腰椎后路内固定融合术并发神经损伤的原因分析和处理

Cause analysis and treatment of nerve damage after posterior lumbar fusion for lumbar disease

目的探讨椎弓根螺钉固定植骨融合治疗腰椎病变并发神经损伤的原因及处理方法,并提出预防性措施。方法回顾性分析1995年1月—2011年12月本院采用椎弓根螺钉固定治疗腰椎病变并发神经损伤的病例48例,其中马尾神经损伤3例,神经根损伤45例。神经损伤的原因：1操作损伤;2螺钉位置不正确损伤;3植骨块卡压;4椎管血肿压迫;5其他原因。1例血肿压迫所致的马尾神经损伤病例进行了椎管探查和血肿清除术,另2例马尾神经损伤患者予非手术治疗;由于操作所致神经根损伤的15例病例予非手术治疗,螺钉位置不正确所致神经根损伤的30例患者均进行了螺钉调整术。结果失访5例,余43例获得12-60个月的随访,平均随访21.2个月。获得随访的3例马尾神经损伤的患者神经功能均有不同程度的恢复。15例因术中操作所致神经根损伤的病例,其中2例失访,其余神经功能完全恢复3例,部分恢复6例,未恢复4例;30例因螺钉位置不正确所致神经根损伤的病例,其中3例失访,其余神经功能完全恢复20例,大部分恢复5例,部分恢复1例,未恢复1例。再次手术病例除1例出现切口深部急性感染外,其余病例切口均Ⅰ期愈合。结论椎弓根螺钉固定融合术后并发神经损伤的原因除了病情的严重性和复杂性,还有手术操作、螺钉位置不正确和植骨块卡压等因素。神经损伤只要尽早发现,及时治疗,大部分病例神经功能可有不同程度的恢复。而对于神经损伤的预防,要求术者对病情全面掌握,选择合适的手术方式,术中操作严谨、细致,并借助影像系统的帮助。

Objective To explore the causes and therapeutic methods for nerve damage after posterior lumbar fusion（PLF） for lumbar diseases,and to propose preventive measures. Methods Clinical data of 48 patients with nerve damage after PLF for lumbar disease from January 1995 to December 2011 were analyzed retrospectively. There were 3 cases of cauda equina injury and 45 nerve root injury. The causes for nerve damage included operation injury,incorrect screw position,graft entrapment,spinal hematoma compression and other unexplained. One patients with cauda equina injury induced by hematoma compression received spinal exploration and hematoma evacuation. Other 2 patients of cauda equina injury received non-surgical treatment. Fifteen patients with operation-induced nerve root injury received non-surgical treatment,and 30 nerve root injury induced by incorrect screw position received screw adjustment. Results Five patients were lost to follow-up. The remaining 43 were followed up for 12- 60 months,mean 21.2 months. Neurological function in 3 cases of cauda equina injury was restored to different degrees. The recovery of neurological function in 15 cases of operation-induced nerve root injury was as follows： loss to follow-up in 2 complete recovery in 3,partial recovery in 6,and no recovery in 4. The recovery of neurological function in 30 cases of nerve root injury induced by incorrect screw position was as follows： loss to follow-up in 3,complete recovery in 20,most recovery in 5,partial recovery in 1,and no recovery in 1. Of patients undergoing reoperation,1 patient suffered from acute infection in the deep incision,and the others had primary wound healing. Conclusion Nerve damage after PLF is not only associated with disease severity and complexity,but also with operative procedure,incorrect screw position and graft entrapment. As long as early detection and timely treatment,neurological function of most patients with nerve damage can restore to different degrees. For preventing nerve damage,surgeons should meticulously master patient＇s condition,and choose suitable surgical approach,and rigorously perform the surgery with the help of imaging systems.