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]