개월，평균40개월。말차수방시，JOA평분위5~11분，평균8.84±1.83분；개선솔위-20%~100%，평균58.17%；료효판정：우13례，량20례，일반9례，차2례，우량솔위75.0%（33/44）。단인소상관분석현시，술전JOA평분、단측/쌍측골화、경막골화、골화생장위치、T2WI척수내고신호、Sato′s분형、MRI척수수압분도급CT횡단면추관전후경잔여솔（추관측계화방정중）、시상위추관전후경잔여솔、추관면적잔여솔여JOA평분개선솔유상관성（P＜0.05），년령、성별、술전병정、뇌척액루、OLF수술절단、MRI골화형태、CT횡단면추관전후경잔여솔（중앙）여JOA평분개선솔무상관성（P＞0.05）。다원회귀분석현시，술전JOA평분여CT횡단면추관전후경잔여솔（방정중）대수술료효적영향유통계학의의（P＜0.05），이단측/쌍측골화、경막골화、골화생장위치、T2WI척수내고신호、Sato′s분형、MRI척수수압분도、CT횡단면추관전후경잔여솔（측계）、시상위추관전후경잔여솔급추관면적잔여솔대수술료효적영향무통계학의의（P＞0.05）。결론：“게개식”흉추관후벽절제술치료단절단흉추OLF료효상대교호，CT횡단면추관전후경잔여솔（방정중）여술전JOA평분시영향수술료효적중요인소。
Objectives: To assess the efficacy of "cap uncovering" en-bloc removal of the spinal canal′s posterior wall and the prognostic associated factors for thoracic myelopathy caused by single-level thoracic os-sification of ligamentum flavum(OLF). Methods: Patients with thoracic myelopathy induced by OLF underwent en-bloc removal of the spinal canal′s posterior wall termed as the "cap uncovering" technique between February 2005 and May 2013 and were retrospectively reviewed. Exclusion criteria were as follows: other tan-dem spinal diseases, OLF of more than one segment, cases caused by injury. A total of 44 cases was in-cluded. Among these 44 cases, there were 23 males and 21 females with a mean age of 56.8 years(range 24-76 years). Segmental distributions was as follows: 20 cases of T10/11, 14 cases of T11/12, 4 cases of T9/10, 2 cases of T8/9, 2 cases of T2/3, 1 case of T4/5, 1 case of T1/2. The modified JOA score and the re-covery rate were used to measure the outcomes. The mean JOA score was 6.68±1.76 preoperatively. The fol-low-up results were classified according to the recovery rate and then the rate of excellent or good was calcu-lated. The degree of spinal canal occupation was graded on axial T2 weighted MRI. The type of OLF and in-tramedullary high signal intensity on T2-weighted MRI was also evaluated. The spinal canal diameters were measured at the maximally stenosed level on axial and sagittal CT. The spinal canal diameter on axial CT was measured at three sites: the midline of the canal, the boundary of the canal, and the paramedian point. The canal diameter occupied ratio and the cross-section area occupied ratio were calculated. Sato′s classification and the growth position of OLF were observed on CT. Correlations between the surgical outcomes and various factors[age, gender, preoprative JOA scores, preoprative duration, unilateral/bilateral ossification, leakage of cere-brospinal fluid(CSF), the growth position, operative segment, high intensity signal in the spinal cord, shape on the sgittal MRI, dural ossification, Sato′s classification, degree of spinal canal occupation on axial MRI, canal diameter occupied ratio on sagittal and axial CT, the cross-section area occupied ratio] were analyzed through univariate linear correlation analysis, and multiple linear regression analysis was then used. Results: The mean follow-up period of these 44 cases was 40 months (range, 10-99 months). At final follow-up, the JOA score increased to 5-11 (mean 8.84 ±1.83), and the JOA recovery rate was -20%-100%(mean 58.17%). Surgical outcomes were as follows: 13 excellent, 20 good, 9 fair and 2 poor. The rate of excellent or good was 75.0%(33/44). The univariate linear correlation analysis showed that preoprative JOA scores, unilateral/bilateral ossification, dural ossification, the growth position, high intensity signal in the spinal cord, Sato′s classification and degree of spinal canal occupation on axial MRI, canal diameter occupied ratio on sagittal CT, canal diameter occupied ratio on axial CT (boundary), canal diameter occupied ratio on axial CT (paramedian), the cross-section area occupied ratio might be correlated to JOA recovery rate (P<0.05). Age, gender, preoprative duration, leakage of CSF, operative segment, shape on the sgittal MRI, canal diameter occupied ratio on axial CT (midline) were not associated with JOA recovery rate (P>0.05). The multiple linear regression analysis revealed that only canal diameter occupied ratio (paramedian) on axial CT and preoprative JOA scores significantly correlated with recovery rate(P<0.05). Unilateral/bilateral ossification, dural ossification, the growth position, high intensity signal in the spinal cord, degree of spinal canal occupation on axial MRI, Sato′s classification and other occupied index had no significant effect on surgical outcome (P>0.05). Conclusions:"Cap uncovering" en-bloc removal of the spinal canal′s posterior wall surgery is effective for single-level thoracic OLF. Canal diameter occupied ratio (paramedian) on axial CT and preoperative JOA scores have significant effect on surgical outcome.