使用超声和常规截骨术去除黄韧带胸骨化（TOLF） 的椎板切除术
Summary
我们提出了一种使用超声截骨术结合传统截骨术进行黄韧带胸骨化椎板切除术的方法。这是一种相对安全且易于学习的方法，可避免与传统方法相关的围手术期并发症。
Abstract
胸部黄韧带骨化 （TOLF） 是进行性胸廓脊髓病的常见病因。TOLF通常通过手术减压治疗。各种手术技术，包括椎板成形术、椎板切除术和椎板开窗术，用于有效治疗 TOLF。然而，传统方法与围手术期并发症的高风险相关，包括硬脑膜撕裂伤和/或医源性脊髓损伤。因此，开发一种高效安全的TOLF手术技术非常重要。在此，我们描述了一种使用超声截骨术结合常规截骨术在胸椎上进行椎板切除术的方法。这种技术可以减少术中并发症。这是一种相对安全且易于学习的方法，应推荐用于治疗 TOLF。
Introduction
胸部黄韧带骨化（TOLF）是胸椎管狭窄的主要原因之一，已被确定为胸廓脊髓病的主要原因1，2，3。TOLF的特征是通过异位新骨形成取代黄韧带。TOLF的发病率在日本高达36%，在中国高达63.9%。大多数患者进展缓慢，为有症状的胸管狭窄或胸廓脊髓病4.减压是TOLF出现症状后唯一有效的治疗方法，因为保守治疗通常无效5。
椎板成形术、椎板切除术和椎板开窗术是三种已被证明对 TOLF6，7，8 有效的手术技术。然而，手术结果并不总是令人满意的。常规方法可导致围手术期并发症的高发生率，例如硬脑膜撕裂伤和/或医源性脊髓损伤9，10。因此，开发一种更有效、更安全的 TOLF 手术技术非常重要。
在这里，我们详细描述了一种使用超声截骨术结合常规截骨术切除椎板的胸椎板切除术的方法（图1）。超声波截骨机是一种精密工具，它利用叶片中的超声波振荡选择性地切割矿化组织，防止侧支组织损伤11.本文提出的技术是一种相对安全且易于学习的方法，应推荐用于治疗TOLF。
超声波截骨系统旨在通过将电输入信号转换为振幅为 0-120 μm 和频率为 39 kHz 的垂直机械振荡，有效地切割硬骨结构，同时保护软组织。该系统由一个动力单元、一个手机、几个尖端和一个脚踏开关组成。灌溉泵也集成到系统中，将盐水输送到切削刃，以减少局部热坏死。
本文介绍的是一例 57 岁男性患者，该患者表现为下肢无力，行走不稳 3 年。右侧的症状更为明显。体格检查显示，患者双下肢肌力12 级为5级（几乎察觉不到肌无力）。此外，在左腹股沟平面下方应用针灸时发生皮肤麻木，在鞍区针刺皮肤时观察到感觉减退，双下肢深部腱反射略有增加，Babinski征13 为阳性。X 线、CT 和 MRI 显示 T10-11 处黄韧带胸骨化。术前数据如图 2所示。
Protocol
获得了提交人所在医院医学伦理委员会的伦理批准。从每位患者获得知情同意。 1. 纳入/排除标准和术前准备 包括术前症状：无法稳定行走、下肢麻木、下肢萎缩、腿部无力、下肢运动不受控制或括约肌功能障碍等，以及符合胸脊髓病的体征和影像学数据。 根据以下标准排除患者：是否存在颈椎管狭窄或腰椎管狭窄（通过 MRI 确认）、胸椎间盘突?…
Representative Results
代表性案例结果术后第一天，CT扫描显示骨化已完全切除，脊髓已完全减压（图5）。病人可以稳定地行走。下肢双肌力量为5.患者在手术后3天出院。 共有71名患者参加了这项研究。所有手术都令人满意地进行。手术的平均持续时间为126分钟±32分钟。平均失血量为98毫升±31毫升。住院时间为7.1天±1.4天。平均随访时间为12.4个月±2.1个月（<st…
Discussion
椎板切除术是胸部黄韧带骨化韧带的常规治疗方法。然而，传统切骨设备使用不当，如高速钻头和旋转毛刺，可导致神经热损伤，抓软组织，硬脑膜撕裂，机械损伤15，16，17。超声波截骨术是一种用于精确截骨术的新型骨切割工具。该装置允许沿着狭窄的切割刀片进行骨解剖，该切割刀片以高频率纵向振动。由于超声波刀片的…
Disclosures
The authors have nothing to disclose.
Acknowledgements
资金由浙江省医疗卫生科技项目（项目编号：2021433841和2023564481）提供。
Materials
| C-arm X-ray machine | GE | 20192060063 | / |
| Cera styptica | Johnson&Johnson (China) Medical Equipment Co., Ltd | W810T | / |
| Conventional osteotome | Suzhou qingniu medical instrument co. | 10012.01 | / |
| Cottonoids | Piaoan Holding Group Co., Ltd | 20182640073 | / |
| Fluid gelatin | Johnson&Johnson (China) Medical Equipment Co., Ltd | 20183142459 | / |
| Gelatin sponge | B.Braun Melsungen AG | 20163642299 | / |
| Jackson–Pratt drainage | Suzhou Weikang Medical Equipment Co., Ltd | 20162140955 | / |
| Kerrison Rongeurs | Jinzhong Medical Instruments Co., Ltd | 2100888 | / |
| Nerve dissector | Jinzhong Medical Instruments Co., Ltd | p23110 | / |
| Pedicle screw | Medtronic | 76446545 | / |
| Towel clamps | KEWEIDUN | 10058468134417 | / |
| Ultrasonic Osteotomy Surgical System | SMTP Technology Co. | FD880A | / |
| Unipolar/bipolar electrotome | Shanghai Hutong Electronics Co., Ltd | 20143251899 | / |
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Cite This Article
Liu, J., Shan, Z., Chen, Y., Zhao, F. Laminectomy for the Removal of Thoracic Ossification of the Ligamentum Flavum (TOLF) Using Ultrasonic and Conventional Osteotomes. J. Vis. Exp. (194), e64339, doi:10.3791/64339 (2023).