胸腰段脊柱骨折内固定术后椎间高度改变的影响因素及临床意义

发布时间：2019-06-18 13:43

【摘要】：胸腰段骨折是最常见的脊柱损伤。胸腰段骨折容易导致神经功能损伤,这就使它的治疗更加重要和困难。胸腰段骨折也常伴随着椎间盘的损伤,导致运动节段高度的丢失、脊柱后凸畸形。随着影像学和生物力学的发展、内固定器械和手术技巧的改进,胸腰段骨折的治疗已取得很大进展,但仍然存在争议。椎间盘是维持脊柱稳定性以及活动节段高度的一个重要结构。胸腰椎骨折常伴有临位椎间盘的损伤,椎间盘损伤的形式以及愈合的方式都会对骨折术后脊柱的稳定性产生影响。而传统后入路短节段内固定术常常对于椎间盘不予处理,这有可能是造成骨折术后脊柱运动节段高度丢失、后凸畸形的一个重要因素。因此,术前对于椎间盘损伤的评估对于手术方案的制定具有重要的意义。选取2014.9-2016.2于我院就诊并行后入路内固定术的胸腰段骨折患者,共20例,年龄20~50岁,平均33.5岁。分别于术前、术后、术后12个月、取内固定术后、取内固定术后6个月进行随访,获得其X线、MRI影像资料。根据患者术前MRI对其椎间盘损伤程度、椎体损伤程度、终板损伤程度进行分级,同时对各个随访点的患者在X线上测量椎间隙高度并对数据进行分析,平均随访14.1月。其中A1型骨折16例,A3型骨折4例;伤椎位于T11椎体2例,位于T12椎体10例,位于L1椎体3例,位于L2椎体5例。目前临床使用的的内固定器材对于解除神经压迫、解除椎管致压物、恢复椎体高度及形态等的技术已相对成熟,但是目前对于胸腰段爆裂骨折特别是不伴有神经功能损伤的患者,在手术与非手术、融合与非融合上,仍然存在着很大的争议。在观察患者影像学资料后我们发现,I、II型椎间盘损伤椎间高度在术前差距不大,而III、IV型椎间高度明显下降。术前有椎间盘损伤患者,骨折愈合取内固定术后椎间高度的丢失率明显比无椎间盘损伤的患者高。而且这个椎间高度丢失率与术前椎间盘损伤程度有关,且III、IV型椎间盘损伤患者其术后椎间高度丢失率明显高于I、II型患者。患者椎间盘损伤程度与椎体损伤程度以及终板损伤程度呈正相关。可以看出,骨折伴椎间盘的损伤会导致内固定术后患者椎间隙的塌陷以及运动节段高度的丢失。因此,为了防止由椎间盘损伤所带来的运动节段高度丢失以及脊柱不稳的问题,就需要清除间盘组织,并进行牢固的椎间融合。
[Abstract]:Thoracolumbar fracture is the most common spinal injury. It is more important and difficult for the treatment of the thoracolumbar fracture to result in a neurological deficit. The thoracolumbar fracture is often accompanied by the injury of the disc, resulting in the loss of the height of the motion segment, and the kyphosis of the spine. With the development of image and biomechanics, the improvement of internal fixation device and surgical technique, the treatment of thoracolumbar fracture has made great progress, but there is still a dispute. The disc is an important structure to maintain the stability of the spine and the height of the active segment. Thoracolumbar fracture is often associated with the injury of the spinal disc, the form of disc injury and the way of healing can have an effect on the stability of the spinal column after the fracture. The internal fixation of the traditional posterior segment of the posterior segment is often not treated for the disc, which may be an important factor in the highly lost and kyphosis of the spinal motion segment after the fracture. Therefore, the preoperative evaluation of the disc injury is of great significance to the development of the operation plan. A total of 20 cases of thoracolumbar fracture with internal fixation with internal fixation of 2014.9-2016.2 in our hospital were selected, with a mean age of 20-50 years and an average of 33.5 years. The X-ray and MRI image data were obtained by follow-up for 6 months after the internal fixation and the internal fixation. The degree of disc injury, the degree of damage of the vertebral body and the degree of endplate injury were graded according to the pre-operative MRI of the patient, and the height of the intervertebral space was measured on the X-ray by the patients at each follow-up point and the data were analyzed, with an average follow-up of 14.1 months. Among them, there were 16 cases of type A1 fracture and 4 cases of A3 type fracture. The injured vertebra was located in 2 cases of T11 vertebral body,10 in the T12 vertebral body,3 in the L1 vertebral body and 5 in the L2 vertebral body. The internal fixation device used in clinical use is relatively mature for the technique of releasing the nerve compression, releasing the vertebral canal pressure, restoring the height and the shape of the vertebral body, etc., but at present, for patients with the thoracolumbar burst fracture, in particular without the nerve function injury, in the operation and the non-operation, There is still a great deal of controversy over the integration and non-fusion. We found that the intervertebral height of type I and type II disc injury was not large before the operation, and the height of type III and IV was significantly lower after the observation of the imaging data of the patient. In patients with disc injury, the rate of loss of intervertebral height after fracture healing was significantly higher than that of patients without disc injury. And the loss rate of the intervertebral height is related to the degree of the pre-operative disc injury, and the loss rate of the postoperative intervertebral height of the patients with type III and IV disc injury is significantly higher than that of the I and II patients. The degree of disc injury in the patient was positively correlated with the degree of vertebral body injury and the degree of damage to the endplates. It can be seen that the injury of the fracture with the disc can lead to the collapse of the intervertebral space and the loss of the height of the motion segment after the internal fixation. Therefore, in order to prevent the loss of the height of the motion segment caused by the disc injury and the problem of spinal instability, it is necessary to clear the tissue of the intervertebral disc and make a firm intervertebral fusion.
【学位授予单位】：吉林大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R687.3

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