Bayley Edward, Boszczyk Bronek M, Chee Cheong Reuben Soh, Srivastava Abhishek
Centre for Spinal Studies and Surgery, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK.
Eur Spine J. 2015 Jan;24(1):162-7. doi: 10.1007/s00586-014-3398-4. Epub 2014 Jul 1.
Major neurological deficit following anterior cervical decompression and fusion (ACDF) is a rare event, with incidences of up to 0.2 % now reported. Post-operative MRI is mandatory to assess for ongoing compression of the cord. In the past, the deficit has often been attributed to oedema or overzealous intra-operative manipulation of the cord. Reperfusion injury is a more recent concept. We describe a case of acute cervical disc prolapse with progressive neurology, and the difficult decision making one is faced with when the neurological deficit continues to deteriorate post ACDF.
A 30-year-old male was referred from the Emergency Department with acute left arm paraesthesia and left leg weakness. A cerebrovascular accident was ruled-out with a CT of the brain, and later an MRI of the cervical spine revealed a large C6/7 disc prolapse with significant compression of the spinal cord. A C6/7 ACDF was performed, but post-operatively the patient could no longer move his lower limbs. An urgent MRI was obtained which showed removal of the disc fragment, cord signal changes and the suggestion of ongoing cord compression. In part, this was due to his narrow cervical canal. The decision was made to proceed to posterior decompression and stabilisation, although cord reperfusion injury was one of the differential diagnoses considered at this stage.
Post-operatively the patient's neurology started to improve over the next 48 h. He was discharged from in-patient rehabilitation at 2 months post-surgery and by 3 months he had returned to work. Latest follow-up revealed normal function with only mild paraesthesia in the T1 dermatome of his left arm.
The management of patients in whom a neurological deficit has increased post-operatively is difficult. Urgent MRI scan is mandatory to assess for epidural haematoma which may need further decompression. Cord reperfusion injury is a diagnosis of exclusion. The difficulty the clinician faces is in interpreting the MRI for 'acceptable' decompression, and therefore excluding the need for further surgery.
颈椎前路减压融合术（ACDF）后出现严重神经功能缺损是一种罕见事件，目前报道的发生率高达0.2%。术后必须进行MRI检查以评估脊髓是否仍受压迫。过去，这种神经功能缺损常归因于水肿或术中对脊髓的过度操作。再灌注损伤是一个较新的概念。我们描述了一例急性颈椎间盘突出伴进行性神经功能障碍的病例，以及在ACDF术后神经功能缺损持续恶化时面临的艰难决策过程。
一名30岁男性因急性左臂感觉异常和左腿无力被急诊科转诊。脑部CT排除了脑血管意外，随后颈椎MRI显示C6/7椎间盘巨大突出，脊髓明显受压。实施了C6/7 ACDF手术，但术后患者双下肢无法活动。紧急MRI检查显示椎间盘碎片已清除，脊髓信号改变，提示仍存在脊髓受压。部分原因是其颈椎管狭窄。尽管此时再灌注损伤是鉴别诊断之一，但还是决定进行后路减压和稳定手术。
术后患者的神经功能在接下来的48小时开始改善。术后2个月他从住院康复中出院，3个月后恢复工作。最新随访显示功能正常，仅左臂T1皮节有轻度感觉异常。
对术后神经功能缺损加重的患者进行管理很困难。必须进行紧急MRI扫描以评估是否存在硬膜外血肿，可能需要进一步减压。脊髓再灌注损伤是一种排除性诊断。临床医生面临的困难在于解读MRI以判断是否已实现“可接受”的减压，从而排除进一步手术的必要性。
