A radical procedure of circumferential spinal cord decompression through a modified posterior approach for thoracic myelopathy caused by severely impinging anterior ossification
A radical procedure of circumferential spinal cord decompression through a modified posterior approach for thoracic myelopathy caused by severely impinging anterior ossification
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DOI：
10.1016/j.spinee.2013.06.091
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发表时间：
2014-04-01
期刊：
影响因子：
4.5
通讯作者：
Chen, Bohua
中科院分区：
文献类型：
--
作者：
Ma, Xuexiao;An, Howard S.;Chen, Bohua
背景：由前部大量骨化斑块引起的胸椎脊髓病通常呈进展性，保守治疗效果不佳。对于严重向前撞击的脊髓，直接去除压迫性骨化是最佳手术。然而，前路和后路减压操作都导致了灾难性的医源性脊髓损伤。需要一种能够对脊髓进行充分和安全减压的严重胸段脊髓病的综合治疗方法。 目的：本研究的目的是证明使用改良后路入路的一期环周减压手术治疗因前部脊柱受压而导致的严重胸段脊髓病患者的有效性、安全性和结果。 研究设计：描述了一种治疗胸段脊髓病的改良环周脊髓减压手术。一项回顾性研究调查了 23 名序贯治疗患者的临床结果。 患者样本：23 名患者接受改良的环脊髓减压术治疗胸段脊髓病。 结果指标：使用日本骨科协会 (JOA) 评分、改良 Frankel 分类、Hirabayashi 恢复率和并发症的一般评估来评估结果。 方法：23 名患者由巨大的前部骨化结构引起的胸椎脊髓病采用广泛的后路椎板切除术、前部骨化切除以及通过改良后外侧入路进行椎间融合和脊柱后凸扭转稳定治疗。术前、术后 2 周、术后 1 年和最后一次随访时根据 JOA 和改良 Frankel 分类评估神经系统结果。手术结果也使用 Hirabayashi 恢复率来描述。在手术前后进行射线照相、计算机断层扫描 (CT) 和磁共振成像。术后进行 CT 扫描以确定减压的效果。从医疗记录中审查手术时间、术中失血量和并发症。此外，一名 48 岁男性因前部撞击多发骨赘而出现严重胸椎脊髓病，被描述为说明性患者。 结果：该系列中骨化部位分布广泛，从 T4-T12。所有患者的前部骨化斑块均被完整切除。五名术中有硬脑膜骨化证据的患者需要切除骨化的硬脑膜。平均运行时间为276分钟。术中平均失血量为 1,350 mL。术后随访2.5～6年，平均4.6年。术前平均JOA评分为4.3±1.5分，术后2周改善至6.1±1.9分，术后1年改善至8.1±1.8分，最近一次随访时改善至8.5±1.9分。期末检查时平林的整体恢复率平均为 63.6 +/- 22.4%。 8名患者被评为优秀，10名患者为良，4名患者为一般，1名患者为无变化。没有患者被评为病情恶化。 22 名患者（95.7%）的瘫痪改善至少 1 级。 3 名患者（13%）在手术后立即出现胸椎脊髓病短暂恶化。 6例患者（26.1%）发生脑脊液漏。 1例患者出现双侧腹股沟剧烈疼痛，3例出现单侧肋间神经痛，1例出现胸膜撕裂。结论：一期后路减压、前路骨化摘除、改良后路椎间融合术是治疗因前部撞击所致严重胸椎脊髓病安全、有效的方法。该手术技术要求高，适应症仅限于T4-T12各种病因的严重前部撞击引起的胸椎脊髓病。 (C) 2014 Elsevier Inc. 保留所有权利。
BACKGROUND CONTEXT: Thoracic myelopathy caused by an anterior, massive ossified plaque is often progressive and responds poorly to conservative treatment. Direct removal of the compressing ossification is the optimal procedure for a spinal cord that is severely impinged anteriorly. However, both anterior and posterior decompressive manipulations have caused catastrophic iatrogenic spinal cord injuries. A comprehensive treatment method for severe thoracic myelopathy that enables a sufficient and safe decompression of the spinal cord is needed.PURPOSE: The purpose of this study is to demonstrate the efficacy, safety, and results of a one-stage circumferential decompressive procedure using a modified posterior approach in patients with severe thoracic myelopathy resulting from anterior spinal compression.STUDY DESIGN: A modified procedure of circumferential spinal cord decompression for thoracic myelopathy is described. A retrospective study was conducted to investigate the clinical outcomes of 23 sequentially treated patients.PATIENT SAMPLE: Twenty-three patients were treated sequentially with a modified procedure for circumferential spinal cord decompression for thoracic myelopathy.OUTCOME MEASURES: Outcomes were assessed using the Japanese Orthopedic Association (JOA) score, modified Frankel classification, Hirabayashi recovery rate, and a general assessment of complications.METHODS: Twenty-three patients with thoracic myelopathy caused by a massive, anterior ossified structure were treated with an extensive posterior laminectomy, anterior removal of the ossification, and interbody fusion with kyphosis-reversing stabilization through a modified posterolateral approach. The neurologic outcomes are evaluated according to the JOA and the modified Frankel classification before surgery, 2 weeks after surgery, 1 year after surgery, and at the final follow-up visit. The surgical outcomes are also described using the Hirabayashi recovery rate. Radiographs, computed tomography (CT), and magnetic resonance imaging were performed before and after surgery. A postoperative CT scan was obtained to determine the efficacy of the decompression. Operative time, intraoperative blood loss, and complications were reviewed from the medical records. In addition, a 48-year-old man who presented with severe thoracic myelopathy resulting from anterior impingement with multiple osteophytes is described as an illustrative patient.RESULTS: The sites of ossification in this series were distributed widely, from T4-T12. The anterior ossified plaques of all patients were resected completely. Five patients who had intraoperative evidence of dural ossification required resection of the ossified dura matter. The average operating time was 276 minutes. Mean intraoperative blood loss was 1,350 mL. The postoperative follow-up ranged from 2.5 to 6 years, with an average of 4.6 years. The average preoperative JOA score was 4.3 +/- 1.5 points, and it improved to 6.1 +/- 1.9 points 2 weeks postoperatively, to 8.1 +/- 1.8 points 1 year postoperatively, and to 8.5 +/- 1.9 points at the most recent follow-up. The overall Hirabayashi recovery rate at the final examination averaged 63.6 +/- 22.4%. Eight patients were graded as excellent, 10 as good, 4 as fair, and 1 as unchanged. No patient was graded as deteriorated. The paralysis improved by at least 1 grade in 22 patients (95.7%). Transient deterioration of thoracic myelopathy occurred immediately after surgery in three patients (13%). Cerebrospinal fluid leakage occurred in six patients (26.1%). One patient sustained severe bilateral groin pain, three had unilateral intercostal neuralgia, and pleura tear occurred in one patient.CONCLUSION: One-stage posterior decompression, anterior extirpation of the ossification, and interbody fusion with instrumentation via a modified posterior approach is a safe and effective treatment for severe thoracic myelopathy resulting from prominent anterior impingement. This procedure is technically demanding, and the indications are limited to thoracic myelopathy caused by severe anterior impingement of various etiologies from T4-T12. (C) 2014 Elsevier Inc. All rights reserved.