胸腰段脊柱骨折前路减压与内固定术的技术改进

目的 针对胸腰段前路手术创伤大、时间长、出血多等问题进行技术改进。方法 采用经第12肋胸膜外-腹膜后入路显露，L4骨折保留第12肋；对伤椎相邻椎体血管不予处理；对螺钉固定位置和操作程序进行改进；同时实施控制性降压。每例病人至少实施四项技术改进中的两项。结果 采用改进技术，治疗胸腰段脊柱骨折25例，手术均获成功，手术时间110～150min（平均130min），术中失血350～900ml（平均550ml），切口长度12～20cm（平均15cm），术中损伤腹主动脉1例，损伤胸膜2例。所有病例均获随访，随访时间3～50个月（平均18．3个月），术后椎管明显扩大，无神经压迫症状加重，发生内固定松动1例。神经功能按ASIA分级标准改变如下：术前3例A级，术后恢复为A级2例，B级1例；术前B级4例，术后恢复为B级1例，C级1例，D级2例；术前14例C级，术后恢复为C级1例，D级3例，E级10例；术前4例D级，术后恢复为E级4例。结论 本技术改进具有缩短手术时间，减少术中失血和减轻手术创伤的优点，更有利于选择前路手术来治疗胸腰段爆裂骨折。

Technique improvement in anterior approach and internal fixation in treating thoracolumbar spine fracture

Objective To investigate the operative technique improvement in order to reduce heavy trauma, long time and much blood loss by anterior approach to the thoracohmhar spine. Methods An exposure via the twelfth rib extrapleural and retroperltoneat was used, retenting of the twelfth rib at L1 fracture; only dealing with artery of the injured vertebra; adjusting the screw position and improving the operation procedure, at the same time the deliberate hypotensian was performed. At least two modified techniques in four were applied an each patient. Results All of the 25 cases were operated successfully by modified techniques. The operation time was 110- 150 minutes（average 130minutes）, the blood loss was 350- 900ml（average 550ml）, the incision length was 12- 20cm（average 15cm）. Abdominal aorta ruptured in 1 patient and pleura injured in 2 during operation. All cases were followed up, the average follow - up was 18.3 months with a range from 3 to 50 months. The spinal canals were enlarged obviously, no patient had neurological deterioration, 1 case was found hardware loosening combined with kyphnsis deformity. The ASIA Scale changed as follows： 3 cases of scale A（3A） changed to2A, 1B; Bin4 before operation and changedto 1B,1C,2D; 14C to 1C,3D,10E; 4Dto4E. Conclusion The technical improvemants have the advantages of minor trauma, less blood loss and shorter operation time. It will help doctors choose anterior approach for the thoracolumbar hast fractures.