经后路椎弓根钉棒系统内固定联合椎体后方蹬骨刀打压植骨复位治疗胸腰椎爆裂性骨折临床疗效分析

发布时间：2018-10-05 18:25

【摘要】：目的:探讨经后路椎弓根钉棒系统内固定联合椎管探查减压蹬骨刀打压植骨复位治疗胸腰椎单节段爆裂性骨折临床疗效分析。方法:对从2012年3月到2013年06月我科收治的36例新鲜胸腰椎单节段椎体爆裂性骨折患者的临床资料进行回顾性分析。其中男24例,女12例,年龄22—50岁,平均(36.8±9.5)岁;致伤因素为高处坠落伤17例,车祸伤12例,重物砸伤7例;受损节段包括T11,6例,T12,12例,L1,10例,L2,8例;术前结合影像学检查依照Denis分类法,均为爆裂性骨折;按改良Frankel神经功能分级标准评定:A级4例,B级8例,C级10例,D级14例;受伤时间至手术时间:2d—9d,平均5.4d。给予经后路椎弓根钉棒系统内固定,椎管探查减压,于椎弓根内侧缘伤椎后方行镫骨刀打压蹬移复位,伤椎植骨强化。手术方法:采用后正中入路,以伤椎为中心作切口,显露伤椎及其上、下临近椎体的椎板、关节突、横突等,暴露椎弓根螺钉进钉点,C型臂X线机透视指引下确定进钉点,在伤椎及临近椎体内置入6枚合适椎弓根螺钉,通过后路撑开器试行撑开复位矫正脊柱序列,临时固定。根据情况行半椎板开窗或者全椎板切除减压,用神经剥离子牵开硬脊膜,从椎弓根内侧缘探至后纵韧带,创建工作通道,经该通道用椎管内复位器镫骨刀对伤椎进行打压蹬移复位,伤椎植骨强化,解除椎管内占位,透视满意后钛棒加压固定植骨融合复位。结果:手术时间130—180分钟,平均150分钟;术中出血量210—700ml,平均(390.0±15.5)ml;所有患者均获得随访,末次随访未发现或提示有内固定松动、断裂、移位等情况,骨折椎体愈合及高度恢复满意,完整取出内固定器,未见螺钉钛棒松动、断裂。伤椎前缘高度比由术前的平均55.42±2.64%恢复到末次随访的92.16±1.06%(P0.01),伤椎稳定高度比由术前的平均33.94±1.34%恢复到末次随访为89.10±1.37%(P0.01),矢状面Cobb角由术前平均25.95°±2.27°恢复到术后的3.26°±0.52°(P0.01)。随访期间伤椎前缘高度比、伤椎稳定高度比、矢状面Cobb角平均分别丢失2.87%、3.96%、2.65°。采用A S I A(American Spinal Injury Association)评分和改良Frankel神经功能分级标准评估神经功能改善情况。36例不完全神经损伤患者末次随访脊髓神经功能均有改善,恢复1级以上的患者有30例,占所有恢复病例数的83.3%。无术中神经损伤及术后损伤加重等并发症。疼痛、腰背部功能应用VAS评分、ODI功能障碍指数、JOA评分进行评估,均较术前有明显改善。日常生活活动能力运用FIM评分和Barthel指数评估,末次随访均较术前有明显改善。结论:应用经后路椎弓根钉棒系统内固定联合椎体后方蹬骨刀打压植骨复位治疗胸腰椎单节段爆裂性骨折,能有效地恢复伤椎高度、改善后凸畸形、重建脊柱序列。同时安全有效地进行椎管前方减压,解除脊髓压迫、恢复血供利于术后神经功能及腰背部功能的恢复。但尚须大宗病例的积累及长期随访验证。
[Abstract]:Objective: to investigate the clinical effect of posterior pedicle screw system internal fixation combined with exploration of spinal canal decompression and pedal knife compression and bone grafting in the treatment of thoracolumbar single level burst fracture. Methods: the clinical data of 36 cases of fresh thoracolumbar vertebral burst fracture treated in our department from March 2012 to June 2013 were retrospectively analyzed. There were 24 males and 12 females, aged 22-50 years, with an average age of (36.8 卤9.5) years. According to Denis classification, all cases were burst fractures, 4 cases of grade A and 8 cases of grade B, 10 cases of grade D and 14 cases of grade D were assessed according to modified Frankel classification standard, and the time of injury to operation was 2 d to 9 days, with an average of 5.4 days. The posterior pedicle screw and rod system were fixed, the spinal canal was decompressed by exploration and decompression, and the stapes knife was used to press and push the pedicle at the posterior of the medial edge of the pedicle, and the injured vertebrae was strengthened with bone graft. Methods: the posterior median approach was used to expose the lamina, articular process and transverse process of the injured vertebrae and its upper and lower vertebrae through the incision centered on the injured vertebrae. The point of entry was determined under the guidance of the C-arm X-ray machine under the guidance of exposure of pedicle screw entry point and C-arm X-ray machine. Six suitable pedicle screws were inserted into the injured and adjacent vertebrae. According to the situation, half lamina fenestration or total laminectomy and decompression were performed. The dura mater was opened with nerve dissection, and the posterior longitudinal ligament was found from the medial margin of pedicle to create a working channel. With the stapes knife in the spinal canal, the injured vertebrae were reduced by compression and pedal, the injured vertebrae were strengthened with bone graft, the space occupied in the spinal canal was relieved, and the fusion reduction of titanium rod compression fixation and bone graft fusion was achieved after the fluoroscopy was satisfied. Results: the operative time was 130-180 minutes (mean 150min), the amount of intraoperative bleeding was 210-700ml (mean 390.0 卤15.5ml) and all the patients were followed up. No internal fixation loosening, breakage and displacement were found or indicated in the last follow-up. Fracture vertebral body healing and high recovery satisfactory, complete removal of internal fixator, no screw titanium rod loosening, fracture. The anterior height ratio of the injured vertebrae recovered from 55.42 卤2.64% before operation to 92.16 卤1.06% at the last follow-up (P0.01), the ratio of stable height of the injured vertebra recovered from 33.94 卤1.34% to 89.10 卤1.37% (P0.01), and the sagittal plane Cobb angle recovered from 25.95 掳卤2.27 掳preoperatively to 3.26 掳卤0.52 掳(P0.01). During the follow-up period, the anterior height ratio of the injured vertebra, the stable height ratio of the injured vertebra, and the sagittal Cobb angle lost 2.87 and 3.96 degrees respectively. The improvement of neurological function was evaluated by A S I A (American Spinal Injury Association) score and modified Frankel criteria. All the 36 patients with incomplete nerve injury were followed up for the last time, and 30 patients recovered to grade 1 or more. It accounted for 83.3% of all cases recovered. There were no complications such as nerve injury during operation and severe injury after operation. Pain, lumbar and back function were evaluated with VAS score and dysfunction index (VAS), which were significantly improved compared with those before operation. Activities of daily living (ADL) were evaluated with FIM score and Barthel index. Conclusion: the treatment of thoracolumbar single level burst fracture with posterior pedicle screw and rod fixation combined with posterior pedicle bone knife reduction can effectively restore the height of injured vertebrae, improve kyphosis deformity and reconstruct spinal sequence. At the same time, decompression of anterior spinal canal, decompression of spinal cord and restoration of blood supply are beneficial to the recovery of postoperative nerve function and lumbar and back function. However, the accumulation of large numbers of cases and long-term follow-up should be verified.
【学位授予单位】：四川医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R687.3

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