重度脊柱畸形合并神经功能障碍的手术治疗

Surgical treatment of severe spinal deformity combined with neurological deficits

目的：探讨脊柱后路手术治疗重度脊柱畸形合并神经功能障碍的疗效。方法回顾性分析14例后路手术治疗重度脊柱畸形合并神经功能障碍患者的临床情况。其中先天性脊柱畸形9例，神经纤维瘤病性脊柱畸形2例，特发性脊柱畸形1例，结核性脊柱畸形1例，退行性脊柱畸形1例。既往有脊柱矫形手术史者2例。术前侧凸Cobb’s角平均98.4°（53～150）°，后凸Cobb’s角平均104°（48～151）°。术前神经功能按Frankel分级，B级2例，C级3例，D级9例。4例行经椎弓根V形截骨术（pediclesubtractionosteotomy， PSO）截骨减压内固定矫形，1例行经后路全脊椎截骨术（posteriorvertebralcolumnresection，PVCR）截骨减压内固定矫形，1例行半椎体切除内固定矫形，4例行椎板切除减压内固定矫形，2例行单纯后路内固定矫形，1例行内固定更换矫形术，1例行内固定取出术。术中7例行体感诱发电位（somatosenory-evokedpotential， SEP）进行神经功能监测，全部患者均行术中唤醒试验。结果14例随访12～69个月，平均36.6个月。术后侧凸Cobb’s角平均55°（5～100）°，矫正率44.1%；后凸Cobb’s角平均62.1°（25～92）°，矫正率40.2%。随访时侧凸和后凸平均丢失1.7°和4.8°。7例术中行SEP监测的患者，5例无法记录到可靠的SEP波形。5例术后神经症状加重（35.7%），行神经营养、激素冲击及高压氧治疗后3例有改善。末次随访脊髓功能，B级2例， D级1例，E级11例。神经功能较术前比，11例改善（78.6%），1例未改善（7.1%），2例恶化（14.3%）。结论重度脊柱畸形合并神经功能障碍的患者，手术治疗在改善神经功能方面可取得较好的效果，但是此类患者畸形严重，术前存在神经功能损伤，术中神经电生理监测困难，难以早期发现脊髓损伤，术后可能出现神经症状加重。

Objective To evaluate the clinical outcomes of surgical treatment of severe spinal deformity combined with neurological deifcits through a posterior approach. Methods A retrospective study on 14 patients with severe spinal deformity combined with neurological deifcits who were treated by posterior surgery was performed. Etiologic diagnoses were congenital in 9 cases, neurofibromatosis in 2 cases, idiopathic in 1 case, tuberculous in 1 case and degenerative in 1 case. Two patients had prior spinal surgeries. The average preoperative Cobb’s angles of scoliosis and kyphosis were 98.4° （ range：53°-150° ） and 104° （ range：48°-151° ） respectively. According to the Frankel grading system, the preoperative neurological function was rated as grade B in 2 cases, grade C in 3 cases and grade D in 9 cases. Pedicle subtraction osteotomy （ PSO ） was performed on 4 patients, posterior vertebral column resection （ PVCR ） on 1 patient, hemivertebra resection on 1 patient, laminectomy and internal ifxation on 4 patients, posterior internal ifxation on 2 patients and revision on 1 patient. And 1 patient underwent ifxation removal surgery. The neurological function in half of the 14 patients were detected by somatosenory-evoked potential （ SEP ） monitoring and all the patients underwent the wake-up test during the surgery. Results The average follow-up period was 36.6 months （ range： 12-69 months ）. The average postoperative Cobb’s angles of scoliosis and kyphosis were 55° （ range：5°-100° ） and 62.1° （ range：25°-92° ）, with the average correction rates of 44.1%and 40.2%and the average losses of correction of 1.7° and 4.8°. Five of the 7 patients with SEP monitoring had no reliable SEP waves intraoperatively. The neurological symptoms got worse postoperatively in 5 patients and the total incidence was 35.7%.Three of them got improved after the treatment of emergent methylprednisolone and neurotrophic drugs and hyperbaric oxygen therapy. In the latest follow-up, the neurological function was improved in 11 patients （ 78.6%）, not improved in 1 patient （ 7.1%） and worse in 2 patients （ 14.3%）. Conclusions The neurological function of the patients with severe spinal deformity combined with neurological deifcits can be effectively improved after surgical treatment. But the deformity of these patients is severe and many patients have no reliable SEP waves intraoperatively. So it is dififcult to ifnd spinal cord injuries at an early stage, and the neurological function may get worse postoperatively.