枕颈部后路手术翻修的原因和对策

目的 :研究和总结枕颈部后路手术翻修的原因并寻求对策。方法 :回顾性研究12例患者 ,男 9例 ,女 3例 ,年龄 2 6～ 69岁 ,平均 47岁 ,对再手术入院病人的症状及X线片进行分析 ,据此分别采用不同的翻修手术。临床症状有局部疼痛、四肢麻木无力、行走不稳等。翻修术采用枕颈部寰椎后弓切除或枕骨大孔扩大减压、取髂骨块行枕颈植骨或C1～ 2 弓间植骨、枕颈部内固定或C1～ 2 间固定。翻修后平均随访 18个月。结果 :翻修的原因包括 ,枕颈融合植骨块吸收 ( 4例 ) ,C1～ 2 植骨块不融合、假关节形成致C1～ 2 不稳 ( 3例 ) ,枕颈部脊髓压迫未减压 ( 2例 ) ,减压不全残余压迫( 2例 ) ,枕颈部内固定松动断裂致枕颈不稳 ( 1例 )。其中因植骨融合失败致再次手术翻修占 5 8.3 % ,未减压或减压不全 3 3 .3 % ,内固定断裂或松动 8.3 %。翻修术后 5例症状缓解 ,6例症状减轻 ,1例改善不明显。结论 :目前枕颈部手术失败的原因主要是植骨不融合或植骨块吸收 ,其次是减压不全 ,第 3位的原因是内固定失败。因此应强调植骨区和植骨块的去皮质和术后的必要制动 ,以及彻底病灶减压。

Revision of posterior occipitocervical surgery:causes and countermeasure

Objective:To study and summarize the associated factors and countermeasure of revision after occipitocervical surgery.Method: A retrospective review of revision after occipitocervical surgery for 12 patients(9 males and 3 females,aged from 26 to 69 years with a mean of 47 years) were conducted.Different revisions were performed to the patients according to their symptoms and X-rays results.Clinical symptoms included local pain,extremity numbness and atony,walking unsteadily,and so on.The methods of revision included resection of C_l posterior bow, resection of occipital macroforamen posterior wall and decompression,occipitocervical fusion with ilium bone graft or grafting between posterior bow of C_l and C_2 and occipitocervical or atlantoaxial fixation.The average follow-up were 18 months.Result:The causes of revision were varied,including absorption of grafted bone between occipital and cervical region(3 cases),nonunion and instability between C_1 and C_2(2 cases),incomplete decompression of occipitocervical region(2 cases),no decompression(2 cases),and the looseness or breakeness of occipitocervical internal fixation(3 cases).Among all these causes, nonunion was present in 41.7% of patients, while no decompression or partial decompression was in 33.3%.The looseness or breakeness of instrument occurred in 8.3% of patients.After revision,symptoms resolved in 5 cases and improved in 6,and were unchanged in 1.Conclusion:The main reason that leads to the failure of occipitocervical surgery is nonunion or absorption of grafted bone.The second cause is incomplete decompression,while the third is failure of internal fixation.Therefore,special attention should to be paid to decortex of bone graft and grafting area,immobilization and total decompression.