Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India.
Br J Neurosurg. 2020 Dec;34(6):638-646. doi: 10.1080/02688697.2019.1670333. Epub 2019 Oct 3.
Ossification of ligamentum flavum (OLF) is an infrequent cause of thoracic spinal stenosis, mostly found in Japan and other East Asian countries, and uncommon in other populations. The incidence of dural ossification (DO) ranges from 11-62%. None of the previously described imaging findings can accurately diagnose DO preoperatively. Author reports outcomes of 15 cases of thoracic OLF from an Indian tertiary center, propose a new MRI finding to preoperatively diagnose DO and compare the various differences between subjects with and without DO. Three and half year retrospective analysis. Demographic, clinico-radiological and operative details, and outcome were analyzed. Correlation between new MRI finding and intraoperative DO was also noted. Fifteen patients (10 males, 5 females) with mean age of 51.3 years were analyzed. Ten (66.6%) cases had DO and the new MRI finding (T2 ring sign) had high correlation with intraoperative DO (sensitivity of 90%, specificity of 100%). The T2 hypointense rim corresponds to the calcified/ossified dura present around the thecal sac. Important clinico-radiological differences were observed in patients with and without DO. Canal diameter was uniformly <5 mm in Nurick grade V cases and <9 mm in those with DO. Mean follow-up duration was 19.5 months (range 4-45 months). All, except one, had significant symptomatic improvement, however, only two patients with DO attained Nurick grade I, perhaps because of the poor preoperative Nurick grade in those patients. Decompressive laminectomy (till the normal interlaminar space caudally and cranially) with complete removal of flavum including ossified dura, if possible, is the ideal treatment. Even after significant improvement, patients with DO may have mild residual myelopathy. Presence of DO, CSF leak and myelomalacia are neither related to wound problems nor clinical improvement. Higher preoperative Nurick grade was consistently associated with good clinical recovery. T2 ring sign is of benefit to surgeons in preoperative diagnosis of DO.
黄韧带骨化(OLF)是胸椎管狭窄的不常见原因,主要见于日本和其他东亚国家,在其他人群中少见。硬脊膜骨化(DO)的发生率为 11-62%。以前描述的影像学发现均不能准确术前诊断 DO。作者报告了来自印度一家三级中心的 15 例胸段 OLF 病例的结果,提出了一种新的 MRI 发现来术前诊断 DO,并比较了有和无 DO 的患者之间的各种差异。这是一项为期 3.5 年的回顾性分析。分析了人口统计学、临床-放射学和手术细节以及结果。还注意到新的 MRI 发现与术中 DO 的相关性。共分析了 15 名(10 名男性,5 名女性)平均年龄为 51.3 岁的患者。其中 10 例(66.6%)有 DO,新的 MRI 发现(T2 环征)与术中 DO 高度相关(灵敏度为 90%,特异性为 100%)。T2 低信号环对应于围绕硬脊膜的钙化/骨化硬脊膜。有和无 DO 的患者在临床-放射学方面存在重要差异。Nurick 分级 V 病例的椎管直径均<5mm,有 DO 的病例的椎管直径均<9mm。平均随访时间为 19.5 个月(4-45 个月)。除 1 例外,所有患者均有明显的症状改善,但仅有 2 例有 DO 的患者达到了 Nurick 分级 I,这可能是因为这些患者术前的 Nurick 分级较差。减压椎板切除术(直到尾侧和头侧的正常椎板间隙),尽可能完全切除黄韧带,包括骨化硬脊膜,是理想的治疗方法。即使症状有明显改善,有 DO 的患者仍可能残留轻度的脊髓病。DO、CSF 漏和脊髓软化既与伤口问题无关,也与临床改善无关。较高的术前 Nurick 分级始终与良好的临床恢复相关。T2 环征有助于外科医生术前诊断 DO。