脊柱畸形手术失败原因与对策

目的探讨脊柱矫形手术失败原因、预防措施、处理方法及翻修手术适应证。方法31例患者,男18例,女13例;翻修手术时年龄4～35岁,平均14.7岁;既往平均手术史1.5次。初次手术距翻修手术时间平均47.9个月(13～114个月)。术前出现腰背部酸困疼痛、活动后加重16例,内植物并发症(断裂、松脱或外露等)5例,畸形进行性加重21例,下肢部分肌力和感觉障碍5例。翻修术前平均侧凸角75.3°,脊柱柔韧性9.8%;后凸角76°,柔韧性25.2%。分别采用脊椎截骨、椎弓根螺钉固定,原位固定和分期手术治疗。结果20例患者平均随访31.8个月,侧后凸平均矫正率分别为55.2%和67.5%。手术并发症:出现暂时性神经功能障碍4例(12.9%),经脱水、激素和电脉冲刺激等治疗,均在术后1～3周内得到完全恢复;内植物断裂2例,无其他严重并发症。结论正确掌握脊柱矫形手术治疗原则、良好的植骨融合、对先天性侧凸进行必要的内固定以及避免过早拆除内固定等,是防止矫形手术失败的有效手段。对有顽固性腰背痛、脊柱假关节和术后畸形进行性加重者,应根据患者年龄、畸形程度和脊柱柔韧性,采用不同的治疗方法。

The reasons and management of failed spinal deformity surgery

Objective To determine the cause, prevention and management of failed spinal deformity surgery, and evaluate the indication of spinal revision. Methods Thirty-one cases of failed spinal deformity surgery were treated surgically. There were 18 males and 13 females with an average age of 14.7 years(ranged from 4 to 35 years) at the present procedures. The average number of previous surgeries for this group of patients was 1.5 times. The duration between the first surgery and revision was 13-114 months, with an average of 47.9 months. There were 16 patients with consistent back pain which became worse after movement, 5 patients with implant complication (broken, loosing, explosing), 21 patients with failure of instrumentation and deterioration of deformity, 5 patients with decreased sensory and motor function. The average preoperative angel of deformity was 75.3 degrees for scoliosis and 76 degrees for kyphosis and the flexibility was 9.8% and 25.2%, respectively. All patients underwent reconstructive surgery with segmental vertebral osteotomy and trans-pedicular fixation and fusion in one or two stages according to the location and degree of the deformity. Results The average follow-up period for this group of patients was 31.8 months in 20 cases. The postoperative correction rate for scoliosis and kyphosis was 55.2% and 67.5%, respectively. There were 4 cases (12.9%) developed temporary neural dysfunction postoperatively and were recovered within 1-3 weeks after appropriate treatment. Instrumentation failure was occurred in two cases and there was no other complication in this group. Conclusion It is might be benefit to follow the principle of spinal deformity correction, fuse with adequate bone grafting and combine with proper pedicle fixation, especially for the congenital scoliosis patients, which are the efficial methods to prevent the failure of spinal deformation surgery. The management for the patients suffered from long-time back pain, spinal pseudarthrosis or progressive aggravated deformity postoperatively should be individuated depending on the degree of deformity, flexibility of the spine and the age of patients.