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2023年8月7日，有骨科同行给我推送了一篇“脑医汇” APP里的文章，是山东大学附属儿童医院神经外科王主任的一篇科普文章，题目是《8岁儿童颈前入路C3-4椎管狭窄手术》。该篇文章还被“脑医汇”加“精”推荐。 王XX教授：8岁儿童颈前入路C3-4椎管狭窄手术 https://www./info/detail?id=39243&t=1668134400 在文章的前半部分，王主任讲解了后纵韧带骨化症的基本概念、影像学特点、分型、治疗办法、转归及愈后。也图文并茂详细地讲解了手术入路的体表定位、颈深筋膜(封套筋膜、气管前筋膜、椎前筋膜)的显露，舌骨下肌群、颈动脉鞘和颈前分区的解剖显露，颈长肌、头长肌、交感链、椎前筋膜的解剖显露，颈前路手术的体位、定位以及切口位置，入路，和透视定位，切除病变和内固定。这部分内容应该是抄袭来的，没有提供出处，就不做评价了。我相信，文中这部分内容里的解剖图片和示意图片不是王主任的原创作品。看着像是幻灯截图，但右下角的Logo看不清楚是哪个医院的。对于此类文中引用解剖图谱里的图片，应该说明出处。患儿孙XX，男，8岁，因“颈部间断疼痛20天”于2023年7月21日入院。现病史：患儿20天前，不慎扭伤颈部，出现颈部疼痛，4天前，当地医院行颈部CT及MRI示颈3-4椎间盘突出，椎管狭窄，建议上级医院就诊，为进一步诊治来我院(山东大学附属儿童医院神经外科)就医。查体：头部无畸形，双侧瞳孔约2-3mm，等大等圆，对光反射灵敏，颈部左右旋转未受影响，前屈、后伸受限，四肢肌力、肌张力未见异常，双侧膝、跟腱反射正常，双侧Babinski征阴性。
入院后颈部CT检查(注：引自王主任原文，图片适当做了修剪，截取有用部分。图中可见颈3、颈4椎体变扁，颈3-4椎间盘突出及钙化，后纵韧带骨化。)
颈椎MRI平扫(注：引自王主任原文，图片适当做了修剪，截取有用部分。图中可见颈3、颈4椎体变扁，颈3-4椎间盘突出，椎间盘及后纵韧带低信号，脊髓受压。)
四肢肌电图检查(注：引自王主任原文，该患儿从查体来看，没有明确的神经损伤表现，就没必要做肌电图检查。)王主任将该病例诊断为后纵韧带骨化症，颈椎管狭窄，做了颈3-4前路椎间盘切除，使用零切迹颈椎椎间融合器进行椎间植骨融合内固定手术。
术中照片(引自王主任原文，原文患儿眼睛没有打码，本文小编予以打码。)请问王主任，你是否与患儿家属或监护人签署了将该患儿的病情资料以及术中脸部肖像用于宣传的知情同意书？山东大学附属儿童医院(济南市儿童医院)神经外科主任，副主任医师，学科创始人兼学科带头人。济南市医师协会小儿神经外科分会主任委员，中华医学会神经外科分会小儿神经外科学组委员，中国医师协会神经外科医师分会小儿神经外科专业委员会委员，山东省医学会神经外科学会委员会委员，济南市神经外科专业医疗质量控制中心副主任。说实话，当我看到这篇文章的时候，心里有点意外。作为山东大学附属儿童医院神经外科主任，济南市医师协会小儿神经外科分会的主任委员，竟然不认识这个病，错误的实施了手术，还大肆宣传！1. 颈椎间盘突出、颈椎管狭窄和后纵韧带骨化的定义中的发病机理问题首先，在所有的医学本科生教材以及骨科或者脊柱外科专业书籍中，在其发病机理中，首先强调的是这些表现是退行性改变。啥叫退行性改变？就是随着年龄的增长，人在衰老的过程中发生的改变。跟胸椎间盘突出、胸椎后纵韧带骨化、胸椎管狭窄、腰椎间盘突出、腰椎管狭窄、腰椎后纵韧带骨化等一样的发病机理。也就是说在诊断的要素里，必须要体现出一定的年龄来，而且这个年龄能看到衰老的过程，颈椎间盘突出症多发生于40-50岁，这就是衰老的体现。一定要有年龄过程。这个孩子才8岁，毫无衰老的证据，毫无退行性改变的证据，哪儿来的颈椎间盘突出、哪来的颈椎管狭窄、哪儿来的后纵韧带骨化诊断？对于儿童的椎间盘突出、椎管狭窄、后纵韧带骨化等这种诊断或者描述一定要加上“儿童”两字。没有儿童两字的椎间盘突出、椎管狭窄，一般都认为是成人椎间盘突出和椎管狭窄。儿童不是成人的缩小版，儿童的疾病有儿童自身的特点，不能拿成人的诊断和治疗原则去套儿童疾病的诊断和治疗。颈椎间盘突出、颈椎管狭窄、颈椎后纵韧带骨化、胸椎间盘突出、胸椎后纵韧带骨化、胸椎管狭窄、腰椎间盘突出、腰椎管狭窄、腰椎后纵韧带骨化等等这些无“症”字的名称是影像学描述名称，不是临床医生应该做的诊断。只有颈(胸、腰)椎间盘突出症、颈(胸、腰)椎管狭窄症、颈(胸、腰)后纵韧带骨化症才是临床医生下的诊断，这个“症”字，代表了患者必须要有症状，也要有体征。这个8岁的孩子，有颈肩痛的症状，但没有任何明确的神经损伤表现的体征。能够判断这个孩子是否有神经损伤的体征是作为一个脊柱外科医生，也是一个神经外科主任级别的医生，最起码的临床基本素养。即使是在成人退变性疾病的诊断治疗过程中，神经根型颈椎病也至少得保守治疗3-6个月才应该做手术，脊髓型颈椎病虽然说一旦诊断成立，应该尽早手术，但在这两个诊断中，必须要有明确的神经损伤表现。假设就把这个8岁孩子的影像学表现，当作是成人的疾病来诊断，颈3-4椎间盘突出，根据这个孩子的临床表现，也达不到颈3-4椎间盘突出症的诊断，无明确的神经损伤表现，就不该手术。神经根型颈椎病和脊髓型颈椎病具体的手术适应证我就不在这里罗列了，医学本科生教材以及脊柱外科相应的专业教材里都有详细的描述，请王主任自学一下。作为科室主任、一个省会城市小儿神经外科主任委员级别的人，不带头学习专业知识，如何能够引领科室工作人员和全市该领域中其他医生的学习并指导他们的工作？儿童颈椎间盘钙化是一种什么样的疾病呢？我们用Calcification of the
intervertebral disc in children，或者paediatric
intervertebral disc calcification搜索www.pubmed.gov, 找到几篇相关文献，并选择一篇文献进行全文翻译，供大家学习和参考。我选择北京空军总院骨科杜俊杰主任2018年发表在BMC Musculosketal Disorders杂志上的一篇文章进行全文翻译和学习。这个病例是杜俊杰主任到北京空军总院后发表的。杜主任原来是我们科的教授，2014年11月，他作为科技人才被引进空总骨科当科主任、学科带头人。从时间上看，这个病例实际上是他在西工作的时候处理的一个病例，到了空总后一直对该病例做着随访。Calcification of the intervertebral disc
and ossification of posterior longitudinal ligament in childrenCalcification of intervertebral disc in
children is rare. Since firstly reported by Baron in 1924, approximately 400
cases were reported[1]. Although traumatic, infectious, inflammatory, and
nutritional mechanisms were thought to contribute to calcification of
intervertebral disc in children, the detailed etiology remain not defined.
Ossification of the posterior longitudinal ligament (OPLL) mainly affect people
ages 50–70 years, also with unclear etiology. Calcification of intervertebral
disc in children is usually thought to be self-limiting with favorable
prognosis, while OPLL in adults usually aggravates gradually and needs surgery
when present with myelopathy or radiculopathy. The coexistence of calcification
of intervertebral disc and OPLL is very rare, only six cases with 3 to 24
months’ follow-up were reported to date[2–6]. We reported the first two cases
of cervical intervertebral disc calcification combined with OPLL in children in
2012[3] and followed one case for more than nine years. The purpose of this
case report is to describe the 9-year follow-up result. To our knowledge,
long-term follow-up for cervical intervertebral disc calcification combined
with OPLL is firstly reported here.儿童椎间盘钙化罕见。Baron于1924年首次报道。到现在约有400例报道[1]。儿童椎间盘钙化的原因一般认为与创伤、感染、炎症和营养等有关，但具体病因尚不明确。后纵韧带骨化（OPLL）主要影响50-70岁人群，病因也不清楚。儿童椎间盘钙化常为自限性疾病，预后良好，而成人OPLL常会逐渐加重，当出现脊髓损伤或神经根损伤时需要手术治疗。椎间盘钙化和OPLL并存非常罕见，迄今为止仅有6例随访3至24个月的病例报道[2-6]。2012年我们报道了两例儿童颈椎间盘钙化合并OPLL的病例[3]，并对一例进行了9年多的随访。本文描述9年的随访结果。据我们所知，本文首次报道了颈椎间盘钙化合并OPLL的长期随访。A 6-year-old boy presented with right-sided
neck pain for 6 months was admitted in our institution on July 2007, with no
history of recent trauma, fever or infection. The pain localized in the right
side of neck, without radiating pain. The pain exacerbated for several days and
not alleviated by using analgesics. Visual Analogue Scale (VAS) for cervical
pain was 7.0. Physical examination revealed no palpable masses or torticollis.
Neurological examination revealed nothing abnormal. Laboratory tests revealed
normal white blood cell count (6170/mm3, normal range:
5000–12,000/mm3) and elevated ESR (69 mm/h, normal range: 0 to 20
mm/h) and CRP (11.80 mg/L, normal range: 0 to 5 mg/L). Radiograph and CT showed
calcification of intervertebral disc at C2/3 and C3/4 levels, accompanied by
C3/4 level OPLL (Fig. 1a, c and d). MRI revealed decreased signal intensity of
C2–4 discs and C3/4 posterior longitudinal ligament on T2-weighted images, with
slight dura compression (Fig. 1b). The patient was treated with analgesics for
2 weeks, interrupted cervical traction for 2 weeks and cervical collar for 1
month. After a one-month conservative treatment, the patient’s symptoms greatly
improved. VAS for cervical pain decreased to 1.0. Nineteen months later, in
March 2009, the boy complained no discomfort. Laboratory tests (including white
blood cell count, ESR and CRP) revealed nothing abnormal. C3/4 intervertebral
disc calcification and OPLL had disappeared, only minor calcification at C2/3
intervertebral disc left (Fig. 2a, c and d). MRI demonstrated restoration of
T2-weighted signal intensity of C2/3 and C3/4 discs (Fig. 2b).
Fig. 1. Radiological
imaging at admission. A: Lateral cervical spine radiograph showed C2/3 and C3/4
IDC (thin arrows) and OPLL at C3 and C4 (thick arrow). B: Magnetic resonance
imaging showed that spinal cord was compressed anteriorly at the C3/4 level
(arrow). C: Axial computed tomography through C2/3 revealed IDC (thick arrows)
at C2/3. D: Axial computed tomography through C3/4 revealed IDC (thick arrows)
at C3/4 and OPLL at C3/4 level (thin arrow). (Adopted and reedited from Du et
al.[3] with permissions of all authors)入院时的影像学检查。a: 颈椎侧位X线片, 显示C2/3和C3/4椎间盘钙化(细箭头)和C3及C4平面后纵韧带骨化(粗箭头); b: 颈椎MRI，显示C3/4平面脊髓受压(三角箭头); c: 颈2/3平面CT平扫显示颈2/3椎间盘钙化（粗箭头）；d: 颈3/4平面CT平扫，显示颈3-4平面椎间盘钙化(粗箭头)及后纵韧带骨化。
Fig. 2.
Radiological imaging at 19-month follow-up. A: Computed tomography revealed the
IDC and OPLL at the C3/4 level has disappeared, only minor calcification at
C2/3 intervertebral disc left. B: Magnetic resonance imaging revealed
restoration of T2-weighted signal intensity of C2/3 and C3/4 discs. C: Axial
computed tomography through C2/3 revealed minor calcification at C2/3 intervertebral
disc left. D: Axial computed tomography through C3/4 revealed IDC and OPLL at
the C3/4 level disappeared. (Adopted and reedited from Du et al.[3] with
permissions of all authors)19个月随访时的影像学检查。a: CT扫描显示C3/4平面椎间盘钙化及后纵韧带骨化消失，仅有C2/3椎间盘残留部分轻度钙化；b: 颈椎MRI显示C2/3和C3/4椎间盘T2加权相信号恢复；c:
C2/3平面CT平扫显示C2/3参与轻度钙化；d: C3/4平面CT平扫显示椎间盘钙化及后纵韧带骨化消失。患儿男性，6岁，因右侧颈部疼痛6个月于2007年7月入院。无外伤、发烧或感染病史。疼痛局限于右侧颈部，无放射性疼痛。疼痛加重数天，使用止痛药无缓解。颈部疼痛VAS评分7.0。查体未见明显肿块或斜颈。神经系统检查无异常。实验室检查显示白细胞正常，ESR升高（69 mm/h，正常范围为0至20 mm/h）和CRP升高（11.80
mg/L，正常范围0至5 mg/L）。X线片和CT显示C2/3和C3/4椎间盘钙化，并伴C3/4后纵韧带骨化（图第1a、c和d段）。MRI扫描T2加权像显示C2–4椎间盘和C3/4后纵韧带低信号，伴轻微硬脊膜压迫（图1b）。予以镇痛药2周、间断颈部牵引2周，颈围制动1个月治疗。经过一个月保守治疗，患者症状明显改善。颈部疼痛VAS评分降至1.0。19个月后，2009年3月，该患儿无不适。实验室检查（包括白细胞计数、ESR和CRP）没有发现异常。C3/4椎间盘钙化和OPLL消失，仅有C2/3椎间盘轻微钙化（图2a、c和d）。MRI显示C2/3和C3/4椎间盘的T2加权信号强度恢复（图2b）。When last seen in October 2016, there was
still no discomfort. Laboratory tests revealed nothing abnormal. No sign of
C3/4 intervertebral disc calcification and OPLL was observed (Fig. 3a, c and
d). Minor calcification at C2/3 intervertebral disc remained (Fig. 3a, c and
d). MRI demonstrated loss of T2-weighted signal intensity of C2/3 disc and
decrease of T2-weighted signal intensity of C3/4 disc (Fig. 3b). Narrowing of
C2/3 intervertebral space, flatting of C3 body, widening of posterior edge of
C3/4 disc were observed in CT scan (Fig. 3c and d).2016年10月，最后一次面诊随访，患儿无任何不适。各项化验指标正常。未见C3/4椎间盘钙化和OPLL征象（图3a、c和d）。C2/3椎间盘仍有轻微钙化（图3a、c和d）。MRI显示C2/3椎间盘T2加权信号消失，C3/4椎间盘的T2加权信号降低（图第3b）。CT扫描见C2/3椎间隙变窄、C3体扁平、C3/4椎间盘后缘加宽（图3c和d）。
Fig.3. Radiological
imaging at 9-year follow-up. A: Lateral cervical spine radiograph showed minor
IDC remained at C2/3. B: Magnetic resonance imaging revealed loss of
T2-weighted signal intensity of C2/3 disc and decrease of T2-weighted signal
intensity of C3/4 disc. C and D: Computed tomography revealed minor
calcification at C2/3 intervertebral disc left, IDC and OPLL at the C3/4 level
disappeared. Narrowing of C2/3 intervertebral space, flatting of C3 body, widening
of posterior edge of C3/4 disc were observed.9年随访时影像学检查。A: 颈椎侧位X线片显示C2/3残留轻度椎间盘钙化。B:颈椎MRI显示C2/3椎间盘T2加权相信号消失以及C3/4椎间盘T2加权相信号降低。C和D: CT扫描显示C2/3椎间盘轻度钙化，C3/4椎间盘钙化及后纵韧带骨化消失。C2/3椎间隙变窄，C3椎体变扁，C3/4椎间盘后缘增宽。Discussion and conclusionsThe incidence of intervertebral disc
calcification (IDC) in children is low, with only approximately 400 cases
reported since 1924. Intervertebral disc calcifications in children were
divided in symptomatic and asymptomatic groups by Beluffi[7], who believed the
number of asymptomatic patients could be larger than symptomatic patients.
Blomquist et al.[8] reported 15 cases of IDC in children, of which 11 were symptomatic.
Given that calcification of disc in children may be only an incidental finding
without symptoms[9–12], the exact incidence may be underestimated[13, 14].
IDC mainly affect 5-to 12-year-old children[15], although newborn infant
involvement was reported[7]. Males are more susceptible to IDC than females,
with male-to-female ratio 13:6[15, 16]. IDC mostly occurs in lower cervical
spine and upper thoracic spine[17], with the most common level at C6/7[18,
19]. First reported in 1838, OPLL has been widely reported since the 1960s[20]. OPLL usually affect people ages 50–70, the average onset age is 51.2
years in men and 48.9 years in women[21], with male-to-female ratio roughly
2:1[22]. OPLL is relatively more common in East Asian populations than
Caucasian. The prevalence of OPLL was reported to be 1.5% to 3.7% in Japan and
0.1–1.7%in Europe and United States[21, 23–25]. The most commonly involved
levels are C4–6[26]. IDC with OPLL in children is an extremely rare situation,
only six cases reported to date (Table 1)[2–6]. We reported the first two
cases of cervical IDC with OPLL in children in 2012, while Fu et al.[2]
reported the first thoracic case. Given that most reported cases occurred in
East Asia, like OPLL in adult, IDC with OPLL in children may also have racial
susceptibility. 儿童椎间盘钙化（IDC）的发生率较低，自1924年以来仅报告了约400例。Beluffi将儿童椎间盘钙化分为有症状组和无症状组[7]，他认为无症状患者的数量可能大于有症状患者。Blomquist等人[8]报道了15例儿童椎间盘钙化病例，其中11例有症状。考虑到儿童椎间盘钙化可能为偶然发现，没有症状[9-12]，确切的发病率可能被低估[13，14]。儿童椎间盘钙化主要影响5至12岁儿童[15]，尽管也有新生儿椎间盘钙化的报道[7]。男性比女性更易患椎间盘钙化，男女比例为13:6[15，16]。椎间盘钙化主要发生在下颈椎和上胸椎[17]，最常见的节段为C6/7[18，19]。1838年首次报道OPLL，自20世纪60年代以来一直被广泛报道[20]。OPLL通常影响50-70岁人群，男性平均发病年龄为51.2岁，女性为48.9岁[21]，男女比例约为2:1[22]。相对来说，东亚人群OPLL比白种人群更常见。据报道，日本OPLL患病率为1.5%至3.7%，欧洲和美国为0.1-1.7%[21，23-25]。最常累及的节段为C4–6[26]。儿童椎间盘钙化并OPLL是一种极为罕见的情况，迄今为止仅报告了6例（表1）[2-6]。我们在2012年报道了两例儿童颈椎椎间盘钙化伴OPLL的病例，而Fu等人[2]报道了第一例胸椎病例。鉴于大多数报告的病例发生在东亚，就像成人的OPLL一样，儿童椎间盘钙化合并OPLL也可能具有种族易感性。The etiology of IDC in children is still
unclear. Trauma, infection, nutritional supply, vitamin D disorder, hereditary
deficit may contribute to IDC in children[9, 13, 27–29]. Elevated ESR was
reported to be the most sensitive indicator[15]. Coordinate with previous
reports, elevated ESR and CRP are observed in our case, which suggested that
infection may play a role in etiology of IDC in children. OPLL in adults is
also considered to be multifactorial. Trauma[21], inflammation[30], genetics[31], environment[23], diet[32], glucose intolerance[33], obesity[33] and
hypoparathyroidism[34] may contribute to the onset and progress of OPLL in
adults. Trauma was seen in 2 cases of 6 reported cases of IDC with OPLL in
children (incidence: 33.33%). Elevated inflammation indicators were seen in 3
cases (incidence: 50%, with one case didn’t give out inflammation indicators[6]). These results suggested that trauma and inflammation may play a role in
the etiology of IDC with OPLL in children.儿童椎间盘钙化的病因尚不清楚。创伤、感染、营养供给、维生素D疾患、遗传缺陷等均可导致儿童椎间盘钙化[9，13，27-29]。据报道，ESR升高是最敏感的指标[15]。与既往报道相一致，我们的病例中也观察到ESR和CRP升高，这表明感染可能在儿童椎间盘钙化的病因中发挥作用。成人OPLL也为多因所致。创伤[21]、炎症[30]、遗传[31]、环境[23]、饮食[32]、葡萄糖不耐受[33]、肥胖[33]和甲状旁腺功能减退[34]可能有助于成人OPLL的发生和发展。报告的6例儿童椎间盘钙化伴OPLL病例中，2例与创伤有关（发生率：33.33%）。3例炎症指标升高（发生率为50%，其中1例没有给出炎症指标[6]）。这些结果表明，创伤和炎症可能在儿童椎间盘钙化伴OPLL的病因中发挥作用。The most common clinical symptom of IDC in
children is neck pain, affecting 80–90% cases [35]. Torticollis occurred in 40%
of cases[11]. Other symptoms and signs include: perivertebral muscle spasms,
low-grade fever, radicular pain, tenderness, and dysphagia (in anterior
herniation cases). Only 5% patients of OPLL in adults were free of symptoms,
95% patients had clinical symptoms[21]. Different from IDC in children,
varying degrees radiculopathy and myelopathy can be present in OPLL in adults[22], including balance dysfunction, muscular weakness, stagger, radicular
pain, numbness and dysdiadochokinesia. Neck pain or back pain was seen in all
the 6 reported cases of IDC with OPLL in children (incidence: 100%),
neurological deficit (radicular pain), cervical stiffness, and torticollis was
present in 1 case (incidence: 16.67%), respectively.儿童椎间盘钙化最常见的临床症状是颈部疼痛，占80-90%的病例[35]。40%的病例有斜颈[11]。其他症状和体征包括：脊椎周围肌肉痉挛、低热、神经根疼痛、压痛和吞咽困难（颈椎间盘向前疝出病例）。5%的成人OPLL患者没有症状，95%的患者有临床症状[21]。与儿童椎间盘钙化不同，成人OPLL中可出现不同程度的神经根损伤和脊髓损伤[22]，包括平衡功能障碍、肌无力、蹒跚步态、沿神经根走行的放射性疼痛、麻木和上位神经损伤表现。报告的6例儿童椎间盘钙化伴OPLL均有颈部疼痛或背部疼痛（发生率：100%），1例有神经功能障碍（沿神经根走行的放射性疼痛）、颈部僵硬和斜颈（发病率：16.67%）。Conservative treatment, including
analgesics, NSAIDS, muscle relaxants, cervical collar, traction and limited
physical activity, is the mainstay treatment for IDC in children. Vast majority
of children with IDC can be cure by conservative treatment. 66.7% patients got
a complete relief of symptoms within 3 weeks and 95% patients would complete
relieve within 6 months [19]. Recurrence of symptoms rarely occurs[36], but
Hoffman[37] reported a child with IDC who suffered from neck pain and
neurological deficit requiring surgery 6 years after initial diagnosis. Cases
of IDC with symptom relapse 1 year after the initial onset were also
reported[36]. Surgical treatment is controversial in cases with neurological
deficit. Some authors suggested that conservative therapy could produce
satisfactory results even when neurological deficit was present[9, 10].
Conservative treatment was proven effective even for the patient with neurological
impairment due to large posterior protrusion[10]. Different from IDC with OPLL
in children, surgery is more common for patients with OPLL in adults because of
the progressive nature and poor prognosis[38]. Due to the extremely stenosis
of cervical canal of the OPLL patients in adult, spinal cord injury (SCI) can
occur even with minor trauma. Concerning that conservative treatments were
adopted for all the 6 reported cases of IDC with OPLL in children with good
effect, we suggest conservative treatment should be the first choice for these
patients. Surgery should only be under consideration for cases with rapid
progressive neurologic deterioration and high risk of paraplegia.保守治疗，包括止痛药、非甾体抗炎药、肌肉松弛剂、颈围、牵引和制动，是儿童椎间盘钙化的主要治疗方法。绝大多数椎间盘钙化患儿可以通过保守治疗治愈。66.7%的患儿3周内症状完全缓解，95%的患儿6个月内症状完全缓解[19]。症状很少复发 [36]，但Hoffman[37]报道了1例儿童椎间盘钙化，在确诊6年后因颈部疼痛和出现神经损伤表现，做了手术。儿童椎间盘钙化首次发病1年后症状复现的病例也有报道[36]。即使出现神经损伤表现，是否需要手术治疗也有争议。一些作者认为，即使存在神经损伤表现，保守治疗也能产生令人满意的结果[9，10]。对于(儿童)巨大椎间盘突出导致神经损伤的患者[10]，保守治疗也有效。与儿童椎间盘钙化合并OPLL不同，成人OPLL因其进行性发展和预后较差，常需手术[38]。由于成人OPLL患者的颈椎管极为狭窄，即使是轻微创伤也可能发生脊髓损伤。鉴于6例儿童椎间盘钙化并OPLL病例均采用保守治疗，效果良好，我们建议这些患者应首选保守治疗。只有在神经系统迅速恶化且截瘫风险较高的情况下才应考虑手术治疗。Coordinate with previous reports [16,
39–42], narrowing of the involved intervertebral space, flatting and wedging of
adjacent vertebral body were observed in the current case at 9-year follow-up.
IDC with OPLL in children seemed benign and self-limiting. Only mild IDC of
C2/3 remained but IDC of C3/4 and OPLL at C3/4 totally disappeared in the
current case at 9-year follow-up. For all the 6 reported cases of IDC with OPLL
in children, IDC disappeared in 3 cases (50%), aggravated in 1 case (16.67%),
relieved but remained in 2 cases (33.33%). OPLL disappeared in 4 cases
(66.67%), relieved but remained in 2 cases (33.33%). The only aggravated IDC
case was treated by a 2-week lumbar belt immobilization [2]. Aggravation of IDC
but relief of OPLL result in a reduction in spinal canal stenosis for the
patient at 3-month follow-up, which made the conservative treatment still a promising
choice. Given that this only reported aggravated IDC case was in thoracic disc,
we can infer that thoracic IDC in children may have a different nature history
with cervical IDC in children.与以往报告[16,39-42]相一致，我们的病例，在9年的随访中，也观察到受累椎间隙变窄、相邻椎体变扁和楔形变。儿童椎间盘钙化合并OPLL似乎为良性和自限性。本病例C2/3只有轻度椎间盘钙化残留， 9年后随访，C3/4的椎间盘钙化和C3/4的OPLL完全消失。在报道的6例儿童椎间盘钙化并OPLL病例中，椎间盘钙化消失3例（50%），加重1例（16.67%），缓解但仍有残留2例（33.33%）。OPLL消失4例（66.67%），减轻但仍有残留2例（33.3%）。唯一加重的（腰椎）椎间盘钙化病例予以腰围制动2周 [2]。椎间盘钙化加重但OPLL减轻的患者，3个月随访时椎管狭窄程度减轻，使保守治疗仍为一个有希望的选择。鉴于这唯一报告的椎间盘钙化加重病例发生在胸椎间盘，我们推断，儿童胸椎椎间盘钙化可能与儿童颈椎椎间盘钙化有不同的自然史。Through the 9-year follow-up, the changes
of T2-weighted signal intensity for the involved discs drew our attention.
Dehydration of intervertebral discs, which led to hypointense of T2-weighted
signal intensity in MRI, was considered as a typical imaging manifestation of
disc degeneration [43–45]. Restorations of T2-weighted signal intensity in MRI
of degenerated discs were reported in several researches after dynamic
stabilization systems implantation for low back pain patients, which were
considered as decelerations of the degeneration process and regenerations of
degenerated discs [46–49]. Nineteen months after initial diagnosis, restoration
of T2-weighted signal intensity of C2/3 and C3/4 discs was observed in the
current case through MRI. Similar change was reported by Liu [16], who reported
a calcified disc restored to normal T2-weighted signal intensity at 2-year
follow-up for a 10-year-old girl. The mechanisms of “rehydration” of the calcified
discs are still unclear. Given that the spontaneous “rehydration” phenomenon is
only seen in children but seldom adults, we can infer that this might be
attribute to differences between discs of children and adults. The biggest
differences between discs in children and in adults are the presence of
microvascular blood supply for cartilage endplate and annulus fibrosus, as well
as notochord cells, in children. Intervertebral discs appear vascularized more
well in children than in adults [50]. Blood vessels penetrate into the anulus
in infants but disappear by late childhood apart from some small capillaries
[50–52]. The capillaries penetrate in the subchondral plate of intervertebral
discs by regularly spaced nutrient canals in fetus and infants but disappear in
childhood [52, 53]. The thickness of cartilaginous endplates of intervertebral
discs diminishes with age [52, 54]. The notochordal cells exist in the
intervertebral discs of fetus and infants but disappear by 10 years of age in
humans, just as the time morphological signs of degeneration can be seen [55].
So, we speculated that these may contribute to the spontaneous “rehydration”
phenomenon. Interestingly, similar “rehydration” phenomenon is seen in adult
low back pain patients after dynamic stabilization systems implantation
[46–49]. We can infer that the change of load distribution may also play a role
in the “rehydration” phenomenon.通过9年的随访，我们注意到本病例受累椎间盘T2加权信号强度的变化。椎间盘脱水导致MRI中T2加权低信号，被认为是椎间盘退变的典型影像学表现[43-45]。在为腰痛患者植入动态稳定系统后的几项研究中，显示退化椎间盘MRI中T2加权信号强度有恢复，认为动态稳定系统有助于减缓椎间盘退化和退化椎间盘的再生[46-49]。在确诊19个月后，本病例MRI显示C2/3和C3/4椎间盘的T2加权信号强度有恢复。刘[16]也报告了类似的变化，他报告了一名10岁女孩在2年的随访中钙化椎间盘恢复到正常的T2加权信号强度。钙化椎间盘的“再水化”机制尚不清楚。鉴于自发“再水化”现象只在儿童中出现，而在成年人中很少见，我们可以推断这可能是由于儿童和成人椎间盘之间的差异。儿童椎间盘与成人椎间盘最大的区别就是儿童软骨终板和纤维环以及脊索细胞有微血管血液供应。与成人相比，儿童椎间盘血管化程度更高[50]。婴儿的血管会穿入纤维环中，但在儿童晚期会消失，除了一些小毛细血管[50-52]。胎儿和婴儿的毛细血管经规则间隔的滋养管穿入椎间盘软骨下终板，但在儿童时期消失[52，53]。椎间盘软骨终板的厚度随着年龄的增长而减小[52，54]。脊索细胞存在于胎儿和婴儿的椎间盘中，但在人类10岁时消失，正如可以看到退化的时间形态学迹象一样[55]。因此，我们推测这些可能导致自发“再水化”现象。有趣的是，在植入动态稳定系统后的成年腰痛患者中也出现了类似的“再水化”现象[46-49]。我们可以推断，负荷分布的变化也可能在“再水化”现象中发挥作用。IDC with OPLL in children is very rare.
Conservative treatments are recommended with affirmative short-term and
long-term clinical effects. But given that such cases were so rare and
radiographic changes in more than 30% cases didn’t improve, more intensive
observation with long-term follow-ups may be needed to warrant the clinical
effects.儿童椎间盘钙化合并OPLL非常罕见。推荐保守治疗，短期及长期临床效果确切。但鉴于此类病例非常罕见，超过30%病例的影像学变化没有改善，可能需要更深入的观察和长期随访来保证临床效果。下面提供我自己曾经处理过的两个颈椎间盘钙化病例，因为年龄小于14岁的患儿，我一般首诊后就转诊给我们小儿骨科继续处理，所以，我只有保存的当时的病例影像资料，没有后期随访的资料。不过我给患儿及家属的建议，都是对症处理，保守治疗。病例1. 14岁，男性，颈肩痛，无明确的神经损伤表现。
2020年4月6日在986医院做的颈椎CT矢状面二维重建, 显示颈3-4椎间盘突出钙化。
2020年4月6日在986医院做的颈椎CT横截面扫描, 显示颈3-4椎间盘突出钙化。病例2. 患儿女性，8岁，
颈肩痛及斜颈就诊，拍片发现颈椎间盘钙化，对症治疗，斜颈可手法纠正，建议其颈围制动。
2021年6月28日在西安市第三医院拍摄的颈椎正侧位X线片，显示斜颈，颈5-6椎间盘钙化。
2021年8月16日在西拍摄的颈椎正侧位X线片，显示斜颈已纠正，颈5-6椎间盘钙化。下面再提供一个其他脊柱外科医生门诊处理的儿童颈椎间盘突出并钙化病例和转归。患儿男性，11岁，颈肩部剧烈疼痛，佩戴头颈胸支具及口服非甾体抗炎药，两月后门诊复查症状消失，影像学如下：
治疗前颈椎侧位X线片，显示颈3、颈4椎体变扁，椎间隙变窄。
治疗前颈椎CT矢状面二维重建，可见颈3、颈4椎体变扁，颈3-4椎间盘突出并后纵韧带骨化，椎管狭窄。
治疗前颈椎CT横截面扫描，可见颈3-4椎间盘突出并后纵韧带骨化，椎管狭窄。
治疗前颈椎MRI矢状面扫描，可见颈3、颈4椎体变扁，颈3-4椎间盘突出并后纵韧带低信号，椎管狭窄，脊髓受压。
治疗前颈椎MRI横截面扫描，可见颈3-4椎间盘突出并后纵韧带高低信号混杂，椎管狭窄，脊髓受压。佩戴头颈胸支具及口服非甾体抗炎药，两月后门诊复查, 影像资料如下：
治疗后颈椎CT矢状面二维重建，显示颈3、颈4椎体变扁，颈3-4后纵韧带骨化大部分已吸收消失。
治疗后颈椎CT横截面扫描，显示颈3-4后纵韧带骨化大部分已吸收消失。
治疗后颈椎MRI矢状面扫描，显示颈3、颈4椎体变扁，颈3-4后纵韧带骨化大部分已吸收消失，椎管容积扩大。下面提供的这几篇参考文献，所有文章中的结论，对于儿童颈椎间盘钙化和后纵韧带骨化，均建议保守治疗，我就不提供全文和翻译了。在www.pubmed.gov中很容易查到更多全文文献，也请王主任认真学习一下，最好组织全科以及全市的神经外科医生认真学习一下相关知识。
这就是山东大学附属儿童医院神经外科主任，济南市医师协会小儿神经外科分会主任委员王主任给这个8岁的孩子做手术后的切口和引流管外观照片，这本不应该发生的。1. Jun-Jie Du, Yu-Fei Chen, Ye Peng,
Xiao-Jie Li, Wei Ma. Calcification of the intervertebral disc and ossification
of posterior longitudinal ligament in children. BMC Musculoskelet Disord. 2018
Sep 5;19(1):316. doi: 10.1186/s12891-018-2227-z.2. Hunter J King, Rohin Ramchandani,
Christina Maxwell, Atom Sarkar, Tina Loven.To cut or not to cut? A case report on
pediatric intervertebral disc calcification. Case Reports Surg Neurol Int. 2021
Jun 28;12:307. doi: 10.25259/SNI_207_2021. eCollection 2021.3. Kai Chen, Xin Chen, Yuxi Su. Is
conservative treatment a good choice for pediatric intervertebral disc
calcification in children? Eur Spine J. 2022 Dec;31(12):3324-3329. doi:
10.1007/s00586-022-07417-2. Epub 2022 Oct 30.4. Xu-Dong Wang, Xian-Jun Su, Yao-Kun Chen,
Wen-Gang Wang. Regression of intervertebral disc calcification combined with
ossification of the posterior longitudinal ligament: A case report. World J
Clin Cases. 2021 Aug 26;9(24):7285-7291. doi: 10.12998/wjcc.v9.i24.7285.
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