骨盆后环骨折合并腰骶丛损伤的临床研究

发布时间：2018-05-11 23:13

本文选题：骨盆后环骨折 + 腰骶丛　；参考：《山东大学》2015年硕士论文

【摘要】：目的：1、探讨骨盆后环骨折合并腰骶丛损伤的临床特点；2、探讨骨盆后环骨折合并腰骶丛损伤的诊断策略；3、总结分析我院近年来接诊的骨盆后环骨折合并腰骶丛损伤的不同治疗方式效果,得出最恰当治疗方案。对象与方法：2005年1月至2013年1月,山东省立医院创伤骨科共收治205例骨盆骨折患者,其中43例患者被诊断出骨盆后环骨折合并腰骶丛损伤。男28例,女15例；年龄16-58岁,平均36.3岁。受伤原因：车祸伤28例,重物砸伤2例,坠落伤6例,爆炸伤1例,碾压伤6例。骨盆骨折按Tile分型：A型3例,B型15例,C型25例；按骨盆后环骨折部位分类：髂骨翼骨折3例,骶髂关节骨折9例,骶骨骨折31例；骶骨骨折按Denis分型：Denis Ⅰ型2例,Denis Ⅱ型13例,Denis Ⅲ型16例。其中闭合性骨盆骨折39例,开放性骨盆骨折4例,陈旧型骨盆骨折7例。ISS评分16-43分,平均22.2分。所有患者按照骨盆急救流程处理,待其病情稳定后,综合患者临床症状、体格检查、影像学检查结果确立诊断,然后根据其会阴和下肢感觉障碍区、运动障碍进行腰骶丛神经根损害节段定位,根据AISA脊髓损伤评分标准对患者下肢进行感觉评分和运动评分。11例患者行神经损害保守治疗,32例患者行神经减压松解术,其中单纯前路减压10例,单纯后路减压17例,前后联合入路减压5例。36例行骨折复位固定,其中外固定架固定4例(2例外固定架为终极固定,2例二期行髂腰固定),后路“M”形钢板内固定5例,髂腰固定13例,骶髂前路重建双钢板固定9例,骶髂螺钉固定5例,同时前环固定15例。结果：(1)骨盆后环骨折合并腰骶丛损伤临床特点43例腰骶丛损伤患者出现会阴和下肢功能障碍,或表现为会阴及下肢区域感觉障碍,或表现为下肢运动障碍及膀胱、肛周括约肌功能障碍,或二者同时存在。52侧肢体出现感觉障碍,9例患者(神经减压松解组8例、神经保守治疗组1例)出现双侧下肢感觉障碍,减压松解组3侧和保守治疗组1侧下肢出现放射性疼痛。其中单纯腓总神经损伤感觉障碍表现15侧(28.85%),腓总神经合并胫神经损伤感觉障碍表现30侧(57.69%),股神经损伤感觉障碍6侧(11.54%),股后皮神经损伤感觉障碍21侧(40.38%)。L2-S2节段神经感觉支受损,其中L2神经根损伤5侧(9.61%),L3节段神经根损伤5侧(9.61%),L4节段神经根损伤6侧(11.54%),L5节段神经根损伤26侧(50.00%),S1节段神经根损伤31侧(59.61%),S2神经根损伤21侧(40.38%)。48侧肢体出现运动障碍,9例患者(神经减压松解组8例、神经保守治疗组1例)出现双侧下肢运动障碍。其中单纯腓总神经支配肌肉肌力下降11侧(22.92%),腓总神经合并胫神经支配肌肉肌力下降30侧(62.50%),股神经支配肌肉肌力下降5侧(10.42%),臀上神经支配臀中肌、臀小肌肌力下降2侧(4.17%)。L2-S1节段神经运动支受损,其中L2节段神经根损伤5侧(10.42%),L3节段神经根损伤5侧(10.42%),L4节段神经根损伤24侧(50.00%),L5节段神经根损伤25侧(52.08%),S1神经根损伤30侧(62.50%)。18例(41.86%)患者出现鞍区感觉障碍、膀胱、肛周括约肌功能障碍等马尾神经损伤表现,表现为大小便失禁、性功能障碍。(2)保守治疗与神经减压松解腰骶丛损伤的临床效果对比减压松解组患者术中发现腰骶丛神经均受损,其中骶管内骨质压迫神经13例,骶孔狭窄变形4例,腰骶干被骨折块、骨痂压迫9例,骨折缝隙卡压腰骶干1例,骶管内骨质压迫神经合并腰骶干被骨块压迫5例,合并神经受牵拉而变细8例,合并部分神经根撕脱性损伤5例。术后患者手术刀口均获得一期愈合,未发生皮肤坏死和感染,无医源性神经损伤发生。40例(减压松解组30例、保守治疗组10例)患者获得随访,随访时间12-46个月,平均18个月。35患者骨折获得临床愈合,愈合时间8-15周,平均10.8周;1例外固定架终极固定患者骨盆畸形愈合,患侧肢体比对侧肢体出现短缩2cm。根据ASIA脊髓损伤评分标准,神经保守治疗组患者入院时患肢感觉评分平均为30.77分,随访患肢感觉评分平均为33.08分,感觉评分增量平均为2.13分；减压松解组患者入院时患肢感觉评分平均为29.69分,随访患肢感觉评分平均为34.46分,感觉评分增量平均为4.77分；两组样本感觉评分增量均数t检验示有统计学意义。根据ASIA脊髓损伤评分标准,神经保守治疗组患者入院时患肢运动评分平均为18.80分,随访患肢运动评分平均为21.13分,运动评分增量平均为2.33分；减压松解组患者入院时患肢运动评分平均为16.18分,随访患肢运动评分平均为22.63分,运动评分增量平均为6.45分；两组运动评分增量样本均数t检验示存在统计学意义,减压组运动评分增量高于非减压组。综合考虑腰骶丛神经下肢功能,根据英国医学研究院神经外科学会提出的MCRR标准,末次随访保守治疗组神经功能恢复情况：优4侧,良4侧,可2侧,差1侧,优良率为72.73%。减压松解组神经功能恢复情况：优19侧,良12侧,可5侧,差2侧,优良率81.58%。减压组优良率(82.05%)和非减压组优良率(70.00%)之间无明显统计学差异(P=0.405)。18例鞍区感觉减退合并膀胱、肛周功能括约肌、性功能障碍患者,完全恢复9例,部分恢复5例,无恢复4例。结论：1、骨盆后环骨折合并腰骶丛损伤其损伤平面在骨盆,临床表现为80%患腓总神经损伤症状,约60%合并胫神经损伤症状,约40%患马尾神经损伤表现,偶有股神经损伤症状。腰骶丛神经根损伤主要集中于L4-S2,L4运动支损伤几率远远高于L4感觉支损伤几率。2、骨盆后环出现骨折时,一旦出现上述症状,应仔细查看患者CT,确定是否存在骨质压迫神经的可能,如有疑虑,进一步行MR检查或肌电图。结合临床症状,正确诊治腰骶丛是否损伤并对损伤水平定位。3、对损伤的腰骶丛进行探查减压,其神经恢复效果整体上未优于保守治疗。但对于腰骶丛损伤患者的感觉功能评分以及运动功能评分提升量,减压松解组优于保守治疗组(P0.05)。
[Abstract]:Objective: 1, to explore the clinical characteristics of posterior pelvic ring fracture combined with lumbosacral plexus injury; 2, to explore the diagnostic strategy of posterior pelvic ring fracture combined with lumbosacral plexus injury; 3, to summarize and analyze the effect of different treatment methods on posterior pelvic ring fracture combined with lumbosacral plexus injury in our hospital in recent years. The object and method: 1 in 2005. From month to January 2013, 205 cases of pelvic fracture were treated in Shangdong Province-owned Hospital trauma department of orthopedics, of which 43 patients were diagnosed with posterior pelvic ring fracture combined with lumbosacral plexus injury. 28 cases were male, 15 women, 16-58 years old and 36.3 years old. The cause of injury: 28 cases of accident injury, 2 cases of heavy weight injury, 1 falling injuries, 1 cases of explosion injury, 6 cases of roller injury. Tile classification: 3 cases of type A, 15 cases of type B, 25 cases of type C; classification of fracture site of posterior pelvic ring: 3 cases of iliac wing fracture, 9 cases of sacroiliac joint fracture, 31 cases of sacral fracture, 2 cases of Denis I, 13 cases of Denis II, 16 cases of Denis type III, 9 closed pelvic fractures, 4, obsolete type of open pelvic fracture. The.ISS score of 7 cases of pelvic fracture was 16-43 points, with an average of 22.2 points. All patients were treated according to the pelvic emergency procedure. After the disease was stable, the clinical symptoms, physical examination, and imaging findings of the patients were diagnosed, and then the segmental location of the lumbosacral plexus nerve root damage was made according to the perineal and lower extremities, and the segment of the lumbosacral plexus nerve root damage was located, according to AISA The score of the spinal cord injury score and the score of the lower extremities of the patients were treated with the conservative treatment of nerve damage in.11 patients. 32 patients underwent decompression of nerve decompression, including 10 cases with simple anterior decompression, 17 cases with simple posterior decompression and 5 cases of.36 routine fracture reduction and fixation, including 4 external fixators (2 exceptions). The final fixation was the ultimate fixation, 2 cases were fixed in two stages of ilium and lumbar fixation, 5 cases of internal fixation with "M" shaped plate, 13 cases of iliac lumbar fixation, 9 cases of double plate fixation of sacroiliac anterior approach, 5 sacroiliac screw fixation and 15 cases with anterior ring fixation. Results: (1) the clinical characteristics of posterior pelvic ring fracture combined with lumbosacral plexus injury, 43 cases of lumbosacral plexus injury patients appeared perineal and lower extremities. Dysfunction, or manifested as perineal and lower extremities sensory disorders, or manifested as lower extremity dyskinesia and bladder, perianal sphincter dysfunction, or the simultaneous presence of.52 side limbs in the two cases, 9 cases (8 cases of neurodecompression and 1 cases of neuroconservative treatment group) with bilateral lower limb sensation disorder, 3 sides of decompression and release group, and 3 sides and protection. In the 1 sides of the treatment group, 1 sides of the lower extremities had radioactivity pain, of which 15 sides (28.85%) were found in the simple peroneal nerve injury sensation disorder, 30 side (57.69%), 6 side (11.54%) of the sensory barrier of the femoral nerve injury, and 21 (40.38%).L2-S2 segments of the posterior femoral cutaneous nerve injury, of which the nerve sensory branches were damaged, of which L2 Nerve root injury in 5 sides (9.61%), nerve root injury in L3 segment 5 sides (9.61%), nerve root injury in L4 segment 6 side (11.54%), nerve root injury in 26 side of L5 segment (50%), nerve root injury in 31 side (59.61%), S2 nerve root injury in 21 side (40.38%).48 side limbs, 9 cases (nerve decompression group 8 cases, conservative treatment group of nerve conservative treatment group) The muscle strength of the simple peroneal nerve was decreased by 11 sides (22.92%), the muscle strength of the peroneal nerve combined with the tibial nerve decreased by 30 sides (62.50%), the muscle strength of the femoral nerve innervated by 5 sides (10.42%), the superior gluteal superior gluteal muscle, and the muscle strength of the gluteus minimus decreased in 2 sides (4.17%).L2-S1 segment of the nerve motor branch. 5 sides (10.42%) of nerve root injury in middle L2 segment, 5 sides of nerve root injury in L3 segment, 24 side of nerve root injury in L4 segment (50%), 25 side of nerve root injury in L5 segment (52.08%), and 30 side of S1 nerve root injury (62.50%).18 cases (62.50%), patients with saddle area sensation disorder, bladder, perianal sphincter dysfunction, and so on. Clinical effects of urinary incontinence and sexual dysfunction. (2) comparison of the clinical effects of conservative treatment and decompression of the lumbosacral plexus injury, the lumbar and sacral plexus injuries were found in the decompression group, including 13 cases of sacral compression, 4 cases of sacral stenosis, 9 cases of lumbosacral fracture, 9 cases of callus compression, 1 cases of lumbosacral pressure in the fracture crevice, sacral canal. 5 cases of internal osteoponial compression combined with lumbosacral trunk were compressed by lumbosacral lump, 8 cases with nerve distraction and 5 cases of avulsion of nerve root, 5 cases were combined with partial nerve root avulsion injury. The postoperative patients were all healed, without skin necrosis and infection, no iatrogenic nerve injury occurred in.40 cases (30 cases of decompression release group and 10 cases of conservative treatment group). The follow-up time was 12-46 months, the average 18 months of.35 patients were healed, the healing time was 8-15 weeks, an average of 10.8 weeks. 1 cases with the ultimate fixator were healed, the side limb was compared with the side limb, 2cm. was based on the ASIA spinal cord injury score, and the patients in the nerve conservative treatment group were admitted to the hospital. The average of 30.77 points was 33.08, the average of sensory score was 2.13, the average of the sensory score was 29.69, the average of the patients was 34.46, the increment of sensory score was 4.77, and the increment of sensory score in two groups of samples was t test. According to the ASIA spinal cord injury score standard, the average of the limb movement score of the patients in the conservative treatment group was 18.80, the average of the follow-up limb movement score was 21.13, the average of the exercise score was 2.33. The average of the limb movement score of the patients in the decompression group was 16.18, and the average of the follow-up limb movement score was 2. 2.63 points, the average increment of the exercise score was 6.45, and the average number of incremental samples in the two groups was statistically significant. The increment of the exercise score in the decompression group was higher than that of the non decompression group. The MCRR standard of the lumbosacral plexus and the lower limb of the lumbosacral plexus was taken into consideration, according to the standard of the Department of Neurosurgery Institute of the Institute of medical research of the British Medical Institute and the last follow-up of the conservative treatment group. Functional recovery: excellent 4 sides, good 4 sides, 2 sides, 1 sides, excellent rate of 72.73%. decompression group nerve function recovery: excellent 19 side, good 12 side, 5 side, poor 2 side, excellent rate of 81.58%. decompression group (82.05%) and non decompression group (70%) without significant statistical difference (P=0.405).18 case saddle area hyposensory combined bladder, 9 cases of anal functional sphincter and sexual dysfunction were recovered completely, 5 cases recovered partially and 4 cases were not recovered. Conclusion: 1, the posterior pelvic ring fracture combined with lumbosacral plexus injury in the pelvis, the clinical manifestation is that 80% of the peroneal nerve injury symptoms, about 60% combined with the tibial nerve injury symptoms, about 40% of the cauda equina injury, and occasional shit lesion Injury symptoms. Lumbosacral plexus nerve root damage is mainly concentrated in L4-S2, L4 motor branch damage is far higher than the risk of L4 sensory injury risk.2, when the pelvic posterior ring fracture, once the symptoms of the pelvic posterior ring, should be carefully examined the patient CT, determine whether there is the possibility of bone compression of the nerve, if there is doubt, further MR examination or electromyography. Combined clinical Symptoms, correct diagnosis and treatment of lumbosacral plexus damage and location of the damage level.3, the damaged lumbosacral plexus are explored and decompressed, and the effect of nerve recovery is not better than conservative treatment on the whole. But for the sensory function score of the patients with lumbosacral plexus injury and the improvement of motor function score, the decompression and release group is better than the conservative treatment group (P0.05).

【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R687.3

【参考文献】