伤椎椎体后上缘骨块对胸腰椎爆裂骨折手术入路的影响  

Surgery approach for thoracolumbar burst fracture in response to posterosuperior fracture fragment of injured vertebral body

作　　者：陈意磊[1] 张旭阳 邱小明[1] 单治[1] 刘军辉[1] 梅正峰[2] 赵凤东[1] 范顺武[1] 

机构地区：[1]浙江大学医学院附属邵逸夫医院骨科,杭州310016 [2]杭州市第三人民医院骨科

出　　处：《中华创伤杂志》2017年第11期998-1004,共7页Chinese Journal of Trauma

基　　金：浙江省教育厅课题（Y201431312）

摘　　要：目的探讨胸腰椎爆裂骨折椎体后上缘骨折块的影像学特征对手术入路的影响。方法采用回顾性病例对照研究分析2014年1月-2015年12月收治的45例行前路或后路手术治疗的急性胸腰椎爆裂骨折患者临床资料，其中男24例，女21例；年龄23～52岁，平均33．6岁。损伤节段：T12 6例，L1 15例，L2 14例，L3 5例，L4 5例。按AO分型：A3型10例，A4型35例，其中A4型合并B2型4例。根据手术方式将患者分为前路组和后路组，11例行前路手术，34例行后路手术。记录两组手术时间和术中出血量，测量伤椎后上缘骨块移位和翻转角度、后凸Cobb角和椎管前后径，根据美国脊髓损伤协会（ASIA）分级评估神经功能。结果所有患者获随访11～24个月，平均17个月。除1例前路手术患者术后3个月发生钉棒松动，其余患者均未发生并发症。前路组平均手术时间138．3min，术中出血量293．7ml；后路组平均手术时间77．5min，术中出血量54．7ml（P均〈0．05）。前路组术后椎管前后径较术前增加55．5％，后路组较术前增加14．9％（P〈0．01）。后凸Cobb角矫正度数两组差异无统计学意义。前路组和后路组分别有73％和24％的患者ASIA分级较术前恢复（P〈0．05）。在椎管减压方面，前路组减压效果确切，术后椎管前后径为94．4％，要大于后路组的88．5％，尽管差异并无统计学意义，但当骨块移位≤8mm时，后路手术可获得97．4％的椎管前后径，几乎与前路手术减压效果相当；而当骨块移位〉8mm时，后路手术后椎管前后径明显偏小，仅能达到78．5％（P〈0．05）。类似的，当骨块翻转角≤25°和〉25°时，后路手术后的椎管前后径同样有显著性差异，分别为95．4％和80．8％（P〈0．05）。结论胸腰椎爆裂骨折后路手术尽管操作简单、手术时间短、术中出血量少，但并不能确保椎管的有效减压。当后上�Objective To investigate the radiographic characteristies of posterosuperior fracture fragment of the injured vertebral body and its effects on the results of surgical treatment in thoracolmnbar burst fractures. Methods A total of 45 patients with acute thoracolumbar burst treated by either anterior or posterior surgery from January 2014 to December 2015 were analyzed by retrospective casecontrol study. There were 24 males and 21 females with a mean age of 33.6 years （range, 23-52 years）. Fractured segments included Tl2 in six cases, L1 in 15, L2 in 14, L3 in 5, and L4 in 5. Based on AO classification, there were ten cases of A3 fractures and 35 cases of A4 fractures, among which four cases of A4 were combined with B2 injuries. Eleven patients underwent anterior surgery and 34 patients posteri- or surgery. The operation time and intraoperative blood loss were recorded. The following parameters were also measured pre- and post-operatively, namely the displacement and inversion angle of posterosuperior fracture fragment, Cobb angle, anteroposterior diameter （APD） of spinal canal, and American spinal injury association （ASIA） neurological scale. Results All patients were followed up for 11-24 months （mean, 17 months）. There were no complications except for one case of implant loosening at three months after anterior surgery. The average operation time was 138.3 minutes and intraoperative blood loss was 293.7 ml in anterior surgery while the average operation time was 77.5 minutes and intraoperative blood loss was 54.7 ml in posterior surgery （ P 〈 0. 05 ）. Compared with postoperative situation, the canal APD was increased by 55.5% in anterior surgery and the corresponding increase was 14.9% in posterior surgery （P 〈 0.01 ）. There was no significant difference between two groups in Cobb angle correction. Compared with situation before surgery, the postoperative ASIA grading was improved in 73% of the patients in anterior surgery and while it was enhanced in 24% of the patients in posterior

关 键 词：脊柱骨折 胸椎 腰椎 骨折固定术 内 

分 类 号：R687.3[医药卫生—骨科学]