【摘要】：目的:分析后路全脊椎截骨治療嚴(yán)重僵硬性先天性脊柱畸形的并發(fā)癥,探討術(shù)中體感誘發(fā)電位監(jiān)測(cè)的應(yīng)用價(jià)值。方法:2007年6月至2012年11月,88例嚴(yán)重僵硬性脊柱畸形患者在我院接受后路全脊椎截骨治療。男性39例,女性49例,年齡6~46歲,平均(17±7)歲。先天性側(cè)凸18例,先天性側(cè)后凸63例,先天性后凸7例。27例合并椎管內(nèi)畸形,15例術(shù)前神經(jīng)功能異常,25例肺功能異常。測(cè)量患者術(shù)前、術(shù)后及隨訪時(shí)Cobb角、平衡情況,記錄手術(shù)情況、術(shù)中神經(jīng)電生理監(jiān)測(cè)情況、神經(jīng)并發(fā)癥及隨訪情況等。分析并發(fā)癥發(fā)生率,探討發(fā)生神經(jīng)系統(tǒng)并發(fā)癥的高危因素。并分析體感誘發(fā)電位波幅變化率與手術(shù)因素的相關(guān)性。結(jié)果:所有患者隨訪24~88個(gè)月,平均47個(gè)月。切除椎體1~3個(gè),平均1.3個(gè),固定椎體數(shù)3~16個(gè),平均10.9個(gè),手術(shù)時(shí)間165.0~880.0min,平均(502.4±170.3)min,出血量100~11500ml,平均(2238±2214)ml,出血比9%~299%,平均69.3%。冠狀位Cobb角由術(shù)前平均93.6°±25.1°矯正至22.2°±13.1°,末次隨訪22.9°±13.2°,矯形率76.8%。冠狀位失衡(絕對(duì)值)由術(shù)前平均2.5cm減少至1.3cm。矢狀位Cobb角由術(shù)前平均88.2°±25.6°矯正至28.7°±16.9°,末次隨訪29.2°±17.0°,矢狀位Cobb角平均減少59.0°±16.8°。矢狀位失衡(絕對(duì)值)由術(shù)前平均3.1cm減少至1.2cm。術(shù)中術(shù)后并發(fā)癥共計(jì)42例(47.7%),術(shù)中并發(fā)癥40例(45.5%),包括出血比50%37例(42.0%),胸膜破裂1例(1.1%)、硬膜破裂1例(1.1%)及術(shù)中神經(jīng)電生理監(jiān)測(cè)異常12例(13.6%);術(shù)后并發(fā)癥24例(27.3%),包括上呼吸道感染2例(2.3%)、肺部感染并胸腔積液1例(1.1%)、泌尿系感染1例(1.1%)、蘇醒延遲7例(8.0%)、肺膨脹不良1例(1.1%)、腦脊液漏1例(1.1%)、一過性呼吸困難1例(1.1%)、神經(jīng)并發(fā)癥12例(13.6%)。手術(shù)時(shí)間≥480 min、肺功能異常、出血比50%、T7~T9截骨及術(shù)前神經(jīng)功能異常患者神經(jīng)并發(fā)癥發(fā)生率較高(P=0.046,0.000,0.000,0.033,0.043)。12例患者出現(xiàn)術(shù)中體感誘發(fā)電位監(jiān)測(cè)異常,敏感性83.3%,特異性97.4%,假陽性率2.6%,假陰性率16.7%。手術(shù)時(shí)間、出血比、固定節(jié)段與術(shù)中體感誘發(fā)電位監(jiān)測(cè)波幅的下降率存在直線相關(guān)(p=0.000,0.000,0.000),出血比影響最大。結(jié)論:后路全脊椎截骨治療嚴(yán)重僵硬性先天性脊柱畸形能夠獲得滿意的療效。肺功能異常、出血比50%是其神經(jīng)并發(fā)癥的高危因素;術(shù)中體感誘發(fā)電位監(jiān)測(cè)敏感性較高,但影響因素多、單獨(dú)使用存在缺陷,因此需要合理的聯(lián)合使用多種監(jiān)測(cè)手段。
[Abstract]:Objective: to analyze the complications of posterior total spinal osteotomy in the treatment of severe rigid congenital spinal deformity and to explore the value of monitoring somatosensory evoked potentials (SEP) during operation. Methods: from June 2007 to November 2012, 88 patients with severe stiff spinal deformity were treated with posterior total spinal osteotomy in our hospital. Male 39 cases, female 49 cases, age 646 years, mean (17 鹵7) years old. There were 18 cases of congenital scoliosis, 63 cases of congenital scoliosis, 7 cases of congenital kyphosis, 27 cases of intraspinal malformation, 15 cases of preoperative neurological dysfunction and 25 cases of pulmonary dysfunction. The Cobb angle, balance, operation, intraoperative electrophysiological monitoring, neurologic complications and follow-up were measured. To analyze the incidence of complications and explore the high risk factors of neurological complications. The correlation between the amplitude of somatosensory evoked potential (SEP) and surgical factors was analyzed. Results: all patients were followed up for 24 ~ 88 months (mean 47 months). The number of fixed vertebrae was 3 ~ 16 (mean 10.9). The operative time was 165.0 ~ 880.0min, and the average bleeding volume of (502.4 鹵170.3) min, was 100 ~ 11500 ml, the average ml, bleeding was (2238 鹵2214) ml,. The coronal Cobb angle was corrected from 93.6 擄鹵25.1 擄to 22.2 擄鹵13.1 擄, and the last follow-up was 22.9 擄鹵13.2 擄. The coronal imbalance (absolute value) was reduced from preoperative mean 2.5cm to 1.3 cm. The sagittal Cobb angle was corrected from 88.2 擄鹵25.6 擄to 28.7 擄鹵16.9 擄, the last follow-up was 29.2 擄鹵17.0 擄, and the sagittal Cobb angle was reduced by 59.0 擄鹵16.8 擄. Sagittal imbalance (absolute value) was reduced from preoperative mean 3.1cm to 1.2 cm. There were 42 cases (47.7%) of intraoperative complications, 40 cases (45.5%) of intraoperative complications, including 507 cases (42.0%) of bleeding, 1 case (1.1%) of pleural rupture. Dural rupture occurred in 1 case (1.1%) and abnormal neurophysiological monitoring in 12 cases (13.6%). Postoperative complications were found in 24 cases (27.3%), including upper respiratory tract infection in 2 cases (2.3%), pulmonary infection with pleural effusion in 1 case (1.1%), urinary tract infection in 1 case (1.1%), delayed recovery in 7 cases (8.0%). Pulmonary dyspnea was found in 1 case (1.1%), cerebrospinal fluid leakage in 1 case (1.1%), transient dyspnea in 1 case (1.1%), neurological complications in 12 cases (13.6%). The incidence of neurologic complications was higher in patients with abnormal pulmonary function than 50% T7 / T9 osteotomy and preoperative neurologic dysfunction (P0. 046 / 0. 0000.0000.000 / 0. 03 / 0.043). 12 patients had abnormal monitoring of somatosensory evoked potentials (SEP) during the operation, and 12 patients had abnormal monitoring of somatosensory evoked potentials (SEP) during operation. Sensitivity 83.3%, specificity 97.4%, false positive rate 2.6%, false negative rate 16.7%. There was a linear correlation between the operation time, bleeding ratio and fixed segment and the decrease rate of somatosensory evoked potential monitoring amplitude during the operation (P < 0.000 ~ 0.000 ~ 0.000), and the bleeding ratio was the most significant. Conclusion: posterior total spinal osteotomy can achieve satisfactory results in the treatment of severe rigid congenital spinal deformity. Abnormal lung function and 50% bleeding ratio were the high risk factors for neurological complications. The sensitivity of somatosensory evoked potential monitoring was high, but there were many influencing factors, so it was necessary to use a reasonable combination of multiple monitoring methods.
【學(xué)位授予單位】：第四軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類號(hào)】：R687.3

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1 楊軍林;黃紫房;鄧耀龍;李佛保;舒海華;陳裕光;魏明;劉衛(wèi)鋒;孫新銳;;SSEP、MEP和DNEP在重度脊柱畸形截骨矯形術(shù)中同時(shí)聯(lián)合監(jiān)測(cè)的意義[J];脊柱外科雜志;2011年06期

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