【脊柱侧弯-精】6.3-成人退行性脊柱侧凸手术风险评估和风险预防

成人退行性脊柱侧凸

手术风险评估和并发症预防

EvaluationofSurgicalRiskFactorsandPreventionofComplicationsinADS手术指征和治疗目的严重疼痛缓解疼痛PainRelief侧凸进展矫正稳定CorrectionandStabilization神经压迫减压松解Decompression脊柱失衡恢复平衡RestoreBalanceLee,etal.ContemporarySpineSurgery,2010Russo,etal.CurrentOrthopedicPractice,2008TribusC.B.JAAOS2003;11:174-183Jeong&BendoCORR2004;425:110-125Howhigh?HowLow?AnteriororPosterior?Howmuchtocorrect?OsteotomyHowtoavoidPJK?HowExtensive?MISorOpen?TechnicalChallenges手术可以这么做吗？风险评估RiskEvaluation一个病例，说明了什么？56岁女性，发现后背不平、双肩不等高53年。近十年自觉活动后胸闷气短，进行性加重，严重腰背痛及下肢无力。手术的风险因素年龄较大、脊柱侧后凸严重僵硬长期胸廓畸形、术前存在肺动脉高压及阻塞性通气障碍为主射血分数：70%我们做了什么…T9顶椎区进行VCR截骨L1-4Ponte截骨去除右侧4根肋骨术中出血4500ml手术时间6.2小时术后发生了什么…术后即可失血性休克、急性肾衰肌酐、BUN持续升高术后第8天急性Ⅱ型呼吸衰竭高钾血症、心功能不全肝损害、贫血术后25天肺部感染、痰堵窒息、昏迷术后45天全身情况好转平稳出院术后9月门诊随访腰背痛基本缓解呼吸改善非手术治疗VS手术治疗PseudoartrosisWoundinfectionParesthesiasRadiculopthyCSFfistulasPulmonaryembolismMyocardialinfractionHardwarefailureDrugreactionUrinarytractinfectionCompressionfracturesAdultrespiratorydistresssyndromeHighrevisionsurgeryrateGrubbetal.Spine1994;19:1610–1627Marchesi&Aebi.Spine1992;17-8S:304-309Hanley.Spine1995;20:S143–S153Vaccaro&BallOrthopaedics2000;23:260-271手术并发症发生率Incidence:20-60%非计划内二次手术率Un-intentionalRe-Op:18%~58%近期并发症与术中失血量EBL（>2000ml）和融合节段FusionLevels（>5）密切相关邻近节段退变ASD远期并发症失状面的失稳是导致邻近节段退变的主要因素SagittalImbalanceDLSComplications肺部——主要致死原因肺炎肺不张

ARDS

肺栓塞泌尿系统最常见泌尿系感染神经系统脊柱外科最关注神经根损伤脊髓损伤心血管——发生几率较低心律不齐深静脉血栓术前肺功能评估术前改善呼吸功能术后严密监护术后早期活动使用有效的抗生素术前高危因素评估短节段矫正后凸后方撑大角度矫正术中严密监护术后密切观察功能手术并发症与再手术2015年ISSG回顾成人脊柱畸形并发症率11,318patients→3,615complications,complicationsrate55%.围术期并发症(18.5%)神经损伤、伤口感染、内固定/植骨失败、失血过多短期术后并发症(15.7%)脑脊液漏、胃肠道并发症、短暂性神经损伤、伤口感染等长期并发症(20.5%)假关节、内固定/植骨失败、PJK、ASD、新发症状取钉2015年Glassman等报道成人脊柱畸形再手术率为18%PROSandCONS非手术治疗NS手术风险高全身情况差合并其他系统疾病较高的并发症发生率保守治疗进展手术治疗S麻醉技术进步手术技术进步内固定器械进步术中监护的应用期望值增高平衡详细的治疗选择评估LifeQualityRiskHowmuchpainrelief疼痛缓解程度Howmuchdeformitycorrection畸形矫正程度Howmuchriskacceptable风险承担？？？术前手术风险评估保证手术安全的关键适当的患者精良的技术优秀的团队围手术期关键患者评估与选择手术计划与准备手术中执行术后医护患者评估与选择PatientSelection患者选择SurgicalPreparation/Planning手术计划IntraoperativeExecution术中执行PostoperativeConsiderations术后处理PathologicalSign病种因素A.手术适应证SurgicallyAppropriateB.身体条件MedicallyAppropriateC.社会支持SociallyAppropriateD.心理状态PsychologicallysoundandmotivatedE.Knowwhentosay“No”

SelectionofLIV畸形进展Progression疼痛Disablingpain失稳Malalignment影响功能和生活Declineinfunction/qualityoflifeA.手术适应证SurgicallyAppropriate其他系统疾病MedicalCo-morbidities：well-controlledandmanageable术前药物服用Pre-opmedicalclearancethatishealthandageappropriate骨质疏松的处理TreatmentforthosewithosteoporosisB.身体条件MedicallyAppropriate患者评估与选择SelectionofLIV吸烟Non-Smoker酒/毒品Non-Alcoholic/Druguser

社会支持SocialsupportsystemsC.社会支持SociallyAppropriateSRS心理评分ReviewSRSMentalDomainScoreDRAM评估DRAMassessment正式心理评估FormalPsychologicalassessmentD.心理状态Psychologicallysoundandmotivated患者评估与选择患者评估与选择E.Knowwhentosay“No”该说不时要说不！！！Severephysical/psychologicalproblem严重生理和心理状况PreopscreeningandoptimizationSevereOsteoporosis严重骨质疏松Nottakengoodcareoftheirhealth无法很好照顾自己RiskStratificationtools风险分层工具显示高风险风险评估和并发症预防RISKSTRATIFICATION高危患者Pre-opconferencetoclearcomplexpatients,incl.anesthesiaandinternalmedicine2attendingsurgeonsIntra-opmanagementofcoagulopathycomplicationratefrom52%16%标准化围手术期路径和规范合并状况评价和处理术前多学科会诊Optimalpreparation=RiskreductionSmoking?吸烟史Obesity?肥胖BoneMineralDensity?骨密度Optimizemedication药物使用opiates止痛药anti-TNFmedication抗肿瘤坏死因子药物anti-coagulants抗凝药吸烟Smoking和假关节形成相关和深部感染相关和不良疗效相关SmokingMorewoundinfectionsMorepost-oppainPooreroutcomeMorenon-unionsSmokingcessationimprovedpatient-reportedpainAdvise:Stopsmoking,3monthspre-op肥胖ObesityComplications:MoreTreatmenteffect:“Inconclusiveevidence”骨密度BoneMineralDensityLowBMDintra-opfracture,post-opfracture,Prox.Junct.FailureimplantlooseningOption1:pre-opoptimizeBMD(medical)Option2:acceptlowBMD,andtakeextrameasuresE.g.cementaugmentscrews,augmentUIV+1Verbeek3206238Zieookcementaugmfoto’sAdvise:measureBMDinelderlypatientsMedication术前药物使用Opiatedrugs皮质激素Anti-coagulants抗凝药？？？PlateletaggregationAcetylsalicylicacidASA(e.g.Aspirin)Clopidogrel(Plavix)noprovenincreasedrisksCuellarJM,etal.Spine2015.VitKantagonistsCoumadin,warfarinAdvise:trytostopopiatespre-opAdvise:stopVitKantagonist1weekpre-opADS术前评估的重要性Pre-opwork-upspineTime-outIndicationforsurgeryAdmissiontohospitalInOR手术Pre-opwork-upgeneralhealthandanesthesiology门诊Makesurgicalplan“Failingtoprepareispreparingtofail”

meticulousplanning我们的做法术前评估和准备列表全身状况评估，注意危险因素手术计划评估，注意手术适度多科联合评估，注意适时放弃反复医患沟通，注意心理评估该收手时就收手！！！适当的患者精良的技术优秀的团队Conclusion:

OnlyperformcomplexASDsurgery，if…..Andthatstartspre-operatively从术前就开始！！！精确识别责任病灶评估侧弯柔韧性制定个体化方案

影像学评估患者因素外科医生的经验合适的融合节段内固定选择软组织松解截骨方式ADS手术目的缓解疼痛、减少致残率、改善生活质量神经减压重建脊柱骨盆力线矢状位失平衡的矫正＞冠状位失平衡的矫正在保证安全性的基础上使远期手术效果最大化与临床疗效与生活质量密切相关Ultimately精准定位责任病灶优化患者合并症有效安全地完成手术术后最佳的康复理想的手术效果TeamWork安全稳定平衡并发症预防ComplicationPrecaution并发症分类1.神经损伤Neurologicaldeficit2.内固定断裂Symptomaticrodfracture3.螺钉松动或断裂Screwloosening/breakage4.假关节形成Symptomaticpseudarthrosis5.PJK6.DJK7.躯干失平衡Coronal/Saggitaldecompensation8.感染Infection9.出血Bleeding10.深静脉血栓DVT神经损伤直接损伤压缩，牵拉compression,traction撕裂lacerationandavulsion间接损伤缺血ischemicphenomena血管压缩compressionofvascularization神经损伤AretrospectiveStudy564patientsmeanage57Incidence99patients(17.6%)Results神经根损伤(35,30.2%)运动异常(25,21.6%)感觉异常(14,12.1%)神经损伤术前详细评估pre-operativeimagingstudies术中操作Skilledandcarefuloperation术中血压控制MAP:60-80mmHgtopreventcordischemia唤醒试验Wake-up-test术后即刻查体AfulllowerextremitymotorexampriortoleavingtheOR内固定断裂术后12月内与假关节形成有关术后12月以上金属疲劳危险因素应力集中处棒过度弯曲躯干失平衡高BMI假关节形成JustinS,ChristopherI,ChristopherP,etal.Neurosurgery.2012,71:862-8.KimYJ,BridwellKH,LenkeLG,etal.Spine.2007;32(20):2189-2197.螺钉松动、断裂多见于长节段融合融合至骶骨和骨盆高龄、高体重、骨质疏松螺钉松动、断裂螺钉松动、断裂预防措施尽量避免融合至骶骨、骨盆避免应力集中螺钉位置双皮质螺钉平衡的重要性骨质疏松治疗支具假关节发生率10.5%危险因素>55yrs腰椎三柱减压LIV至S1PSO截骨DouglasD,LGLenke,KHBridwell,etal.Spine.2014,39:1190-5.KimYJ,BridwellKH,LenkeLG,etal.Spine.Spine2007;32:2189-97.假关节L5/S1TLIFL4/5TLIF#8132,♀,55Y假关节预防preventionPSO截骨处行椎间融合截骨处应用卫星棒强化植骨术后支具DouglasD,LGLenke,KHBridwell,etal.Spine.2014,39:1190-5.KimYJ,BridwellKH,LenkeLG,etal.Spine.Spine2007;32:2189-97.PJK邻近节段退变邻近椎体压缩性骨折内固定失败假关节形成矢状面平衡丢失PJKUIV下终板与UIV+2椎体上终板Cobb角大于10°或较术前增加10°发生率20%-40%占术后并发症13%因PJK行翻修手术占9%近端交界区后凸ProximalJunctionalKyphosis/FailureKukloTR.Principlesforselectingfusionlevelsinadultspinaldeformitywithparticularattentiontolumbarcurvesanddoublemajorcurves[J].Spine,2006,31(19Suppl):132-138PJK24°7°12°术前术后1月随访PJK预防避免前后路联合手术正确地选择融合节段适度矫形恢复脊柱平衡手术对TK和LL的矫正匹配度术中保护邻近节段韧带和小关节骨水泥强化椎板、横突钩在UIV和近端椎体使用骨水泥强化交界区骨折发生率16.7%在UIV采用骨水泥强化交界区骨折发生率100.0%不使用骨水泥强化交界区骨折发生率83.3%

HartRA,PrendergastMA,RobertsWG,etal.Proximaljunctionalacutecollapsecranialtomulti-levellumbarfusion:acostanalysisofprophylacticvertebralaugmentation.Thespinejournal，:875-881DJKPre-opPost-op5Y-follow-up冠状面失平衡功能受限Functionalcompromise腰背痛Backpain下肢不等长Limb-lengthdiscrepancy骨盆倾斜Pelvicobliquity姿势不稳Sittingand/orstandingimbalance影响外观Severecosmetictruncaldeformity增加内固定失败风险Anincreaseinimplantfailures冠状面失平衡冠状面失平衡与功能改善密切相关plumblineoffsetshowednostatisticallysignificantcorrelationwithself-reportedpainbyVAS冠状面失平衡危险因素及预防骨质疏松既往手术史术前躯干向凸侧偏移腰椎椎体旋转过度矫形内固定失败UIV过高L5/S1退变PloumisA,etal.CoronalSpinalBalanceinAdultSpineDeformityPatients.JSDT.2015;28(9):341-7.ThompsonJP,etal.DecompensationafterCotrel-Duboussetinstrumentationofidiopathicscoliosis.Spine.1990;15:927–31矢状