一期后路全脊椎截骨术治疗严重脊柱畸形术后30天非计划再手术原因分析及处理策略

Causal analysis and management strategies of 30-day unplanned revision surgery following single-stage posterior vertebral column resection for severe spinal deformity

目的 探讨一期后路全脊椎截骨术（PVCR）治疗严重脊柱畸形术后30 d非计划再手术的原因及处理措施.方法 回顾性分析2010年5月至2015年12月于解放军第三○六医院骨科行一期PVCR手术治疗的112例严重脊柱畸形患者资料,其中6例术后30 d发生非计划再手术,男性2例,女性4例;年龄12～38岁,平均21岁.包括先天性脊柱侧后凸4例,椎板切除术后脊柱侧后凸1例,陈旧结核性脊柱角状后凸1例.术前3例患者合并下肢神经损伤表现,脊髓功能Frankel分级：C级1例,D级2例.记录PVCR术后30 d非计划再手术的原因、处理措施及临床转归.结果 本组PVCR术后30 d非计划再手术发生率为5.4％.原因：脑脊液漏1例,神经损伤并发症5例,包括硬脊膜褶皱压迫1例、截骨端残留骨块1例、硬膜外血肿2例、急性硬膜下血肿1例.6例患者均进行再次手术,包括硬膜修补、椎板扩大减压、清除骨块及血肿清除等对症处理,均完全恢复.随访时间10～60个月,平均30.8个月.本组6例患者冠状面侧凸Cobb角由术前平均87.7°矫正至34.2°,矫正率为61.0％;矢状面后凸Cobb角由术前平均119.5°矫正至45.5°,矫正率为61.9％.脊髓功能Frankel分级：1例术前C级、2例D级均恢复至E级.结论 一期PVCR手术是治疗严重脊柱畸形的有效方法.术后30 d非计划再手术原因包括脑脊液漏、截骨区硬脊膜褶皱、残留骨块、血肿等;及时再次手术可获得良好的临床疗效.

Objective To investigate the causes of 30-day unplanned revision surgery following one-stage posterior vertebral column resection （PVCR） for severe spinal deformity and the methods of prevention and management.Methods A total of 112 severe deformity patients underwent one-stage PVCR for surgical treatment in the 306th Hospital of People＆#39; s Liberation Army from May 2010 to December 2015 were retrospectively reviewed.Six patients required reoperation within 30 days after PVCR,including 2 males and 4 females with average age of 21 years （ranging from 12 to 38 years）.Four cases were congenital kyphoscoliosis,1 was post-laminectomy kyphoscoliosis and 1 was post-tuberculous angular kyphosis.Three cases associated with preoperative neurologic deficit （Frankel C in 1 patient and D in 2 patients）.The causes,management and outcomes of unplanned revision surgery within 30 days after PVCR were recorded.Results The total incidence of unplanned revision surgery within 30 days following PVCR was 5.4% （6/112）.There was 1 case due to cerebrospinal fluid leak,5 cases with varying degrees of new neurologic deficits,the causes were as followed：dural buckling in 1 case,residual bone compression in 1 case,epidural hematoma compression in 2 cases,spinal subdural hematoma in 1 case.All the 6 cases underwent surgical exploration again,including further dural repair,decompression and hematoma clearance.After unplanned reoperation,6 cases recovered completely.The average follow-up time after surgery was 30.8 months （ranging from 10 to 60 months）.The major curve at coronal plane was improved from preoperative 87.7° to 34.2°,with a mean correction of 61.0% at final follow-up;the sagittal kyphosis curve was improved from preoperative 119.5° to 45.5°,with a mean correction of 61.9% at final follow-up.Two patients＆#39; neurological status improved from Frankel D to Frankel E,one patient＆#39;s neurological status improved from Frankel C to Frankel E.Conclusions One-stage PVCR could be an effective method for treatment of severe spinal deformity.The causes of 30-day unplanned reoperation after PVCR are as followed：cerebrospinal fluid leak,dural buckling,residual bone compression and hematoma compression.Timely surgical exploration can gain good clinical outcomes.