opll頸椎后縱韌帶骨化

1、OPLL經(jīng)典綜述講讀,王雪鵬杭州市骨科研究所杭州市第一人民醫(yī)院骨科,,,,,,Ossification of the posterior longitudinal ligament (OPLL) results from pathologic replacement of the PLL with lamellar bone, potentially causing spinal cord compression and neuro

2、logic deteriorationOPLL was first described in Japanese patients and has classically been considered a cause of myelopathy in patients of East Asian origin,,spondylosismyelopathyradiculopathystenosisdisc herniation,

3、,,Among patients in Japan with cervical spine disorders, the incidence has been estimated at 1.9% to 4.3% and, in other Asian countries, up to 3.0%OPLL has been recognized as an etiology of myelopathy regardless of ethn

4、icity, with an estimated incidence rate of 0.1% to 1.7% among North Americans and Europeans,Pathoanatomy,The PLL runs along the dorsal surface of the C1 anterior arch and cervical vertebral bodies and consists of longitu

5、dinal fibers confluent with the tectorial membrane cranially and ending at the sacrum caudallyfunctionally,the PLL resists spine hyperflexion,Pathophysiology,The pathologic process leading to OPLL begins with chondrobla

6、st- and fibroblast-like spindle cell proliferation, along with vascular infiltration leading to PLL degeneration and hypertrophy. Endochondral ossification follows, resulting in its replacement with mature lamellar bone

7、Genetics,local tissue characteristics, and associated medical comorbidities have all been implicated in this final common pathway,,,Medical comorbidities are also associated with the development of OPLLUp to 50% of Cauc

8、asian patients with OPLL also have diffuse idiopathic skeletal hyperostosisHypoparathyroidism,hypophosphatemic rickets,hyperinsulinemia, and obesity have been identified as risk factors,Natural History,Patients with OPL

9、L commonly present in their fifth and sixth decades,with men affected twice as often as women.Most patients have some neurologic symptoms at diagnosis, with 28% to 39% fulfilling diagnostic criteria for myelopathy,,,In

10、patients with myelopathy, 64% had deteriorated,however, and 89% of patients with Nurick grade 3 or 4 myelopathy who refused surgery had progressed to a wheelchair- or bed-bound state,,Risk factors for the development of

11、 myelopathy include ＞60% spinal canal stenosis,＜6 mm of space available for the cord, increased cervical range of motion, and OPLL that is laterally deviated within the spinal canalAge, gender, and the number of levels

12、affected by OPLL do not affect the prognosis,Clinical Presentation,Changes in gait or balance, loss of fine motor control, and upper extremity weakness,numbness, or paresthesias are suggestive of myelopathyEarly muscula

13、r fatigue or worsening symptoms at the extremes of cervical motion are also concerning,,Patients with OPLL are at an increased risk of acute spinal cord injury with trauma,and rapid neurologic deterioration in associatio

14、n association with even a minor trauma or whiplash injury should raise concern for the development of central cord syndrome,Physical Examination,Radiologic Evaluation,,The lateral radiograph is also used to determine the

15、 relationship of the OPLL to the kyphosis line (K-line),which is drawn from the center of the canal at C2 to the center of the canal at C7A large OPLL mass or loss of cervical lordosis causes the OPLL to protrude poster

16、ior to the K-line (referred to as K-line negative). This is a negative prognostic factor for posterior surgery alone,,,CT with sagittal and coronal reformatting has emerged as the benchmark for radiographic evaluation of

17、 OPLL and is necessary to reliably characterize it,,Greater than 60% canal occupancy at any level and a laterally deviated mass are associated with high rates of myelopathyThis “double layer sign” on axial or sagittal C

18、T images is associated with dural tear rates ＞50% with anterior decompression versus 13% when the sign is absent,,Nonsurgical Management,Prophylactic surgery is neither necessary nor recommended Management includes temp

19、orary immobilization with a neck brace, steroidal or nonsteroidal anti-inflammatory medications, activity modification,and physical therapy,,patients should be advised to avoid activities that may result in sudden or

20、 excessive cervical spine motion because OPLL is associated with a high rate of acute spinal cord injury, even in patients who do not meet surgical criteria,Surgical Treatment,Surgical decompression is the treatment of c

21、hoice for patients with Nurick grade 3 or 4 myelopathy or severe radiculopathy caused by OPLL via either an anterior or posterior approach,Anterior Decompression and Fusion,Proponents argue that it allows for a superior

22、decompression and is more effective at maintaining or restoring cervical lordosis than is posterior surgery. Associated anterior pathology, such as disk herniations,can also be addressed,,Disadvantages include technical

23、difficulty, inability to decompress cranial to C2, and high rates of pseudarthrosis and dysphagia when three or more levels require treatment Dural tears are also much more common with an anterior approach, given that a

24、nterior dural ossification occurs in 13% to 15%,,Exposure is provided by the standard Smith-Robinson approach, and diskectomy, hemicorpectomy,or subtotal corpectomy sufficient to allow exposure of the underlying OPLL mas

25、s is performedCorpectomies of up to five levels have been performed with success,but removal of three or more contiguous levels is associated with increased complication and reoperation rates,,Complications occur as par

26、t of the approach (eg, dysphagia, dysphonia), the decompression (eg, C5 palsy, dural tears), or the fusion (eg,graft subsidence, pseudarthrosis),,Nerve root palsies occur in 4% to 17% of patients through either direct tr

27、auma or traction.Patients present with weakness, numbness,pain, or paresthesias, most commonly in the C5 distribution,,Dural tears occur in 4% to 20% of patients, often because of dural ossification or attenuation.Cerebr

28、ospinal fluid leakage may result in pseudomeningocele or fistula formation, leading to neural damage, airway compression,meningitis, or wound complications,,Tears recognized intraoperatively are treated by direct repair

29、or by application of autogenous fascial or synthetic collagen grafts. Closure of pinhole defects or augmentation of repairs is done with thrombogenic sealants, such as fibrin glue or gelatin foam. Postoperatively, divert

30、ing lumbar drains and bed rest can be used,,In an effort to reduce dural tear rates, Yamaura et al introduced the“anterior floating method” for cervical decompression, consisting of subtotal vertebral body resection and

31、thinning, but not removal, of the OPLL. The posterior vertebral body is not reconstructed, allowing the OPLL to “float” anteriorly and away from the spinal canal. At 5-year follow-up, the authors achieved a mean recovery

32、 rate of 68.5% and improvement in Japanese Orthopaedic Association scores from 8.3 to 14.2. No leaks of cerebrospinal fluid occurred, but 14% of patients were left with an inadequate decompression. In these patients,or w

33、ith OPLL progression, the authors recommended subsequent posterior decompression.,,When addressing more than two or three levels, fibular strut grafts are preferred for their structural support. For one or two levels, st

34、ructural grafts of tricortical iliac crest, fibula, and vertebral bodies have all been described.More recently,interbody cages with nonstructural bone graft or bone graft substitutes have been used.Overall rates of pseud

35、arthrosis vary from 3% to 15%, with the highest rates occurring in patients undergoing fusion of three or more levels.,,,,,,Posterior Decompression,When more than two or three cervical levels are affected by OPLL, poster

36、ior surgery (ie, laminoplasty, or laminectomy and fusion) is preferred because of the technical ease and lower rate of complications. Disadvantages include the risk of postoperative disease progression, inability to corr

37、ect cervical kyphosis, and poor results in K-line negative patients.,,Laminoplasty accomplishes this by hinging open the laminae with either an “open door” or “French door” technique, resulting in a 30% to 40% increase i

38、n the size of the spinal canalLaminectomy and fusion entails removal of the laminae followed by instrumented posterolateral fusion,resulting in a 70% to 80% increase in canal volume,,,,,,,,,A full analysis of the advant

39、ages and disadvantages between laminoplasty compared with laminectomy and fusion has been discussed elsewhereOur preference is to use laminectomy and fusion for OPLL because the retained cervical motion with laminoplast

40、y may allow disease progression,and the risk for progression to kyphosis at the affected levels is eliminated with fusion,,For severe disease, recovery rates after posterior decompression appear to be lower than those fo

41、llowing anterior decompression, but with a lower complication rate,,Iwasaki et al retrospectively compared the results of anterior decompression and fusion with those of laminoplasty; they reported better outcomes after

42、anterior surgery in patients with an OPLL mass occupying ＞60% of the canal; however,it results in a reoperation rate of 26% versus 2% in the laminoplasty group. With＜60% canal occupancy,recovery rates were equivalent.,,A

43、 prospective comparison of anterior decompression and fusion versus laminoplasty found similar results. Patients with ＞50% canal occupancy had superior recovery rates with anterior surgery but equivalentrates with ＜50% i

44、nvolvementPatients with ＜5°of cervical lordosis also had significantly worse outcomes from laminoplasty, and 50% lost lordosis versus none in the fusion group.Half of the laminoplasty patients experienced OPLL prog

45、ression versusonly one after anterior surgeryHowever, surgical complications heavily favored laminoplasty, with a 23% complication rate and a 14% reoperation rate in the anterior group and none in the laminoplasty patie

46、nts,Only one study to date has examined the results of laminectomy and fusion for OPLL.,,,Chen et al reported a mean recovery rate of 62% at 5 years among 83 patients who underwent instrumented laminectomy and fusion fro

47、m C2 or C3 to C7. Patients with a good outcome had significantly more postoperative lordosis (16.1° versus10.4°). No other factors, including occupying ratio, were significant between groups. The reoperation ra

48、te was 4%, all the result of epidural hematoma formation. Whether posterior fusion had an effect on disease progression was not evaluated, although the authors noted no longterm decline in neurologic recovery, as is com

49、monly seen in laminoplasty patients.,,,,The most common complication of posterior surgery is low cervical nerve root palsy, which occurs in 4% to 12% of patients.Injury may occur from direct trauma or from traction neura

50、praxia as the cord migrates posteriorlyComplications specific to laminoplasty include closure of the laminoplasty and fracture of the laminar hinge,whereas laminectomy and fusion may be complicated by hardware failure,

51、pseudarthrosis, or a post-laminectomy membrane,,Both procedures can be complicated by chronic pain, loss of lordosis, epidural hematoma, and progression of disease,Combined Anterior andPosterior Decompression,When the d

52、isease involves more than three levels, however,the addition of a posterior decompression allows the remainder of the cervical spine to be addressed while avoiding a multilevel anterior dissection Posterior instrumentat

53、ion may also be used to increase the stability of an anterior construct and promote fusion Finally, late posterior surgery may also be preferable to revision anterior surgery in the event of disease progression or pseud