脊柱畸形后路截骨术神经并发症分析

Analysis of neurological deficits complications in the treatment of spinal deformity with posterior spinal osteotomy

目的探讨脊柱畸形后路截骨术神经并发症的发生率及原因。方法2007年1月至2010年12月，采用脊柱后路截骨术治疗脊柱畸形患者321例，男性124例，女性197例；年龄2-56岁，平均（19±11）岁。术前主弯侧凸Cobb角平均108°±33°，后凸Cobb角平均74°±29°。其中226例行经椎弓根椎体截骨术、95例行全椎体切除术，均采用椎弓根螺钉钉棒系统矫形固定。术中采用体感诱发电位、术中唤醒试验等方法监测神经功能变化。结果共有11例患者术后出现下肢的感觉和肌力的改变，发生率为3．4％。神经损伤的原因包括截骨端移位2例、骨断端合拢压迫2例、骨块残留压迫1例、操作失误2例、螺钉误置1例、血肿压迫1例、矫形牵拉2例。其中术前即存在神经损害的患者发生率（20．0％）显著高于术前神经功能正常患者（2．6％）（X^2=13，060，P=0．011）；虽然神经并发症发生率在年龄、病因、畸形程度、截骨方式、手术类型各组内差异无统计学意义（P〉0．05），但先天性脊柱侧凸、神经肌肉型脊柱侧凸、脊柱后凸、成人脊柱畸形、100。以上的重度脊柱侧后凸患者的发生率较高，分别为4．6％、7．1％、5．1％、5．9％和5．9％。11例患者均行甲泼尼龙冲击、神经营养药物及高压氧治疗，其中4例行再次手术探查，最后随访时7例完全恢复，2例好转，2例无恢复。结论脊柱截骨术是治疗重度脊柱畸形的有效方法；手术操作难度高、风险大，术前即存在神经损害的患者为发生神经并发症的高危因素。

Objective To investigate the incidence and causes of neurologic deficits complications in the treatment of spinal deformity with posterior spinal osteotomy. Methods From January 2007 to December 2010, 321 cases of scoliosis or kyphosis patients were treated with posterior spinal osteotomy. There were 124 male and 197 female with an average age of （19±11 ） years （2-56 years）. The average preoperative main Cobb angle was 108°±33°（48°-175°） , the average kyphotie angle was 74°±29° （53°-170°） before operation. Pedicle subtraction osteotomy was used in 226 cases, 95 cases with vertebral column resection. Pediele screw-rod system was used for fixation. The patients were monitored by Somatosensory-evoked potentials monitoring and Stagnara wake-up test. Results There were 11 eases with varying degrees of new neurologie deficits and the total incidence was 3.4%. The causes were as followed, spinal translation in 2 cases, compromised by close of reseeted areas in 2 cases, residual bone compression in 1 ease, inadvertent operation in 2 eases, screw malposition in 1 case, hematoma compression in 1 case and spine elongation in 2 eases. There was significant difference between the patients with preexisting neurologic deficits（20.0% ） and the patients with intact neurologic function（2. 6% ） （X^2 = 13. 060,P = 0. 011 ） , no significant differences in different classes of the age, etiology, deformity, osteotomy type and surgical type （P 〉0. 05 ）. But the incidence of neurologic deficits was 4. 6% in congenital scoliosis, 7. 1% in neuromuscular scoliosis ,5. lifo in hyperkyphosis, 5.9% in adult deformity and 5.9% in Cobb angle more than 100°, which was higher than other classes. All the 11 cases were given emergent Methylprednisolone, neurotrophic drugs and hyperbaric oxygen therapy, 4 cases were underwent surgical exploration again. After treatment, 7 cases recovered completely, 2 cases recovered partially and 2 cases failed to improve at the last follow-up. Conclusions Severe spinal deformity could be effectively treated with posterior spinal osteotomy.But the procedure is technical demanding and risky for neurologic deficits. The high risk factor is preexisting neurologic deficits.