脊柱畸形截骨矫形术神经损伤的相关因素△ （开放获取）

Factors related to nerve injury in corrective surgery with osteotomy for spinal deformity (OA)

摘要:

[目的]探讨脊柱畸形截骨矫形术中神经损伤的危险因素。[方法]2016 年 1 月—2021 年 12 月截骨矫形手术治疗脊柱畸形 312 例纳入本研究，观察术中神经电生理监测（intra-operative neurophysiological monitoring, IONM）情况，通过单因素和多因素逻辑回归分析筛选发生神经损伤的相关因素。[结果]312 例患者术中发生 IONM 异常 26 例，占比 8.3%。术后发生神经损伤 11 例，占比 3.5%。IONM 异常组术前 MRI 脊髓有无异常比率 [有/无, (5/21) vs (7/279), P=0.017]、术前 CT 椎管有无异常比率 [有/无, (8/18) vs (25/261), P=0.029] 、Cobb 角＞110°占比 [例 (%), 19 (73.1) vs 31 (10.8), P=0.011]、柔韧度＜10%占比 [例 (%), 20 (76.9) vs 29 (10.1), P＜0.001]、截骨等级比率 [≤2/≥3, (4/22) vs (193/93), P=0.005]、手术时间 [(262.4±27.3) min vs (215.6±30.3) min, P=0.019] 均显著高于 IONM 无异常组。两组年龄、性别、BMI、既往脊柱手术史、术前主弯角度、矫正率、术中出血量比较的差异均无统计学意义（P＞0.05）。多因素逻辑回归分析显示，术前柔韧度差（OR=9.824, P＜0.001）、术前 Cobb 角度大（OR=6.751, P=0.004）、 术前 CT 椎管异常（OR=3.343, P=0.017）、术前 MRI 脊髓异常（OR=3.117, P=0.021）、手术截骨等级大（OR=2.897, P=0.026）和手术时间长（OR=1.043, P=0.031）是脊柱畸形截骨矫形术中发生 IONM 异常和神经损伤并发症的独立危险因素。[结论] 脊柱畸形截骨矫形手术是治疗重度脊柱畸形的有效方法，术中应高度警惕神经损伤的风险，术前核磁和术前 CT 三维重建检查仔细评估脊髓和椎管状况非常重要，手术中尽量减少截骨等级和手术时间，将有益于避免或减少脊柱畸形截骨矫形术中神经损伤。

Abstract:

[Objective] To search the risk factors of nerve injury during correction surgery with osteotomy for spinal deformity. [Methods] A retrospective study was conducted on 312 patients who received osteotomy and instrumented correction with intraoperative neurophysiological monitoring (IONM) for spinal deformities in our department from January 2016 to December 2021. The factors related to nerve injury were screened by univariate comparison and multifactorial logistic regression analysis. [Results] IONM abnormalities occurred in 26 of 312 patients, accounting for 8.3%, while postoperative nerve injury occurred in 11 cases (3.5%). In term of univariate comparison, the IONM abnormal group proved significantly greater than the normal group in terms of the proportion of preoperative MRI spinal cord abnormalities [Yes/No, (5/21) vs (7/279), P=0.017], the proportion of preoperative CT spinal canal abnormalities [Yes/No, (8/18) vs (25/261), P= 0.029], and the proportion of Cobb angle ＞110° [cases (%), 19 (73.1) vs 31(10.8), P=0.011], flexibility＜ 10% [Cases (%), 20 (76.9) vs 29 (10.1), P＜0.001), osteotomy grade [≤2/≥3, (4/22) vs (193/93), P=0.005] and operation time [(262.4±27.3) min vs (215.6±30.3) min, P= 0.019]. However, there were no significant differences in age, sex, BMI, previous spinal surgery history, preoperative main curvature angle, correction rate, and intraoperative blood loss between the two groups (P＞0.05). As results of multi-factor logistic regression analysis, the poor preoperative flexibility (OR=9.824, P＜0.001), large preoperative Cobb angle (OR=6.751, P=0.004), preoperative abnormal spinal canal CT (OR=3.343, P=0.017), preoperative abnormal spinal cord MRI (OR=3.117, P=0.021), high grade of osteotomy (OR=2.897, P=0.026) and long operation time (OR=1.043, P=0.031) were independent risk factors for IONM abnormality and nerve injury complications during corrective surgery for spinal deformities. [Conclusion] Corrective surgery is an effective method for the treatment of severe spinal deformity, while the risk of nerve injury should be highly alert during surgery. It is very important to carefully evaluate spinal cord and spinal canal abnormalities by preoperative MRI and preoperative CT three-dimensional reconstruction. Minimizing osteotomy extent and operation time during surgery will be beneficial to avoid or reduce nerve injury during corrective surgery for spinal deformities.