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应用矢状位重建CT进行颈椎后纵韧带骨化手术方式的选择

Use sagittal reconstruction CT for making decisions regarding the surgical strategy for cervical ossification of the posterior longitudinal ligament

摘要:

目的 应用矢状位重建CT明确颈椎后纵韧带骨化(OPLL)患者手术方式选择的策略.方法 选取2007年7月至2010年11月所有因OPLL进行手术治疗并获得超过1年随访的161例患者.其中男性106例,女性55例.手术时年龄26~77岁,平均54.5岁.随访时间12~54个月,平均28个月.40例患者接受颈椎前路手术(前路组).其中14例接受颈前路椎体次全切除减压植骨融合术,26例接受颈前路间盘切除减压内固定植骨融合术.120例患者接受颈椎后路棘突纵割式颈椎管扩大人工骨桥成形术(SLAC手术)(后路组).1例患者接受前后路联合手术.矢状位重建CT显示,前路组造成脊髓压迫的主要诊断为颈椎间盘突出,后路组为OPLL;前路组患者脊髓压迫的节段数量为1~2节,后路组患者脊髓压迫的节段数量为1~5节,以2~4节为主;前路组OPLL分型为节段型或局限型,以节段型为主;后路组各型的分布较为平均.后路手术患者应用改良K线的方法分组,并进行临床效果的比较.改良K线是矢状位重建CT上连接枢椎及C7椎管中点的连线.脊髓压迫未超过K线为阳性组,超过K线为阴性组.采用t检验、x2检验进行统计分析,并对矢状位CT颈椎整体曲度及中立位X线颈椎整体曲度进行相关性分析.结果 前路组患者末次随访的JOA改善率(72%±27%)较后路组(59%±35%)高,差异有统计学意义(t =2.238,P=0.027).后路组患者中,改良K线阳性患者末次随访时的JOA改善率(63%±37%)高于阴性的患者(49%±30%),差异有统计学意义(t=2.150,P=0.034).矢状位CT颈椎整体曲度为11°±9°与中立位X线颈椎整体曲度10°±10°相比较差异无统计学意义(P>0.05),并有较强的相关性(r=0.947,P<0.01).结论OPLL手术方式的选择,需应用矢状位重建CT,结合脊髓压迫的主要诊断、压迫的节段及范围、OPLL 分型、是否后凸等因素综合考虑.改良K线是预测颈椎后路椎管扩大成形术减压效果的有效评价指标.

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abstracts:

Objective Use sagittal reconstruction CT to verify the surgical strategy for cervical ossification of the posterior longitudinal ligament (OPLL).Methods A retrospective study of 161 patients (106 males and 55 females) who had undergone surgery for OPLL from July 2007 to November 2010 was performed.The mean age at surgery was 54.5 years ( range from 26 to 77 years).The mean follow-up period was 28 months (12-54 months).There were 40 patients accept anterior approach surgeries (anterior group)which include 14 cases of anterior cervical corpectomy and fusion and 26 cases of anterior cervical discectomy and fusion.There were 120 patients accept posterior approach surgeries (posterior group) which was spinous process-splitting laminoplasty for cervical myelopathy using coralline hydroxyapatite,One patient accepted combined anterior and posterior approach.According to the sagittal reconstruction CT,the main reason for spinal cord compression was cervical disc herniation in anterior group,and OPLL in posterior group.The level of spinal cord compression was 1 to 2 levels in anterior group,and 1 to 5 levels in posterior group with a major of 2 to4 levels.As the classification of OPLL,segmentsl type and circumscribed type were major of segmental type in anterior group and all of the four types were in posterior group,the distribution of each type was average.The patients of posterior group were classified into two groups according to the modified K-line classification,and clinical results were compared between the two groups.The modified K-line was defined as a line that connects the midpoints of the spinal canal at C2 and C7 on sagittal CT myelography.Compression to the spinal cord did not exceed the K-line in the modified K-line ( + ) group and did exceed it in the modified K-line ( - ) group.Clinical data were compared using t-test or x2 test.Correlation analysis was used to determine the relationships of C2-C7 angulation between sagittal reconstruction CT and neutral position X-ray.Results The patient of anterior group had better recovery rate of the JOA score (72% ±27% ) than the posterior group (59% ± 35% ) at the latest follow-up (t =2.238,P=0.027).In posterior group,the patients of modified K-line ( + ) group had better recovery rate of the JOA score (63% ±37% ) than the K-line ( - ) group (49% ±30% ) at the latest follow up (t =2.150,P=0.034).The C2-C7 angulation on sagittal reconstruction CT was 11°± 9° which has significandy correlated with the C2-C7 angulation on neutral position X-ray which was 10°±10°( r =0.947,P< 0.01 ).Conclusions Considering the selection of surgical approach,it should be combined with the main clinical diagnosis for spinal cord compression,the level of compression,the classification of OPLL and the kyphotic alignment of the cervical spine.The modified K-line is a simple and practical tool for making decisions regarding the surgical strategy for cervical OPLL patients.

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