胸腰椎爆裂骨折手术治疗的研究进展

脊柱骨折中最常受累的节段是T10～L2，尤其是T11、L1、L2，脊柱胸腰段指T11～L2，爆裂骨折与高能创伤有关，常由于高处坠落伤所致。胸腰段椎体是胸椎后凸与腰椎前凸的转折点，又具有较大的活动度，因此最容易受到传导暴力造成损伤，其中垂直压缩暴力导致的爆裂骨折较多见。该型损伤的特点是脊柱中柱受累，在轴向应力的作用下使椎体呈爆     

骨质疏松性胸腰椎爆裂骨折的手术治疗策略

目的探讨骨质疏松性胸腰椎爆裂骨折的治疗方法。方法对28例骨质疏松性胸腰椎爆裂骨折采用经椎弓根植骨后路短节段椎弓根内固定,椎间盘变性破裂者切除椎间盘行椎体间植骨融合术。结果患者术后伤椎前缘高度和Cobb角恢复满意,患者获随访24～36个月,伤椎矫正度无明显丢失。结论经椎弓根植骨内固定治疗骨质疏松性胸腰椎爆裂骨折远期疗效满意,对椎间盘破裂者需同时切除椎间盘行椎体间充分植骨融合。     

前路Z型钢板加钛网固定治疗胸腰椎爆裂性骨折

目的　探讨前路“Z”型钛钢板结合钛网在治疗严重胸腰椎爆裂骨折中的应用价值。方法　对 32例胸腰椎爆裂骨折伴脊髓或马尾损伤患者 ,采用胸膜外 -腹膜后入路对骨折椎体施行胸腰椎侧前方减压 ,椎体间钛网加自体骨植骨及“Z”型钛钢板固定术。结果　术后随访 1 2～ 32个月 ,平均 1 9. 7个月 ,全部病例椎间植骨均牢固融合 ,脊柱序列正常 ,钢板螺钉无松动。结论　胸腰椎侧前方减压、椎体间钛网加自体骨植骨及“Z”型钛钢板内固定是治疗严重胸腰椎爆裂骨折的理想方法之一     

后路单节段固定融合治疗胸腰椎爆裂骨折的研究进展

胸腰椎爆裂骨折的定义、分型"爆裂型骨折"一词由Holdsworth[1]于1963年初次提出,他把爆裂骨折定义为由于轴向载荷导致椎间盘髓核压入椎体引起上下终板骨折,并且造成椎体骨碎片向外移位的爆裂骨折.1983年Denis[2]以三柱理论重新把爆裂骨折定义为椎体前中柱的压缩骨折、椎体后缘的骨折碎块后突入椎管内,放射学显示骨折椎体呈爆裂性.几乎90％的脊柱骨折发生在胸腰段,而胸腰椎爆裂骨折占此类骨折的10％～20％.胸腰椎爆裂骨折的治疗目前尚无一个统一的原则,无论保守治疗还是手术治疗都有取得良好效果的报道,最佳的治疗方案仍然是不明确的,本文综述单节段固定融合治疗胸腰椎爆裂型骨折的进展.     

前路Z型钢板加钛网固定治疗胸腰椎爆裂性骨折

目的 探讨前路“Z”型钛钢板结合钛网在治疗严重胸腰椎爆裂骨折中的应用价值。方法 对32例胸腰椎爆裂骨折伴脊髓或马尾损伤患者，采用胸膜外-腹膜后入路对骨折椎体施行胸腰椎侧前方减压，椎体间钛网加自体骨植骨及“Z”型钛钢板固定术。结果 术后随访12～32个月，平均19．7个月，全部病例椎间植骨均牢固融合，脊柱序列正常，钢板螺钉无松动。结论 胸腰椎侧前方减压、椎体间钛网加自体骨植骨及“Z”型钛钢板内固定是治疗严重胸腰椎爆裂骨折的理想方法之一。     

360°植骨治疗胸腰椎爆裂型骨折

胸腰椎爆裂型骨折常发生终板骨折,椎间盘突入椎体内,椎体内骨小梁结构被挤压破坏,后路手术恢复椎体高度时,骨小梁系统不能同时恢复,产生椎体内空隙,即"蛋壳样"椎体.这种椎体其实已丧失了结构的完整性,不具有负重能力,常导致后期内固定物松动和矫正度丢失.本院2000年1月～2007年10月采用经椎弓根椎体前路植骨联合后外侧植骨(360°植骨)治疗胸腰椎爆裂型骨折,现总结如下.     

胸腰椎爆裂性骨折的影像学诊断与分类

目的 :进一步讨论胸腰椎爆裂性骨折的影像学诊断和分类。方法 :回顾性分析了 12 6例 13 9处胸腰椎爆裂性骨折 ,依据Atlas标准进行分类并比较其稳定性 ,对照了三种影像学诊断方法的优势及不足。结果 :Atlas分类A型 14例次 ,B型 79例次 ,C型 11例次 ,D型 19例次 ,E型 16例次。X线平片能发现大多数胸腰椎爆裂性骨折 ,但易漏诊、误诊 ;CT可准确显示椎体后缘、游离骨折片或椎间盘凸入椎管的程度 ;MRI能清晰显示韧带、椎间盘和脊髓变化。结论 :对怀疑或X线已诊断的胸腰椎骨折应常规作CT检查 ,MRI可作为判定脊髓损伤程度的补充。     

360°植骨治疗胸腰椎爆裂型骨折

胸腰椎爆裂型骨折常发生终板骨折，椎间盘突入椎体内，椎体内骨小梁结构被挤压破坏，后路手术恢复椎体高度时，骨小梁系统不能同时恢复，产生椎体内空隙，即“蛋壳样”椎体。这种椎体其实已丧失了结构的完整性，不具有负重能力，常导致后期内固定物松动和矫正度丢失。本院2000年1月~2007年10月采用经椎弓根椎体前路植骨联合后外侧植骨（360°植骨）治疗胸腰椎爆裂型骨折，现总结如下。     

360°植骨治疗胸腰椎爆裂型骨折

胸腰椎爆裂型骨折常发生终板骨折,椎间盘突入椎体内,椎体内骨小梁结构被挤压破坏,后路手术恢复椎体高度时,骨小梁系统不能同时恢复,产生椎体内空隙,即“蛋壳样”椎体。这种椎体其实已丧失了结构的完整性,不具有负重能力,常导致后期内固定物松动和矫正度丢失。本院2000年1月～2007年10月采用经椎弓根椎体前路植骨联合后外侧植骨（360°植骨）治疗胸腰椎爆裂型骨折,现总结如下。     

椎间盘损伤对胸腰椎椎体骨折脱位手术疗效的影响

目的：分析、探讨椎间盘损伤对胸腰椎椎体骨折脱位手术疗效的影响。方法：收集我院1998年1月～2010年1月门诊及住院胸腰椎椎体骨折脱位伴随间盘损伤患者资料,分析、讨论胸腰椎椎体骨折脱位合并严重椎间盘损伤患者手术前后影像学资料及手术疗效。结果：16例胸腰椎椎体骨折脱位合并椎间盘损伤患者中椎体复位不良者10例,椎间隙成角畸形4例,脱位椎体复位欠满意4例,椎间隙过撑2例,内固定断裂10例。内固定取出后椎间隙高度降低8例,再脱位6例,后凸成角畸形4例。结论：胸腰椎椎骨折脱位、特别是严重胸腰椎椎体骨折脱位患者,术前需要进行完善的术前检查,包括X线、CT和MRI检查,明确是否存在椎间盘的损伤,并根据椎间盘损伤程度选择合适的手术方案,以确保手术疗效。     

The radiographic description of thoracolumbar fractures

The x-ray films of 40 patients with thoracolumbar fractures were studied in order to classify the fractures, to investigate the causes of neural compression, and to define which fractures were unstable. Each fracture could be classified as a wedge fracture, a burst fracture, or a fracture-dislocation. The fragment of bone that produced neural compression in wedge and burst fractures almost always arose from the upper half of the vertebral body and had a characteristic triangular shape, as viewed on lateral x-ray films of the spine. Based on radiographic evidence, fracture-dislocations, severe burst fractures, and wedge fractures associated with marked subluxation, traumatic spondylolisthesis, or horizontal fractures of a pedicle were considered to be unstable. Mild burst fractures and most wedge fractures were considered to be stable.     

前路减压植骨内固定治疗胸腰椎爆裂性骨折

目的探讨前路减压植骨融合内固定手术在治疗胸腰椎爆裂性骨折的疗效。方法回顾性分析2000年5月～2005年3月前路减压植骨融合內固定治疗胸腰椎爆裂性骨折58例。骨折节段—单椎体骨折:T101例,T114例,T1213例,L118例,L211例,L32例;双椎体骨折:T12与L16例,L1与L23例。结果平均随访13.5个月,按Frankel分级评定神经功能恢复1级以上。影像学检查比较,未发现明显的矫正度丢失。植骨块位于中央、己融合,无假关节形成及內固定失败。结论前路减压植骨内固定治疗胸腰椎爆裂性骨折,减压更彻底、更安全,能较好地重建前中柱稳定性。     

经椎弓根椎管前方减压治疗胸腰椎爆裂骨折

目的探讨后路经椎弓根椎管前方骨块切除减压重建治疗胸腰椎爆裂骨折的临床疗效。方法 2007年6月至2009年5月采用后路经椎弓根椎管前方骨块切除减压重建治疗胸腰椎爆裂骨折26例（20例获得随访,6例失访）。高空坠落伤8例,车祸伤10例,重物压砸伤2例。T113例,T127例,L18例,L22例。采用A S IA分级进行神经功能评估。通过术前、术后1周、术后6个月随访时的X线及CT片比较椎管容积及Cobb角变化,评估椎管减压及复位情况。结果手术时间2.3～3.5 h,平均2.8 h,术中出血500～1 800 mL,平均700 mL,术中无神经及血管进一步损伤,术后无感染及深静脉血栓等并发症。20例患者得到随访,平均随访18个月（12～24个月）。椎管容积（CT测量实际椎管容积占正常椎管容积的百分比）术前平均53.23%,术后1周95.17%,术后6个月96.47%,与术前比较明显改善（P〈0.05）;Cobb角术前平均20.6,°术后1周4.3,°术后6个月4.9,°与术前比较明显改善（P〈0.05）。所有病例脊髓获得有效减压,A S IA分级改善1级者10例,改善2级者7例,2例无明显改善者术前均为A级,1例术前为E级者术后仍为E级。所有病例术后6个月植骨均达骨性愈合,内固定未见松动、断裂。结论后路经椎弓根椎管前方骨块切除减压重建治疗胸腰椎爆裂骨折可以有效恢复椎管容积及Cobb角度,是安全、有效的手术方法。     

Pyramesh钛网配合Z-plate治疗严重胸腰椎爆裂性骨折

目的探讨Pyramesh钛网配合Z-plate在治疗严重胸腰椎爆裂性骨折中的应用价值.方法16例胸腰椎爆裂性骨折伴脊髓或马尾损伤患者进行前路椎体次全切除减压,自体碎骨装入Pyramesh钛网后行椎体间植骨,加用Z-plate内固定.结果术后随访3～13个月,平均9.5个月,全部病例椎间植骨均牢固融合,椎间高度和生理曲度保持满意,神经功能恢复良好,钢板螺钉未松动.结论采用Pyramesh钛网配合Z-plate治疗胸腰椎严重爆裂性骨折可使椎管减压彻底,植骨融合率高,能有效的维持椎间高度和生理曲度,有利神经功能恢复,是治疗严重胸腰椎爆裂性骨折的理想方法之一.     

Intervertebral disc viability after burst fractures of the thoracic and lumbar spine treated with pedicle screw fixation and direct end-plate restoration

Background contextControversies persist for the best treatment of burst fractures of the thoracolumbar spine. Anterior corpectomy and discectomy followed by reconstruction with intervertebral cage and posterior fixation, for example, are based mainly on the widespread assumption that intervertebral discs involved in burst-type fractures, typically, do not survive the traumatic event and will degenerate irrevocably.PurposeTo evaluate whether intervertebral discs, located adjacent to traumatic burst fractures and treated with pedicle screw fixation and direct end-plate restoration, survive the traumatic event or irrevocably progress to severe disc degeneration.Study designProspective trial.Patient sampleTwenty adult patients with traumatic burst fractures of the thoracolumbar spine and treated with pedicle screw fixation and direct end-plate reduction were included.Outcome measuresDisc degeneration according to the Pfirrmann classification.MethodsMagnetic resonance imaging scans were obtained preoperatively, 1 month after surgery and 1 month after pedicle screw removal 12 to 18 months after index surgery. Degeneration of the intervertebral discs adjacent to the fracture was assessed using the Pfirrmann classification. Grade 1/2/3 was defined as mild-to-moderate degeneration of the intervertebral disc (MDID), whereas Grade 4/5 was defined as severe-to-endstage degeneration of the intervertebral disc (SDID). Repeated measure analysis was performed to detect significant differences between MDID and SDID scores.ResultsA total of 19 patients (38 discs) were fully documented and available for study. All discs showed MDID preoperatively, and while five discs (13%) progressed to SDID at 12 to 18 months posttrauma, the other discs did not show progression of degeneration.ConclusionsIntervertebral discs adjacent to traumatic burst fractures treated with pedicle screw instrumentation and direct end-plate restoration do not routinely seem to progress to severe degeneration at 12 to 18 months postinjury.     

胸腰椎爆裂性骨折手术治疗的研究进展

【摘要】胸腰椎爆裂性骨折占脊柱骨折的一半以上。由于涉及到脊柱稳定性和神经功能损害,外科处理的复杂性往往建立在个性化、甚至经验方面的的考虑,因此,胸腰椎爆裂性骨折的最好治疗方法备受争议,结点是手术治疗和保守治疗的选择,尤其是神经功能尚好的骨折。目前,开放手术一直是外科治疗的主要方式,既通过不同入路途径进行椎管减压、骨折复位及固定,达到椎体的融合和促进神经功能恢复目的。微创治疗胸腰椎爆裂性骨折并不很多,目前尚缺乏高证据水平,但随着微创技术和新型固定材料的进步,微创条件下治疗胸腰椎骨折不断增多,如采用腔镜下前外侧入路或经皮入路的固定术式。     

伤椎椎弓根螺钉固定横突间植骨治疗胸腰段爆裂骨折

目的评价经伤椎行椎弓根螺钉固定结合横突间植骨治疗胸腰椎单节段椎体爆裂性骨折的临床疗效。方法回顾性分析我院2006年6月至2009年1月期间经伤椎行椎弓根螺钉固定结合横突间植骨治疗胸腰椎爆裂性骨折病例资料16例,其中男性11例,女性5例;年龄21～68岁,平均42.4岁。收集的病例均为单节段椎体爆裂性骨折,伤椎仅一侧椎弓根置钉,即五钉固定法。比较术前术后椎体前缘高度、脊柱后凸角（矢状面Cobb′s角）、椎管正中矢状径、神经功能Frankel分级等指标。结果术后随访6～24个月,平均随访10.8个月,术后均获得较好复位,高度及外形基本恢复正常,无内固定物松动、断裂等并发症,手术前后椎体前缘高度、脊柱后凸角（矢状面Cobb′s角）、椎管正中矢状径比较差异均有统计学意义（P〈0.05）,疼痛明显减轻,神经功能Frankel分级亦有改善。结论经伤椎行椎弓根螺钉固定结合横突间植骨治疗胸腰椎椎体爆裂性骨折可获得不错疗效,可以较好重建椎体高度,减少并发症,增强固定的稳定性及抗扭转能力,是治疗胸腰段椎体爆裂性骨折一种可行、有效的方法 。     

Concomitant fractures of the acetabulum and spine: a retrospective review of over 300 patients

BACKGROUND: The incidence and spectrum of concomitant acetabulum and spine trauma has not been clearly defined. METHODS: We retrospectively reviewed 307 acetabulum fracture patients over 5 years, and evaluated this cohort for concomitant spine injuries. Patient and injury demographics, spine and neurologic injury and delay in diagnosis were examined. RESULTS: Complete data were available for 275 (90%) of the cohort, and 55 spine injuries (54 fractures and 1 traumatic disc herniation) were identified in 34 patients. Thus, the incidence of concomitant acetabulum and spine fractures was approximately 13% (34 of 275). Four percent of the patients sustained significant thoracolumbar fractures (burst, flexion-distraction, or dislocation). An average 8.6-day delay in diagnosis occurred in three spine fracture patients. One suffered progressive neurologic injury. CONCLUSIONS: It is essential that the traumatologists have a high index of suspicion for spine injury, particularly thoracolumbar injury in patients who sustain fractures of the acetabulum. We recommend early thoracolumbar computed tomography imaging in patients with fractures of the acetabulum if plain radiographs are not possible or inadequate.     

Incomplete burst fractures of the thoracolumbar spine: a review of literature

Purpose

The purpose of this review was to analyze the biomechanical basis of incomplete burst fractures of the thoracolumbar spine, summarize the available treatment options with evidence from the literature, and to propose a method to differentiate fracture severity.

Methods

The injury pattern, classification, and treatment strategies of incomplete burst fractures of the thoracolumbal spine have been described following a review of the literature. All level I–III studies, studies with long-term results and comparative studies were included and summarized.

Results

Details of five randomized control trials were included. Additionally, three comparative studies and two studies with long-term outcomes were detailed in this review. The fracture severity reported in the included studies varied tremendously. Most classification used did not adequately describe the complexity of fracture configuration. A wide variety of treatment strategies were outlined, ranging from non-operative therapy to aggressive surgical intervention with combined anterior-posterior approaches. Thus, the treatment of incomplete burst fractures of the thoracolumbar spine is quite diverse and remains controversial.

Conclusions

Incomplete burst fractures can differ tremendously regarding the degree of instability they confer to the thoracolumbar spine. Based on a detailed review of the literature, it is clear that good results can be obtained with both non-operative and operative strategies to treat these injuries. In the authors’ opinion, the intervertebral disc plays a key role in determining the long-term clinical and radiological outcome. Thus, an incorporation of the intervertebral disc pathology into the existing classification systems would be a valuable prognostic factor.

     

有限减压相邻节段植骨内固定术治疗胸腰椎骨折

[目的]研究有限减压相邻节段椎弓根内固定椎间、椎内植骨融合术治疗胸腰椎骨折的可行性和临床疗效。[方法]回顾性研究应用该技术治疗的43例胸腰椎骨折患者,观察植骨融合及复位情况、神经功能恢复情况,及矫正丢失、腰痛后遗症和融合椎体相邻椎间盘退变等并发症发生情况。[结果]平均随访21.4个月,所有患者均达到坚强骨性融合,均得到满意的复位,复位率达96.1%,近期内无明显矫正丢失,术后神经功能均得到不同程度的恢复,术前术后秩和检验P<0.01,且融合节段相邻椎间盘退变率仅为4.65%,未出现顽固性腰痛、腰椎活动受限等并发症,临床疗效明显优于长节段内固定。[结论]只要适应证选择合适,有限减压相邻节段内固定椎间、椎内植骨融合内固定术不但可以达到满意复位、坚强骨性融合,而且可以明显降低顽固性腰痛、相邻椎间盘退变等并发症的发生率。