强直性脊柱炎后凸截骨矫形致神经损伤并发症分析

Analysis of neurological complications of spinal osteotomy for thoracolumbar and lumbar kyphosis inankylosing spondylitis

目的探讨截骨矫形治疗强直性脊柱炎后凸畸形神经系统并发症的原因及预防措施。方法回顾性分析2006年1月至2012年1月行截骨矫形术治疗126例强直性脊柱炎后凸畸形患者资料，其中18例术后发生神经系统并发症，男15例，女3例；手术时年龄25-56岁，平均3618岁；术前后凸Cobb角57°-96°，平均76.3°；患者术前ASIA分级均为E级。回顾术中操作情况，分析术后发生神经并发症的原因。结果18例患者均获得随访，随访时间6-49个月，平均35个月；术后后凸Cobb角为19°-38°，平均27°；获得截骨角度31°-76°，平均49.3°，外观得到明显改善。3例（2．4％，3／126）发生脊髓损伤，其中1例在T12截骨处产生矢状面移位，术中经调整上下螺钉高度和预弯棒角度，重新恢复截骨处的矢状面排列后患者无异常；1例截骨闭合后椎管狭窄导致脊髓受压，重新减压后患者随访无异常；1例术中发生医原性颈椎骨折脱位造成脊髓损伤，复位固定后6个月随访时ASIA分级为B级。15例（11．9％，15／126）发生神经根损伤，其中2例为截骨闭合时L3神经根受到挤压，1例为L3椎弓根置钉失误所致，以上3例患者表现为股四头肌乏力；其余12例表现为相应神经根区域皮肤麻木，主要原因是截骨时神经根受到过度牵拉，截除椎弓根下壁时过度激惹神经根；经脱水、神经营养治疗后恢复正常。结论神经损伤是截骨矫形术中灾难性并发症。认识强直性脊柱炎的病理特点，避免截骨端发生位移，截骨处充分减压，正确摆放患者手术体位，能够有效降低神经损伤的发生。

Objective To analyze cause and preventative measures of neurological complications of spinal osteotomy for thoracolumbar and lumbar kyphosis in ankylosing spondylitis. Methods Data of 126 patients with kyphosis caused by ankylosing spondylitis, who had undergone spinal osteotomy in our hospital from January 2006 to January 2012, were retrospectively analyzed. Among them, 18 patients developed neurological complications after spinal osteotomy, including 15 males and 3 females, aged from 25 to 56 years. The average preoperative Cobb angle of these patients was 76.3° According to American Spinal Injury Association （ASIA） classification, all patients were rated as grade E. Results All 18 patients were followed up for 6 to 49 months （average, 35 months）. The postoperative Cobb angle ranged from 19° to 38° （average, 27°）. The average Cobb angle was corrected 49.3°. Neurological complications included spinal cord injury （3 cases） and nerve root injury （15 eases）. The reasons of spinal cord injury consisted of sagittal migration of vertebra, spinal steno- sis due to operation and iatrogenic cervical spine fracture and dislocation. The reasons of nerve root injury included compression injury （2 cases）, malposition of screw （1 case） and excessive drag of nerve root during osteotomy （12 cases）. Conclusion Nerve injury is one of the most serious complications of spinal osteotomy in the treatment of kyphosis in ankylosing spondylitis. The incidence of the neurological complications could be obviously reduced by fully decompressing, making patients in a proper surgical position, recognizing the pathological nature of ankylosing spondylitis and avoiding sagittal migration of osteotomy part.