长期固定对胸腰段关节突关节影响的研究

发布时间：2019-07-09 18:37

【摘要】：目的：胸腰段是固定的胸椎与活动的腰椎之间的转换点,是胸椎生理后突与腰椎生理前凸衔接点,是关节突关节面朝向的移行,是躯干活动应力、肩背负重应力的集中点,因此胸腰段也就成为了脊柱骨折的好发部位[1]。在高能量损伤中胸腰段骨折占有较大比例,目前常用技术为椎弓根螺钉内固定系统。探讨胸腰段骨折中椎弓根固定系统的影响有着重要意义。本文意在探讨脊柱胸腰段骨折后行单纯椎弓根螺钉固定(大于1年),长期固定因素(大于1年)对胸腰段关节突关节的影响。方法：回顾分析病历,自2012年7月至2014年12月29个月内51例病人。其中男性35例,女性16例,年龄21-57岁,平均年龄39.42±9.63岁。这些病人,受伤部位为胸腰段,骨折类型为压缩骨折、没有后柱损伤的爆裂骨折、椎管占位1/3、没有神经损伤、Frankle/ASIA[2]分级为E级。这些病人具备手术指征,[3,4]同时可以腰椎后路单纯椎弓根螺钉固定术。受伤当时关节突关节无退行性变化,骨折不累及关节突关节,经肌间隙入路行单纯螺钉固定术,术中操作不对关节突关节造成影响。这些病人经长期(大于1年)单纯椎弓根螺钉固定术后,再次经肌间隙入路,不影响关节突关节,取出椎弓根固定装置。内固定装置取出术后,给予常规康复锻炼、护理,患者手术切口疼痛不重时行胸腰段过伸-过屈位X线检查,通过测量胸腰段过伸位被固定椎体矢状位Cobb角、胸腰段过屈位固定范围内的矢状位Cobb角,通过配对t检验,评估矢状面上固定范围内关节突关节的活动度。通过CT分别从矢状面、水平面、冠状面扫面、观察固定范围内的关节突关节,CT扫描厚度为1.2mm,扫描范围包含了被固定关节突关节。并与固定范围内关节突关节相临近的未被固定的关节突关节对比,通过关节突突关节关节间隙狭窄、关节突关节是否有完整骨痂形成、关节间隙是否中断三个方面评估长期固定因素对关节突关节的影响。回顾查看受伤后患者经单纯椎弓根螺钉内固定术,术后经过2个月康复,于门诊复查,行VAS评分、ODI评分(Oswestry评分),内固定取除术后经1.5个月至2个月的康复锻炼、护理,再次行VAS评分、IDO评分(Oswestry评分),对比内固定术后的VAS评分数值、ODI评分数值(Oswestry评分),用以评价长期固定(大于1年)因素对关节突关节影响在临床症状方面的表现。结果：矢状位动态X线检查,分别测得的固定范围内椎体过伸位Cobb角,过屈位Cobb角,进行配对t检验,得出P0.05,矢状面上固定范围内椎体过伸位Cobb角与过屈位Cobb角无统计学差异。CT检查,以单个关节突关节为观察对象,关节突关节关节间隙狭窄75.49%,关节间隙连续性中断10.29%,完整骨痂形成1.47%。内固定术后2月VAS评分,平均2.39±1.36分,取出椎弓根螺钉固定装置2个月后VAS评分,平均2.27±1.42分,二者没有统计学差异。取出固定装置后2个月ODI评分,平均6.64%±5.26%,功能评价优良率100%。结论：长期(大于1年)固定后关节突关节没有达到骨性融合,但仍造成关节突关节活动度消失。这种改变并不会引起明显的临床症状,也不会影响整体功能。
文内图片：

图片说明：图２ａ邋４２岁中年男性，受伤时间２０１１年１０月，伤椎为第２腰椎，，固定节段为逡逑
[Abstract]:Objective: The thoracolumbar segment is the transition point between the fixed thoracic and the active lumbar vertebra. It is the point of connection between the back and the back of the thoracic and lumbar vertebrae. It is the migration of the articular surface of the joint. It is the central point of the stress of the trunk and the heavy stress on the shoulder. Therefore, the thoracolumbar segment also becomes a good position of the fracture of the spinal column[1]. In that high-energy injury, the thoracolumbar fracture occupy a large proportion, and the common technique is the internal fixation system of the pedicle screw. It is of great significance to study the effect of the pedicle fixation system in the thoracolumbar fracture. The purpose of this study is to study the effect of simple pedicle screw fixation (more than 1 year) and long-term fixation (more than 1 year) on the joint of the thoracolumbar segment after the fracture of the thoracolumbar spine. Methods: The medical records were reviewed and 51 patients were from July 2012 to December 29,2014. Among them,35 were male,16 female,21-57 years old, and the mean age was 39.42 and 9.63 years. These patients, the injured part is the thoracolumbar section, the fracture type is the compression fracture, the burst fracture with no post-post injury, the spinal canal space is 1/3, no nerve damage, the Frankle/ AIA[2] is grade E. The patients had an indication of surgery,[3,4], while the lumbar posterior pedicle screw fixation could be performed at the same time. At that time, there was no degenerative changes in the articular process of the articular process, and the fracture did not involve the joint of the articular process. After the patients had been fixed with the pedicle screw for a long time (more than 1 year), the joint of the articular process was not affected, and the pedicle fixation device was taken out without affecting the joint of the joint. After the internal fixation device is taken out, the routine rehabilitation exercise and the nursing are performed, and the chest and waist section through-extension-over-flexion X-ray examination is performed when the pain of the surgical incision of the patient is not heavy, the sagittal Cobb angle of the sagittal position Cobb of the vertebral body is fixed by measuring the over-extension position of the thoracolumbar section, and the sagittal Cobb angle in the flexion-position fixing range of the thoracolumbar section is fixed, The range of motion of the articular process joints on the sagittal plane was evaluated by the paired t-test. The CT scan thickness was 1.2 mm from the sagittal plane, the horizontal plane and the coronal plane through the CT, and the scan range included the fixed articular process joint. And the effect of the long-term fixation factors on the articular process joint is evaluated through the three aspects of whether the joint gap is narrow, the joint process joint has a complete bone formation, and whether the joint gap is interrupted or not is compared with the non-fixed joint process joint adjacent to the joint process joint in the fixed range. It was reviewed that the patients with post-injury underwent a simple pedicle screw internal fixation, and the patients were recovered after 2 months after the operation, and the VAS score and the ODI score (Oswestry score) were performed in the out-patient clinic, and the recovery exercise, nursing and the VAS score after 1.5 months to 2 months after the operation were fixed in the internal fixation. The score of the IDO score (Oswestry score), the VAS score value after the internal fixation, and the ODI score value (Oswestry score) were used to evaluate the performance of long-term fixation (more than 1 year) on the effect of long-term fixation (more than 1 year) on the clinical symptoms of the articular process. Results: The Cobb angle and the Cobb angle of the body in the fixed range were measured by the sagittal dynamic X-ray examination. The Cobb angle and the Cobb angle of the over-flexion position were not statistically different from the angle of Cobb in the fixed range of the sagittal plane. The results showed that the joint space of the joint was 75.49%, the continuity of the joint was 10.29%, and the total bone rate was 1.47%. The VAS score was 2.39 and 1.36 points after the internal fixation, and the VAS score after 2 months after the fixation of the pedicle screw was taken out, with an average of 2.27 and 1.42 points, and there was no statistical difference between them. The score of ODI in 2 months after removal of the fixation device was 6.64% and 5.26%, and the excellent and good rate was 100%. Conclusion: In the long-term (more than one year), the joint of the articular process does not reach the bony fusion, but still causes the joint movement of the joint to disappear. This change does not cause significant clinical symptoms and does not affect the overall function.
【学位授予单位】：滨州医学院
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R687.3

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