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。     

Biomechanical comparison of three fixation techniques for unstable thoracolumbar burst fractures. Laboratory investigation

OBJECT: Increased structural stability is considered sufficient justification for higher-risk surgical procedures, such as circumferential fixation after severe spinal destabilization. However, there is little biomechanical evidence to support such claims, particularly after traumatic lumbar burst fracture. The authors sought out to compare the biomechanical performance of the following 3 fixation strategies for spinal reconstruction after decompression for an unstable thoracolumbar burst fracture: 1) short-segment anterolateral fixation; 2) circumferential fixation; and 3) extended anterolateral fixation. METHODS: Thoracolumbar spines (T10-L4) from 7 donors (mean age at death 64+/-6 years; 1 female and 6 males) were tested in pure moment loading in flexion-extension, lateral bending, and axial rotation. Thoracolumbar burst fractures were surgically induced at L-1, and testing was repeated sequentially for each of the following fixation techniques: short-segment anterolateral, circumferential, and extended anterolateral. Primary and coupled 3D motions were measured across the instrumented site (T12-L2) and compared across treatment groups. RESULTS: Circumferential and extended anterolateral fixations were statistically equivalent for primary and off-axis range-of-motions in all loading directions, and short-segment anterolateral fixation offered significantly less rigidity than the other 2 methods. CONCLUSIONS: The results of this study strongly suggest that extended anterolateral fixation is biomechanically comparable to circumferential fusion in the treatment of unstable thoracolumbar burst fractures with posterior column and posterior ligamentous injury. In cases in which an anterior procedure may be favored for load sharing or canal decompression, extension of the anterior instrumentation and fusion one level above and below the unstable segment can result in near equivalent stability to a 2-stage circumferential procedure.     

A reduction-fixation system for unstable thoracolumbar burst fractures.

Thirty-three patients with unstable burst fractures of the lower thoracic and lumbar spine were treated with a reduction-fixation system. The new system is used both as a reduction and a fixation device for disorders of the lower thoracic and lumbar spine. In treatment of spinal fractures, it provides symmetric lordotic distraction to obtain the best possible reduction of intracanal fragments, and rigidly stabilizes the fractured vertebra while involving the minimum number of segments. All patients had a minimum follow-up of 24 months. Most patients in this series had a near-anatomic reduction of all three columns in the involved segment. The "indirect" neurologic decompression was successful in cases treated early after injury. The fixation was rigid enough to allow early mobilization and rehabilitation in a light orthosis within 1 week after surgery, and there was minimal loss of reduction during the follow-up period. The complications were minor. The reduction-fixation system achieved the surgical goals of posterior instrumentation for treatment of unstable thoracolumbar burst fractures.     

Percutaneous augmented instrumentation of unstable thoracolumbar burst fractures

Background  

Internal fixation of unstable thoracolumbar spine fractures requires correction of the lacking anterior column support. This usually entails insertion of a vertebral body replacement strut through an anterior approach, or a long posterior construct spanning at least two vertebrae above and two vertebrae below the fracture. Posterior short-segment pedicle instrumentation (SSPI)—one vertebra above and below—is suitable for approximately 40% of fractures, but not for all.     

Technical nuances of the minimally invasive extreme lateral approach to treat thoracolumbar burst fractures

Purpose

Contemporary minimally invasive techniques have evolved to enable direct access to the anterior spinal column via the extreme lateral approach. We have employed this access approach to treat selected burst fractures. We report our technique. Thoracolumbar burst fractures that require surgical intervention have traditionally been managed with anterior, posterior, or combined approaches.

Methods

We have applied the minimally invasive extreme lateral approach to perform vertebral corpectomy, cage placement, and lateral instrumentation to treat burst fractures. Indications for surgery were incomplete spinal cord injury with persistent neural element compression due to ventral fracture fragments in the canal. We present the technical nuances of this surgical approach for the treatment of thoracolumbar burst fractures with two case illustrations.

Results

There were no peri- or intra-operative complications. Both patients in our series remained neurologically intact at their last follow-up (11 and 29 months, respectively), and maintained their correction of kyphosis.

Conclusion

The minimally invasive extreme lateral approach is an effective treatment option for the management of thoracolumbar burst fractures.

     

Combined posteroanterior fusion versus transforaminal lumbar interbody fusion (TLIF) in thoracolumbar burst fractures

BackgroundThe optimal treatment strategy for burst fractures of the thoracolumbar junction is discussed controversially in the literature. Whilst 360° fusion has shown to result in better radiological outcome, recent studies have failed to show its superiority concerning clinical outcome. The morbidity associated with the additional anterior approach may account for these findings. The aim of this prospective observational study was therefore to compare two different techniques for 360° fusion in thoracolumbar burst fractures using either thoracoscopy or a transforaminal approach (transforaminal lumbar interbody fusion (TLIF)) to support the anterior column.MethodsPosterior reduction and short-segmental fixation using angular stable pedicle screw systems were performed in all patients as a first step. Monocortical strut grafts were used for the anterior support in the TLIF group, whilst tricortical grafts or titanium vertebral body replacing implants of adjustable height were used in the combined posteroanterior group. At final follow-up, the radiological outcome was assessed by performing X-rays in a standing position. The clinical outcome was measured using five validated outcome scores. The morbidity associated with the approaches and the donor site was assessed as well.ResultsThere were 21 patients in the TLIF group and 14 patients in the posteroanterior group included. The postoperative loss of correction was higher in the TLIF group (4.9° ± 8.3° versus 3.4° ± 6.4°, p > 0.05). There were no significant differences regarding the outcome scores between the two groups. There were no differences in terms of return to employment, leisure activities and back function either. More patients suffered from donor-site morbidity in the TLIF group, whilst the morbidity associated with the surgical approach was higher in the posteroanterior group.ConclusionThe smaller donor-site morbidity in the posteroanterior group is counterbalanced by an additional morbidity associated with the anterior approach resulting in similar clinical outcome. Mastering both techniques will allow the spine surgeon to be more flexible in specific situations, for example, in patients with neurological deficits or severe concomitant thoracic trauma.     

Percutaneous pedicle screw fixation and kyphoplasty for management of thoracolumbar burst fractures

OBJECTIVE: To evaluate outcome and potential advantages of a percutaneous posterior approach to burst fractures of the thoraco-lumbar junction without neurological complications by means of a technique combining balloon kyphoplasty and percutaneous pedicule screw fixation. METHODS: In this preliminary study patients who suffered traumatic of the thoraco-lumbar junction presented a Magerl type A3 fracture. The mean age of the patients was 64 years (54-78 years). All had a normal neurological examination. A combined technique using balloon kyphoplasty, that allows restoration of the vertebral height and fixation by means of cement injection with percutaneous osteosynthesis was performed as a minimal invasive alternative treatment. Mean follow-up (plain radiograph and CT scan, pain assessment) was 12 months (range 5-14 months). RESULTS: All patients experienced an early pain relief, successfully mobilized on day 1 after surgery and discharged after a mean stay of 4.5 days. Immediately postoperatively the mean vertebral height restoration was 11.5% and the reduction of the kyphotic angle was 9 degrees. Those results were maintained over the complete follow-up period. Only one patient required analgesic treatment with weak opioids (step II of the WHO pain ladder) 3 months after surgery. CONCLUSIONS: The treatment of burst fractures of the thoraco-lumbar junction with no neurological complication by associating minimally invasive techniques results in good fracture reduction and stabilisation. The main advantage of this approach is to shorten the hospital stay.     

胸腰椎骨折的微创手术策略

目的 探讨不同类型胸腰椎骨折微创手术策略.方法 回顾性分析1997年2月至2007年10月采用微创手术治疗的220例胸腰椎骨折患者.骨折按Gertzbein综合分型:A型185例,B型26例,C型9例;载荷分享评分4～9分.采用经皮椎弓根螺钉内固定术治疗123例,胸腔镜或头灯光源辅助的小切口胸腰椎前路手术治疗75例,后路小切口270°减压重建术治疗22例.采用Frankel分级评定术后神经功能恢复情况,通过术前、术后和随访时的X线及CT片比较伤椎Cobb角的矫正和丢失情况,评估椎管减压范围、植骨块位置及愈合情况.结果 220例患者均一期完成手术,189例患者获得随访,术前不完全性神经损伤患者术后神经功能均有不同程度恢复.经皮椎弓根螺钉内固定组、小切口胸腰椎前路手术组、后路小切几270°减压重建术组手术时间平均分别为75min、125min、215min.切口长度平均分别为2.3 cm、5.6 cm、5.8 cm,术后Cobb角矫止平均为11°、18.6°、21.3°.仅小切口胸腰椎前路手术组有6例出现手术相关并发症.经治疗后症状消失.所有椎管占位病例术后CT显示椎管腔扩大,减压彻底.结论 合理运用微创手术技术治疗胸腰椎骨折可以取得满意疗效,基于Gertzbein分型和载倚分享评分确立的各种微创手术适应证对指导临床具有重要意义.     

Effect of posterolateral fusion on thoracolumbar burst fractures

Objective: To evaluate the efficacy and significance of posterolateral fusion in preventing failure of shortsegment stabilization for the treatment of thoracolumbar burst fractures.Methods: Sixty patients with thoracolumbar burst fractures were included in the study. The patients were classified into two groups ( n = 30 in each group). In Group A, patients were treated in our hospital with short-segment instrumentation via posterolateral fusion with iliac bone. In Group B, patients were treated in other hospital with shortsegnent fixation without fusion. All cases came to our hospital for reexamination. There were 18 males and 12 females in Group A with a mean age of 42.3 years (range,24 to 52 years) and 16 males and 14 females in Group B with a mean age of 41.5 years ( range, 19 to 54 years).Radiographic ( Cobb angle, kyphosis of the vertebral body,and sagittal index ) and clinical outcomes (Low Back Outcome Score ) were analyzed after an average follow-up of 16 months.Results: After operation, Cobb angle was reduced from 19.3° to 3. 1°in Group A and from 19. 1°to 3.3°in Group B (P ＞ 0.05). It was 5.9° in Group A and 11.9°in Group B at the final follow-up (P ＜ 0.01). Its average loss of correction was 2.8° in Group A and 8.6° in Group B. Average kyphosis of the vertebral body was reduced from 21.3 ° to 6.2 ° in Group A and from 21.7 °to 7.4° in Group B (P ＞ 0.05). It was decreased to7.9° in Group A and 13.5° in Group B at the final follow-up ( P ＜ 0.01 ).Its average loss of correction was 1.7° in Group A and 6.1 °in Group B. Sagittal index was reduced from 21.3° to 3.6° in Group A and from 20. 5° to 3.8° in Group B (P ＜0.05). It was decreased to 5. 1 ° in Group A and 9.8° in Group B at the final follow-up (P ＜ 0. 01 ). Its average loss was 1.5° in Group A and 6.0° in Group B. In Group A, 73.3 % of patients had an excellent result based on Low Back Outcome Score system, while that in Group B was only 43.3 %.Conclusions: Posterolateral fusion is an effective measure to prevent implant failure, and decrease loss of correction, posttraumatic kyphosis and neurogical deficit during the treatment of thoracolumbar burst fractures.Short-segment fixation of thoracolumbar burst fractures without fusion obviously increases failure rate and it is not an optional procedure.     

骨质疏松椎体爆裂骨折椎体后凸成形术与保守治疗比较

[目的]探讨骨质疏松椎体爆裂骨折椎体内空腔形成后椎体后凸成形术和保守治疗的疗效。[方法]2007年6月~2013年2月对84例无神经症状的骨质疏松椎体爆裂骨折椎体内空腔形成患者分为两组,椎体后凸成形术(PKP)治疗组42例,保守组42例。治疗后6、12个月评估疼痛程度(VAS),椎体畸形指数,椎体前-后高度比值及其恢复率和活动能力。[结果]PKP组无患者发生感染、肺栓塞等并发症,14例患者轻度骨水泥渗漏,包括6例椎体前、4例椎间盘内、4例椎管内,但均无临床症状。84例随访12~24个月,平均22.1月。术后12个月时,PKP组VAS(0.88±0.59)分,显著低于保守组(2.52±0.83)分(P=0.001);但PKP组活动能力评级高于保守组,两组差异有统计学意义(P=0.002)。此外,PKP组畸形指数(1.41±0.18),显著低于保守组(1.72±0.11)(P<0.001);PKP组椎体前后高度比为(71.96±18.20)%,保守组为(49.94±6.13)%,PKP组椎体高度恢复率为+16.15%,显著高于保守组(-24.28%)(P<0.001)。[结论]与保守治疗比较,经椎弓根椎体后凸成形术治疗骨质疏松椎体爆裂骨折椎体内空腔形成在疼痛缓解、椎体畸形恢复上更加有效。     

Minimally invasive surgery for the management of thoracolumbar burst fractures

Percutaneous instrumentation is an effective method of managing thoracolumbar burst fractures in certain patients, including those with osteoporosis and ankylosing spinal disorders. By reducing the physiological burden on the patient compared to conventional open surgical techniques, percutaneous fixation enables faster mobilization, shorter length of stays, and decreased opioid use. Though the success of this technique is promising, it is critical to continue to practice safe surgical decision-making and to remain up to date on new advancements in percutaneous fixation of burst fractures as the literature expands.     

经椎间孔腰椎椎体间融合术在胸腰段爆裂性骨折手术中的应用

目的 探讨经椎间孔腰椎椎体间融合术(TLIF)在胸腰段爆裂性骨折手术中的作用.方法 2010年1月至2012年1月应用TLIF技术治疗椎体前缘高度丢失大于50％,椎管占位率大于40％的胸腰段单节段爆裂性骨折患者共23例,男15例,女8例;年龄22～61岁,平均45.3岁;损伤节段:T12 5例,L115例,L23例.骨折按照Denis分型:均为爆裂性骨折.脊髓神经功能受损情况按美国脊髓损伤协会(ASIA)脊髓神经功能障碍分级:A级1例,B级2例,C级7例,D级11例,E级2例.结果 本组患者手术时间100～160 min,平均140 min;出血量200～750 mL,平均370 mL.无术中、术后并发症发生.术后随访5 ～ 24个月(平均12.3个月),末次随访时脊髓神经功能按ASIA分级:A级1例,B级1例,C级4例,D级7例,E级10例,平均提高1.8级.伤椎前缘高度由术前45.2％±17.6％恢复至术后90.2％±13.7％,后缘高度由术前81.5％±14.3％恢复至术后93.5％±15.4％,cobb角由术前28.4°±11.8°改善至术后6.4°±3.8°,以上指标差异均有统计学意义(P＜0.05).结论 TLIF技术可用于胸腰段爆裂性骨折的治疗,能完成对骨折的减压、固定和前柱的支撑植骨融合,值得推广应用.     

Additional vertebral augmentation with posterior instrumentation for unstable thoracolumbar burst fractures

BackgroundTo investigate the role of vertebral augmentation in kyphosis reduction, vertebral fracture union, and correction loss after surgical management of thoracolumbar burst fracture.DesignRetrospective chart and radiographic review.SettingLevel 1 trauma center.MethodsThe analysis included patients treated between April 2007 and June 2015, who received pedicle-screw-rod distraction and reduction within two days following acute traumatic thoracolumbar burst fracture with a load sharing score >6. Medical records were retrospectively reviewed for data regarding operative details, imaging and laboratory findings, neurological function, and functional outcomes.InterventionNot applicable.Main outcome measuresSagittal index, pain score, loss of correction, and implant failure rate.ResultsNineteen patients were enrolled in this study (mean age, 37.2 ± 13 years; age range, 17–62 years; female/male ratio: 10/9). Of the five patients who received only reduction (no augmentation), one underwent revision surgery because of implant failure and pedicle screw backing out. Compared to patients who received only reduction, those who received both reduction and augmentation showed better sagittal alignment after the operation, with better sagittal index immediately postoperatively and during the follow-up (p < 0.05).ConclusionsTranspedicular vertebral augmentation with calcium sulfate/phosphate-based bone cement may reinforce thoracolumbar burst fracture stability, partially restore vertebral body height, and reduce pedicle screw bending and movement, thereby preventing early implant failure and late loss of correction, especially in patients with excellent fracture reduction.Level of evidence: Therapeutic level III, retrospective chart review     

Short segment fixation of thoracolumbar burst fractures without fusion

There continues to be controversy surrounding the management of thoracolumbar burst fractures. Numerous methods of fixation have been described for this injury, but to our knowledge, spinal fusion has always been part of the stabilising procedure, whether this involves an anterior or a posterior approach. Apart from an earlier publication from this centre, there have been no reports on the use of internal fixation without fusion for this type of fracture. The aim of the study was to determine the outcome of patients with thoracolumbar burst fractures who were treated with short segment pedicle screw fixation without fusion. This is a retrospective review of 28 consecutive patients who had short segment pedicle screw fixation of thoracolumbar burst fractures without fusion performed between 1990 and 1993. All patients underwent a clinical and radiological assessment by an independent observer. Outcome was measured using the Low Back Outcome Score. The minimum follow-up period was 2 years (mean 3.1 years). Fifty percent of patients achieved an excellent result with the Low Back Outcome Score, while 12% were assessed as good, 20% fair and 16% obtained a poor result. The only significant factor affecting outcome was the influence of a compensation claim (P < 0.05). The implant failure rate (14% of patients) and the clinical outcome was similar to that from series where fusion had been performed in addition to pedicle screw fixation. The results of this study support the view that posterolateral bone grafting is not necessary when managing patients with thoracolumbar burst fractures by short segment pedicle screw fixation. Received: 24 February 1998 Revised: 1 March 1999 Accepted: 27 May 1999     

后外侧植骨与经椎弓根植骨治疗胸腰段脊柱爆裂骨折的疗效比较

目的 比较胸腰段脊柱爆裂骨折短节段内固定结合后外侧植骨(posterohteral fusion,PLF)与经椎弓根植骨(transpedieular grafting,TPG)的疗效.方法 手术治疗胸腰段脊柱爆裂骨折患者62例,根据手术方式不同,分为PLF组和TPG组.PLF组行短节段内固定加自体髂骨PLF,34例;TPG组行短节段内固定加经椎弓根椎体内植骨,28例.记录手术时间、失血量、住院时间,在术前、术后及末次随访X线片上测量Cobb角、伤椎相对高度,末次随访的过伸过屈位X线片上测量手术节段运动范围,功能评定采用Greenough腰痛评分法(LBOS).平均随访时间:PLF组29个月,TPG组24个月.结果 PLF组平均住院时间20.1 d,术前平均Cobb角20.8°,椎体相对高度降低48.5%,术后平均Cobb角3.1°,椎体相对高度降低6.7%,末次随访平均Cobb角矫正丢失3.7°,椎体相对高度矫正丢失4.0%;TPG组平均住院时间18.8 d.术前平均Cobb角19.0°,椎体相对高度降低46.7%,术后平均Cobb角2.5°,椎体相对高度降低5.%,末次随访平均Cobb角矫正丢失3.9°,椎体相对高度矫正丢失3.5%,两组比较差异无统计学意义.TPG组平均手术时间182.0 min,平均失血量423 ml,供骨区并发症发生率3.6%,低于PLF组的233.0 min、614 ml与23.5%;TPG组手术节段运动范围7.4°,优于PLF组的0.8°.两组术后各时间段LBOS评分差异无统计学意义.结论 胸腰段脊柱短节段固定结合两种植骨方式的短期结果均满意.TPG手术具有如下优点:缩短手术时间、失血量少、减少供骨区并发症,保留手术节段运动范围.     

椎体后凸成形技术与微创经皮椎弓根钉技术治疗胸腰段椎体压缩骨折的对比研究

目的 比较经皮椎体后凸成形术(PKP)和微创内固定术的疗效,为治疗单纯性胸腰段椎体压缩骨折选择手术方案提供临床依据.方法 行PKP及微创内固定手术治疗单纯胸腰段椎体压缩骨折59例.PKP组31例,微创内固定术组28例.记录59例术前术后视觉模拟评分法疼痛评分(VAS)、伤椎前缘高度、Cobb角及伤椎高度恢复率.结果 PKP组及微创内固定组在术后VAS评分、Cobb角、伤椎高度、椎体高度恢复率观测指标中,2组间比较差异均有统计学意义(P＜0.05).结论 PKP术后止痛效果优于微创内固定组,微创内固定在矫正脊柱后凸畸形及恢复伤椎前缘高度效果上优于PKP组.     

Unstable thoracolumbar burst fractures: anterior-only versus short-segment posterior fixation

Operative management of a thoracolumbar burst fracture varies according to many factors. Fracture morphology, neurologic status, and surgeon preference play major roles in deciding upon anterior, posterior, or combined approaches. Optimizing neural decompression while providing stable internal fixation over the least number of spinal segments is the goal. Short-segment constructs via a single-stage approach (anterior versus posterior) have become viable options with advances in instrumentation and techniques. This study compares anterior-only fixation utilizing a corpectomy strut graft and a modern thoracolumbar plating system with a posterior-only construct using pedicle screws and load sharing hooks for the treatment of unstable burst fractures. Functional outcome and sagittal plane restoration and maintenance of sagittal plane alignment were evaluated. Fifty-three patients with unstable burst fractures were assessed with 40 undergoing an anterior-only construct and 13 having a short-segment posterior-only construct. The posterior-only group had no hardware failures; however, the loss of sagittal plane correction averaged 8.1 degrees, whereas the anterior-only group averaged only a 1.8-degree increase in sagittal plane kyphosis. Both techniques resulted in statistically significant initial improvement in sagittal alignment; however, the posterior short-segment group lost this statistical significance at follow-up whereas the anterior-only group continued to demonstrate statistically significant improvement in sagittal alignment at follow-up compared to preoperative measurements.     

Anterior versus posterior surgical treatment of unstable thoracolumbar burst fracture

Objective  

This retrospective study compares clinical outcomes of anterior versus posterior surgery for treatment of unstable thoracolumbar fracture.     

胸腰椎爆裂骨折三种后路内固定方法的稳定性生物力学研究

[目的]比较长节段固定术、短节段固定术和短节段结合椎体成形固定术治疗胸腰椎爆裂骨折的稳定性。[方法]收集6具新鲜尸体的脊柱(T9～L5)标本,对每一具标本依次按完整状态、骨折状态、长节段固定、短节段固定和短节段结合椎体成形的顺序进行测试,计算其在屈曲、背伸、左右侧弯和左右旋转6个方向的运动范围,比较各组间差异。[结果]骨折后脊柱在6个方向上的运动范围均增加(P<0.05);各内固定组的运动范围均小于完整组(P<0.05);长节段固定和短节段结合椎体成形固定的运动范围小于单纯短节段固定组(P<0.05);短节段结合椎体成形固定在屈曲和左右侧屈方向上的运动范围与长节段固定无差别(P>0.05),而在背伸和左右旋转方向上的运动范围短节段结合椎体成形固定则大于长节段固定(P<0.05)。[结论]通过延长固定节段与联合椎体成形均能够增加短节段固定的稳定性,在屈曲和左右侧屈方向上短节段联合椎体成形已经能够达到长节段固定所能够达到的稳定性。