分期经皮脊柱内镜下后路减压术治疗多节段胸椎黄韧带骨化症的临床疗效

Clinical efficacy of staged percutaneous endoscopic posterior decompression for multi-segment thoracic ossification of the ligamentum flavum

中文关键词:  黄韧带骨化症  经皮脊柱内镜  分期  多节段

英文关键词:Ossification of the ligamentum flavum  Percutaneous spinal endoscopy  Staged treatment  Multi-segment

中文摘要:

  【摘要】目的：探讨分期经皮脊柱内镜下后路减压术治疗多节段胸椎黄韧带骨化症（multi-segment thoracic ossification of ligamentum flavum，mTOLF）的临床疗效。方法：回顾性分析2021年6月～2023年6月在我院采用分期经皮脊柱内镜下后路减压术治疗的16例mTOLF患者的临床资料，其中男9例，女7例，年龄46～67岁（55.4±6.8）岁。术前影像学均提示为多节段黄韧带骨化，其中双节段14例，三节段2例；责任节段：上胸段（T1～T4）4个、中胸段（T5～T9）6个、下胸段（T10～T12）24个。对多节段黄韧带骨化分期进行经皮脊柱内镜下后路减压术，一次手术仅针对1个责任节段进行治疗。记录总手术时间、总出血量、住院时间及并发症等情况。记录患者术前、术后3d和末次随访时的Oswestry功能障碍指数（Oswestry disability index，ODI）和改良日本骨科协会（modified Japanese Orthopaedic Association，mJOA）11分法评分等指标，计算末次随访时mJOA改善率，并进行统计学分析。分别于术前、术后3d和末次随访时在CT上测量椎管面积及矢状径，评价影像学改善情况。结果：16例患者均顺利完成手术，未发生脑脊液漏、下肢永久性瘫痪等严重并发症，术中发生1例硬脊膜撕裂。总手术时间80～205min（150.2±36.1min），总出血量30～70mL（50.3±12.4mL），住院时间9～15d（10.8±1.8d）。随访9～20个月（14.3±3.2个月），术前、术后3d和末次随访时mJOA评分分别为5.7±1.3分、7.1±1.3分和8.5±1.4分，ODI分别为（41.4±1.8）%、（17.8±1.6）%和（15.6±1.3）%，术后3d和末次随访时均较术前显著性改善（P＜0.05）。末次随访时mJOA改善率为28.6%～100%[（56.1±19.3）%]，其中优3例，良9例，可4例，无差及恶化病例，优良率75.0%。术前、术后3d及末次随访时手术节段的椎管面积与矢状径分别为76.7±12.5mm2、159.9±22.1mm2、157.7±21.6mm2和7.4±0.5mm、15.5±0.9mm、15.3±0.9mm，与术前相比，术后3d及末次随访时均显著性增大（P＜0.05）。结论：分期经皮脊柱内镜下后路减压术治疗mTOLF安全、有效，临床效果令人满意。

英文摘要:

  【Abstract】 Objectives: To investigate the clinical efficacy of staged percutaneous endoscopic posterior decompression for treating multi-segment thoracic ossification of ligamentum flavum(mTOLF). Methods: The clinical data of 16 patients with mTOLF who were treated with staged percutaneous endoscopic posterior decompression at our hospital between June 2021 and June 2023 were retrospectively analyzed, including 9 males and 7 females, aged 46-67(55.4±6.8) years old. The preoperative imaging examinations of the patients indicated multi-segment ossification of ligamentum flavum, including double segments in 14 cases and triple segments in 2 cases. The responsible segments were as follows: upper thoracic spine(T1-T4) in 4 cases, middle thoracic spine(T5-T9) in 6 cases, and lower thoracic spine(T10-T12) in 24 cases. Staged percutaneous endoscopic posterior decompression was performed for mTOLF, targeting only one responsible segment in each surgery. The operative time, blood loss, hospitalization days, and complications were recorded. The Oswestry disability index(ODI) and the modified Japanese Orthopaedic Association(mJOA) 11-point scale scores were recorded preoperatively, on 3d postoperatively, and at the final follow-up, and the mJOA improvement rate at the final follow-up was calculated. Statistical analysis was performed to evaluate the clinical efficacy. The spinal canal area and the anterior-posterior spinal canal diameter were measured on CT images preoperatively, on 3d postoperatively, and at the final follow-up to evaluate the improvement of imaging findings. Results: All the 16 patients successfully completed the surgery, and no cerebrospinal fluid leakage or permanent lower limb paralysis occurred except for one dural tear during operation. The operative time was 80-205min(150.2±36.1min), blood loss was 30-70mL(50.3±12.4mL), hospitalization days were 9-15d(10.8±1.8d) and the follow-up time ranged from 9-20(14.3±3.2) months. The mJOA scores and ODIs before surgery, on 3d after surgery, and at the final follow-up were 5.7±1.3, 7.1±1.3, 8.5±1.4, and (41.4±1.8)%, (17.8±1.6)%, (15.6±1.3)%, respectively, which were both significantly improved on 3d postoperatively and at final follow-up compared with those values before operation(P<0.05). The mJOA recovery rate was 28.6%-100%[(56.1±19.3)%], and according to the mJOA evaluation criteria, the outcomes were classified as excellent in 3 cases, good in 9 cases, fair in 4 cases, and poor in no case, with an excellent and good rate of 75.0%. The spinal canal area and anterior-posterior diameter before surgery, on 3d after surgery, and at the final follow-up were 76.7±12.5mm2, 159.9±22.1mm2, 157.7±21.6mm2, and 7.4±0.5mm, 15.5±0.9mm, 15.3±0.9mm, respectively. Both the spinal canal area and anterior-posterior diameter on 3d postoperatively and at the final follow-up significantly increased compared to preoperative values(P<0.05). Conclusions: Staged percutaneous endoscopic posterior decompression for treating mTOLF is safe and effective, and yields satisfactory clinical outcomes.