Karol Lori A, Chambers Carol, Popejoy Debra, Birch John G
Texas Scottish Rite Hospital for Children, Dallas, TX 75219, USA.
J Pediatr Orthop. 2008 Oct-Nov;28(7):773-6. doi: 10.1097/BPO.0b013e318186bdbb.
The purpose of this study was to assess the incidence of, risk factors for, and treatment of nerve palsy after hamstring lengthening in children with cerebral palsy.
A medical record review of patients with cerebral palsy who had hamstring lengthening between 1994 and 2005 was performed. Data included the preoperative popliteal angle, the presence of a knee flexion contracture, postoperative pain management, and type of immobilization. The presence of postoperative nerve palsy was established based on the recording of numbness, loss of motor function in the foot, or hypersensitivity of the foot in the inpatient record or the postoperative clinic notes. The need for medical management and time to resolution of symptoms were noted.
A total of 292 children underwent 329 hamstring lengthening surgeries. The mean age at surgery was 9.5 years (range, 2.5-18 years). Twenty-eight patients (9.6%) experienced postoperative nerve palsy. Time to recognition of the palsy ranged from 4 hours to 72 days. Patients diagnosed within 24 hours had loss of motor function and/or lack of sensation of the toes. Patients diagnosed from 8 to 72 days postoperatively had dysesthesias of the feet. Treatment of early palsies consisted of the removal of immobilization, bivalving of casts, or wedging casts into flexion. Fourteen of 28 patients were treated with Neurontin. Twenty-two of 25 patients with adequate follow-up recovered nerve function. Older children, noncommunicative patients, nonambulatory patients, and those who had epidural pain management were at statistically significant higher risk for postoperative palsy. The trend for palsies in spastic quadriplegic patients and after repeat lengthening procedures did not reach significance. There was no significant relationship between popliteal angle or the presence of a knee flexion contracture and development of nerve palsy.
Nerve palsy occurred in 9.6% of patients undergoing hamstring lengthening. Although the greatest risk was in noncommunicative adolescents who were nonambulatory, a small number of younger ambulatory patients developed palsies as well, so that all patients must be considered at risk. Vigilance in patients with epidural pain control to avoid excessive hip flexion and/or knee extension is warranted. Treatment is immediate knee flexion. Resolution of symptoms occurred in 82.1% of patients.
本研究旨在评估脑性瘫痪患儿腘绳肌延长术后神经麻痹的发生率、危险因素及治疗方法。
对1994年至2005年间接受腘绳肌延长术的脑性瘫痪患者的病历进行回顾。数据包括术前腘窝角、膝关节屈曲挛缩的存在情况、术后疼痛管理及固定类型。根据住院记录或术后门诊记录中关于足部麻木、运动功能丧失或足部感觉过敏的记载来确定术后神经麻痹的存在。记录医疗处理的必要性及症状缓解时间。
共有292例儿童接受了329次腘绳肌延长手术。手术时的平均年龄为9.5岁（范围2.5 - 18岁）。28例患者（9.6%）出现术后神经麻痹。发现麻痹的时间从4小时至72天不等。在24小时内确诊的患者存在脚趾运动功能丧失和/或感觉缺失。术后8至72天确诊的患者足部有感觉异常。早期麻痹的治疗包括去除固定、将石膏切开或在石膏中楔入使其屈曲。28例患者中有十四例接受了加巴喷丁治疗。25例有充分随访的患者中有22例恢复了神经功能。年龄较大的儿童、无交流能力的患者、不能行走的患者以及接受硬膜外镇痛的患者术后发生麻痹的风险在统计学上显著更高。痉挛性四肢瘫患者及重复延长手术后麻痹的趋势未达到显著水平。腘窝角或膝关节屈曲挛缩的存在与神经麻痹的发生之间无显著关系。
接受腘绳肌延长术的患者中有9.6%发生神经麻痹。虽然最大风险存在于无交流能力、不能行走的青少年，但也有少数能行走的较年轻患者发生麻痹，因此所有患者都必须被视为有风险。对接受硬膜外镇痛的患者应保持警惕，以避免过度屈髋和/或伸膝。治疗方法是立即屈膝。82.1%的患者症状得到缓解。
