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[摘要]目的探討胸椎黄韧带骨化（TOLF）所致的胸椎管狭窄症（TSS）脊髓MRI T2加权像上信号改变与手术预后的相关性。方法选取手术治疗的TOLF病人69例，所有病人术前均行胸椎CT检查证实为TOLF所致的TSS，术前均行胸椎MRI检查明确脊髓信号情况。根据MRI所示髓内信号情况进行分组，脊髓内信号正常者44例（A组），脊髓内信号出现改变者25例（B组）。所有病人均行后入路胸椎椎管减压内固定术，分别于术前、术后3个月及末次随访行日本骨科学会（JOA）评分及下肢肌力评定，计算JOA评分改善率及肌力改善情况并进行比较。结果B组术前、术后3个月及末次随访JOA评分均低于同时期A组，各随访时间JOA评分改善率低于A组，差异有统计学意义（t=3.459～4.357，P<0.01）。两组组内比较，JOA评分术后3个月较术前、末次随访较术后3个月均有改善，差异有统计学意义（F=114.473、34.983，P<0.01）。两组术后3个月、末次随访肌力分级与术前比较，差异均有显著性（χ2=55.280、15.055，P<0.05）。结论术前存在脊髓MRI T2加权信号改变的TOLF病人，手术治疗后效果明显，但是手术效果劣于术前脊髓信号正常TOLF病人。
[关键词]胸椎;椎管狭窄;黄韧带;核磁共振成像;脊髓损伤;疗效比较研究
[ABSTRACT]ObjectiveTo investigate the association of signal changes on the MRI T2`-weighted image of the spinal cord with surgical outcome in patients with thoracic spinal stenosis （TSS） caused by thoracic ossification of the ligamentum flavum （TOLF）. MethodsA total of 69 patients with TOLF who underwent surgical treatment were enrolled. All patients underwent thoracic spinal CT before surgery to confirm TSS caused by TOLF. Thoracic spinal MRI was performed before surgery to observe the signals of the spinal cord. According to the intraspinal signals on MRI， the patients were divided into group A （44 patients with normal intraspinal signals） and group B （25 patients with changes in intraspinal signals）. All patients underwent thoracic spinal decompression and internal fixation via the posterior approach. The Japanese Orthopedic Association （JOA） score and muscle strength of the lower limbs were evaluated before surgery and at 3 months after the surgery， the improvement rate of JOA score and the improvement in muscle strength were calculated and compared between groups. ResultsCompared with group A， group B had a significantly lower JOA score before surgery， at 3 months after surgery， and at the last follow`-up， as well as a significantly lower improvement rate of JOA score at each follow`-up （t=3.459-4.357，P<0.01）. Both groups had a significant improvement in JOA score from before surgery to 3 months after surgery and from 3 months after surgery to the last follow`-up （F=114.473，34.983;P<0.01）. Both groups had a significant change in muscle strength at 3 months after surgery and at the last follow`-up （χ2=55.280，15.055;P<0.05）. ConclusionPatients with TOLF who have changes in spinal cord signals on T2`-weighted MRI before surgery tend to have a good outcome after surgery， but their surgical outcomes are poorer than patients with normal spinal signals before surgery. [7]FUKUI M， CHIBA K， KAWAKAMI M， et al. Japanese orthopaedic association back pain evaluation questionnaire. part 2. verification of its reliability： the subcommittee on low back pain and cervical myelopathy evaluation of the clinical outcome committee of the Japanese orthopaedic association[J]. Journal of Orthopaedic Science， 2007，12（6）：526`-532.
[8]TAKENAKA S， KAITO T， HOSONO N， et al. Neurological manifestations of thoracic myelopathy[J]. Archives of Orthopaedic and Trauma Surgery， 2014，134（7）：903`-912.
[9]LIAO C C， CHEN T Y， JUNG S M， et al. Surgical expe`-rience with symptomatic thoracic ossification of the ligamentum flavum[J]. Journal of Neurosurgery`-Spine， 2005，2（1）：34`-39.
[10]SUN Jingcheng， ZHANG Chao， NING Guangzhi， et al. Surgical strategies for ossified ligamentum flavum associated with dural ossification in thoracic spinal stenosis[J]. Journal of Cli`-nical Neuroscience， 2014，21（12）：2102`-2106.
[11]ANDO K， IMAGAMA S， KOBAYASHI K， et al. Comparative study of surgical treatment and nonsurgical follow up for thoracic ossification of the posterior longitudinal ligament： radiological and clinical evaluation[J]. Spine， 2017，42（6）：407`-410.
[12]吳德鹏，裴磊，袁伟，等. 胸椎黄韧带骨化症的临床特点及手术治疗[J]. 中华骨与关节外科杂志， 2018，11（1）：30`-34.
[13]KATO S， NOURI A， REIHANI`-KERMANI H， et al. Postoperative resolution of magnetic resonance imaging signal intensity changes and the associated impact on outcomes in degenerative cervical myelopathy analysis of a global cohort of patients[J]. Spine， 2018，43（12）：824`-831.
[14]魏磊鑫，田野，华东方，等. 多节段脊髓型颈椎病伴髓内MRI T2WI高信号改变患者的手术入路选择及疗效分析[J]. 中国脊柱脊髓杂志， 2016，26（2）：101`-107.
[15]刘晓光. 胸椎管狭窄症患者MRI髓内高信号的原因及对预后的影响[J]. 中国脊柱脊髓杂志， 2014，24（7）：581`-582.
[16]YONE K， SAKOU T， YANASE M， et al. Preoperative and postoperative magnetic resonance image evaluations of the spinal cord in cervical myelopathy[J]. Spine， 1992，17（10 Suppl）： S388`-S392.
2期王德训，等. 黄韧带骨化所致胸椎管狭窄症脊髓MRI信号改变与手术效果关系163
[17]NOURI A， MARTIN A R， MIKULIS D， et al. Magnetic re`-sonance imaging assessment of degenerative cervical myelopathy： a review of structural changes and measurement techniques[J]. Neurosurgical Focus， 2016，40（6）： E5.
[18]ALAFIFI T， KERN R， FEHLINGS M. Clinical and MRI predictors of outcome after surgical intervention for cervical spondylotic myelopathy[J]. Journal of Neuroimaging， 2007，17（4）：315`-322.
[19]SHIOKAWA K， HANAKITA J， SUWA H， et al. Clinical analysis and prognostic study of ossified ligamentum flavum of the thoracic spine[J]. Journal of Neurosurgery， 2001，94（2， S）：221`-226. [20]王林峰. 胸椎管狭窄症脊髓高信号的基础研究与临床预后分析[D]. 石家庄：河北医科大学， 2014.
[21]贾宁阳. 脊髓损伤的病理变化及其与磁共振成像演变[J]. 中国矫形外科杂志， 1998，6（3）：63`-64.
[22]李凤宁，张帆，何平，等. MRI T2加权像伴有髓内高信号的轻度脊髓型颈椎病的治疗[J]. 脊柱外科杂志， 2014，12（3）：156`-160.
[23]刘晓明，张锐光，李小强. 胸椎管狭窄症后路手术疗效及相关影响因素分析[J]. 临床医药文献杂志， 2018，5（62）：16.
[24]KUH S U， KIM Y S， CHO Y E， et al. Contributing factors affecting the prognosis surgical outcome for thoracic OLF[J]. European Spine Journal， 2006，15（4）：485`-491.
[25]HE S S， HUSSAIN N， LI S H， et al. Clinical and prognostic analysis of ossified ligamentum flavum in a Chinese population[J]. Journal of Neurosurgery`-Spine， 2005，3（5）：348`-354.
[26]张健，贾连顺，陈雄生，等. 颈脊髓信号改变对颈椎后纵韧带骨化手术疗效的影响[J]. 中国矫形外科杂志， 2017，25（17）：1541`-1545.
[27]贺宝荣，许正伟，郝定均，等. 胸椎黄韧带骨化症患者髓内MRI高信号与手术疗效的关系[J]. 中国脊柱脊髓杂志， 2014，24（10）：928`-932.
[28]曲景文，马清田，张希诺，等. 脊髓型颈椎病减压术后早期脊髓MRI T2WI信号改变对临床疗效的影响[J]. 中国骨与关节杂志， 2018，7（10）：744`-749.
[29]WANG Linfeng， LIU Fajing， ZHANG Yingze， et al. Clinical results and intramedullary signal changes of posterior decompression with transforaminal interbody fusion for thoracic myelopathy caused by combined ossification of the posterior longitudinal ligament and ligamentum flavum[J]. Chinese Medical Journal， 2013，126（20）：3822`-3827.
[30]刘法敬，丁晓坤，曹俊明，等. 胸椎管狭窄程度与脊髓内高信号及临床症状的相关性研究[J]. 现代中西医结合杂志， 2014，23（33）：3664`-3666.
[31]董健. 胸椎管狹窄症术后疗效与脊髓MRI T2WI高信号的关系[J]. 中国脊柱脊髓杂志， 2014，24（7）：582`-583.
[32]冯法博，孙垂国，陈仲强，等. “揭盖式”胸椎管后壁切除术治疗单节段胸椎黄韧带骨化症的疗效及其影响因素[J]. 中国脊柱脊髓杂志， 2014，24（7）：585`-592.
[关键词]胸椎;椎管狭窄;黄韧带;核磁共振成像;脊髓损伤;疗效比较研究
[ABSTRACT]ObjectiveTo investigate the association of signal changes on the MRI T2`-weighted image of the spinal cord with surgical outcome in patients with thoracic spinal stenosis （TSS） caused by thoracic ossification of the ligamentum flavum （TOLF）. MethodsA total of 69 patients with TOLF who underwent surgical treatment were enrolled. All patients underwent thoracic spinal CT before surgery to confirm TSS caused by TOLF. Thoracic spinal MRI was performed before surgery to observe the signals of the spinal cord. According to the intraspinal signals on MRI， the patients were divided into group A （44 patients with normal intraspinal signals） and group B （25 patients with changes in intraspinal signals）. All patients underwent thoracic spinal decompression and internal fixation via the posterior approach. The Japanese Orthopedic Association （JOA） score and muscle strength of the lower limbs were evaluated before surgery and at 3 months after the surgery， the improvement rate of JOA score and the improvement in muscle strength were calculated and compared between groups. ResultsCompared with group A， group B had a significantly lower JOA score before surgery， at 3 months after surgery， and at the last follow`-up， as well as a significantly lower improvement rate of JOA score at each follow`-up （t=3.459-4.357，P<0.01）. Both groups had a significant improvement in JOA score from before surgery to 3 months after surgery and from 3 months after surgery to the last follow`-up （F=114.473，34.983;P<0.01）. Both groups had a significant change in muscle strength at 3 months after surgery and at the last follow`-up （χ2=55.280，15.055;P<0.05）. ConclusionPatients with TOLF who have changes in spinal cord signals on T2`-weighted MRI before surgery tend to have a good outcome after surgery， but their surgical outcomes are poorer than patients with normal spinal signals before surgery. [7]FUKUI M， CHIBA K， KAWAKAMI M， et al. Japanese orthopaedic association back pain evaluation questionnaire. part 2. verification of its reliability： the subcommittee on low back pain and cervical myelopathy evaluation of the clinical outcome committee of the Japanese orthopaedic association[J]. Journal of Orthopaedic Science， 2007，12（6）：526`-532.
[8]TAKENAKA S， KAITO T， HOSONO N， et al. Neurological manifestations of thoracic myelopathy[J]. Archives of Orthopaedic and Trauma Surgery， 2014，134（7）：903`-912.
[9]LIAO C C， CHEN T Y， JUNG S M， et al. Surgical expe`-rience with symptomatic thoracic ossification of the ligamentum flavum[J]. Journal of Neurosurgery`-Spine， 2005，2（1）：34`-39.
[10]SUN Jingcheng， ZHANG Chao， NING Guangzhi， et al. Surgical strategies for ossified ligamentum flavum associated with dural ossification in thoracic spinal stenosis[J]. Journal of Cli`-nical Neuroscience， 2014，21（12）：2102`-2106.
[11]ANDO K， IMAGAMA S， KOBAYASHI K， et al. Comparative study of surgical treatment and nonsurgical follow up for thoracic ossification of the posterior longitudinal ligament： radiological and clinical evaluation[J]. Spine， 2017，42（6）：407`-410.
[12]吳德鹏，裴磊，袁伟，等. 胸椎黄韧带骨化症的临床特点及手术治疗[J]. 中华骨与关节外科杂志， 2018，11（1）：30`-34.
[13]KATO S， NOURI A， REIHANI`-KERMANI H， et al. Postoperative resolution of magnetic resonance imaging signal intensity changes and the associated impact on outcomes in degenerative cervical myelopathy analysis of a global cohort of patients[J]. Spine， 2018，43（12）：824`-831.
[14]魏磊鑫，田野，华东方，等. 多节段脊髓型颈椎病伴髓内MRI T2WI高信号改变患者的手术入路选择及疗效分析[J]. 中国脊柱脊髓杂志， 2016，26（2）：101`-107.
[15]刘晓光. 胸椎管狭窄症患者MRI髓内高信号的原因及对预后的影响[J]. 中国脊柱脊髓杂志， 2014，24（7）：581`-582.
[16]YONE K， SAKOU T， YANASE M， et al. Preoperative and postoperative magnetic resonance image evaluations of the spinal cord in cervical myelopathy[J]. Spine， 1992，17（10 Suppl）： S388`-S392.
2期王德训，等. 黄韧带骨化所致胸椎管狭窄症脊髓MRI信号改变与手术效果关系163
[17]NOURI A， MARTIN A R， MIKULIS D， et al. Magnetic re`-sonance imaging assessment of degenerative cervical myelopathy： a review of structural changes and measurement techniques[J]. Neurosurgical Focus， 2016，40（6）： E5.
[18]ALAFIFI T， KERN R， FEHLINGS M. Clinical and MRI predictors of outcome after surgical intervention for cervical spondylotic myelopathy[J]. Journal of Neuroimaging， 2007，17（4）：315`-322.
[19]SHIOKAWA K， HANAKITA J， SUWA H， et al. Clinical analysis and prognostic study of ossified ligamentum flavum of the thoracic spine[J]. Journal of Neurosurgery， 2001，94（2， S）：221`-226. [20]王林峰. 胸椎管狭窄症脊髓高信号的基础研究与临床预后分析[D]. 石家庄：河北医科大学， 2014.
[21]贾宁阳. 脊髓损伤的病理变化及其与磁共振成像演变[J]. 中国矫形外科杂志， 1998，6（3）：63`-64.
[22]李凤宁，张帆，何平，等. MRI T2加权像伴有髓内高信号的轻度脊髓型颈椎病的治疗[J]. 脊柱外科杂志， 2014，12（3）：156`-160.
[23]刘晓明，张锐光，李小强. 胸椎管狭窄症后路手术疗效及相关影响因素分析[J]. 临床医药文献杂志， 2018，5（62）：16.
[24]KUH S U， KIM Y S， CHO Y E， et al. Contributing factors affecting the prognosis surgical outcome for thoracic OLF[J]. European Spine Journal， 2006，15（4）：485`-491.
[25]HE S S， HUSSAIN N， LI S H， et al. Clinical and prognostic analysis of ossified ligamentum flavum in a Chinese population[J]. Journal of Neurosurgery`-Spine， 2005，3（5）：348`-354.
[26]张健，贾连顺，陈雄生，等. 颈脊髓信号改变对颈椎后纵韧带骨化手术疗效的影响[J]. 中国矫形外科杂志， 2017，25（17）：1541`-1545.
[27]贺宝荣，许正伟，郝定均，等. 胸椎黄韧带骨化症患者髓内MRI高信号与手术疗效的关系[J]. 中国脊柱脊髓杂志， 2014，24（10）：928`-932.
[28]曲景文，马清田，张希诺，等. 脊髓型颈椎病减压术后早期脊髓MRI T2WI信号改变对临床疗效的影响[J]. 中国骨与关节杂志， 2018，7（10）：744`-749.
[29]WANG Linfeng， LIU Fajing， ZHANG Yingze， et al. Clinical results and intramedullary signal changes of posterior decompression with transforaminal interbody fusion for thoracic myelopathy caused by combined ossification of the posterior longitudinal ligament and ligamentum flavum[J]. Chinese Medical Journal， 2013，126（20）：3822`-3827.
[30]刘法敬，丁晓坤，曹俊明，等. 胸椎管狭窄程度与脊髓内高信号及临床症状的相关性研究[J]. 现代中西医结合杂志， 2014，23（33）：3664`-3666.
[31]董健. 胸椎管狹窄症术后疗效与脊髓MRI T2WI高信号的关系[J]. 中国脊柱脊髓杂志， 2014，24（7）：582`-583.
[32]冯法博，孙垂国，陈仲强，等. “揭盖式”胸椎管后壁切除术治疗单节段胸椎黄韧带骨化症的疗效及其影响因素[J]. 中国脊柱脊髓杂志， 2014，24（7）：585`-592.