颈椎前路手术后并发椎管内硬膜外血肿的研究

Study on epidural hematomas after anterior approach surgery for cervical spondylosis

目的 探讨颈椎前路手术发生硬膜外血肿的原因及防治策略。方法 回顾分析2013年1月至2015年1月我院收治并行颈椎前路手术的768例手术患者的临床资料。患者均接受前路经颈椎间盘或椎体次全切除减压术、自体髂骨或Cage融合术、肽合金板内固定术治疗。结果 5例患者出现椎管内硬膜外血肿压迫导致脊髓功能下降（其中2例为高血压患者,术中出血50-1 200 m L）,术前日本骨科学会（JOA）评分10-14分,平均12分。5例中2例患者术后即刻出现脊髓功能障碍加重,1例于术后6 h出现双下肢麻木与活动障碍,1例于术后8 h出现单侧肢体感觉功能障碍,1例于术后10 h出现四肢麻木;5例患者早期均给予大剂量甲基强的松龙冲击治疗,并二次行颈椎前路探查术,其中1例患者同时又行后路单开门椎管扩大成形术;术中探查均发现椎管内硬膜外血肿压迫颈髓,经手术清除血肿后,术后神经功能均能恢复,随访3-6个月,平均4个月,术后3个月,4例患者脊髓功能（JOA评分）恢复或优于术前水平,1例患者接近术前水平;术后6个月,5例患者脊髓功能均恢复或优于术前。结论 椎管内硬膜外血肿较椎管外血肿更难发现,可导致严重神经功能障碍。术后24 h是硬膜外血肿的高发期,应密切注意患者肢体感觉和运动情况。如果发现和处理及时,脊髓功能大多数可以恢复至术前水平。术中止血切底,早期发现及手术干预是避免脊髓功能永久性障碍的主要对策。

Objective To investigate the treatment and prevention strategies of postoperative epidural hematomas after anterior approach surgery for patients with cervical spondylotic myelopathy. Methods The clinical data of 768 patients with cervical spondylotie myelopathy who treated with anterior approach surgery in our hospital from January 2013 to January 2015 were retrospectively studied. The surgeries in- cluded anterior cervical diskeetomy（ or corpectomy） and interbody fusion （iliac bone graft or cage or titanium mesh） and locking plates fixa- tion. Results There were 5 patients with spinal cord dysfunction instantly or early after operation, of which 2 patients were combined with hy- pertesion,the blood loss was 50 to 1200 mL. The Japanese Orthopaedic Association（JOA） score was 10 to 14 point,with average 12.4 point preoperatively. Primary clinical manifestations were neurological dysfuction. The symptoms included instant spinal cord injury in 2 patients, loss of the motor and feeling of both legs at 6 hours after surgery in 1 case, paralysis of one side limbs at 8 hours after surgery in 1 case and numbness of limbs at 10 hours after surgery in 1 case. All 5 patients were treated by large dose of methylprednisolone. All the 5 patients un- derwent a second anterior exploration surgery, of which 1 patient received posterior cervical one-door expansive laminoplasty. After surgical in- terventions,the patients presented improvement in neurological function. All the 5 patients were followed up for 3 to 6 months, mean 4 months. The Japanese Orthopedic Association （JOA） score of 4 cases after 3 months were improved, and the score of the other one was im- proved at the final follow-up. Conclusion It is moor difficulty to find the epidural hematomas for it without subcutaneous swelling and blook- ing drain than common postoperative hematomas outside the spinal canal. So close attention should be paid to respiratory and limb sensation and motion functions, especially within 24 hours after anterior approach operation, and MRI should be done resolutely in time. The major cau- ses of postoperative spinal cord injury in anterior approach surgery for cervical spondylotic myelopathy are the delayed postoperative injury. Early detection and early surgical interventions are the key countermeasures to avoiding the severe resluts. The spinal cord can recover to nor- maf and has satisfactory prognosis if discovered promptly.