今日の臨床サポート

後縦靱帯骨化症(頚椎および胸椎)

著者: 岩﨑幹季 大阪労災病院整形外科

監修: 酒井昭典 産業医科大学 整形外科学教室

著者校正/監修レビュー済:2020/02/05
参考ガイドライン:
  1. 日本整形外科学会日本脊椎脊髄病学会:頚椎後縦靱帯骨化症診療ガイドライン 2019
患者向け説明資料

概要・推奨   

  1. 臨床症状を認めない画像所見としての「後縦靱帯骨化」と神経症状を伴う「後縦靱帯骨化症」を区別する。
  1. 診断には、神経学的所見と画像所見との整合性が重要。
  1. 進行性あるいは明白な脊髄症状を認める場合は手術適応。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
岩﨑幹季 : 特に申告事項無し[2021年]
監修:酒井昭典 : 講演料(旭化成ファーマ(株),第一三共(株),中外製薬(株)),奨学(奨励)寄付など(旭化成ファーマ(株),第一三共(株),中外製薬(株))[2021年]

改訂のポイント:
  1. 最近発刊された「脊柱靱帯骨化症診療ガイドライン2019」 に基づき確認を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 脊柱靱帯には、椎体前面の前縦靱帯と椎体後面を縦走する後縦靱帯、脊柱管後壁の黄色靱帯がある。
 
頚椎の靱帯(頚椎側面像)

椎体前面を縦走するのが前縦靱帯、椎体後面を縦走するのが後縦靱帯である。

出典

 
頚椎の靱帯(頚椎横断像)

頚髄は脊柱管の中を通っており、その脊柱管前方の椎体後面に後縦靱帯がある。黄色靱帯は椎弓の間を左右に膜を張ったように存在し、脊柱管の後方にある。

出典

 
  1. 後縦靱帯骨化症は、椎体後面すなわち脊柱管前壁の脊柱靱帯の肥厚・骨化により、脊柱の可動性制限や脊髄などの神経組織が圧迫されて神経症状が出現した病態を指す。
  1. 後縦靱帯の骨化を画像上認めても、それによる臨床症状を認めない場合は「後縦靱帯骨化症」と呼ばず、「後縦靱帯骨化」として区別する[1]
  1. 後縦靱帯骨化は頚椎に好発するが、次いで胸椎、腰椎の順に認められる。
  1. 無症候性の後縦靱帯骨化も多く存在するが、臨床上問題となる症状は頚椎あるいは胸椎レベルでの圧迫性脊髄症である。
  1. 頚椎後縦靱帯骨化症は日本人に多く、圧迫性脊髄症の原因として多い疾患である。
  1. 頚椎後縦靱帯骨化症は、女性に比して男性に多く、発症年齢は中高年が多い[1]
  1. 頚椎後縦靱帯骨化症の原因は特定されていないが、患者兄弟の約30%に後縦靱帯骨化が認められたことや、一卵性双生児の兄弟では85%に頚椎後縦靱帯骨化が認められたこと、HLAハプロタイプ解析などから遺伝的な背景が関与している(遺伝様式は不明)[1]
  1. 胸椎後縦靱帯骨化症や全脊柱におよぶ重篤な骨化を示す症例は、女性に多い。
  1. 後縦靱帯骨化症は、指定難病であり、重症の場合などは申請し認定されると保険料の自己負担分の一部が公費負担として助成される。([平成27年1月施行])
  1.  難病法に基づく医療費助成制度 
問診・診察のポイント  
問診:
  1. 局所の疼痛が主訴なのか、手の使いにくさなど手指の巧緻運動障害や歩行障害が主訴なのかを確認する。特に歩行障害は、階段昇降での手すりの必要性や易転倒性の有無を聞き出す[2]。(図<図表>
  1. 頚椎後縦靱帯骨化症は、転倒などの外傷を契機に発症することがあるので、軽微な外傷や頚椎過伸展損傷の有無を尋ねる。

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文献 

著者: Shunji Matsunaga, Makoto Kukita, Kyoji Hayashi, Reiko Shinkura, Chihaya Koriyama, Takashi Sakou, Setsuro Komiya
雑誌名: J Neurosurg. 2002 Mar;96(2 Suppl):168-72.
Abstract/Text OBJECT: The goal of this study was to clarify the pathogenesis of myelopathy in patients with ossification of the posterior longitudinal ligament (OPLL) based on the relationship between static compression factors and dynamic factors.
METHODS: There was a total of 247 patients, including 167 patients who were conservatively followed for a mean of 11 years and 2 months and 80 patients who had myelopathy at initial consultation and underwent surgery. The changes in clinical symptoms associated with OPLL in the cervical spine were examined periodically. During the natural course of OPLL in the cervical spine, 37 (22%) of 167 patients developed or suffered aggravated spinal symptoms. All of the patients with a space available for the spinal cord (SAC) less than 6 mm suffered myelopathy, whereas the patients with an SAC diameter of 14 mm or greater did not. No correlation was found between the presence or absence of myelopathy in patients whose SAC diameter ranged from 6 mm to less than 14 mm. In patients with myelopathy whose minimal SAC diameter ranged from 6 mm to less than 14 mm, the range of motion of the cervical spine was significantly greater.
CONCLUSIONS: These results indicate that pathological compression by the ossified ligament above a certain critical point may be the most significant factor in inducing myelopathy, whereas below that point dynamic factors may be largely involved in inducing myelopathy.

PMID 12450279  J Neurosurg. 2002 Mar;96(2 Suppl):168-72.
著者: Shunji Matsunaga, Takashi Sakou, Kyoji Hayashi, Yasuhiro Ishidou, Masataka Hirotsu, Setsuro Komiya
雑誌名: J Neurosurg. 2002 Sep;97(2 Suppl):172-5.
Abstract/Text OBJECT: In these prospective and retrospective studies the authors evaluated trauma-induced myelopathy in patients with ossification of the posterior longitudinal ligament (OPLL) to determine the effectiveness of preventive surgery for this disease.
METHODS: The authors studied 552 patients with cervical OPLL, including 184 with myelopathy at the time of initial consultation and 368 patients without myelopathy at that time. In the former group of 184 patients retrospective analysis was performed using an interview survey to ascertain the relationship between onset of myelopathy and trauma. In the latter group of 368 patients prospective examination was conducted by assessing radiographic findings and noting changes in clinical symptoms apparent during regular physical examination. The follow-up period ranged from 10 to 32 years (mean 19.6 years). In the retrospective investigation, 24 patients (13%) identified cervical trauma as the trigger of their myelopathy. In the prospective investigation, 70% of patients did not develop myelopathy over a follow-up period greater than 20 years (determined using the Kaplan-Meier method). Of the 368 patients without myelopathy at the time of initial consultation, only six patients (2%) subsequently developed trauma-induced myelopathy. Types of ossification in patients who developed trauma-induced myelopathy were primarily a mixed type. All patients in whom stenosis affected 60% or greater of the spinal canal developed myelopathy regardless of a history of trauma.
CONCLUSIONS: Preventive surgery prior to onset of myelopathy is unnecessary in most patients with OPLL.

PMID 12296674  J Neurosurg. 2002 Sep;97(2 Suppl):172-5.
著者: Shunji Matsunaga, Takashi Sakou, Eiji Taketomi, Setsuro Komiya
雑誌名: J Neurosurg. 2004 Mar;100(3 Suppl Spine):245-8.
Abstract/Text OBJECT: Ossification of the posterior longitudinal ligament (OPLL) may produce quadriplegia. The course of future neurological deterioration in patients with radiographic evidence of OPLL, however, is not known. The authors conducted a long-term follow-up cohort study of more than 10 years to clarify the clinical course of this disease progression.
METHODS: A total of 450 patients, including 304 managed conservatively and 146 treated by surgery, were enrolled in the study. All patients underwent neurological and radiographical follow-up examinations for a mean of 17.6 years. Myelopathy was graded using Nurick classification and the Japanese Orthopaedic Association scale. Fifty-five (17%) of 323 patients without myelopathy evident at the first examination developed myelopathy during the follow-up period. Risk factors associated with the evolution of myelopathy included greater than 60% OPLL-induced stenotic compromise of the cervical canal, and increased range of motion of the cervical spine. Using Kaplan-Meier analysis, the myelopathy-free rate in patients without first-visit myelopathy was 71% after 30 years. A significant difference in final functional outcome was not observed between nonsurgical and surgical cases in which preoperative Nurick grades were 1 or 2. In patients with Nurick Grade 3 or 4 myelopathy, however, only 12% who underwent surgery eventually became wheelchair bound or bedridden compared with 89% of those managed conservatively. Surgery proved ineffective in the management of patients with Grade 5 disease.
CONCLUSIONS: Results of this long-term cohort study elucidated the clinical course of OPLL following conservative or surgical management. Surgery proved effective for the management of patients with Nurick Grades 3 and 4 myelopathy.

PMID 15029912  J Neurosurg. 2004 Mar;100(3 Suppl Spine):245-8.
著者: Motoki Iwasaki, Yoshiharu Kawaguchi, Tomoatsu Kimura, Kazuo Yonenobu
雑誌名: J Neurosurg. 2002 Mar;96(2 Suppl):180-9.
Abstract/Text OBJECT: The authors report the long-term (more than 10-year) results of cervical laminoplasty for ossification of the posterior longitudinal ligament (OPLL) of the cervical spine as well as the factors affecting long-term postoperative course.
METHODS: The authors reviewed data obtained in 92 patients who underwent cervical laminoplasty between 1982 and 1990. Three patients were lost to follow up, 25 patients died within 10 years of surgery, and 64 patients were followed for more than 10 years. Results were assessed using the Japanese Orthopaedic Association (JOA) scoring system for cervical myelopathy. The recovery rate was calculated using the Hirabayashi method. The mean neurological recovery rate during the first 10 years after surgery was 64%, which declined to 60% at the last follow-up examination (mean follow up 12.2 years). Late neurological deterioration occurred in eight patients (14%) from 5 to 15 years after surgery. The most frequent causes of late deterioration were degenerative lumbar disease (three patients), thoracic myelopathy secondary to ossification of the ligamentum flavum (two patients), or postoperative progression of OPLL at the operated level (two patients). Postoperative progression of the ossified lesion was noted in 70% of the patients, but only two patients (3%) were found to have related neurological deterioration. Additional cervical surgery was required in one patient (2%) because of neurological deterioration secondary to progression of the ossified ligament. The authors performed a multivariate stepwise analysis, and found that factors related to better clinical results were younger age at operation and less severe preexisting myelopathy. Younger age at operation, as well as mixed and continuous types of OPLL, was highly predictive of progression of OPLL. Postoperative progression of kyphotic deformity was observed in 8% of the patients, although it did not cause neurological deterioration.
CONCLUSIONS: When the incidence of surgery-related complications and the strong possibility of postoperative growth of OPLL are taken into consideration, the authors recommend expansive and extensive laminoplasty for OPLL.

PMID 12450281  J Neurosurg. 2002 Mar;96(2 Suppl):180-9.
著者: Motoki Iwasaki, Shin'ya Okuda, Akira Miyauchi, Hironobu Sakaura, Yoshihiro Mukai, Kazuo Yonenobu, Hideki Yoshikawa
雑誌名: Spine (Phila Pa 1976). 2007 Mar 15;32(6):647-53. doi: 10.1097/01.brs.0000257560.91147.86.
Abstract/Text STUDY DESIGN: Retrospective study of 66 patients who underwent laminoplasty for treatment of cervical myelopathy due to ossification of the posterior longitudinal ligament (OPLL).
OBJECTIVES: The present study describes surgical results of laminoplasty for treatment of cervical myelopathy due to OPLL and aims to clarify 1) factors predicting outcome and 2) limitations of laminoplasty.
SUMMARY OF BACKGROUND DATA: During the period 1986 and 1996, laminoplasty was the only surgical treatment selected for cervical myelopathy at our institutions.
METHODS: We reviewed data obtained in 66 patients who underwent laminoplasty for treatment of cervical myelopathy due to OPLL. Mean duration of follow-up was 10.2 years (range, 5-20 years). Surgical outcomes were assessed using the Japanese Orthopaedic Association (JOA) scoring system for cervical myelopathy.
RESULTS: Surgical outcome was significantly poorer in patients with occupying ratio greater than 60%. Multiple regression analysis showed that the most significant predictor of poor outcome after laminoplasty was hill-shaped ossification, followed by lower preoperative JOA score, postoperative change in cervical alignment, and older age at surgery.
CONCLUSIONS: Laminoplasty is effective and safe for most patients with occupying ratio of OPLL less than 60% and plateau-shaped ossification. However, neurologic outcome of laminoplasty for cervical OPLL was poor or fair in patients with occupying ratio greater than 60% and/or hill-shaped ossification.

PMID 17413469  Spine (Phila Pa 1976). 2007 Mar 15;32(6):647-53. doi: 1・・・
著者: Motoki Iwasaki, Shin'ya Okuda, Akira Miyauchi, Hironobu Sakaura, Yoshihiro Mukai, Kazuo Yonenobu, Hideki Yoshikawa
雑誌名: Spine (Phila Pa 1976). 2007 Mar 15;32(6):654-60. doi: 10.1097/01.brs.0000257566.91177.cb.
Abstract/Text STUDY DESIGN: Retrospective study of 27 patients who underwent anterior decompression and fusion (ADF) for treatment of cervical myelopathy due to ossification of the posterior longitudinal ligament (OPLL).
OBJECTIVES: To compare surgical outcome of ADF with that of laminoplasty.
SUMMARY OF BACKGROUND DATA: During the period 1986 and 1996, laminoplasty was the only surgical treatment selected for cervical myelopathy at our institutions. According to surgical results of laminoplasty performed during this period, we have performed either laminoplasty or ADF for patients with OPLL since 1996.
METHODS: We reviewed clinical data obtained in 27 patients who underwent ADF between 1996 and 2003. Mean duration of follow-up was 6.0 years (range, 2-10 years). Surgical outcomes were assessed using the Japanese Orthopedic Association (JOA) scoring system for cervical myelopathy. Surgical results of ADF were compared with those of laminoplasty, which was performed in 66 patients during the period 1986 and 1996.
RESULTS: ADF yielded a better neurologic outcome at final follow-up than laminoplasty in patients with occupying ratio > or =60%, although graft complications occurred in 15% and additional surgical intervention was required in 26%. Neither occupying ratio of OPLL, sagittal shape of ossification, nor cervical alignment was found to be related to surgical outcome of ADF.
CONCLUSIONS: Although ADF is technically demanding and has a higher incidence of surgery-related complications, it is preferable to laminoplasty for patients with occupying ratio of OPLL > or =60%.

PMID 17413470  Spine (Phila Pa 1976). 2007 Mar 15;32(6):654-60. doi: 1・・・
著者: T Matsuoka, I Yamaura, Y Kurosa, O Nakai, S Shindo, K Shinomiya
雑誌名: Spine (Phila Pa 1976). 2001 Feb 1;26(3):241-8.
Abstract/Text STUDY DESIGN: Results of the anterior floating method used to decompress ossification of the posterior longitudinal ligament were studied for an average postoperative interval of 13 years.
OBJECTIVE: To investigate the long-term results of the anterior floating method used to manage ossification of the posterior longitudinal ligament.
SUMMARY OF BACKGROUND DATA: The anterior floating method is a technique that differs from the extirpation method used to manage ossification of the posterior longitudinal ligament. Reports of the long-term results from anterior decompression used to manage cervical ossification of the posterior longitudinal ligament are rare.
METHODS: The anterior floating method was used to decompress cervical ossification of the posterior longitudinal ligament in 63 patients. These patients were followed for more than 10 years with neurologic evaluations using a scoring system proposed by the Japanese Orthopedic Association (JOA score).
RESULTS: The recovery rate was 66.5% at 10 years and 59.3% at 13 years, the time of the final survey. Operative outcomes most closely reflected the preoperative duration and severity of myelopathy (JOA score) and the preoperative cross-sectional area of the spinal cord. There was no correlation with the canal narrowing ratio or the thickness of ossification of the posterior longitudinal ligament. Delayed deterioration was attributed to an original inadequate decompression and progression of ossification of the posterior longitudinal ligament outside the original operative field. There was no evidence of significant recurrent ossification of the posterior longitudinal ligament within the margins of prior decompression.
CONCLUSIONS: The anterior floating method appears to yield adequate long-term outcomes when used to manage ossification of the posterior longitudinal ligament.

PMID 11224859  Spine (Phila Pa 1976). 2001 Feb 1;26(3):241-8.
著者: I Yamaura, Y Kurosa, T Matuoka, S Shindo
雑誌名: Clin Orthop Relat Res. 1999 Feb;(359):27-34.
Abstract/Text Ossification of the posterior longitudinal ligament lessens the sagittal diameter of the cervical canal and compresses the spinal cord anteriorly, and may produce severe disabling myelopathy. The anterior floating method is one of the anterior decompression and reconstructions used in the treatment of cervical myelopathy caused by ossification of the posterior longitudinal ligament. This procedure consists of subtotal resection of vertebral bodies and discs, with slight thinning and release of the ossified ligament using air instrumentation. This is followed by reconstruction of the cervical spine using autogenous strut bone graft accompanied by postoperative application of a halo vest. This method is indicated for patients who present with moderate or severe myelopathies, and especially in those where the canal narrowing ratio exceeds 60%. This radical procedure causes decompression of the spinal cord and restores its function by enlarging the neural canal with anterior migration of the ossified ligament. The procedure minimizes the extent of surgical invasions and avoids damage to the neural tissue, because it does not require the removal of the ossification of the posterior longitudinal ligament. It also stops postoperative regrowth of the ossification. The operative results with long term followup indicate a 71% average recovery rate based on the criteria established by the Japan Orthopedic Association.

PMID 10078126  Clin Orthop Relat Res. 1999 Feb;(359):27-34.

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