骶骨骨折合并骶神经损伤的MRI诊断及临床应用研究

目的探讨骶骨骨折合并骶神经损伤患者的MRI诊断及其临床应用。方法选择2004年10月～2010年10月,笔者所在医院收治的50例骶骨骨折合并骶神经损伤患者,采用MRI行骶骨斜冠状位扫描,另行骨盆X线拍片、CT及螺旋CT检查患者神经走行及其周围神经丛。X线显示骶骨外侧骨折向后移位,骶结节、骶骨线均模糊,且底孔不对称;CT提示滴管不同断面水平不对称以及骨折后结构发生变化,骶骨外侧骨折向后上移位;MRI提示高位（S1～S3）神经根损伤23例33处,低位（S3以下）神经根损伤12例18处。结果经手术验证高位（S1～S3）神经根损伤25例37处,低位（S3以下）神经根损伤12例18处,高位（S1～S3）漏诊2例,且经骶骨冠状位MRI扫描,发现骶神经损伤且有骨块压迫、神经根改变12例,神经根周围脂肪消失者22例,骶神经根增粗15例,漏诊率4%。结论采用MRI能准确定位骶骨及其周围神经的损伤情况,并结合常规影像学资料对于后续治疗具有重要诊断价值。     

陈旧性Denis Ⅱ型骶骨骨折合并骶神经损伤的诊断与治疗

目的：探讨陈旧性Denis Ⅱ型骶骨骨折合并骶神经损伤的诊断及手术方法。方法：取60具骶骨干标本及26具完整骨盆标本，测量S1棘突与S1后孔同位置关系、骶前区血管、骶神经及梨状肌之间关系；对14例陈旧性DenisⅡ型骶骨骨折合并骶神经损伤患者，在常规骨盆X线片，CT，螺旋CT三维重建的同时，又采用显示骶神经全长的骶骨斜冠状位MR扫描，观察神经走向及眦领关系。11例行自行设计的后略骶神经管扩大减压术，3例行非手术治疗。结果：S1棘突于S1后孔中上1/3者占90%，骶前区主要血管有骶外侧动静脉和骶外侧血管、骶正中血管及臀上血管进入骶前孔的分支。血管位于骶丛神经腹侧，骶外侧斑管距离S1前孔大于10mm，S2前孔大于5mm。骶骨斜冠状位MR扫描可以显示骶神经全长及周围眦领关系。骶神经损伤时，发现有神经根走行改变(13例），损伤处神经很周围脂肪消失（11例），神经根管狭窄(10例)。14例均获得随访。随访时间6--12个月。平均7.1个月，术后改善情况，优9例，无变化1例。结论螺旋CT三维重建及骶骨斜冠状位MR扫描对于骶神经损伤的定位及定性诊断有重要价值。后路骶神经管扩大减压术是针对骶神经管、骶前孔处神经损伤的较理想手术方法。     

磁共振SPACE-STIR序列扫描对骶骨骨折合并骶神经损伤的诊断价值

目的:探讨磁共振SPACE-STIR序列扫描对骶骨骨折合并骶神经损伤的诊断价值。方法:2009年1月~2010年12月我院收治骶骨骨折合并骶神经损伤患者7例,均有骶神经损伤的相应症状和体征,术前均行腰骶部X线片、CT检查及3.0T磁共振常规平扫与SPACE-STIR序列扫描检查,并行手术治疗。对7例患者术前的腰骶部磁共振常规扫描图像、SPACE-STIR序列扫描图像进行回顾性对比分析。结果:术前根据临床症状和体征诊断为骶神经损伤,其中S1神经根损伤5例,S2神经根损伤2例。术前X线片、CT检查均诊断为骶骨骨折,DenisⅡ型5例,Ⅲ型2例,但不能显示有无神经根损伤。术前磁共振常规平扫不能直接显示骶神经根损伤;磁共振SPACE-STIR序列扫描显示骶神经根中断2例,骶神经根受推压移位3例,骶神经根水肿增粗5例,诊断为S1神经根损伤6例,S2神经根损伤1例,其中S1、S2神经根断裂各1例。手术证实S1神经根损伤6例,S2神经根损伤1例,其中S1、S2神经根断裂各1例。SPACE-STIR序列扫描诊断与手术诊断的符合率为100%。结论:3.0T磁共振SPACE-STIR序列扫描可直观显示骶骨骨折引起的骶神经损伤。     

骶骨骨折的外科治疗

目的:探讨骶骨骨折的外科治疗方法和疗效。方法:对36例骶骨骨折病例作回顾分析,根据Denis骶骨骨折分类法,Ⅰ型15例,Ⅱ型16例,Ⅲ型5例。Ⅰ型骨折中2例伴有L4或L5神经根损伤,1例L4、L5神经根损伤。Ⅱ型12例伴有S1、S2神经根损伤。Ⅲ型3例单侧S1、S2神经根损伤,2例双侧S1、S2神经根及马尾神经损伤。Ⅰ型骨折15例予保守治疗,Ⅱ、Ⅲ型骨折21例均予手术治疗,其中8例无神经损伤或损伤轻微者单纯行骶骨骨折切开复位内固定术,13例伴有严重神经损伤者,予骨折切开复位内固定加神经探查松解术。结果:随访6~36个月,36例骶骨骨折均愈合,神经损伤均有不同程度恢复。3例Ⅰ型,10例Ⅱ型,3例Ⅲ型神经症状完全恢复,2例Ⅱ型残留骶神经损伤症状,2例Ⅲ型残留鞍区感觉减退、排尿乏力及性功能减退等症状。结论:骶骨骨折的治疗方案应取决于骨折类型及骶神经损伤程度。Ⅰ型骶骨骨折保守治疗效果满意,Ⅱ、Ⅲ型骶骨骨折需切复内固定手术,有严重骶神经损伤者需神经探查松解术。     

骶前减压骶孔成形术治疗陈旧性骶骨骨折合并骶丛神经损伤的疗效分析

目的探讨经腹直肌外侧入路骶前骶孔扩大成形、骶丛神经减压治疗陈旧性骶骨骨折合并骶丛神经损伤的方法及疗效。方法回顾性分析2013年1月至2018年6月南方医科大学第三附属医院骨科收治的11例陈旧性骶骨骨折合并骶丛神经损伤患者资料。男8例,女3例;年龄17~54岁,平均38岁;骶骨骨折按Denis分型均为Ⅱ区;神经损伤按英国医学研究会(BMRC)标准分级:完全损伤2例,部分损伤9例;受伤至手术时间0.7~12.0个月,平均6个月。经腹直肌外侧入路显露腰骶干及S1神经孔周围结构,直视下行骶孔扩大成形、松解骨折块及骨痂压迫的S1神经根及腰骶干,不稳定骶骨骨折者同时行复位内固定治疗。通过评价骨折愈合、神经功能恢复(BMRC标准)等观察疗效。结果本组11例患者中有10例顺利完成手术,1例因术中探查发现骶骨骨折完全愈合且S1神经孔完全闭塞,无法完成骶孔成形术而终止手术。手术时间70~220 min,平均110 min;术中出血量450~2800 mL,平均1100 mL。术后复查X线片、CT示骶孔扩大成形明显,无手术并发症发生。所有患者术后随访12个月至4年,平均18个月。所有患者末次随访时根据BMRC标准评价神经功能恢复情况:完全恢复5例,部分恢复4例,未恢复1例。结论经腹直肌外侧入路能较好地显露腰骶干及S1神经孔周围结构,直视下骶孔扩大成形、松解骨折块及骨痂压迫的S1神经根及腰骶干,是治疗陈旧性骶骨骨折合并骶丛神经损伤的一种可行的方法。     

DenisⅡ型骶骨骨折伴神经损伤早期手术疗效分析

目的：探讨DenisⅡ型骶骨骨折合并神经损伤的早期手术治疗的疗效。方法：2008年3月至2010年3月收治12例DenisⅡ型骶骨骨折伴神经损伤,男8例,女4例;年龄28～54岁,平均40岁。所有患者经详细体格检查及X线片、CT、MRI扫描等确诊,依据影像学资料进行Denis分型均为Ⅱ型。伤后6～14d手术,平均9d。8例骶前孔明显变形,责任骨块侵入骶孔压迫神经根,行后路骶神经减压内固定术;4例骶前孔轻度变形,无明显责任骨块侵入骶孔,行单纯切开复位内固定术。结果：12例均获随访,时间6个月～2年,骨折均Ⅰ期愈合,其中11例神经损伤患者均有不同程度恢复,Gibbons骶神经损害评分术前平均（2.67±0.49）分,术后平均（1.50±0.67）分,术后评分低于术前。结论：DenisⅡ型骶骨骨折伴神经损伤,全身情况许可应尽早手术治疗,可取得满意疗效。     

锁定加压钢板治疗合并神经损伤的骶骨骨折

目的探讨锁定加压钢板（LCP）治疗合并神经损伤的骶骨不稳定骨折的效果。方法采用LCP固定治疗合并神经损伤的不稳定骶骨骨折患者7例：L5神经根损伤3例，骶丛神经损伤4例.2例术中行经后路神经减压、骨折复位固定术，5例单纯行骨折复位固定术.结果7例均获随访，时间12—36（20．8±8．6）个月.3例L5神经根损伤和2例骶丛神经损伤者Frankel分级由C级恢复至E级，另2例骶丛神经损伤者由C级恢复至D级。术后功能根据Majeed评分标准评定：优3例，良3例，可1例.结论LCP治疗合并神经损伤的骶骨不稳定骨折是一种有效的方法.     

骨盆骨折合并骶丛神经损伤的手术治疗

目的探讨骨盆骨折合并腰骶丛神经损伤治疗的方法.方法回顾本组病例按Denis分类将骨盆骨折中骶骨骨折分为Ⅰ、Ⅱ、Ⅲ区,分析骨盆骨折合并腰骶丛神经损伤的临床特点及治疗效果.结果22例骨盆骨折合并腰骶丛神经损伤,随访6个月～5年.7例Ⅰ型骶骨骨折合并腰骶丛神经损伤,6例完全恢复正常,1例部分恢复;10例Ⅱ型骶骨骨折合并腰骶丛神经损伤,6例恢复正常,3例部分恢复,1例未恢复;5例Ⅲ型骶骨骨折合并腰骶丛神经损伤,2例恢复正常,2例部分恢复,1例未恢复.结论对于骨盆骨折并腰骶丛神经损伤的患者实施积极复位及内固定治疗,是非常重要的一环.有明显骨块压迫者,宜行神经探查松解术.     

核磁神经成像术在骶骨骨折合并腰骶神经损伤诊治中的应用价值

目的:探讨核磁神经成像术在骶骨骨折合并腰骶神经损伤诊治中的应用价值,总结骶骨骨折合并腰骶神经损伤的临床特征。方法:根据纳入及排除标准,收集2018年10月至2020年10月天津医院收治骶骨骨折合并腰骶神经损伤40例患者的病历资料。单侧骶骨骨折24例,均为Tile分型C1型,Denis分型Ⅱ型16例、Ⅲ型8例;双侧骶骨骨...     

骶骨骨折合并神经损伤的诊断与治疗

[目的]总结骶骨骨折合并骶神经损伤的诊断与治疗方法。[方法]1999～2004年收治骶骨骨折合并神经损伤患者12例,男9例,女3例。所有患者经详细体格检查及X线片、CT、MRI扫描等获得确诊。依据影像学资料进行Denis分型：Ⅰ型2例,Ⅱ型6例,Ⅲ型4例。不同分型采取相应的治疗方法：Ⅰ、Ⅱ型骨折先行骨盆牵引等保守治疗,观察4～6周,若症状改善不显著则转为手术治疗;Ⅲ型骨折尽早行后路骶椎管减压神经根探查松解手术;陈旧性Ⅱ、Ⅲ型骨折只要存在神经损伤表现,仍主张手术。共保守治疗7例,手术治疗5例。[结果]12例患者经6个月～3年随访,2例Ⅰ型骨折,6例Ⅱ型骨折患者完全恢复。4例Ⅲ型骨折患者中,1例完全恢复,2例显著改善,1例略有恢复。[结论]骶骨位置隐蔽,骨折所造成的神经损伤症状不明显,临床容易漏诊,需详细体检并结合影像学检查以提高确诊率。不同分型骨折可采用不同的治疗方法,手术方式以后路骶管减压骶神经松解为宜,陈旧性骨折只要存在神经损伤症状就有手术探查必要。     

GSS系统内固定及骶管减压治疗不稳定骶骨骨折伴神经损伤

目的探讨不稳定骶骨骨折伴神经损伤手术治疗方法。方法5例不稳定骶骨骨折伴神经损伤患者使用GSS内固定系统固定及骶管减压。结果骨折均一期愈合,4例坐骨神经损伤中,3例下肢顽固性疼痛和感觉过敏者,2例疼痛消失,1例疼痛减轻,感觉均恢复;1例足下垂未恢复;1例鞍区麻木、大小便失禁者,术后鞍区感觉及括约肌功能得到恢复。结论GSS内固定及骶管减压治疗不稳定骶骨骨折伴神经损伤是一种较为理想的方法。     

Study of the morphology and biomechanics of sacral fracture

Objective:To observe the morphological characteristics of sacral fracture under different impact loads. Method: Ten fresh pelvic specimens were loaded in dynamic or static state. A series of mechanical parameters including the pressure strain and velocity were recorded. Morphological characteristics were observed under scanning electron microscope. Results: The form of sacral fracture was related to the impact energy. Under low-energy impact loads, ilium fracture, acetabulum fracture and crista iliaca fracture were found. Under high-energy impact loads, three types of sacral fracture occurred according to the classification of Denis: sacral ala fracture, Type I fracture; sacral foramen cataclasm fracture, Type II fracture; central vertebral canal fracture, Type III fracture. Nerve injury of one or two sides was involved in all three types of sacral fracture. The fracture mechanism of sacrum between the dynamic impact and static compression was significantly different. When the impact energy was above 25 J, sacral foramen cataclasm fracture occurred, involving nerve root injury. When it was below 20 J, ilium and sacral fracture was most likely to occur. When it was 20 - 25 J, Type I fracture would occur. While in the static test, most of the fracture belonged to ilium or acetabulum fracture. The cross section of sacrum was crackly and the bone board of Haversian system was brittle, which could lead to separation of bone boards and malposition of a few of cross bone boards. Conclusions: In dynamic state, sacrum fracture mostly belongs to Type I and Type n , and usually involves the nerve roots. Sacrum fracture is relevant to the microstructures, the distribution of the bone trabecula, the osseous lacuna and the Haversian system of sacrum. The fracture of ilium and acetabulum more frequently appears in static state, with slight wound of peripheral tissues.     

Transverse sacral fracture in children: a case report presenting with neurological injury and review of the literature

Transverse fractures of the sacrum are exceptional in children. We report a case in a 10-year-old girl. The patient presented an isolated flexion fracture of the sacrum in Denis zone III (transverse "U" fracture) of S1-S2 with neurological signs at the initial examination: sensorial deficit in the perineum and sphincter dysfunction. Treatment consisted in laminectomy and bone resection to relieve compression causing the neurological injury. Orthopedic treatment led to correct bone healing. Outcome was favorable with complete resolution of the neurological deficit and stability at three years. Eight cases of transverse sacral fracture before the age of 18 years have been reported in the literature. The diagnostic elements are similar to those in adults, but can be missed in children who rarely present sacral fracture. The therapeutic approach has varied, both for children and adults. We advocate surgical treatment in the event of neurological complications and orthopedic treatment of stable bone lesions.     

骶骨骨折的手术治疗

目的 探讨骶骨骨折的手术治疗方法。方法 对16例骶骨骨折的患者行切开复位、松质骨螺丝钉内固定术，5例合并骶神经损伤者同时行神经探查。结果 对全部病例随访12～48个月，平均18个月，骨折均为一期愈合，一例坐骨神经损伤未恢复，治愈率达93％。结论 骶骨骨折切开复位内固定可以恢复骶骨的解剖关系，有利于神经损伤的恢复。对伴有神经损伤症状者应同时行神经探查。     

Longitudinal fracture of the sacrum

A longitudinal fracture of the sacrum without an associated neurological deficit was described. A 47-year-old man was involved in a motor vehicle crash, suffering from multiple injures including a vertical displaced fracture of the sacrum unassociated with neurological deficit, fracture of the pelvis, and second lumbar burst fracture. A three-dimensional computed tomographic (CT) scanning was also discussed for proper clinical evaluation. The sacral nerve roots were pushed to either side of the fracture, there were no neurological problems in the present case.     

The problem of the sacrum fracture. Clinical analysis of 377 cases]

Sacral fractures are rare injuries that are often neglected because of the general severity of the patient's injuries. They are typical injuries in patients with polytraumata. A "hidden" injury, they are often diagnosed late or are even missed. In a well-documented consecutive series of 1,350 patients with pelvic fractures treated in the trauma department of the Hannover Medical School between 1972 and 1991, a total of 377 sacrum fractures were evaluated in a retrospective study. The cause of the accident, mechanism of injury, concomitant injuries, diagnostic procedures, classification of the pelvic injury (TILE), as well as the classification of the sacrum injury (DENIS), treatment and outcome were analyzed in all cases. Observed complications with special attention to injuries to the lumbosacral plexus were correlated with the classification of the sacrum and pelvis, as well as with a detailed analysis of the fracture pattern and fracture characteristics. In 89.4% at least one additional body region was injured in these patients. PTS (Hannover Polytrauma Score) groups III and IV included 42.5% of the patients. With an improved diagnostic protocol (radiological a.p. views, oblique views and CT scan), the observed rate of sacrum fractures was 33%. Neurological deficits occurred in 15.1% of the patients. In contrast to the literature, the rate of neurological deficits was related more to the degree of pelvic instability (TILE) than to the specific fracture pattern in the sacrum. In stable injuries (TILE A) neurological deficits were only seen in exceptions. In type B injuries the maximum rate was 10%, whereas in unstable fractures (TILE C) the rate of neurological deficits was 32.6% in transalar fractures (DENIS zone I), 42.9% in transforaminal fractures (DENIS zone II), and 63.6% in central fracture types (DENIS zone III). Additional risk indicators for neurological impairment are avulsion fractures of the sacrum, comminuted and bilateral fracture lines. The fracture classification should thus be modified. Our own experience with operative therapy for sacral fractures (open revision of the sacral plexus together with internal stabilization of the fracture) is still limited, but based on the experience presented, further development of the treatment protocol for sacrum fractures should be considered.     

Urinary retention due to an isolated sacral root injury caused by sacral fracture

STUDY DESIGN: A case report.Setting:Urodynamic laboratory in a university hospital, Chiba, Japan. CASE REPORT: A young woman who suffered from urinary retention following a skiing accident. A sacral X-ray (lateral view) revealed an S2-3 sacral fracture. The patient gradually regained the ability to urinate. At 3 months after the accident, she still suffered difficult urination, although her neurological findings were normal. A urodynamic study showed an acontractile detrusor and a neurogenic sphincter electromyogram (EMG), together indicative of isolated sacral nerve injury. CONCLUSIONS: It was postulated that the S2-3 sacral fracture had led to bilateral traction of the S2-3 nerve roots, producing transient bladder paralysis (parasympathetic fibers) and incomplete sphincter paresis (somatic fibers). Sacral fracture is also of high clinical suspicion for urinary retention in frail elderly people, because it can result from simple falls.     

Transverse fracture-dislocation of the sacrum: a diagnostic pitfall and a surgical challenge

Transverse fracture-dislocations of the sacrum are rare. Associated lesions of the lumbosacral spine as well as neurological injuries are common. Conventional radiographs of the pelvis often fail to clearly visualize the fracture. Delayed diagnosis increases the risk of progressive neurological disfunction. True lateral sacral views and CT-scans with 3-dimensional reconstructions are very helpful in establishing the full extent of the injury. These examinations should be considered in all patients with a history of high energy trauma and clinical signs indicating lumbosacral injury, such as severe low back pain and neurological disturbances of the lower extremities. The management of transverse sacral fracture-dislocations with or without associated neurological damage is controversial. Conservative treatment is associated with a high rate of persistent deformity and residual neurological dysfunction. Surgical management allows for anatomical fracture reduction, stable fixation and revision of the spinal canal and lumbosacral nerve roots. The dorsal approach is preferred. Two patients with transverse sacral fracture-dislocations and neurological disturbances are presented. One patient had an additional fracture-dislocation of the lumbar spine at the L4L5 level with intrusion of the lumbosacral spine into the pelvis. Both lesions in this patient were successfully stabilized using an internal fixator system. The other patient presented with a bilateral transforaminal sacral fracture. The transverse component was not recognized on the initial radiographs, which resulted in loss of reduction and progressive neurological disfunction after sacroiliac screw fixation.