Major neurological deficit following anterior cervical decompression and fusion: what is the next step?

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• 作者：Edward Bayley ; Bronek M. Boszczyk ; Reuben Soh Chee Cheong…
• 关键词：Cord compression ; Anterior cervical decompression and fusion ; Reperfusion injury ; Surgical outcome
• 刊名：European Spine Journal
• 出版年：2015
• 出版时间：January 2015
• 年：2015
• 卷：24
• 期：1
• 页码：162-167
• 全文大小：458 KB
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• 刊物类别：Medicine
• 刊物主题：Medicine & Public Health
  Surgical Orthopedics
  Neurosurgery
  
• 出版者：Springer Berlin / Heidelberg
• ISSN：1432-0932

文摘

Introduction 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. Materials and methods 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. Results 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. Conclusion 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.