脊柱内固定术后翻修原因及其治疗对策

Causes and tactics for revision of internal spinal instrumentation

目的:分析脊柱内固定翻修的原因并探讨翻修手术策略。方法:对我院自2004年1月～2011年12月收治的行脊柱内固定翻修手术的44例患者资料进行回顾总结,平均随访3年(1～81个月)。翻修原因可分为:(1)内置物相关副损伤,3例;(2)内置物断裂、移位,21例;(3)内置物位置欠佳,3例;(4)内置物丧失作用,1例;(5)内置物残留,1例;(6)内置物邻近节段退变,2例;(7)内置物影响感染控制,12例;(8)血肿致神经压迫,1例。针对不同原因采取相应的翻修策略,对内置物进行了更换或拆除。所有内固定翻修患者采用X线平片、三维CT、MRI进行影像学评价,其中脊髓型颈椎病患者采用改良JOA评分法进行评价,腰椎退变性疾病患者采用Stucki评分法进行评价,脊柱骨折脱位伴脊髓损伤的病例采用ASIA损伤分级进行评价。结果:所有翻修手术均顺利完成,无术中并发症发生。1例脊髓型颈椎病患者首次行前路减压内固定手术后出现血肿压迫脊髓,翻修手术行血肿清除,术后再次出现血肿压迫,造成短暂的神经功能障碍,再次翻修取出内固定物及清除血肿后,患者神经症状恢复。脊髓型颈椎病患者翻修术前JOA评分为17.38分,术后为17.46分,手术前后无明显变化;腰椎退变性疾病患者根据Stucki评分90%的患者对翻修手术满意,90%的患者翻修术后疼痛缓解并对行走功能恢复满意,80%的患者对下肢力量及平衡能力满意;脊柱骨折脱位伴脊髓损伤患者翻修手术后ASIA损伤分级无变化。所有患者翻修后保留或更换的内固定物位置良好,骨融合率100%,感染得到控制。结论:脊柱内固定术后翻修原因较多,选择合理的翻修手术仍可取得较满意结果。应掌握脊柱内固定应用原理,规范操作以避免翻修手术。

Objectives： To analyse the causes and to find out the tactics of spinal revision surgery for internal instrumentation.Methods： A retrospective analysis was carried out for the forty-four cases suffered from a revision surgery of internal spinal instrumentation in our department from January 2004 to December 2011,with a mean follow-up of 3 years（1 to 81 months）.The causes of revision surgery were divided into eight types：（1）secondary injury of the implant,3 cases;（2）implant broken and displacement,21 cases;（3）unsatistac tory implant placement,3 case;（4）implant lose function,1 case;（5）residual implant,1 case;（6）adjacent seg ment degeneration of the implant,2 cases;（7）implant affect the infection control,12 cases;（8）non-implant compression,1 case.According to the different causes,the different tactics of changing or removing the im plant were underwent.All these patients were evaluated radiologically by X-ray plain film,three-dimensional CT and magnetic resonance imaging.Among all,the cervical myelopathy patients were evaluated by the modi fied JOA scoring method;the lumbar degenerative patients were evaluated by the Stucki scoring method;and the patients of spine fracture and dislocation with spinal cord injury were evaluated by the ASIA injury grade.Results： There was no intraoperative complication among all the revision patients.But one complication after the surgery was found as the transitory nurological dysfunction caused by hematomaic compression,the patient received the revision surgery again with the removal of hematoma and internal fixation,and nurological function was recoverd.The JOA score of the cervical myelopathy patients before and after the revision surgery did not change significantly;according to the Stucki scoring method,90% of the the lumbar degenerative patients were satisfied with the surgery,90% of them were satisfied with the pain relief and recovery of ambulatory function,and 80% of them were satisfied with the lower limb strength and the balance capability;the patients of spine fracture and dislocation with spinal cord injury had no change on the ASIA injury grade after the revision surgery.After the revision surgery,implants were in good position,fusion rate was 100%,and the infections were controlled.Conclusions： There are many causes of spinal revision surgery for internal instrumentation and appropriate tactic can achieve satisfactory result.As well,we should manage the principle of the internal spinal instrumentation and standardize the procedure to avoid revision surgery.