退变性脊柱侧弯内固定术后神经并发症的原因及处置

目的：探讨椎弓根螺钉内固定术治疗退变性脊柱侧弯（degenerativescoliosis，DS）术后出现神经并发症的发生原因及处理办法。方法：回顾性分析2000年1月至2013年4月行椎弓根螺钉内固定术的DS患者325例，术后出现神经并发症22例，表现为下肢疼痛及麻木16例，下肢感觉、运动功能较术前明显减退6例，对其发生原因进行分析，并根据病因给以营养神经、脱水、激素、再次手术等治疗。在术后3个月、6个月、1年分别通过VAS评分及肌力改善情况对22例患者的神经损伤恢复情况进行观察和评估。结果：轻度神经损伤的16例患者术后3个月症状均有所改善。VAS评分2．81±0．66，与术后1周比较差异有统计学意义（P〈0．05）；术后6个月明显改善，VAS评分1．94±0．77，与术后1周比较差异有统计学意义（P〈0．05）；术后1年症状基本消失，VAS评分0．63±0．62，与术后1周比较差异有统计学意义（p（0．05）。重度神经损伤的6例患者术后3个月2例有所恢复，肌力改善，4例无明显改善，平均VAS评分4．83±1．17，与术后1周比较差异无统计学意义（P〉0．05）；6个月仍无明显改善者3例，VAS评分4．17±0．75，与术后1周比较差异无统计学意义（P〉0．05）；术后1年无明显改善者2例，VAS评分3．00±1．26，但与术后1周比较差异有统计学意义（P〈0．05）。结论：内固定术治疗DS术后出现神经并发症的主要原因包括：术中侧弯过度矫形对脊髓、神经根的牵拉、扭转性损伤；椎弓根螺钉位置不当对神经根的直接性损伤；以及脊髓缺血造成的神经功能障碍。避免上述因素的出现可减少并发症的发生，对并发症的早期发现、及时治疗可减少由此带来的不良后果。

Causes and managements of postoperative neurological complications in internal fixation for the treatment of degenerative scoliosis

Objective: To investigate the causes and managements of postoperative neurological complications in pedicle screw internal fixation for the treatment of degenerative scoliosis(DS). Methods: The data of 325 patients with degenerative scoliosis underwent pedicle screw internal fixation was retrospectively analyzed from February 2000 to April 2013. There were 22 patients with postoperative neurological complications. Of them,16 cases complicated with numbness or pain of lower limb and 6 cases with obvious sensation and motor function decreasing in lower limb. The patients were treated with trophic nerve,dehydration,glucocorticoids,reoperation according to the causes of disease. Postoperative at 3,6 months and 1 year later,according to VAS scoring and muscule power improvement,the recovery of nerve injury was assessed. Results: Postoperative at 3,6 months and 1 year later,VAS scoring of 16 patients with slightly nerve injury was 2.81±0.66,1.94±0.77,0.63±0.62,respectively,and the symptoms had obviously improved than 1 week after operation(P<0.05). Postoperative at 3 months,among 6 patients with severe nerve injury,muscule power improved in 2 cases and no-improved in 4 cases,with VAS scoring of 4.83±1.17; postoperative at 6 months,muscule power still had not improved in 3 cases,with VAS scoring of 4.17±0.75;both of the VAS scoring had not significant difference than 1 week after operation(P>0.05). One year later,there was no muscule power improvement in 2 cases,with VAS scoring of 3.00±1.26,there was significant difference than 1 week after operation(P<0.05). Conclusion: The causes of postoperative neurological complication in internal fixation for the treatment of dengenerative scoliosis includes:dragging and torsion injury of spinal marrow and nerve root because of excessive orthopedic of scoliosis;inderect injury of nerve root because of malposition of pedicle screw;nerve functional impairment caused by spinal cord ischemia. Avoiding the above factors could decrease the complication and early discovery and treatment could decrease the adverse outcomes.