颈椎后纵韧带骨化症的手术并发症分析

Surgical complications of cervical ossification of posterior longitudinal ligament

目的:探讨颈椎后纵韧带骨化症(ossification of the posterior longitudinal ligament,OPLL)的手术并发症原因以及防治措施。方法:对2000年1月至2007年2月收治的126例颈椎OPLL手术治疗患者进行回顾性分析。将所有患者分为前路组和后路组,记录两组患者术中术后所有并发症的发生情况、干预措施及恢复情况。结果:前路组51例患者中,脑脊液漏7例(13.7%),均因对骨化的后纵韧带进行打磨、分离所致,经腰大池置管并在切口局部加压后愈合,3例术后出现轻微头痛,余4例无特殊症状;喉返神经损伤4例(7.8%),未予特殊治疗,均在术后10d～3周内恢复正常,短期吞咽困难2例(3.9%),均于1周内缓解,其原因与术中显露术野时过度牵拉有关;喉上神经损伤1例(2%),限制患者进水及含水食物,加强护理,2周后恢复,主要原因与手术节段位置较高、显露困难和操作粗暴有关;食管瘘1例(2%),予禁食水、静脉加强营养,局部保持通畅引流等治疗,于术后6周痊愈,可能与牵拉过度和操作不慎有关;2年随访时发现邻近节段退变8例和内置物下沉2例,均无临床症状,继续密切观察。后路组75例患者中,颈项部疼痛9例(12%),给予对症治疗,2年随访时均有所缓解,其原因与后方软组织剥离或椎小关节破坏有关;颈部屈伸活动明显受限7例(9.3%),主要因为长节段内固定所致,未对日常生活造成明显影响,未特殊处理;C5神经根麻痹6例(8%),通过加强患肢力量训练,辅以神经营养药物,术后3～8个月恢复,主要与减压后脊髓持续移位对C5的牵拉效应有关;骨化明显进展5例(6.7%),发生机制包括术后局部应力改变、不稳等,颈椎生理前凸消失3例(4%),二者均未诱发或加重症状,继续密切随访;硬膜外血肿1例(1.3%),术后13h及时再次手术清除血肿后症状迅速缓解,主要原因与第一次手术止血不佳有关。结论:颈椎OPLL前路或后路手术治疗均可发生多种并发症,术前仔细分析病情,术中细心操作,术后加强管理,才能最大限度地降低并发症的发生率。

Objective：To investigate the possible causes,prevention and management of surgical complications due to cervical ossification of posterior longitudinal ligament（OPLL）.Method：126 patients from Jan.2000 to Feb.2007 suffering cervical myelopathy due to OPLL and undergoing surgical intervention were reviewed retrospectively.All patients were classified into anterior or posterior surgery group.The status,management and outcome of all intra- and post-operative complications were documented.Result：The complications in anterior surgery group included：cerebrospinal fluid leakage in 7（13.7%）,which was due to the detachment of OPLL,and resolved by lumbar subarachnoid continuous drainage combined with pressure dressing,3 patients presented with mild postoperative headache and the other 4 patients presented no symptom;injury of recurrent laryngeal nerve occurred in 4 cases（7.8%）,all recovered within 3 weeks without special intervention,and trantient dysphagia in 2（3.9%） due to over-retraction,which resolved within 1 week,injury of superior laryngeal nerve occurred in 1（2%） due to the difficulty of exposure and rude maneuver,the patient recovered to normal after 2 weeks＇ diet limitation and more attentive care,esophageal fistula occurred in 1（2%） due to inappropriate maneuver,after sufficient intravenous nutrition and continuous local drainage,the patient recovered and was discharged 6 weeks later,adjacent level degeneration occurred in 8（16%） and graft subsidence in 2（4%） at 2 years follow-up,no clinical symptom was found.The complications of posterior surgery group included pain in nuchal region in 9（12%） due to stripping of posterior soft tissues or destruction of facet joints,all relived through conservative treatments at 2 years follow-up,significant decrease of cervical spine ROM in 7（9.3%） due to long segment instrumentation,no treatment was applied due to no interference with daily life,C5 palsy in 6（8%）,which was largely attributed to the extraction to C5 root,the patients recovered by 3-8 months＇ physical exercise and use of neuronutritional medicines,progression of OPLL in 5（7%） due to instability and load bearing,loss of cervical lordosis in 3（4.2%） with no neurological deterioration,the patients were advised to follow-up closely.Epidural hematoma in 1（1.3%） due to inadequate haemostasis in primary procedure,the symptoms diminished rapidly after removal of hematoma 13h after the primary surgery.Conclusion：Various complications may occur both in anterior and in posterior approach.Sufficient preoperative preparations,careful operative maneuver and postoperative care can minimize the incidence of these complications.