OPLL颈椎后纵韧带骨化教学文案课件.ppt

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1、OPLL颈椎后纵韧带骨化,OPLL颈椎后纵韧带骨化,OPLL颈椎后纵韧带骨化教学文案课件,OPLL颈椎后纵韧带骨化教学文案课件,OPLL颈椎后纵韧带骨化教学文案课件,Ossification of the posterior longitudinal ligament (OPLL) results from pathologic replacement of the PLL with lamellar bone, potentially causing spinal cord compression and neurologic deteriorationOPLL was first desc

2、ribed in Japanese patients and has classically been considered a cause of myelopathy in patients of East Asian origin,Ossification of the posterior,spondylosismyelopathyradiculopathystenosisdisc herniation,spondylosis,OPLL颈椎后纵韧带骨化教学文案课件,Among patients in Japan with cervical spine disorders, the inci

3、dence 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 ethnicity, with an estimated incidence rate of 0.1% to 1.7% among North Americans and Europeans,OPLL颈椎后纵韧带骨化教学文案课件,Pathoanatomy,The PLL runs along the

4、 dorsal surface of the C1 anterior arch and cervical vertebral bodies and consists of longitudinal fibers confluent with the tectorial membrane cranially and ending at the sacrum caudallyfunctionally,the PLL resists spine hyperflexion,PathoanatomyThe PLL runs along,Pathophysiology,The pathologic pro

5、cess leading to OPLL begins with chondroblast- 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 boneGenetics,local tissue characteristics,

6、 and associated medical comorbidities have all been implicated in this final common pathway,PathophysiologyThe pathologic,OPLL颈椎后纵韧带骨化教学文案课件,Medical comorbidities are also associated with the development of OPLLUp to 50% of Caucasian patients with OPLL also have diffuse idiopathic skeletal hyperosto

7、sisHypoparathyroidism,hypophosphatemic rickets,hyperinsulinemia, and obesity have been identified as risk factors,Medical comorbidities are also,Natural History,Patients with OPLL commonly present in their fifth and sixth decades,with men affected twice as often as women.Most patients have some neur

8、ologic symptoms at diagnosis, with 28% to 39% fulfilling diagnostic criteria for myelopathy,Natural HistoryPatients with O,OPLL颈椎后纵韧带骨化教学文案课件,In 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 whe

9、elchair- or bed-bound state,In patients with myelopathy, 6,Risk factors for the development of 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

10、 of levels affected by OPLL do not affect the prognosis,Risk factors for the developme,Clinical Presentation,Changes in gait or balance, loss of fine motor control, and upper extremity weakness,numbness, or paresthesias are suggestive of myelopathyEarly muscular fatigue or worsening symptoms at the

11、extremes of cervical motion are also concerning,Clinical PresentationChanges i,Patients with OPLL are at an increased risk of acute spinal cord injury with trauma,and rapid neurologic deterioration in association association with even a minor trauma or whiplash injury should raise concern for the de

12、velopment of central cord syndrome,Patients with OPLL are at an i,Physical Examination,Physical Examination,Radiologic Evaluation,Radiologic Evaluation,The lateral radiograph is also used to determine the relationship of the OPLL to the kyphosis line (K-line),which is drawn from the center of the ca

13、nal at C2 to the center of the canal at C7A large OPLL mass or loss of cervical lordosis causes the OPLL to protrude posterior to the K-line (referred to as K-line negative). This is a negative prognostic factor for posterior surgery alone,The lateral radiograph is also,OPLL颈椎后纵韧带骨化教学文案课件,CT with sa

14、gittal and coronal reformatting has emerged as the benchmark for radiographic evaluation of OPLL and is necessary to reliably characterize it,CT with sagittal and coronal r,Greater than 60% canal occupancy at any level and a laterally deviated mass are associated with high rates of myelopathyThis “d

15、ouble layer sign” on axial or sagittal CT images is associated with dural tear rates 50% with anterior decompression versus 13% when the sign is absent,OPLL颈椎后纵韧带骨化教学文案课件,OPLL颈椎后纵韧带骨化教学文案课件,Nonsurgical Management,Prophylactic surgery is neither necessary nor recommended Management includes temporary

16、 immobilization with a neck brace, steroidal or nonsteroidal anti-inflammatory medications, activity modification,and physical therapy,Nonsurgical ManagementProphyla,patients should be advised to avoid activities that may result in sudden or excessive cervical spine motion because OPLL is associated

17、 with a high rate of acute spinal cord injury, even in patients who do not meet surgical criteria,patients should be advised to,Surgical Treatment,Surgical decompression is the treatment of choice for patients with Nurick grade 3 or 4 myelopathy or severe radiculopathy caused by OPLL via either an a

18、nterior or posterior approach,Surgical TreatmentSurgical dec,Anterior Decompression and Fusion,Proponents argue that it allows for a superior decompression and is more effective at maintaining or restoring cervical lordosis than is posterior surgery. Associated anterior pathology, such as disk herni

19、ations,can also be addressed,Anterior Decompression and Fus,Disadvantages include technical 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, g

20、iven that anterior dural ossification occurs in 13% to 15%,Disadvantages include technica,Exposure is provided by the standard Smith-Robinson approach, and diskectomy, hemicorpectomy,or subtotal corpectomy sufficient to allow exposure of the underlying OPLL mass is performedCorpectomies of up to fiv

21、e levels have been performed with success,but removal of three or more contiguous levels is associated with increased complication and reoperation rates,Exposure is provided by the st,Complications occur as part of the approach (eg, dysphagia, dysphonia), the decompression (eg, C5 palsy, dural tears

22、), or the fusion (eg,graft subsidence, pseudarthrosis),Complications occur as part of,Nerve root palsies occur in 4% to 17% of patients through either direct trauma or traction.Patients present with weakness, numbness,pain, or paresthesias, most commonly in the C5 distribution,Nerve root palsies occ

23、ur in 4%,Dural tears occur in 4% to 20% of patients, often because of dural ossification or attenuation.Cerebrospinal fluid leakage may result in pseudomeningocele or fistula formation, leading to neural damage, airway compression,meningitis, or wound complications,Dural tears occur in 4% to 20%,Tea

24、rs recognized intraoperatively are treated by direct repair 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, diverting lumbar drains an

25、d bed rest can be used,Tears recognized intraoperativ,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 thinning, but not removal, of the OPLL. The posterior vertebral body i

26、s 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 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 patie

27、nts were left with an inadequate decompression. In these patients,or with OPLL progression, the authors recommended subsequent posterior decompression.,In an effort to reduce dural t,When addressing more than two or three levels, fibular strut grafts are preferred for their structural support. For o

28、ne or two levels, structural 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 pseudarthrosis vary from 3% to 15%, with the highest rates occurr

29、ing in patients undergoing fusion of three or more levels.,When addressing more than two,OPLL颈椎后纵韧带骨化教学文案课件,OPLL颈椎后纵韧带骨化教学文案课件,OPLL颈椎后纵韧带骨化教学文案课件,OPLL颈椎后纵韧带骨化教学文案课件,OPLL颈椎后纵韧带骨化教学文案课件,Posterior Decompression,When more than two or three cervical levels are affected by OPLL, posterior surgery (ie, lam

30、inoplasty, 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 correct cervical kyphosis, and poor results in K-line negative patients.,Posterior DecompressionWhen mo,

31、Laminoplasty accomplishes this by hinging open the laminae with either an “open door” or “French door” technique, resulting in a 30% to 40% increase in the size of the spinal canalLaminectomy and fusion entails removal of the laminae followed by instrumented posterolateral fusion,resulting in a 70%

32、to 80% increase in canal volume,Laminoplasty accomplishes this,OPLL颈椎后纵韧带骨化教学文案课件,OPLL颈椎后纵韧带骨化教学文案课件,OPLL颈椎后纵韧带骨化教学文案课件,OPLL颈椎后纵韧带骨化教学文案课件,OPLL颈椎后纵韧带骨化教学文案课件,OPLL颈椎后纵韧带骨化教学文案课件,OPLL颈椎后纵韧带骨化教学文案课件,A full analysis of the advantages and disadvantages between laminoplasty compared with laminectomy and f

33、usion has been discussed elsewhereOur preference is to use laminectomy and fusion for OPLL because the retained cervical motion with laminoplasty may allow disease progression,and the risk for progression to kyphosis at the affected levels is eliminated with fusion,A full analysis of the advanta,For

34、 severe disease, recovery rates after posterior decompression appear to be lower than those following anterior decompression, but with a lower complication rate,For severe disease, recovery r,Iwasaki et al retrospectively compared the results of anterior decompression and fusion with those of lamino

35、plasty; they reported better outcomes after 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. With60% canal occupancy,recovery rates were equivalent.,Iwasaki et al retrospectively,A prospect

36、ive 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% involvementPatients with 5of cervical lordosis also had significantly worse outcomes from la

37、minoplasty, and 50% lost lordosis versus none in the fusion group.Half of the laminoplasty patients experienced OPLL progression versusonly one after anterior surgeryHowever, surgical complications heavily favored laminoplasty, with a 23% complication rate and a 14% reoperation rate in the anterior

38、group and none in the laminoplasty patients,A prospective comparison of an,Only one study to date has examined the results of laminectomy and fusion for OPLL.,Only one study to date has exa,Chen et al reported a mean recovery rate of 62% at 5 years among 83 patients who underwent instrumented lamine

39、ctomy and fusion from 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 rate was 4%, all the result of epidural hematoma formation. Whether poster

40、ior fusion had an effect on disease progression was not evaluated, although the authors noted no longterm decline in neurologic recovery, as is commonly seen in laminoplasty patients.,OPLL颈椎后纵韧带骨化教学文案课件,OPLL颈椎后纵韧带骨化教学文案课件,OPLL颈椎后纵韧带骨化教学文案课件,The most common complication of posterior surgery is low ce

41、rvical nerve root palsy, which occurs in 4% to 12% of patients.Injury may occur from direct trauma or from traction neurapraxia as the cord migrates posteriorlyComplications specific to laminoplasty include closure of the laminoplasty and fracture of the laminar hinge,whereas laminectomy and fusion

42、may be complicated by hardware failure, pseudarthrosis, or a post-laminectomy membrane,The most common complication o,Both procedures can be complicated by chronic pain, loss of lordosis, epidural hematoma, and progression of disease,Both procedures can be complic,Combined Anterior andPosterior Deco

43、mpression,When the disease 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 instrumentation may also be used to increase the stability of an anterior

44、 construct and promote fusion Finally, late posterior surgery may also be preferable to revision anterior surgery in the event of disease progression or pseudarthrosis,Combined Anterior andPosterio,OPLL颈椎后纵韧带骨化教学文案课件,OPLL颈椎后纵韧带骨化教学文案课件,OPLL颈椎后纵韧带骨化教学文案课件,Take Home Messages,Take Home Messages,Thank You !,Thank You !,此课件下载可自行编辑修改，仅供参考！感谢您的支持，我们努力做得更好！谢谢,此课件下载可自行编辑修改，仅供参考！感谢您的支持，我们努力,