摘要
目的:回顾性分析腰椎后路术后有神经症状的硬脊膜外血肿的原因及诊治过程,探讨相应的处理对策。方法:2002年1月~2014年12月共有12827例患者行腰椎后路手术,术后发生有神经症状的硬脊膜外血肿21例,其中腰椎间盘突出症2例,腰椎管狭窄症17例,腰椎滑脱症2例(均为Ⅰ度滑脱)。男13例,女8例,年龄53.0±11.6岁(34~78岁);手术节段数:1个节段8例,2个节段9例,3个节段及以上4例。所有患者手术过程顺利,麻醉时间219±66min(141~383min);手术时间147±51min(96~312min);术中出血量485±410ml(50~2000ml)。术后均放置1根引流管。术后在麻醉清醒后1h^5d出现神经损害症状,神经功能ASIA分级A级7例,B级3例,C级8例,D级3例。均行手术探查、血肿清除术,随访观察患者神经功能变化情况。结果:手术探查发现4例椎管内静脉丛有活动性出血,2例止血材料下方血凝块形成,压迫硬膜囊和神经根;2例引流管在伤口内打折,引流受阻;11例血肿压力较高,椎管内未见明确出血点;2例术区为陈旧性积血和凝血块,未见出血,神经根及硬膜囊水肿。其中在出现症状6h以内探查的9例(A级2例,B级1例,C级4例,D级2例)患者探查术后当天神经功能D级8例,E级1例;6~24h内探查的7例(A级2例,B级1例,C级3例,D级1例)患者探查术后神经功能B级1例,C级2例,D级3例,E级1例;超过24h探查的5例(A级3例,B级1例,C级1例)患者探查术后神经功能A级1例,B级2例,C级2例。21例患者均获得随访,随访时间11个月~4年,平均2.0±0.8年,末次随访时,16例神经功能恢复至E级,4例恢复至D级,患者对神经功能恢复满意;另1例术后5d出院回家后出现症状的患者,再次入院探查时已在12d后,神经功能ASIA评级为A级,探查术后无明显改善,经康复治疗11个月后恢复到C级。结论:腰椎后路术后有神经症状的硬脊膜外血肿患者的神经功能在血肿探查清除术后大多可获得改善,越早进行探查手术清除血肿,神经功能恢复越好。术中止血彻底、术后引流通畅、及时有效处理是减少和防治血肿的关键。
Objectives： A retrospective study was made to analyze the causes and management of symptomatic epidural hematoma after the posterior lumbar surgery. Methods： From January 2008 to December2014, 21 of 12827 cases got symptomatic epidural hematoma after the posterior lumbar surgery, 2 cases with lumbar disc herniation, 17 cases with lumbar spinal stenosis, and 2 cases with lumbar spondylolisthesis（gradeⅠ）. 13 males and 8 females with a mean age of 53.0±11.6 years old（range, 34 to 78 years） were included in this study. Operation segments included 1 segment in 8 cases, 2 segments in 9 cases, and more than 3segments in 4 cases. All patients were operated successfully, the anesthesia time was 219 ±66 min（range, 141-383min）, the operation time was 147±51min（range, 96-312min）, and the bleeding volume was 485±410ml（range, 50-2000ml）. After operation, 1 drainage tube was placed. Postoperative neurological symptoms of 21 patients occurred after anesthesia awake from 1h to 5d, neural function was assessed according to the ASIA neurological function grade： A in 7 cases, B in 3 cases, C in 8 cases, and D in 3 cases. All of them under-went lumber canal exploration and hematoma debridement. The causes of complications and corresponding in-terventions were documented. The recovery of ASIA grade was ewcorded. Results： In all of 21 patients who had undergone lumber canal exploration and hematoma debridement, the intraspinal venous plexus were still bleeding in 4 cases, the dural sac and nerve root were compressed by the blood clot under collagen sponge hemostatics in 2 cases, and drainage tubes were folded in the wound in 2 cases. However, hematoma pressure of 11 cases was higher than normal, but no bleeding was found. 2 cases obsolete blood clots and dark color had no bleeding, dural sac or nerve root edematous. 9 cases（A in 2 cases, B in 1 case, C in 4cases, D in 2 cases） were performed reoperation within the first 6 hours. The neural function was assessed E in 1 case and D in 8 cases. 7 cases（A in 2 cases, B in 1 case, C in 3 cases, D in 1 case） were performed reoperation within 6-24 hours and the neural function was improved to B in 1 case, C in 2 cases, D in 3cases, E in 1 case. But 5 cases（A in 3 cases, B in 1 case, C in 1 case） were performed reoperation after 24 hours of surgery recovered dissatisfiedly, their neural function was assessed A in 1 case, B in 2 cases, C in2 cases. All of 21 patients were followed up by an average of 2.0 ±0.8 years（range, 11 months-4 years）. At the final follow-up, all of them were satisfied with recovery of neural function： E in 16 cases, D in 4 cases.1 case had neurological symptoms 5 days after surgery discharged from hospital, and 12 days later, he was admitted to hospital again. ASIA grade was A, no improvement was found after the exploration, and after 11 month recovery therapy, it improved to grade C. Conclusions： After lumbar epidural hematoma is debrided,most of cases gain improvement. The earlier to explore and debride hematoma the better to neural functional recovery. So careful hemostasis, effective drainage, and timely management are key measures to prevent and treatment epidural hematoma.
出处
《中国脊柱脊髓杂志》
CAS
CSCD
北大核心
2015年第8期733-738,共6页
Chinese Journal of Spine and Spinal Cord
