Segmental vessel ligation in patients undergoing surgery for anterior

The Journal of Bone and Joint Surgery (Br) 2008 90: 474-479.
脊柱変形に対する前方手術施行患者における分節血管の結紮
Segmental vessel ligation in patients undergoing surgery
for anterior spinal deformity
By A.I. Tsirikos, MD, FRCS, PhD*, S.P. Howitt, and M.J. McMaster, MD, FRCS
Abstract:
Segmental vessel ligation during anterior spinal surgery
has been associated with paraplegia. However, the incidence and risk factors for this devastating complication
are debated.
We reviewed 346 consecutive paediatric and adolescent patients ranging in age from three to 18 years who
underwent surgery for anterior spinal deformity through
a thoracic or thoracoabdominal approach, during which
2651 segmental vessels were ligated. There were 173
patients with idiopathic scoliosis, 80 with congenital
scoliosis or kyphosis, 43 with neuromuscular and 31 with
syndromic scoliosis, 12 with a scoliosis associated with
intraspinal abnormalities, and seven with a kyphosis.
There was only one neurological complication, which
occurred in a patient with a 127° congenital thoracic
scoliosis due to a unilateral unsegmented bar with contralateral hemivertebrae at the same level associated with a
thoracic diastematomyelia and tethered cord. This patient
was operated upon early in the series, when intra-operative spinal cord monitoring was not available.
Intra-operative spinal cord monitoring with the use
of somatosensory evoked potentials alone or with motor
evoked potentials was performed in 331 patients. This
showed no evidence of signal change after ligation of
the segmental vessels.
In our experience, unilateral segmental vessel ligation
carries no risk of neurological damage to the spinal cord
unless performed in patients with complex congenital
spinal deformities occurring primarily in the thoracic
spine and associated with intraspinal anomalies at the
same level, where the vascular supply to the cord may
be abnormal.
要　約：
脊椎前方手術時に行う分節血管の結紮により，対麻痺
を合併することがある．しかし，この深刻な合併症の発
生率や危険因子については議論が多い．
脊柱変形のため，胸部または胸腹部進入法による前方
手術を受けた，3 〜 18 歳の小児ないし思春期の連続し
た 346 例の検討を行った．2,651 の分節血管の結紮が行
われた．特発性側弯症が 173 例，先天性側弯症または
後弯症が 80 例，神経筋性側弯症が 43 例，症候性側弯
症が 31 例，脊柱管内異常を伴う側弯症が 12 例，後弯
症が 7 例であった．
神経学的合併症が生じたのは 1 例のみで，胸椎部脊
髄正中離開症および脊髄係留を伴う，同一レベルの片側
性椎骨分節障害および対側の半椎による 127°の先天性
胸椎側弯症の患者であった．この患者は本シリーズの最
初のころに手術を受けたが，当時はまだ術中脊髄モニタ
リングが利用できなかった．
331 例に体性感覚誘発電位単独または運動誘発電位と
併用した術中脊髄モニタリングを行ったが，分節血管の
結紮後の明らかな電位の変化は認めなかった．
われわれの経験では，片側の分節血管の結紮は脊髄へ
の神経損傷の危険性はない．ただし，主として胸椎部に
発生し，同一レベルの脊柱管内奇形を伴う複雑な先天性
脊柱変形患者は，脊髄血流が異常である可能性があるた
めこの例外である．
* Scottish National Spine Deformity Centre, Royal Hospital
for Sick Children, Sciennes Road, Edinburgh EH9 1LF, UK.
E-mail: [email protected]
The Journal of Bone and Joint Surgery (Br) 2008 90: 474-479.
Reproduced with permission and copyright of The British Editorial Society of Bone and Joint Surgery [J Bone Joint Surg Br. 2008; 90: 476]