OPLL颈椎后纵韧带骨化.ppt

OPLL颈椎后纵韧带骨化.ppt

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OPLL经典综述讲读经典综述讲读王雪鹏王雪鹏杭州市骨科研究所杭州市骨科研究所杭州市第一人民医院骨科杭州市第一人民医院骨科Ossificationoftheposteriorlongitudinalligament（OPLL）resultsfrompathologicreplacementofthePLLwithlamellarbone,potentiallycausingspinalcordcompressionandneurologicdeteriorationOPLLwasfirstdescribedinJapanesepatientsandhasclassicallybeenconsideredacauseofmyelopathyinpatientsofEastAsianoriginspondylosismyelopathyradiculopathystenosisdischerniationAmongpatientsinJapanwithcervicalspinedisorders,theincidencehasbeenestimatedat1.9%to4.3%and,inotherAsiancountries,upto3.0%OPLLhasbeenrecognizedasanetiologyofmyelopathyregardlessofethnicity,withanestimatedincidencerateof0.1%to1.7%amongNorthAmericansandEuropeansPathoanatomyThePLLrunsalongthedorsalsurfaceoftheC1anteriorarchandcervicalvertebralbodiesandconsistsoflongitudinalfibersconfluentwiththetectorialmembranecraniallyandendingatthesacrumcaudallyfunctionally,thePLLresistsspinehyperflexionPathophysiologyThepathologicprocessleadingtoOPLLbeginswithchondroblast-andfibroblast-likespindlecellproliferation,alongwithvascularinfiltrationleadingtoPLLdegenerationandhypertrophy.Endochondralossificationfollows,resultinginitsreplacementwithmaturelamellarboneGenetics,localtissuecharacteristics,andassociatedmedicalcomorbiditieshaveallbeenimplicatedinthisfinalcommonpathwayMedicalcomorbiditiesarealsoassociatedwiththedevelopmentofOPLLUpto50%ofCaucasianpatientswithOPLLalsohavediffuseidiopathicskeletalhyperostosisHypoparathyroidism,hypophosphatemicrickets,hyperinsulinemia,andobesityhavebeenidentifiedasriskfactorsNaturalHistoryPatientswithOPLLcommonlypresentintheirfifthandsixthdecades,withmenaffectedtwiceasoftenaswomen.Mostpatientshavesomeneurologicsymptomsatdiagnosis,with28%to39%fulfillingdiagnosticcriteriaformyelopathyInpatientswithmyelopathy,64%haddeteriorated,however,and89%ofpatientswithNurickgrade3or4myelopathywhorefusedsurgeryhadprogressedtoawheelchair-orbed-boundstateRiskfactorsforthedevelopmentofmyelopathyinclude60%spinalcanalstenosis,6mmofspaceavailableforthecord,increasedcervicalrangeofmotion,andOPLLthatislaterallydeviatedwithinthespinalcanalAge,gender,andthenumberoflevelsaffectedbyOPLLdonotaffecttheprognosisClinicalPresentationChangesingaitorbalance,lossoffinemotorcontrol,andupperextremityweakness,numbness,orparesthesiasaresuggestiveofmyelopathyEarlymuscularfatigueorworseningsymptomsattheextremesofcervicalmotionarealsoconcerningPatientswithOPLLareatanincreasedriskofacutespinalcordinjurywithtrauma,andrapidneurologicdeteriorationinassociationassociationwithevenaminortraumaorwhiplashinjuryshouldraiseconcernforthedevelopmentofcentralcordsyndromePhysicalExaminationRadiologicEvaluationThelateralradiographisalsousedtodeterminetherelationshipoftheOPLLtothekyphosisline（K-line）,whichisdrawnfromthecenterofthecanalatC2tothecenterofthecanalatC7AlargeOPLLmassorlossofcervicallordosiscausestheOPLLtoprotrudeposteriortotheK-line（referredtoasK-linenegative）.ThisisanegativeprognosticfactorforposteriorsurgeryaloneCTwithsagittalandcoronalreformattinghasemergedasthebenchmarkforradiographicevaluationofOPLLandisnecessarytoreliablycharacterizeitGreaterthan60%canaloccupancyatanylevelandalaterallydeviatedmassareassociatedwithhighratesofmyelopathyThis“doublelayersign”onaxialorsagittalCTimagesisassociatedwithduraltearrates50%withanteriordecompressionversus13%whenthesignisabsentNonsurgicalManagementProphylacticsurgeryisneithernecessarynorrecommendedManagementincludestemporaryimmobilizationwithaneckbrace,steroidalornonsteroidalanti-inflammatorymedications,activitymodification,andphysicaltherapypatientsshouldbeadvisedtoavoidactivitiesthatmayresultinsuddenorexcessivecervicalspinemotionbecauseOPLLisassociatedwithahighrateofacutespinalcordinjury,eveninpatientswhodonotmeetsurgicalcriteriaSurgicalTreatmentSurgicaldecompressionisthetreatmentofchoiceforpatientswithNurickgrade3or4myelopathyorsevereradiculopathycausedbyOPLLviaeitherananteriororposteriorapproachAnteriorDecompressionandFusionProponentsarguethatitallowsforasuperiordecompressionandismoreeffectiveatmaintainingorrestoringcervicallordosisthanisposteriorsurgery.Associatedanteriorpathology,suchasdiskherniations,canalsobeaddressedDisadvantagesincludetechnicaldifficulty,inabilitytodecompresscranialtoC2,andhighratesofpseudarthrosisanddysphagiawhenthreeormorelevelsrequiretreatmentDuraltearsarealsomuchmorecommonwithananteriorapproach,giventhatanteriorduralossificationoccursin