严重胸腰椎骨折合并椎间盘损伤的手术治疗

目的：探讨胸腰椎骨折合并椎间盘损伤的情况及其对选择手术方式和预后的意义。方法：对61例严重的胸腰椎骨折常规行MRI检查，了解合并椎间盘损伤的程度和位置以及椎管占位情况，并依此同时结合临床表现、X线片、CT检查结果，确定治疗方案。结果：61例中，合并有上或下位椎间盘损伤者共41例。单纯伤椎的上位椎间盘损伤26例，单纯伤椎的下位椎间盘损伤11例，伤椎的上下位椎间盘同时有损伤4例。对41例合并椎间盘损伤行前路手术，所有患者均获得良好骨融合，未出现后凸畸形复发或加重。结论：严重的胸腰椎骨折常合并有椎间盘的损伤，其中以上位椎间盘损伤多见。MRI是确定椎间盘损伤的重要手段之一。椎间盘损伤程度应作为选择手术方式的重要参考因素之一。     

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。     

急诊手术治疗不稳定型胸腰椎骨折合并多发伤的安全性分析

目的:探讨急诊手术治疗合并多发伤的不稳定型胸腰椎骨折的安全性。方法:回顾性分析我院2015年1月～2018年3月收治的51例合并多发伤的不稳定型胸腰椎骨折患者的临床资料,男40例,女11例;年龄18～60岁(36.0±4.9岁)。高处坠落34例,车祸11例,重物砸伤6例。合并胸部损伤26例,腹部损伤17例,头部损伤16例,上肢损伤13例,下肢损伤9例,颈部损伤1例,面部损伤1例,体表损伤1例。其中21例对胸腰椎骨折行急诊手术治疗(急诊组),30例行择期手术治疗(择期组)。两组患者性别比、受伤机制、损伤严重程度(ISS)评分、胸腰椎骨折椎体数和AO分型、神经功能损伤Frankel分级均无统计学差异(P>0.05),比较两组患者的手术时间、术中出血量、术后伤口引流量、ICU监护时间、输血量、住院时间、神经功能恢复情况、手术并发症发生率、术前术后伤椎矢状位Cobb角、术前术后伤椎前缘高度压缩率、术后Oswestry功能障碍指数(ODI)和伤椎椎管狭窄率改善情况。结果:急诊组术前伤椎前缘高度压缩率、伤椎椎管狭窄率显著高于择期组,差异有统计学意义(P<0.05)。急诊组手术时间、术后...     

胸腰椎爆裂骨折椎间盘影像改变的相关临床应用研究

目的 通过评价胸腰椎爆裂骨折后椎间盘影像的改变,探讨不同类型胸腰椎爆裂骨折与椎间盘损伤程度的相关性以及处理受损椎间盘的重要意义.方法 收集24例胸腰椎爆裂骨折的影像学资料,根据Atlas对胸腰椎爆裂骨折的分类方法评估患者的骨折类型.结合其受伤椎体邻近椎间盘的Oner椎间盘损伤分级,收集数据后对其进行相关统计分析.结果 在Atlas分类A型骨折中,所有受累下位椎间盘损伤级别为2型而其相应的上位椎间盘损伤级别为3、4、和5型.在Atlas分类B型骨折中,所有受累下位椎间盘损伤级别皆为1型而其相应的上位椎间盘损伤级别都高于下位椎间盘.结论 胸腰椎爆裂骨折患者椎间盘终板的损伤与椎间盘的损伤密切相关,受损椎体上位椎间盘较下位椎间盘更易损伤且损伤程度更重.对于胸腰椎爆裂骨折患者前路手术较后路手术具有更好的稳定性.     

后路非融合内固定术治疗胸腰椎骨折的研究进展

交通事故与高处坠落伤,常合并胸腰椎骨折。对压缩性骨折,于复位后融合骨折椎与其上位椎,对爆裂性骨折,视其上位或下位椎间盘破坏而定,融合骨折椎与椎间盘损伤的邻位椎。但融合内固定术后所导致的并发症,如长期顽固性腰痛、腰椎活动受限及融合椎体邻近节段退变等越来越受到人们的重视,因此非融合内固定术被越来越多的学者所提倡。非融合内固定术面临椎体高度和角度丢失的问题,且破入椎体内的已损伤的椎间盘是一个潜在的不稳定因素。本文主要综述非融合内固定术治疗胸腰椎骨折的优缺点,探讨适应证及其有待进一步研究的方向。     

胸腰椎骨折继发脊柱后凸畸形的原因分析

目的总结分析陈旧性胸腰椎骨折继发后凸畸形的原因。方法回顾性分析自2007-02—2014-02诊治的27例陈旧性胸腰椎骨折合并后凸畸形。21例既往有手术史,6例采取卧床非手术治疗。病程平均58(28~86)个月,后凸Cobb角平均58°(45°~106°)。结果胸腰椎骨折后继发脊柱后凸畸形的原因:(1)6例采取了不适当的手术方式治疗。(2)8例脊柱三柱严重受损的骨折只采用伤椎上下2个椎体4钉固定,导致椎弓根钉棒系统无法维持脊柱稳定性。(3)3例B3型钳夹样骨折未进行有效植骨,导致椎间盘嵌入骨折断端间隙,影响骨折的愈合。(4)4例术后骨折未完全愈合就取出内固定。(5)6例具有手术适应证但采用非手术治疗。结论只有对脊柱生物力学有清晰的认识,对脊柱骨折的分型及预后有明确的判断,才能在正确诊断的基础上对脊柱损伤采取适当的治疗方案,进而避免陈旧性胸腰椎骨折继发后凸畸形。     

伤椎斜向长椎弓根钉固定联合椎体间融合治疗合并椎间盘损伤的胸腰椎骨折脱位

目的 探讨伤椎斜向长椎弓根钉固定联合椎体间融合治疗合并椎间盘损伤的胸腰椎骨折脱位的临床疗效。方法 2017年1月—2022年6月,采用后路减压、伤椎斜向长椎弓根钉固定联合椎体间融合治疗28例合并椎间盘损伤的胸腰椎骨折脱位患者。其中,男22例,女6例;年龄22～58岁,平均41.4岁。致伤原因：高处坠落伤18例,交通事故伤5例,重物砸伤5例。骨折节段：T₁₁ 1例,T₁₂ 7例,L₁ 9例,L₂ 11例。神经功能美国脊髓损伤协会(ASIA)分级：A级4例,B级2例,C级11例,D级11例。术前椎管内占位率为17.7%～75.3%,平均44.0%;胸腰椎损伤分类和严重程度评分(TLICS)为9～10分,平均9.9分。17例存在合并损伤。受伤至手术时间1～4 d,平均2.3 d。记录围术期相关指标(手术时间、术中出血量、手术并发症)、临床疗效评价指标[疼痛视觉模拟评分(VAS)和Oswestry功能障碍指数(ODI)]、影像学评价指标[伤椎前缘高度比(anterior vertebral height r...     

A型胸腰椎骨折患者术前椎间盘损伤程度与术后疗效的相关性研究

[目的]探讨A型(AO分型)胸腰椎骨折的患者,应用术前MRI中椎间盘组织的影像学特点评估患者预后疗效的可行性,为A型胸腰椎骨折临床治疗提供理论依据。[方法]分析2008年1月~2012年6月收治的90例胸腰椎骨折患者术前的MRI资料,按照椎间盘损伤的影像学特点分为3组(A、B、C组),每组30例,所有患者均采用传统短节段椎弓根钉固定结合伤椎置钉并椎体内植骨进行治疗,分别测量术后2周、术后1年、内固定取出半年的疼痛评分(VAS)、Cobb角及伤椎前高率,并做统计学分析。[结果]术后平均随访19.3个月(15~23个月),无断钉、断棒及内固定松动发生,所有伤口均Ⅰ期愈合,未出现其他并发症。术后1年时,C组患者的Cobb角与A、B组比较差异有统计学意义(P<0.01),内固定取出半年时,C组患者的三项检查指标[疼痛评分(VAS)、Cobb角、伤椎前高率]与A、B组比较差异均有统计学意义(P<0.01)。[结论]MRI检查是判断椎间盘损伤的重要手段,通过本项研究,作者认为术前MRI表现符合C组的患者,无论前路还是后路手术,切除受损的椎间盘组织同时行牢固的植骨融合内固定是手术的重要目的之一。     

颈椎前纵韧带损伤的诊断与治疗

目的 探讨颈椎前纵韧带损伤的诊断与治疗.方法 2001年3月至2003年7月经影像学证实为前纵韧带损伤的患者46例.患者均在伤后3 h～3 d内摄颈椎正、侧位X线片并行MRI检查.颈椎椎前阴影增宽35例,椎体不稳征象14例.颈椎MRI T<,1>加权像表现为前纵韧带呈灰色或灰白色信号,部分可见连续性中断、增厚;T<,2>加权像表现为椎体前缘增厚的片状纵行不均匀高信号,边界不清晰,部分可见高信号掀起、连续性中断.19例合并脊髓损伤的患者行早期手术治疗.27例单纯颈部疼痛患者中,早期前路手术治疗6例,颈围石膏固定5例,颈托固定16例. 结果 45例患者获6～41个月(平均16.7个月)随访.5例脊髓完全性损伤患者术后有2例转为不完全性损伤,14例脊髓不完全损伤患者术后有10例获得不同程度的好转.21例单纯颈部疼痛患者中,早期手术的6例无神经症状患者随访时未发生颈椎后凸畸形及颈部慢性疼痛症状;21例早期保守治疗的患者中,7例伤后4～6周因存在颈椎不稳征象而行颈椎前路手术,2例伤后2～3年因损伤节段椎间盘退变突出压迫脊髓而行前路减压植骨内固定术,3例有慢性颈部疼痛不适,余8例患者无特殊不适主诉,另1例失访.结论 MRI检查是诊断颈椎前纵韧带损伤最有价值的方法.合并脊髓受压征象或椎间严重不稳的颈椎前纵韧带损伤,可早期行减压融合术;不伴脊髓损伤的颈椎前纵韧带合并椎间盘损伤,可考虑早期行前路椎间盘切除融合术.     

6枚万向椎弓根钉固定在胸腰椎骨折治疗中的应用

目的 探讨6枚万向椎弓根钉固定用于胸腰椎骨折治疗的效果。方法 对44例胸腰椎骨折患者经伤椎及上、下邻椎各置入2枚万向椎弓根钉固定。记录骨折愈合时间及手术前后胸腰痛VAS评分、伤椎Cobb角、内固定系统上位及下位邻近节段椎间高度指数、伤椎前缘高度比。结果 患者均获得12个月随访。骨折均愈合，时间3～6个月。(1)胸腰痛VAS评分：术后7 d及1、3、6、12个月均低于术前(P<0.05);术后7 d、1个月、3个月随时间逐渐降低(P<0.05)。(2)伤椎Cobb角：术后7 d及1、3、6个月均小于术前(P<0.05),术后12个月与术前比较差异无统计学意义(P>0.05);术后1、3、6、12个月均大于术后7 d(P<0.05)。(3)内固定系统上位邻近节段椎间高度指数：术前及术后7 d、1个月、3个月比较差异均无统计学意义(P>0.05);术后6个月及12个月分别低于术前、术后7 d、术后1个月(P<0.05)。(4)内固定系统下位邻近节段椎间高度指数：术后7 d明显高于术前(P<0.05),术后1、3个月均低于术后7 d(P<0...     

Correlation of MR images of disc injuries with anatomic sections in experimental thoracolumbar spine fractures

This cadaver study evaluated the value of MR images for detection of acute intervertebral disc damage associated with fractures of the thoracolumbar spine. Damage to the intervertebral disc may be a major contributor to chronic instability in non-operative treatment or failure of fixation and recurrence of deformity in posterior fixation methods. MR imaging can help us to understand the injury patterns and their prognostic significance. However, before we can justify the use of MRI in clinical cases, determination of MRI’s ability to detect acute injury to the disc is necessary. Ten fresh cadaver specimens were used for this study. After obtaining radiograms and MR images, injuries were created with a weight-dropping apparatus using a variety of weights and compression angles. Post-injury radiograms and MR images were taken and the specimens were frozen at –20 °C. Slides of these specimens obtained with cryosection techniques were compared with MR images for evaluation of the damage to different parts of the discs. A total of 20 fractures were observed on cryosections. In 12 of the discs adjacent to fractured vertebral bodies, macroscopic damage was seen on the sections. These were all detected on the corresponding MR images. The study showed that MRI is able to detect acute, macroscopic injury to the intervertebral disc. It is therefore justified to use MR for the study of acute disc damage associated with thoracolumbar fractures. Received: 4 August 1998 Revised: 12 January 1999 Accepted: 27 January 1999     

经后路改良楔形截骨治疗创伤后胸腰椎骨折后凸畸形

目的 观察后路经椎弓根椎体椎间隙楔形截骨治疗创伤后胸腰椎骨折后凸畸形的临床疗效。方法 自2011-01-2014-01共22例创伤后胸腰椎骨折脊柱后凸畸形患者采用改良PSO截骨矫形技术治疗,所有患者均有严重的胸腰区慢性疼痛,VAS评分≥7分,无神经功能障碍。结果 1例术中发生硬膜撕裂,无神经血管损伤。在Cobb角,VAS评分和ODI评分方面,术后两次测量结果较之术前,差异均有统计学差异（P〈0.05）,所有病例截骨面均骨性愈合。结论 经椎弓根椎体椎间隙楔形截骨矫正创伤后胸腰椎骨折后凸畸形是一种有效的手术方法,截骨面融合率高,并发症发生率低。     

Traumatic intervertebral disc lesion – magnetic resonance imaging as a criterion for or against intervertebral fusion

Lesions of the intervertebral disc accompanying vertebral fractures are the subject of controversy and discussion regarding the extent and manner of surgical intervention. The question of when to perform disc resection and intervertebral fusion, in particular, has not been answered satisfactorily. In order to evaluate short- and medium-term lesions of the discoligamentous complex associated with thoracolumbar burst fractures, magnetic resonance images made after stabilisation and again after implant removal were compared. Between 1997 and 1998, 20 patients who had suffered thoracolumbar burst fractures (AO classification A3 and B1 [26]) underwent posterior reduction and stabilisation using a Universal Spine System (USS, Synthes, Switzerland) titanium internal fixator. The implant was removed after an average of 10 months. Magnetic resonance imaging (MRI) scans were performed 1 week after both operations, allowing the changes in a total of 40 intervertebral discs adjacent to the fractured vertebral body to be investigated. The analysis was based on signal intensity of the intervertebral disc in T2-weighted scans and on morphological criteria. A total of 81% of the discs with initially normal T2-weighted signal showed the same signal after implant removal; 5 discs with initially increased signal intensity in T2-weighted scans normalised, 5 showed a decrease in intensity and 3 suffered a partial loss of signal. Among the 9 discs with initially decreased T2-weighted signal, only one had normalised by the time the implant was removed. A total of 86% of the 14 morphologically intact discs retained their structural integrity. Of the 25 discs with minor defects, only one could be considered as intact after implant removal, 15 remained the same and 9 deteriorated in structure. No disruption of the fibrous ring or of the posterior longitudinal ligament was observed, nor was there any prolapse of intervertebral discs. When the intervertebral disk is intact and has normal morphology and a normal T2-weighted MRI signal, resection or fusion of the fracture adjacent discs appears unjustified. In our opinion, the results do not support the possibility of predicting degradation in those discs that showed an altered T2-weighted signal after the first operation.     

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.     

胸腰椎骨折术后后凸畸形分析：39例报道

［摘要］ 目的 总结分析胸腰椎骨折短节段内固定术后继发后凸畸形的原因。方法 回顾性分析我科自2014年至2018年胸腰椎骨折行短节段内固定治疗术后继发后凸畸形39例。结果 胸腰椎骨折术后脊柱后凸原因较多,早期主要在于手术操作有欠缺;1年内发生后凸畸形,多为固定节段短或螺钉短,不能有效支撑固定;未佩戴外固定支具或支具不牢靠且活动量大;患者骨质疏松;取出内固定后发生脊柱后凸主要在于稳定性差的骨折减压固定未给予充分植骨融合;椎间盘严重损伤,取出后再次塌陷。结论 从当前病例总结,胸腰椎骨折的手术治疗效果在于胸腰椎骨折的正确诊断、合适手术方式和有效的植骨融合。     

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.     

MRI对胸腰椎爆裂性骨折的诊断价值

本文对５６例胸腰椎爆裂性骨折的ＭＲＩ检查结果进行回顾性分析,以探讨ＭＲＩ的诊断价值,重点观察骨折,韧带及椎间盘损伤、脊髓马尾损害及血肿情况。结果有５３例前、中柱骨折在ＭＲＩ图像上得到明确显示,其椎管狭窄及后凸畸形程度与Ｘ线平片或ＣＴ扫描结果成正相关,有非常显著的统计学意义（Ｐ＜０．０１）,而ＭＲＩ所示韧带损伤多数无法根据Ｘ线平片或ＣＴ扫描结果作出诊断。作者认为,ＭＲＩ对于胸腰椎爆裂性骨折的诊断具有重要价值,必要时应与ＣＴ扫描同时选用。     

椎体内植骨结合椎弓根内固定治疗无神经损伤的胸腰椎骨折

目的探讨椎体内植骨结合椎弓根内固定治疗无神经损伤的胸腰椎骨折的疗效。方法回顾性分析2006年7月～2009年1月22例不伴神经损伤的胸腰椎骨折患者,行椎弓根内固定及伤椎植骨,观察包括椎体高度改变、Cobb角改变及椎管狭窄率改变。结果随访9～25个月,平均13个月,术后及随访期椎体高度、Cobb角及椎管狭窄率恢复满意。结论椎体内植骨结合经椎弓根内固定治疗无神经损伤的胸腰椎骨折有良好的临床疗效,是一种较为方便、安全、可靠的方法。     

有限切口在胸腰段骨折前路手术治疗的应用

[目的]讨论胸腰段骨折前路手术中采用有限切口的方法和疗效。[方法]对34例严重的胸腰段骨折的患者不是常规采用高于伤椎二位肋骨的胸腹联合切口，而采用左侧经胸膜后，腹膜后入路椎管前方减压去除位于后纵韧带前方的致压骨折块及破裂后突的椎间盘组织。术前通过X线平片、CT和／或MRI扫描来确定骨折的类型、脊髓受压情况等，确认导致脊髓神经压迫或损伤的致压物来自硬膜囊前方的椎体碎骨折块及破裂的椎间盘组织，作为选择治疗方式的重要参考因素。[结果]采用此技术，治疗胸腰段骨折34例，均无术中并发症，出血量300—800ml，平均600ml，手术时间120—150min。术后随访6—24个月。术后无脊髓再损伤病例，伤椎部位脊椎曲度恢复正常，无明显侧凸或后凸畸形发生；术后3个月复查植骨愈合良好，无植骨块塌陷及高度丢失现象，随访期内无植骨不愈合或钢板螺钉断裂现象。[结论]有限的胸腰段骨折前路入路操作技术，可减少对患者肺功能的严重影响，减轻前路手术创伤，为患者顺利恢复创造条件。