术中超声辅助下环形减压术治疗多节段胸椎后纵韧带骨化症

doi:10.19723/j.issn.1671-167X.2022.05.032

北京大学学报（医学版） ›› 2022, Vol. 54 ›› Issue (5): 1021-1027. doi: 10.19723/j.issn.1671-167X.2022.05.032

术中超声辅助下环形减压术治疗多节段胸椎后纵韧带骨化症

翟书珩,胡攀攀,刘晓光*()

北京大学第三医院骨科, 骨与关节精准医学工程研究中心, 脊柱疾病研究北京市重点实验室, 北京 100191

收稿日期:2022-06-22 出版日期:2022-10-18 发布日期:2022-10-14
通讯作者: 刘晓光 E-mail:xgliudoctor@163.com
作者简介:刘晓光, 医学博士, 北京大学第三医院骨科教授, 博士生导师。中国康复医学会常务理事、颈椎病专业委员会名誉主委、脊柱脊髓专业委员会副主委、微创学组副主委。中华医学会骨科分会委员、疼痛分会常委、微创学组副组长。中华预防医学会卫生应急分会副主委, 中国医师协会骨科分会常委、教育委员会副主委, 中国中西医结合学会骨科专业委员会副主委, 北京医学会骨科分会副主委、微创学组组长, 北京中西医结合学会骨科分会副主委等。主持国家自然科学基金、科技部"十五攻关"课题、国家重点研发计划、首都医学发展科研基金、教育部"985青年基金"、中央保健委基金等多项课题, 作为分项目负责人承担了国家卫生健康委员会(原卫生部)、教育部创新团队等多项重点基金课题的研究, 资金总额超千万元。发表SCI及核心期刊论文百余篇, 主编、主译专著3部, 参与编写和翻译专著8部, 获得国家实用新型专利8项。研究成果获教育部高校科技创新二等奖(两项), 北京市科学技术奖一等奖及二等奖, 北京市优秀中青年医师"名医奖"。获得中国医师奖提名奖, 全国劳动模范, 首都劳动奖章, 中共中央、国务院、中央军委联合表彰的全国抗震救灾先进个人。
主要研究方向为胸椎管狭窄症、颈椎病、腰椎管狭窄、腰椎间盘突出、脊柱畸形、脊柱陈旧骨折、脊柱肿瘤、脊柱结核、脊柱微创技术治疗各类脊柱疾患(脊柱内镜手术、微创减压融合术、穿刺活检、椎体成形、射频、粒子植入等), 擅长脊柱病变的穿刺活检和复杂手术治疗。完成CT监测下经皮穿刺脊柱肿瘤活检1 000余例, 数量和准确率均在国内外领先。经皮穿刺寰枢椎侧块关节植骨融合术、经皮穿刺放射性粒子植入治疗脊柱肿瘤及颈椎椎管内病变经皮穿刺活检术为国际首创。完成国内首例经皮穿刺射频腰间盘髓核成型术, 并在国内率先开展经皮穿刺椎体成型术、颈椎病的经皮镜下手术等。国际上独创"涵洞塌陷法"胸椎360度脊髓环形减压术, 解决了以往手术高致瘫率的难题
基金资助:
国家自然科学基金(81972103)

Intraoperative ultrasound assisted circumferential decompression for multilevel ossification of the posterior longitudinal ligament in thoracic vertebrae

Shu-heng ZHAI,Pan-pan HU,Xiao-guang LIU*()

Department of Orthopaedics, Peking University Third Hospital; Engineering Research Center of Bone and Joint Precision Medicine; Beijing Key Laboratory of Spinal Disease Research, Beijing 100191, China

Received:2022-06-22 Online:2022-10-18 Published:2022-10-14
Contact: Xiao-guang LIU E-mail:xgliudoctor@163.com
Supported by:
the National Natural Science Foundation of China(81972103)

摘要/Abstract

摘要：

目的: 分析多节段胸椎后纵韧带骨化症(ossification of the posterior longitudinal ligament, OPLL)术中超声辅助下环形减压术的手术疗效和术后神经功能改善情况。方法: 选择2016年1月至2021年1月北京大学第三医院多节段胸椎OPLL患者的病例资料进行回顾性分析, 所有病例均完成后壁切除后行术中超声检查确定环形减压节段, 并进行环形减压。纳入研究的30例患者男性14例, 女性16例, 平均年龄(49.3±11.4)岁。首发症状以下肢麻木无力为主(83.3%), 平均症状持续时间为(33.9±42.9)个月(1~168个月)。神经功能通过术前及末次随访时改良日本骨科协会(modified Japanese Orthopedic Association, mJOA)评分(0~11分)评估, 神经功能改善率根据Harabayashi法计算。根据神经功能改善率是否大于25%将患者分为较优改善组和较差改善组, 收集两组患者的年龄、体重指数(body mass index, BMI)、病程时间、手术时间、出血量、mJOA评分、手术节段、脑脊液漏并进行分析比较。结果: 病例平均手术时间为(137.4±33.8) min(56~190 min), 平均出血量为(653.7±534.2) mL(200~3 000 mL); 术前mJOA评分为(6.0±2.1)分(2~9分), 末次随访时mJOA评分为(7.6±1.9)分(4~11分), 所有患者神经功能均较术前改善(P < 0.001)。神经功能改善率平均为(38.1±24.4)%(14.3~100.0%), 其中神经功能改善率75%~100% 4例, 50%~74% 3例, 25%~49% 14例, 0~24% 9例。较优改善组与较差改善组相比较, 术中出血量差异具有统计学意义(P=0.047)。结论: 通过术中超声辅助下胸椎环形减压术可以对长节段OPLL患者进行有效的减压, 并显著改善患者的神经功能, 控制患者术中出血量有助于术后神经功能的改善。

关键词: 后纵韧带骨化症, 胸椎, 环形减压术, 术中超声, 胸椎管狭窄

Abstract:

Objective: To analyze the effect of short-segment circumferential decompression and the nerve function improvement in 30 cases of multilevel thoracic OPLL assisted by intraoperative ultrasound. Methods: A total of 30 patients with multilevel thoracic OPLL from January 2016 to January 2021 were enrolled, all of whom were located by intraoperative ultrasound and underwent circumferential decompression. There were 14 males and 16 females, with an average age of (49.3±11.4) years. The initial symptoms were mainly numbness and weakness of lower limbs (83.3%), and the mean duration of symptoms was (33.9±42.9) months (1-168 months). Neurological function was assessed by the Modified Japanese Orthopedic Association (mJOA) score (0-11) preoperative and at the last follow-up, in which the rate of neurological improvement was calculated by the Harabayashi method. The patients were divided into excellent improved group and poor improved group according to the improvement of neurological function. The age, body mass index (BMI), duration of symptoms, operation time, blood loss, mJOA score, surgical level, and cerebrospinal fluid leakage of the two groups were collected and analyzed for statistical differences. The factors influencing the improvement of neurological function were analyzed by univariate and multivariate Logisitic regression analysis. Results: The mean operation time was 137.4±33.8 (56-190) min, and the mean blood loss was (653.7±534.2) mL (200－3 000 mL). The preoperative mJOA score was 6.0±2.1 (2－9), and the last follow-up mJOA score was 7.6±1.9 (4－11), which was significantly improved in all the patients (P < 0.001). The average improvement rate of neurological function was 38.1%±24.4% (14.3%－100%), including 75%－100% in 4 cases, 50%－74% in 3 cases, 25%－49% improved in 14 cases, and 0%－24% in 9 cases. There was significant difference in intraoperative blood loss between the excellent improved group and the poor improved group (P=0.047). Intraoperative blood loss was also an independent risk factor in regression analysis of neurological improvement. Conclusion: Thoracic circumferential decompression assisted with intraoperative ultrasound can significantly improve the neurological function of patients with multilevel OPLL and achieve good efficacy. The improvement rate of nerve function can be improved effectively by controlling intraoperative blood loss.

Key words: Ossification of the posterior longitudinal ligament, Thoracic vertebra, Circumferential decompression, Intraoperative ultrasound, Thoracic spinal stenosis

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翟书珩,胡攀攀,刘晓光. 术中超声辅助下环形减压术治疗多节段胸椎后纵韧带骨化症[J]. 北京大学学报（医学版）, 2022, 54(5): 1021-1027.

Shu-heng ZHAI,Pan-pan HU,Xiao-guang LIU. Intraoperative ultrasound assisted circumferential decompression for multilevel ossification of the posterior longitudinal ligament in thoracic vertebrae[J]. Journal of Peking University (Health Sciences), 2022, 54(5): 1021-1027.

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参考文献 13

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6	刘晓光, 刘忠军, 陈仲强, 等. "涵洞塌陷法"360°脊髓环形减压术治疗胸椎管狭窄症[J]. 中华骨科杂志, 2010, 30 (11): 1059- 1062. doi: 10.3760/cma.j.issn.0253-2352.2010.11.010
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10	Gao A , Yu M , Wei F , et al. One-stage posterior surgery with intraoperative ultrasound assistance for thoracic myelopathy with simultaneous ossification of the posterior longitudinal ligament and ligamentum flavum at the same segment: A minimum 5-year follow-up study[J]. Spine J, 2020, 20 (9): 1430- 1437. doi: 10.1016/j.spinee.2020.05.097
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Items	Value
Gender, n (%)
Male	14 (46.7)
Female	16 (53.3)
Age/years, $\bar x \pm s$ (range)	19.3±11.4 (26－72)
BMI /(kg/m²), $\bar x \pm s$ (range)	28.0±4.8 (17.0－41.0)
Disease duration/months, $\bar x \pm s$ (range)	33.9±42.9 (1－168)
Initial symptoms, n (%)
Limbs numbness and weakness	25 (83.3)
Chest and back pain	5 (16.7)
Ossification of the ligamentum flavum, n (%)	13(43.3)
Follow-up time/months, $\bar x \pm s$ (range)	42.8±18.7 (18.5－75.9)
Hospital stay/d, $\bar x \pm s$ (range)	8.0±1.5 (5－13)
Postoperative hospital stay/d, $\bar x \pm s$ (range)	5.3±1.0 (4－8)
OPLL segment (vertebrae), $\bar x \pm s$ (range)	3.5±0.9 (3－6)
Posterior thoracic wall resection segments (vertebrae), $\bar x \pm s$ (range)	3.5±0.9 (3－6)
Circumferential decompression segments (vertebrae)	1
Circumferential decompression site，n (%)
Upper thoracic spine	6 (20)
Middle thoracic spine	16 (53.3)
Lower thoracic spine	8 (26.7)
Operation time/min, $\bar x \pm s$ (range)	137.4±33.8 (56－190)
Operation blood loss/mL, $\bar x \pm s$ (range)	653.7±534.2 (200－3000)
Preoperative mJOA score, $\bar x \pm s$ (range)	6.0±2.1 (2－9)
The last follow-up mJOA score, $\bar x \pm s$ (range)	7.6±1.9 (4－11)
Neurological improvement rate, $\bar x \pm s$ (range)	38.1±24.4 (14.3－100.0)
75%－100%	4 (13.3)
50%－74%	3 (10.0)
25%－49%	14 (46.7)
0%－24%	9 (30.0)
< 0%	0 (0)
Postoperative cerebrospinal fluid leakage，n (%)	16 (53.3)
Postoperative transient loss of muscle strength, n (%)	8 (26.7)

Items	Excellent improved group	Poor improved group	P
Case number	21	9
Age/years, $\bar x \pm s$	49.5±11.5	49.0±12.1	0.921
BMI/(kg/m²), $\bar x \pm s$	28.6±4.2	26.6±6.1	0.394
Disease duration/months, $\bar x \pm s$	31.3±40.1	39.8±51.2	0.667
Operation time/min, $\bar x \pm s$	136.9±28.0	138.4±46.7	0.911
Operation blood loss/mL, $\bar x \pm s$	467.1±203.9	1088.9±791.3	0.047^*
Preoperative mJOA score, $\bar x \pm s$	6.5±2.2	4.9±1.3	0.052
The last follow-up mJOA score, $\bar x \pm s$	8.3±1.8	6.0±1.1	0.002^*
Neurological improvement rate/%, $\bar x \pm s$	46.6±24.6	18.2±28.4	< 0.001^*
Operation segments, $\bar x \pm s$	3.4±0.7	4.0±1.0	0.121
Cerebrospinal fluid leakage，n	11	5	0.873

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术中超声辅助下环形减压术治疗多节段胸椎后纵韧带骨化症

Intraoperative ultrasound assisted circumferential decompression for multilevel ossification of the posterior longitudinal ligament in thoracic vertebrae

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