经皮内窥镜下治疗胸椎管黄韧带骨化症1例

2019-06-05 贺毅 李星晨 周红刚 临床骨科杂志

患者,男,64岁,双下肢麻木无力不能行走1年余,于2016年4月8日入院。自诉“无诱因出现双下肢麻木无力,逐渐不能下床行走”。体格检查:颈部无明显不适,双上肢无明显麻木,三角肌、肱二头肌、肱三头肌、腕屈伸肌力5级,腱反射正常。T10,11水平棘突间隙压痛,双侧下肢踝关节阵挛,双侧屈髋肌力、股四头肌肌力、腘绳肌肌力、踝背伸及跖屈肌力均2级,肌张力高,双侧膝腱反射、跟腱反射均亢进。脐水平面以下感觉减退

临床资料

患者,男,64岁,双下肢麻木无力不能行走1年余,于2016年4月8日入院。自诉“无诱因出现双下肢麻木无力,逐渐不能下床行走”。体格检查:颈部无明显不适,双上肢无明显麻木,三角肌、肱二头肌、肱三头肌、腕屈伸肌力5级,腱反射正常。T10,11水平棘突间隙压痛,双侧下肢踝关节阵挛,双侧屈髋肌力、股四头肌肌力、腘绳肌肌力、踝背伸及跖屈肌力均2级,肌张力高,双侧膝腱反射、跟腱反射均亢进。脐水平面以下感觉减退,大便功能正常,小便费力。MRI显示T10,11后方黄韧带增厚,脊髓受压;CT显示T10,11后方黄韧带增厚钙化。考虑“胸椎管黄韧带骨化症”。患者入院后经科内讨论,拟行局部麻醉下经皮内窥镜后外侧入路椎板减压手术。征求患者本人及家属同意,并经医院伦理委员会批准。

按照经皮内窥镜的常规操作流程,C臂机定位确定穿刺间隙,棘突中线旁开6~8CM确定为穿刺点,穿刺方向平行于目标椎间隙,根据术前测定穿刺角度和穿刺深度,标定术中穿刺针的穿刺路径体表投影(见图1)。患者俯卧位,局麻下应用18号穿刺针沿标定的方向和角度穿刺至T10,11椎板边缘,放入导丝,置入绿色导杆(2mm),放入一级扩张管(3.5mm),然后将扩张管内的导杆换成同样长度和直径的克氏针,小锤钉入椎板,C臂机透视穿过一层骨皮质为宜。逐级扩张通道,将三级环锯(7.5mm)替换扩张管逐级环切椎板,以环锯头端锯齿过椎板最后一层皮质。C臂机定位见位置完好后再逐级取出环锯并将钙化骨质一并带出体内,钝性导杆轻轻探查通道,感觉探查处有弹性可知背侧骨质基本去除。同理逐级环切后,置入工作套管(7.5mm),镜下处理残余骨质和钙化黄韧带。术中见椎板下黄韧带均成黄色退变脆性组织,黄韧带与硬膜囊粘连较重,神经拉钩轻探两者间隙,钝性分离后45°髓核钳咬除韧带。镜下环切距离硬膜囊远处的骨质,并用动力磨钻充分扩大操作范围,射频刀头充分探查并止血后见硬膜囊随患者心跳波动。同法处理对侧。术毕切口不放置引流管。



术后给予脱水、神经营养药物,患者卧床休息24h后在医生指导下下床活动。术后24h双侧屈髋肌力、股四头肌肌力、腘绳肌肌力、踝背伸及跖屈肌力均恢复至3+级,双侧膝腱反射、跟腱反射均活跃,可自主直腿抬高,感觉平面未有明显变化,麻木症状减轻。术后CT及矢状位MRI显示T10,11椎板减压较为充分(见图2)。术后6个月随访,患者双侧屈髋肌力、股四头肌肌力、腘绳肌肌力、踝背伸及跖屈肌力均4-级,双侧膝腱反射、跟腱反射均活跃,可去除拐杖行走。术后1年随访,双侧屈髋肌力、股四头肌肌力、腘绳肌肌力、踝背伸及跖屈肌力均恢复至5级,双侧膝腱反射、跟腱反射均正常,下腹部及双下肢无疼痛及感觉异常,JOA评分为10分,RR值为83.3%,为优秀。

讨论

胸椎管容积小,储备空间有限,同时胸段脊髓很脆弱,能否应用椎间孔镜技术治疗胸椎管黄韧带骨化目前无可借鉴的经验。本例手术行胸椎椎板钻孔入路,术中不需剥离肌肉,在椎板制造一个7.5mm的骨道,不破坏小关节突,对脊柱稳定性无损伤。手术在局麻下完成,术中患者完全清醒,通过精确穿刺和逐级扩张置管,在内镜下应用镜下磨钻摘除骨化块,直视下脊髓完全松弛、充分减压。手术过程中不需牵拉神经根及硬膜,手术切口仅7mm。术后患者症状即刻缓解,疗效满意。

注意事项:术中损伤可能导致脊髓损伤加重,甚至造成不可逆损伤,因此在椎板制作骨道及置管时,动作要缓慢、轻柔,避免突然落空损伤脊髓,在此期间适时与患者沟通,密切观察患者下肢活动情况。内窥镜下视野范围有限,术者应熟悉镜下解剖位置,禁止未辨明解剖结构时盲目操作。摘除骨化块过程中因出血干扰视野,可调整水压及工作通道位置,同时使用射频止血,射频止血时应避免与硬膜囊直接接触而造成脊髓热损伤。如骨化块与硬脊膜粘连,可以应用镜下神经剥离器进行分离;不能分离的,用镜下磨钻将骨块游离,并打磨成较薄接近透明的骨块,使之不产生直接压迫。对于骨化块占据椎管容积超过2/3者,不建议行内窥镜手术,因硬脊膜无避让空间,易导致直接损伤及缺血再灌注损伤。

原始出处:

贺毅,李星晨,周红刚.经皮内窥镜下治疗胸椎管黄韧带骨化症1例[J].临床骨科杂志,2019,22(02):255-256.

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    2019-08-12 drwjr
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    2019-06-25 bioon1
  4. [GetPortalCommentsPageByObjectIdResponse(id=2023728, encodeId=308a2023e28ce, content=<a href='/topic/show?id=466b10323086' target=_blank style='color:#2F92EE;'>#黄韧带#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=103230, encryptionId=466b10323086, topicName=黄韧带)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=08e964, createdName=drwjr, createdTime=Mon Aug 12 06:48:00 CST 2019, time=2019-08-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2078480, encodeId=22f520e848032, content=<a href='/topic/show?id=fdd510162e2f' target=_blank style='color:#2F92EE;'>#骨化症#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=101627, encryptionId=fdd510162e2f, topicName=骨化症)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=fc0372, createdName=bnurmamat, createdTime=Thu Feb 27 00:48:00 CST 2020, time=2020-02-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1809913, encodeId=73dc1809913cd, content=<a href='/topic/show?id=27ee8412270' target=_blank style='color:#2F92EE;'>#胸椎管#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84122, encryptionId=27ee8412270, topicName=胸椎管)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=bioon1, createdTime=Tue Jun 25 20:48:00 CST 2019, time=2019-06-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1724262, encodeId=420e1e24262e9, content=<a href='/topic/show?id=71c1628e901' target=_blank style='color:#2F92EE;'>#椎管#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=62879, encryptionId=71c1628e901, topicName=椎管)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=7d4e33593434, createdName=caobinglei8090, createdTime=Sat Nov 23 01:48:00 CST 2019, time=2019-11-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1481559, encodeId=daa8148155980, content=<a href='/topic/show?id=0641304e995' target=_blank style='color:#2F92EE;'>#内窥镜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=30479, encryptionId=0641304e995, topicName=内窥镜)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=db497802700, createdName=紫砂壶, createdTime=Fri Jun 07 06:48:00 CST 2019, time=2019-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1489979, encodeId=a11714899e9c7, content=<a href='/topic/show?id=2d258411ea9' target=_blank style='color:#2F92EE;'>#胸椎#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84117, encryptionId=2d258411ea9, topicName=胸椎)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6d688662973, createdName=yyj065, createdTime=Fri Jun 07 06:48:00 CST 2019, time=2019-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1507429, encodeId=7699150e4297a, content=<a href='/topic/show?id=16b7100010c7' target=_blank style='color:#2F92EE;'>#韧带#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=100010, encryptionId=16b7100010c7, topicName=韧带)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d9b19890064, createdName=juliusluan81, createdTime=Fri Jun 07 06:48:00 CST 2019, time=2019-06-07, status=1, ipAttribution=)]
  5. [GetPortalCommentsPageByObjectIdResponse(id=2023728, encodeId=308a2023e28ce, content=<a href='/topic/show?id=466b10323086' target=_blank style='color:#2F92EE;'>#黄韧带#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=103230, encryptionId=466b10323086, topicName=黄韧带)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=08e964, createdName=drwjr, createdTime=Mon Aug 12 06:48:00 CST 2019, time=2019-08-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2078480, encodeId=22f520e848032, content=<a href='/topic/show?id=fdd510162e2f' target=_blank style='color:#2F92EE;'>#骨化症#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=101627, encryptionId=fdd510162e2f, topicName=骨化症)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=fc0372, createdName=bnurmamat, createdTime=Thu Feb 27 00:48:00 CST 2020, time=2020-02-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1809913, encodeId=73dc1809913cd, content=<a href='/topic/show?id=27ee8412270' target=_blank style='color:#2F92EE;'>#胸椎管#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84122, encryptionId=27ee8412270, topicName=胸椎管)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=bioon1, createdTime=Tue Jun 25 20:48:00 CST 2019, time=2019-06-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1724262, encodeId=420e1e24262e9, content=<a href='/topic/show?id=71c1628e901' target=_blank style='color:#2F92EE;'>#椎管#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=62879, encryptionId=71c1628e901, topicName=椎管)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=7d4e33593434, createdName=caobinglei8090, createdTime=Sat Nov 23 01:48:00 CST 2019, time=2019-11-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1481559, encodeId=daa8148155980, content=<a href='/topic/show?id=0641304e995' target=_blank style='color:#2F92EE;'>#内窥镜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=30479, encryptionId=0641304e995, topicName=内窥镜)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=db497802700, createdName=紫砂壶, createdTime=Fri Jun 07 06:48:00 CST 2019, time=2019-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1489979, encodeId=a11714899e9c7, content=<a href='/topic/show?id=2d258411ea9' target=_blank style='color:#2F92EE;'>#胸椎#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84117, encryptionId=2d258411ea9, topicName=胸椎)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6d688662973, createdName=yyj065, createdTime=Fri Jun 07 06:48:00 CST 2019, time=2019-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1507429, encodeId=7699150e4297a, content=<a href='/topic/show?id=16b7100010c7' target=_blank style='color:#2F92EE;'>#韧带#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=100010, encryptionId=16b7100010c7, topicName=韧带)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d9b19890064, createdName=juliusluan81, createdTime=Fri Jun 07 06:48:00 CST 2019, time=2019-06-07, status=1, ipAttribution=)]
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    2019-06-07 yyj065
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