Heese Oliver, Fritzsche Erik, Heiland Max, Westphal Manfred, Papavero Luca
Department of Neurosurgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
Eur Spine J. 2006 Dec;15(12):1839-43. doi: 10.1007/s00586-006-0070-7. Epub 2006 Feb 14.
Early postoperative dysphagia after anterior cervical surgery is a well-known phenomenon with so far unknown etiology. We hypothesised that direct pressure induced by the medial retractor blade on pharynx/esophagus mucosal wall leads to local ischemia. Subsequently postoperative hyperemia and swelling of the pharynx/esophagus may result in swallowing disturbance. To prove the hypothesis local blood flow inside the pharynx/esophagus wall during anterior cervical surgery was measured using a laser Doppler (LD) perfusion monitor unit. Fifteen patients underwent standard anterior cervical discectomy and fusion (ACDF). The LD probe was placed underneath the medial retractor blade in order to gain information at the maximum point of pressure applied onto the pharynx/esophagus wall. Local perfusion was measured prior to retractor opening (5 min), during spreading of the retractor and after its closure (5 min). Perfusion was measured semiquantitatively in perfusion units (PU). Local perfusion ranged from 30 to 210 PU (mean 107) prior to retractor opening, from 7 to 60 PU (mean 30) with open retractor and from 15 to 280 PU (mean 117) after retractor closure. In all 15 patients the open retractor led to hypoperfusion ranging from 21 to 93% compared to the baseline level. In seven patients a reactive hyperemia at the end of the procedure was detected (32-89% compared to baseline level). In four patients after hypoperfusion during spreading of the retractor the baseline levels were reached again and in four patients perfusion remained diminished even after retractor closure. To best of our knowledge, this is the first report on intraoperative measurement of local perfusion of the pharynx/esophagus wall during anterior cervical surgery. Diminished local perfusion was observed in all patients during spreading of the retractor and post-procedure hyperemia was recorded in 46% of the patients. The local ischemia of the pharynx/esophagus wall may be a crucial step in the development of postoperative dysphagia.
颈椎前路手术后早期吞咽困难是一种众所周知的现象，但其病因至今不明。我们推测，内侧牵开器叶片对咽/食管粘膜壁产生的直接压力会导致局部缺血。随后，术后咽部/食管充血和肿胀可能会导致吞咽障碍。为了验证这一假设，我们使用激光多普勒（LD）灌注监测装置测量了颈椎前路手术期间咽/食管壁内的局部血流。15例患者接受了标准的颈椎前路椎间盘切除融合术（ACDF）。将LD探头放置在内侧牵开器叶片下方，以便在施加于咽/食管壁的最大压力点获取信息。在牵开器打开前（5分钟）、牵开器展开期间和关闭后（5分钟）测量局部灌注。灌注以灌注单位（PU）进行半定量测量。牵开器打开前，局部灌注范围为30至210 PU（平均107），牵开器展开时为7至60 PU（平均30），牵开器关闭后为15至280 PU（平均117）。在所有15例患者中，牵开器展开导致与基线水平相比灌注减少21%至93%。在7例患者中，在手术结束时检测到反应性充血（与基线水平相比为32%至89%）。在4例患者中，牵开器展开期间灌注减少后，基线水平再次达到；在4例患者中，即使牵开器关闭后，灌注仍持续减少。据我们所知，这是关于颈椎前路手术期间咽/食管壁局部灌注术中测量的首次报告。在所有患者中，牵开器展开期间均观察到局部灌注减少，46%的患者术后出现充血。咽/食管壁的局部缺血可能是术后吞咽困难发生的关键步骤。
