腰椎内固定融合术后10日内翻修原因及对策

Causes and countermeasures of revision surgery within 10 days secondary to primary lumbar instrumented fusion

摘要:

[目的]探讨腰椎内固定术后 10 d 内翻修原因以及翻修术后效果。[方法]回顾性分析 2015 年 1 月—2020 年 8 月行腰椎固定融合的 1 412 例患者的临床资料。其中 26 例患者初次术后 10 d 行翻修术，记录翻修原因，按是否伴神经损害症状将患者分为两组，比较翻修患者一般情况、手术资料及 VAS、腰痛 JOA 及 ODI 评分。[结果] 1 412 例腰椎融合固定术患者中， 26 例 10 d 内翻修，占 1.84%，其中男 12 例，女 14 例；年龄 40~80 岁，平均 (58.58±8.33) 岁 。翻修原因如下：螺钉误置 11 例，占 42.31%；减压不彻底 5 例，占 19.23%；术后感染 4 例，占 15.38%；融合器退出 2 例，占 7.69%；切口愈合不良 4 例， 15.38%。26 例患者中，18 例出现神经症状加重，占 69.23%，主要原因是螺钉误置、减压不彻底；8 例未出现神经损害加重， 占 30.77%。神经损害加重组初次手术置钉准确性显著差于未加重组(P＜0.05)。随时间推移，两组 VAS、ODI 和 JOA 评分均呈波浪状改变，相同时间点间变化差异均有统计学意义(P＜0.05)。末次随访时，神经症状未加重组 VAS、JOA 评分和 ODI 评分均显著优于加重组 (P＜0.05)。相关分析表明，初次手术至翻修术的时间与末次随访临床 VAS、ODI、JOA 评分均无相关性 (P＞0.05)。[结论] 螺钉误置、减压不彻底是腰椎术后早期翻修和神经损伤加重的主要原因，且预后较其他并发症症差，螺钉准确置入和术中充分减压可大大降低早期翻修率和术后神经损伤并发症的发生率。

Abstract:

[Objective] To investigate the causes and outcomes of revision surgery within 10 days secondary to primary lumbar instru- mented fusion. [Methods] From January 2015 to August 2020, 1412 patients who underwent lumbar fixation fusion were reviewed. Among them, 26 patients underwent revision surgery in 10 days after the primary operation. The reasons for revision were recorded, and the pa- tients were divided into two groups according to whether nerve symptom deteriorated. The general condition, surgical data, VAS, JOA and ODI scores of the revised patients were compared. [Results] Among 1412 patients who underwent lumbar instrumented fusion, 26 patients (1.84%) received revision surgery within 10 days, including 11 males and 14 females aged ranged from 40 to 80 years, with an average of 58.58±8.33 years. In term of revision reasons, screw misplacement occurred in 11 cases (42.31%) , decompression incomplete in 5 cases (19.23%) , postoperative infection in 4 cases (15.38%), displacement of the fusion cage in 2 cases (7.69%) and poor wound healing in 4 cas- es (15.38%) . Among the 26 patients, 18 cases (69.23%) showed aggravation of nerve damage (the AND group) , mainly due to screw mis- placement and incomplete decompression, while 8 cases (30.77%) had no aggravation of nerve damage (the non-AND group) . The non- AND group proved significantly higher accuracy of screw placement in primary surgery than the AND group (P＜0.05) . The VAS, ODI and JOA scores varied in curve manner over time in both groups, which were statistically significant (P＜0.05) . At the latest follow-up, the non- AND group proved significantly superior to the AND group in terms of VAS, JOA scores and ODI scores (P＜0.05) . With regard to correla- tion analysis, there were no correlations between the time elapsed from primary to revision surgeries and the clinical VAS, ODI and JOA scores at the latest follow-up (P＞0.05) . [Conclusion] The screw misplacement and incomplete decompression are the main causes of early revision surgery, while aggravation of nerve damage after lumbar instrumented fusion has worse prognosis than other complications. Accu- rate screw placement and adequate intraoperative decompression are important to reduce the rate of early revision and the incidence of post- operative nerve injury complications.