Wang Peng Wei, Chung Ming Hsuan, Hueng Dueng Yuan, Hsia Chung Ching
Department of Surgery, Taoyuan Armed Forced General Hospital, Taoyuan, Taiwan.
Department of Neurological Surgery, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan.
Front Surg. 2024 Feb 12;11:1329860. doi: 10.3389/fsurg.2024.1329860. eCollection 2024.
Spine surgery is a prevalently performed procedure. Some authors have proposed an age-related surge in surgical and general complications. During spine surgery, patients are placed in positions that are not physiologic, would not be tolerated for prolonged periods by the patient in the awake state, and may lead to complications. Understanding these uncommon complications and their etiology is pivotal to prevention and necessary. The patient is a 76-year-old woman referred to the outpatient department of neurosurgery in February 2022 by her physiatrist with a chief complaint of chronic low back pain and numbness over the left leg. Lumbar spine magnetic resonance imaging revealed degenerative disc disease and posterior disc bulging at the levels of L2/3∼L5/S1 with compression of the thecal sac. After receiving anti-inflammatory medication, nerve block and caudal block, her symptoms persisted. She was referred to a neurosurgeon for surgical intervention. We diagnosed spinal stenosis with left L3 and L4 radiculopathy, and elective decompression surgery was scheduled a few days later. We performed discectomies at L2/3 and L3/4 and left unilateral laminectomy at L2 and L3 for bilateral decompression. Following an uneventful surgery, the patient was extubated, and her left leg pain improved, but pain over the right outer calf with drop foot developed. A second lumbar MRI the next day revealed no evidence of recurrent disc herniation or epidural hematoma. Then, she received nerve conduction velocity and needle electromyogram on postoperative day 2, and the studies indicated right common peroneal nerve entrapment neuropathy. After medication with steroids and foot splint use, right leg pain improved. However, weak dorsiflexion of the right ankle persisted. We referred this patient to a physiatrist and OPD for follow-up after discharge. Perioperative peripheral nerve injury (PPNI) is most commonly caused by peripheral nerve ischemia due to abnormal nerve lengthening or pressure and can be exacerbated by systemic hypotension. Any diseases affecting microvasculature and anatomical differences may contribute to nerve injury or render patients more susceptible to nerve injury. Prevention, early detection and intervention are paramount to reducing PPNI and associated adverse outcomes. The use of intraoperative neuromonitoring theoretically allows the surgical team to detect and intervene in impending PPNI during surgery.
脊柱手术是一种常见的手术操作。一些作者提出，手术及全身并发症会随年龄增长而激增。在脊柱手术过程中，患者所处的体位不符合生理状态，清醒状态下患者无法长时间耐受，且可能导致并发症。了解这些罕见并发症及其病因对于预防至关重要且很有必要。该患者为一名76岁女性，2022年2月由其理疗师转诊至神经外科门诊，主诉为慢性下腰痛及左腿麻木。腰椎磁共振成像显示L2/3至L5/S1节段椎间盘退变及椎间盘后凸，伴有硬脊膜囊受压。在接受抗炎药物、神经阻滞及骶管阻滞治疗后，她的症状仍持续存在。她被转诊至神经外科医生处进行手术干预。我们诊断为伴有左侧L3和L4神经根病的腰椎管狭窄症，并计划在几天后进行择期减压手术。我们在L2/3和L3/4节段进行了椎间盘切除术，并在L2和L3节段进行了左侧单侧椎板切除术以进行双侧减压。手术过程顺利，患者拔管后，左腿疼痛改善，但右小腿外侧出现疼痛伴足下垂。第二天的第二次腰椎磁共振成像未显示椎间盘突出复发或硬膜外血肿的迹象。然后，她在术后第2天接受了神经传导速度和针极肌电图检查，检查结果提示右侧腓总神经卡压性神经病。在使用类固醇药物并佩戴足部夹板后，右腿疼痛有所改善。然而，右踝关节背屈无力仍然存在。我们在患者出院后将其转诊至理疗师处及门诊进行随访。围手术期周围神经损伤（PPNI）最常见的原因是由于神经异常延长或受压导致的周围神经缺血，全身低血压会使其加重。任何影响微血管的疾病及解剖学差异都可能导致神经损伤或使患者更容易发生神经损伤。预防、早期发现和干预对于减少PPNI及相关不良后果至关重要。术中神经监测的应用理论上可使手术团队在手术过程中检测并干预即将发生的PPNI。
