颈椎前路手术并发食管瘘的治疗

目的 :探讨颈椎前路手术并发食管瘘的治疗措施及其效果。方法 :回顾性分析2006年9月~2016年7月颈椎前路手术并发食管瘘的8例患者资料,其中男6例,女2例;年龄31~71岁(52.32±13.05岁)。外伤性颈椎骨折4例(其中强直性脊柱炎2例),颈椎病2例,颈椎结核1例,颈椎畸形1例。术中发现食管瘘1例,当即给予修补;术后早发性(1个月内)食管瘘6例,其中2例经呋喃西林纱布条换药处理,2例行清创探查引流术并在术中给予修补,1例清创探查术后给予胸锁乳突肌瓣填塞,1例因脓毒血症死亡;迟发性(1个月后)食管瘘1例,行内固定取出清创探查,并肌瓣填塞。同时所有患者行伤口细菌培养,应用敏感抗生素,鼻饲饮食加强营养等治疗。结果:1例强直性脊柱炎合并颈椎骨折脱位患者,于术后第4天出现食管瘘,术后第7天因脓毒血症死亡;其余7例食管瘘口均愈合,愈合时间为2周~2.5个月;随访1~5年(2.86±1.36年),7例均无复发,且吞咽功能良好。结论:依据食管瘘发生的时间,结合其大小和污染程度采取不同的治疗方案,可取得较好的疗效。     

颈椎前路内固定术后食管瘘

目的探讨颈椎前路内固定术后食管瘘的病因、治疗及预防措施。方法总结1999年以来5例患者,采用手术清创、钢板取出,瘘口修补或旷置,术后严格禁食水,加强支持治疗及抗感染等。结果经0.5-6个月全部病例均愈合恢复进食,随访3-24个月无复发。结论颈椎前路内固定术后食管瘘是一种严重的并发症,关键在于预防,发生后常需取出内固定钢板。     

颈椎前路内固定术后中远期食管并发症

 目的 探讨颈椎前路内固定术后中远期食管并发症的发生率及其诊疗策略。方法 对2001年1月至2011年12月2316例行颈椎前路内固定手术患者发生的中远期食管并发症情况进行回顾性分析。食管中远期并发症包括术后2周以上发生的食管穿孔、食管气管瘘、食管皮下瘘、食管憩室、食管胸膜瘘及食管狭窄等。结果 共4例患者发生中远期食管并发症,发生率为0.17%(４/２３1６),其中食管穿孔发生率为0.09%(2例)。病例1为31岁男性患者,自体髂骨移植融合加钢板内固定(C5)术后7年发现食管憩室合并食管穿孔。手术取出内固定,清创后切除憩室,胸骨舌骨肌及肩胛舌骨肌肌瓣修补食管。病例2为46岁男性患者,自体髂骨移植融合加钢板内固定(C5)术后3年发现食管憩室。手术取出内固定,切除食管憩室,胸骨舌骨肌及肩胛舌骨肌肌瓣修补食管。病例3为58岁女性患者,自体髂骨移植融合加钢板内固定(C6)术后5年出现食管憩室。手术取出内固定,切除食管憩室,胸锁乳突肌肌瓣修补食管。病例4为56岁女性患者,钛网植骨融合加钢板内固定(C6)术后3年出现食管穿孔。手术取出内固定,清创后胸锁乳突肌肌瓣修补食管。4例患者术后食管并发症均获得成功治疗,恢复良好。结论 颈椎前路内固定术后中远期食管并发症的发生率较低,X线片、消化道造影及消化道内镜检查是主要的诊断方法,手术是其主要的治疗手段。     

早期清创闭合负压引流二期修复治疗颈椎前路术后并发食道瘘的疗效观察

目的:观察早期清创闭合负压引流二期修复治疗颈椎前路手术后并发食道瘘的效果。方法:2006年2月~2012年2月我院收治颈椎前路手术后并发食道瘘患者5例,其中我院行颈椎前路手术728例中术后并发食道瘘3例,外院转入2例。4例术后5~9d出现食道瘘,1例术后46d出现。经食道镜确诊食道瘘后,立即放置胃管,改鼻饲营养支持,静脉使用广谱抗菌素,沿原手术切口进入,拆除所有缝线,行清创术。1例迟发性食道瘘患者术中发现植骨颗粒已经部分感染、溶解,取出内固定和植骨块,术后行Halo外固定架固定;其余4例内固定均予保留。彻底清创后,将负压引流泡沫修剪成合适大小楔形放置于切口内,缝合皮肤固定泡沫,用生物贴膜覆盖泡沫贴紧于切口周围皮肤上以保持切口内密闭状态,接负压引流持续冲洗10~12d后,拆除密闭负压引流装置,常规换药2~3d后行二期食道修补术,食道瘘口均使用可吸收线缝合;迟发性食道瘘者瘘口较大术中加用生物蛋白胶覆盖已修复的瘘口,并再次行自体髂骨植入,使用Halo外固定架固定。术后常规放置切口引流管2~3d,9~12d切口拆线。结果:4例患者食道修补术后颈部切口愈合良好;随访6个月~6年,原颈部切口瘢痕愈合,无吞咽困难与颈部疼痛,无迟发性感染出现。1例迟发性食道瘘患者食道修补术拆线后切口仍有少许淡黄色透明分泌物,常规换药后1周瘢痕愈合,出院后1个月在家中死亡,死因不明,死亡时颈部切口愈合良好。结论:早期清创闭合负压引流二期修复治疗颈椎前路术后并发食道瘘有效。     

置管并负压引流治疗颈椎前路手术并发食管瘘

目的探讨颈椎前路手术并发食管瘘的原因及预防措施,并观察置管冲洗负压引流治疗的效果。方法回顾性分析自2001-03—2014-10诊治的18例颈椎前路手术并发的食管瘘。3例行一期清创、瘘道口缝合,放置引流管引流。4例行一期清创、瘘道口部分缝合,伤口畅开呋喃西林纱条填塞。11例行一期清创、瘘道口缝合,放置冲洗管和负压引流管。结果 18例均获得随访2~36个月,平均12个月。一期清创、瘘道口缝合、负压引流11例中1例因瘘道口未愈合,反复感染,经长期换药20周窦道形成,随访36个月后窦道未完全愈合。将一期清创、瘘道口缝合、单纯引流和呋南西林纱条填塞治愈的7例定为换药组,将一期清创、瘘道口缝合、负压引流治愈的10例定为冲洗组。换药组食管瘘停止时间为(11.2±6.8)周,冲洗组为(4.2±4.9)周,冲洗组食管瘘停止时间明显早于换药组,差异有统计学意义(t=2.848,P0.05)。结论颈椎前路术后并发食管瘘治疗较棘手,在结合手术修补、全身支持治疗的同时,采用置管冲洗并负压引流的方法治疗可以取得较满意的疗效。     

颈前路术后口服亚甲蓝诊断早期食管损伤

[目的]探讨一种早期发现颈椎前路手术后食管瘘的诊断方法。[方法]回顾性分析2006年1月～2018年12月在5所三甲医院脊柱外科采用颈椎前路手术治疗的6 182例颈椎疾病患者资料,所有患者均在术后2～6 h即开始口服亚甲蓝溶液,若引流管内或切口内有蓝色液体渗出,则考虑存在食管瘘。[结果] 1例颈椎结核患者术中发现食管瘘,未进行修补;10例在术后第1 d口服完500 ml亚甲蓝溶液后发现了早期食管瘘,无迟发性食管瘘发生。所有患者均采取禁饮食,留置胃空肠管,预防感染及对症营养支持治疗后获得治愈。[结论]颈椎前路手术后并发食管瘘诊疗的关键是早期发现,进食之前留置胃空肠管旷置处理即可治愈。颈前路术后口服亚甲蓝是一种安全,有效、值得推广的诊断早期食管瘘的方法。     

颈前路再手术后并发颈动脉窦强烈反应致难治性低血压1例报告

<正>颈椎前路术后食管瘘的发生率为0.06%,取出内置物是治疗的关键[1]。但由于周边重要血管神经的存在及组织的粘连,导致颈前路再手术出现并发症的风险大大增加。我科收治1例颈前路术后食管瘘患者,取出内置物后出现难治性低血压,考虑由颈动脉窦强烈反应(carotid sinus hyperactivity,CSR)所致,报道如下。患者男性,58岁,因"颈椎外伤术后近10年,右颈部     

颈椎前路内固定术后并发颈前部血肿的原因分析及其治疗策略

目的探讨颈椎前路内固定术后早期并发颈前部血肿的原因及其治疗策略。方法回顾性分析自2008-01—2015-12颈椎前路内固定术后并发颈部血肿5例(脊髓型颈椎病2例,神经根型颈椎病2例,颈椎骨折1例),均于全身麻醉下行颈前部术口探查及血肿清除术。结果 5例获得随访15~75个月,平均34.6个月。末次随访时,颈椎骨折患者ASIA分级由C级恢复到E级,2例脊髓型颈椎病患者JOA评分提高到术后14.5分及15分,2例神经根型颈椎病患者VAS评分降低至术后2.5分及2分。颈椎前路手术效果显著,血肿清除术未影响手术疗效。结论颈椎前路内固定术后早期并发颈前部血肿可压迫气道引起呼吸困难,甚至危及生命,及时行术口探查血肿清除术至关重要。颈椎前路内固定术中仔细轻柔操作、缝合切口前确保无活动性出血是预防颈前部血肿形成的关键。     

非恶性食管-气管/支气管瘘的外科治疗

目的探讨非恶性食管-气管/支气管瘘的临床特点和处理方法。方法回顾性分析2002年1月至2011年10月北京协和医院收治12例非恶性食管-气管/支气管瘘患者的临床资料,其中男6例,女6例;平均年龄49.8(32～72)岁。食管气管瘘7例,食管支气管瘘1例,食管癌术后胸胃支气管瘘2例,食管憩室支气管瘘2例。右侧开胸入路9例,左侧开胸3例。行食管瘘、气管瘘修补7例;食管瘘、支气管瘘修补1例;胸胃瘘、支气管瘘修补术2例;食管下段、左肺下叶切除,食管胃弓下吻合术1例;左肺下叶切除,食管憩室瘘修补术1例。结果全部患者均顺利恢复,无手术合并症或死亡,7～10 d恢复经口进食。术后3个月～1年内复查纤维支气管镜及上消化道造影,无气管支气管狭窄,无食管狭窄,不必采用支架或扩张治疗。术后随诊3个月～10年,均恢复良好。结论食管-气管/支气管瘘排除恶性病因,明确瘘口位置,术前给予充分营养支持,手术Ⅰ期修补瘘口,可以获得良好的治疗效果。     

颈椎前路减压并发脑脊液漏的手术治疗

目的探讨颈椎病前路减压并发脑脊液漏的手术治疗方式及其疗效。方法对颈椎前路减压术后脑脊液漏6例采用非手术治疗,仍持续存在脑脊液漏,均再次行手术探查修补治疗。结果经探查修补手术治疗后,6例均治愈。术后随访3～20个月,神经功能恢复良好,无切口感染及脑脊液囊肿形成。结论对颈椎前路减压术后脑脊液漏经非手术治疗后效果不明显者,采用手术探查人工硬脑膜、纤维蛋白凝胶等修补治疗,疗效满意。     

Pharyngocutaneous fistula after anterior cervical spine surgery

Pharyngocutaneous fistulae are rare complications of anterior spine surgery occurring in less than 0.1% of all anterior surgery cases. We report a case of a 19 year old female who sustained a C6 burst fracture with complete quadriplegia. She was treated urgently with a C6 corpectomy with anterior cage and plating followed by posterior cervical stabilization at another institution. Post operatively she developed a pharyngocutaneous fistula that failed to heal despite several attempts of closure and esophageal exclusion with a Jpeg tube. The patient was eventually successfully treated with a three-stage procedure consisting of firstly a posterior approach to reinforce the posterior stabilization of the cervical spine that was felt to be inadequate, secondly an anterior approach with removal of all the anterior instrumentation followed by iliac crest bone graft and thirdly a superior based sternocleidomastoid flap that was interposed between the esophagus and the anterior cervical spine. The patient's fistula healed successfully. However, yet asymptomatic, the anterior iliac crest bone graft resorbed almost completely at 16 months follow up. In light of this complication, we discuss the surgical options for the treatment of pharyngocutaneous fistulae and the closure of this fistula using a superiorly based sternocleidomastoid muscle flap.     

颈椎前路手术早期并发症原因分析及对策

目的总结颈椎前路手术的术中、术后早期并发症,分析原因并提出对策。方法回顾1992年1月至2003年12月颈椎前路手术412例,男308例,女104例;年龄18～76岁,平均45.6±12.9岁。颈椎病258例,颈椎外伤138例,颈椎肿瘤8例,颈椎结核8例。412例患者,病史最短4小时,最长达20年,平均548d。全瘫58例(14.1%),不全瘫192例(46.6%),无瘫痪症状162例(39.3%)。麻醉包括三大类(5种)局麻(局部浸润35例、颈丛阻滞52例、局部浸润 颈丛阻滞6例、全麻318例、全麻 颈丛1例。前路减压、自体髂骨植骨融合33例,前路减压、椎间融合器椎间融合术32例,前路减压、自体髂骨植骨融合、前路钢板内固定术347例。结果共42例51例次出现早期并发症,并发症的例次发生率为12.37%。28例次(6.80%)同手术直接相关,喉上神经损伤5例次,喉返神经损伤4例次,颈部切口感染及血肿4例次,脊髓损害症状加重5例次,神经根损伤2例次,植骨块移位2例次,取骨区感染及血肿各1例次,钢板、螺钉松动2例次,螺钉位置不当1例次,食管瘘1例次;23例次(5.08%)同手术间接相关。结论降低颈椎前路手术并发症的发生率,不仅要熟悉颈椎前路临床解剖,提高手术技巧,还要做好颈椎前路手术围手术期的处理。     

成人颈椎结核外科治疗的术式选择

目的 探讨成人颈椎结核外科治疗的术式选择.方法 2例枢椎结核患者,行前路经颈部病灶清除、自体髂骨植骨融合并Halo架外固定,其中1例1个月后再次行后路枕颈融合术.13例下颈椎结核患者, 9例采用经前路一期病灶切除、自体骼骨植骨融合并前路钛合金钢板内固定术,4例采用前路病灶清除并自体髂骨植骨及Halo架外固定.15例均接受9～12个月的规范抗结核药物治疗.结果 所有患者切口均一期愈合,随访1～6年,局部无复发,植骨均融合,平均融合时间为3.9个月(3.5～4.5个月).6例脊髓损害患者中,4例恢复至E级,2例C级仅感觉改善,肌力无恢复.结论 颈椎结核应积极采用手术治疗.彻底病灶清除及有效稳定性重建是治疗颈椎结核的关键环节.     

Cervical spondylosis: the role of anterior instrumentation after decompression and fusion

The role of plate stabilization after anterior decompression and fusion of the cervical spine for cervical spondylosis remains controversial. This study aimed to justify the use of instrumentation to stabilize anterior cervical fusion for cervical spondylosis through a risk-benefit analysis and comparison of the results with those reported in the literature on the outcome of fusion without instrumentation. The authors retrospectively reviewed the charts and radiographs of 47 patients with symptoms secondary to cervical spondylosis who underwent anterior cervical decompression and instrumented fusion. After operation, patients were mobilized early, and neither neurologic injury nor infection developed in any patient. At an average 3.4 years after surgery, the rate of graft complications, including nonunion (4.26%), was low, whereas the rate of hardware-related morbidity was minimal (6%). An average 0.4 degrees loss of the intraoperative correction of cervical lordosis was observed at the last follow-up examination. Accelerated degenerative changes at levels adjacent to the fusion were seen in 17% of patients, but only two patients required repeat operation for persistent symptoms. The use of instrumentation to stabilize the cervical spine in patients with cervical spondylosis after anterior decompression and fusion is relatively safe. It permits early pain-free mobilization, successfully maintains sagittal cervical spine alignment, and promotes consistent and reliable spinal fusion.     

Delayed esophageal injury without instrumentation failure: complication of anterior cervical instrumentation

The authors describe a case of a 67-year-old man who presented with a delayed esophageal perforation 4 years after anterior cervical spine surgery for spondylotic myelopathy. Diagnosis was made with esophagoscopic visualization of the lesion and repair performed with hardware removal and esophageal closure utilizing a sternocleidomastoid muscle flap. The pertinent literature is reviewed and the therapeutic implications discussed.     

Esophageal injury associated with anterior cervical spine surgery

BACKGROUND: Anterior cervical spinal surgery has been used to treat a variety of conditions including spondylosis, fracture, tumor, infection, trauma, and instability. Esophageal perforation, a rare and unusual complication of anterior cervical procedures, has been largely relegated to only incidental case reports with few large retrospective studies performed to determine true incidence, treatment, etiology, and outcome. METHODS: More than 3000 anterior cervical spine surgeries conducted over a 30-year period by 5 active practicing surgeons were reviewed. There were 3 cases of esophageal injury identified with subsequent critical evaluation to determine presentation, diagnosis, risk factors, management, and outcomes. In addition, incidence rates were calculated based on overall occurrence and antecedent risk factors. RESULTS: Two of the patients with esophageal injury had predisposing risk factors, including diverticula or cervical spine trauma. The third patient had no antecedent risk factors. Symptoms included axial spine pain, odynophagia, dysphagia, purulent spondylitis, and sepsis. Treatment consisted of one or more of the following: reoperation with exploration and repair, esophageal diversion, esophageal rest, antibiotic administration, and wound drainage. Functional outcomes were achieved in all cases with no deaths. CONCLUSIONS: Esophageal injury incidence based on overall occurrence in this study was 0.1%. Patients with no antecedent risk factors had an incidence of 0.03%. Our results compare favorably with those of the Cervical Spine Research Society survey from 1989, which predicted an incidence of 0.25% based on questionnaires filed by surgeons, representing 1 of only 2 reports that included more than 1000 patients.     

Esophageal erosion 9 years after anterior cervical plate implantation

BACKGROUND: Anterior cervical discectomy and fusion is 1 of the most common spinal procedures performed. Most complications are observed during the intraoperative or immediate postoperative period. Long-term complications are not often described. A review of literature revealed 5 years as the longest complication interval. We present a case of esophageal erosion 9 years after initial surgery that was successfully treated. CASE DESCRIPTION: We describe a case of a 42-year-old woman who presented with recurrent pneumonia secondary to esophageal erosion almost 1 decade after anterior cervical spine surgery. This is the longest documented delay in presentation of esophageal erosion published to date. The diagnosis was made during EGD and the treatment consisted of plate removal and esophagus repair. The pertinent literature is reviewed and the therapeutic implications are discussed. CONCLUSIONS: In this report, we describe an uncommon case of esophageal erosion 9 years after anterior cervical plating. In cases of hardware migration even many years after surgery or in patients with intrinsic esophageal disease, potential esophageal damage should be considered.     

食管破裂与穿孔15例的临床诊治分析

目的探讨食管破裂与穿孔的诊断与治疗,提高对该疾病的诊治水平。方法总结分析我科15例食管破裂与穿孔的临床病例资料。颈段食管穿孔3例,2例为异物所致,1例为外伤所致,均手术治疗,胸段食管破裂穿孔12例,其中自发性食管破裂穿孔4例,食管异物损伤5例,外伤性食管穿孔2例,医源性损伤1例,根据食管的损伤程度及感染累及范围分别采取食管切开异物取出食管修补,食管部分切除,纵隔引流,瘘口修补等手术治疗12例。结果15例食管破裂与穿孔治愈13例;1例死于合并糖尿病因胸腔和纵隔感染严重,中毒性休克,呼吸衰竭,肾功能衰竭;1例死于食管癌引发食管破裂穿孔致感染性休克,多器官衰竭。结论根据食管破裂与穿孔的大小、时间、部位、纵膈和胸腔污染程度,早期明确诊断,及时采取合适的手术方式是治疗的关键。     

颈椎前路术后早期并发症特点、原因及其处理

目的探讨颈椎前路内固定术后早期并发症的特点、发生原因、对策和预防措施。方法回顾性分析自2010年1月~2016年12月中山大学孙逸仙纪念医院骨科单纯行颈椎前路内固定手术患者391例,其中颈椎病321例,颈椎外伤(骨折脱位、脊髓损伤)54例,颈椎肿瘤11例,颈椎感染5例。对上述病例术后早期并发症的特点、发生原因及处理进行总结分析。结果 391例患者中术后发生并发症共28例,占7.2%。不同颈椎疾患患者及不同节段数手术患者并发症发生率不同。存在并发症的患者中,术后一周仍存吞咽困难者6例,5例对症治疗后完全康复,1例未恢复;脊髓损伤加重者2例,1例术后1周再次行颈椎后路减压手术并获得恢复,1例术后经治疗无效死亡;血肿压迫者3例,均予以紧急手术清除血肿;喉上及喉返神经损伤共4例,经对症治疗后恢复;上呼吸道感染5例,伤口延迟愈合3例,脑脊液漏1例,尿潴留1例,下肢深静脉血栓1例,急性心梗1例,气胸1例,均予对症治疗后康复。结论颈椎疾患严重程度及节段数影响颈椎并发症的发生。术后严重的并发症可致严重后果。术前患者的综合评估、术前严格的准备,术中术者操作、助手密切的配合以及术后严格的观察处理是减少并发症发生的重点。