一期后路截骨矫形术治疗重度脊柱畸形术后的并发症分析及处理

Analysis and treatment of postoperative complications using one.stage posterior spinal osteotomy in the treatment of se- vere spinal deformity

目的探讨一期后路截骨矫形术治疗重度脊柱畸形术后并发症原因及处理。方法回顾性分析2006年9月至2013年5月，采用一期后路截骨矫形内固定术治疗147例重度脊柱畸形患者资料，其中17例术后发生病发症，男5例，女12例；年龄14—51岁，平均22．6岁；先天性脊柱侧凸11例，先天性脊柱后凸4例，先天性脊柱侧后凸2例；术前主弯侧凸Cobb角85。-1600，平均109。；后凸Cobb角65。~152。，平均104。。术前2例患者有神经症状，美国脊髓损伤协会ASIA分级均为D级。手术均采用椎弓根钉棒系统矫形固定，其中采用Smith．Petersen截骨术2例、经椎弓根截骨术11例、全脊椎截骨术4例。结果17例出现并发症，并发症发生率为11．6％（17／147）。其中椎弓根螺钉置入椎管2例、截骨端合拢压迫及牵拉神经2例、截骨处残留骨块压迫神经1例、急性脊髓损伤2例、感染2例、断棒及脱帽3例、肠系膜上动脉综合征5例。术后7例发生神经系统并发症，其中2例由术前ASIA分级D级变为c级，5例由神经功能正常变为c级2例、D级3例。采用再次手术调整钉棒、应用甲基泼尼松龙、神经营养药物、取出内固定、抗感染、翻修换棒及对症处理，15例完全恢复，2例好转。结论严重脊柱畸形一期后路截骨矫形术后会出现神经系统及断棒、脱帽、肠系膜上动脉综合征等并发症。为避免发生并发症，术中应提高椎弓根钉置入的准确性，合理安置螺钉数量及位置，截骨端牵拉加压应适度，并彻底咬除截骨端骨块，术后密切观察肢体感觉及运动变化情况，及时手术探查并解除神经致压因素，同时给予激素冲击、神经营养等药物，术后早期需佩戴合适支具，避免暴力撞击手术部位。

Objective To analyze the cause and treatment of the postoperative complications using one-stage posterior spinal osteotomy in the treatment of severe spinal deformity. Methods From September 2006 to May 2013, 17 patients with se- vere spinal deformity （congenital scoliosis in 11 cases, congenital kyphosis in 4 cases, and congenital kyphoscoliosis in 2 cases） underwent one-stage posterior spinal osteotomy, including 5 males and 12 females with an average age of 22.6 （14 -51） years. The preoperative mean coronal Cobb angle was 109~ （85^- 160~） while the mean sagittal Cobb angle was 104~ （65^- 152~）. Two pa- tients had neurological symptoms preoperatively whose spinal cord function was D, evaluated by ASIA classification. All patients were treated with pedicle subtration osteotomy and pedicle screw internal fixation, which SPO osteotomy 2 cases, PSO osteotomy 11 cases, VCR osteotomy 4 cases. Results There were 17 cases of complications in 147 patients, the complication rate was 11.6%（17/147）. The causes were as followed, screw malposition in 2 cases, compromised by close of resected areas in 2 case, re- sidual bone compression in 1 case, acute spinal cord injury in 2 cases, infection in 2 cases, broken stick or loosen hat in 3 cases, and superior mesenteric artery syndrome in 5 cases. Postoperative neurological complications occurred in 7 cases. Two cases with preoperative ASIA D became ASIA C, 5 cases with normal nerve function became ASIA C in 2 cases and ASIA D in 3 cases. After surgical exploration, given Methylprednisolone and neurotrophic drugs, removal or changing of the internal fixation, anti-infection and symptomatic treatment, 15 cases recovered completely and 2 cases improved partially. Conclusion One-stage posterior spi- nal osteotomy for severe spinal deformity is technical demanding and risky, and the postoperative complications are common. Ap- propriate operative procedure, close observation of sensation and motor function, timely surgical exploration and nerve decompres- sion, and early brace wear are all required.