Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA.
Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA.
World Neurosurg. 2020 Jul;139:151-157. doi: 10.1016/j.wneu.2020.04.016. Epub 2020 Apr 17.
Paralysis (paraplegia or quadriplegia) after posterior fossa surgery is a rare but devastating complication. We investigated previous reports of this complication to examine similarities among patients, risk factors, and methods by which it may be prevented.
A systematic review was completed according to PRISMA guidelines. Electronic databases were searched until November 2019 using keywords "paraplegia," "quadriplegia," or "spinal cord injury" added to "posterior fossa surgery."
Thirteen case reports published between 1996 and 2019 were included. Five (38.5%) involved quadriplegia/quadriparesis and 8 (61.5%) involved paraplegia after surgery. Ten cases (76.9%) were tumor resections and 3 (23.1%) were posterior fossa decompressions (2 for Chiari malformations and 1 for Morquio syndrome). Seven surgeries (53.8%) were performed in the sitting position and 6 (46.2%) were prone. Proposed mechanisms of paralysis involved cervical hyperflexion yielding spinal cord ischemia in 8 patients (61.5%), arterial hypotension in 2 patients (15.4%), spinal cord compression from hematoma in 1 patient (7.7%), and decreased cardiac output in 1 patient (7.7%) (1 study did not propose a cause). Cervical hyperflexion was equally likely in the sitting and prone positions (4 patients each). Only 3 patients (23.1%) involved intraoperative complications (all cardiopulmonary in nature).
Paralysis after posterior fossa surgery often involves spinal cord infarction apparently caused by cervical hyperflexion. Extreme care during patient positioning is needed in both the sitting or prone positions. Electrophysiologic monitoring might enable early identification of spinal cord dysfunction to minimize or avoid this complication.
后颅窝手术后瘫痪（截瘫或四肢瘫）是一种罕见但严重的并发症。我们调查了该并发症的以往报告，以检查患者、危险因素和预防方法之间的相似之处。
根据 PRISMA 指南进行了系统评价。电子数据库搜索至 2019 年 11 月，使用关键词“截瘫”、“四肢瘫”或“脊髓损伤”加上“后颅窝手术”进行搜索。
共纳入 1996 年至 2019 年期间发表的 13 例病例报告。5 例（38.5%）涉及四肢瘫/四肢瘫，8 例（61.5%）涉及手术后截瘫。10 例（76.9%）为肿瘤切除术，3 例（23.1%）为后颅窝减压术（2 例为 Chiari 畸形，1 例为 Morquio 综合征）。7 例（53.8%）手术在坐位进行，6 例（46.2%）在俯卧位进行。瘫痪的提出机制涉及 8 例患者（61.5%）的颈椎过度伸展导致脊髓缺血，2 例患者（15.4%）的动脉低血压，1 例患者（7.7%）的血肿导致脊髓压迫，1 例患者（7.7%）的心输出量减少（1 项研究未提出病因）。颈椎过度伸展在坐位和俯卧位同样常见（各 4 例）。只有 3 例患者（23.1%）涉及术中并发症（均为心肺性质）。
后颅窝手术后瘫痪常涉及明显由颈椎过度伸展引起的脊髓梗死。在坐位或俯卧位时，患者定位时需要格外小心。电生理监测可能有助于早期识别脊髓功能障碍，以尽量减少或避免这种并发症。
