改进的侧前方手术径路在胸腰椎爆裂性骨折中的应用

目的 探讨改进的侧前方手术径路减压内固定治疗胸腰椎爆裂性骨折的疗效. 方法 2003年4月至2006年9月利用胸腰段的解剖关系,改进成"L"形肌间隙经椎间孔入路行骨折减压内固定治疗胸腰椎爆裂性骨折,临床应用16例(改进径路组),并将11例经传统胸腹膜外入路(传统径路组)作为对照组,比较两组住皮肤切口到完全显露椎体出血量、手术时间及总出血量、疗效等方面的差异,并观察术中、术后并发症情况. 结果 27例患者于术均获成功.所有患者获得6～26个月(平均13个月)随访.改进径路组从皮肤切口到完全显露椎体的出血量平均为(80.0±56.5)mL,总出血量平均为(450.0±273.1)mL,手术时间平均为(119.0±35.5)min;传统径路组从皮肤切口到完全显露椎体的出血量平均为(350.0±145.5)mL,总出血量平均为(900.1±421.3)mL,手术时间平均为(193.2±48.3)min,两组上述指标比较差异均有统计学意义(P<0.05).两组在Cobb角改善、伤椎前缘高度比值及神经功能恢复差异均无统计学意义(P>0.05).两组术中均无严重并发症发生,无截瘫加重、植骨块塌陷及高度丢火现象,无假关节肜成和内固定失败. 结论改进的"L"形肌间隙经椎间孔径路行胸腰椎爆裂性骨折侧前方减压入路简捷,出血少.既能充分减压,又能最大限度保持脊柱的稳定性,还可避免加重脊髓损伤、胸腹膜损伤等并发症.     

后路椎体次全切除减压重建治疗胸腰椎爆裂骨折

目的:探讨后路椎体次全切除减压重建治疗胸腰椎爆裂骨折的临床疗效.方法:2004年11月～2006年12月共收治胸腰椎爆裂骨折患者28例,其中坠落伤12例,重物压伤7例,车祸伤9例.合并颅脑伤3例,股骨骨折1例,脾破裂1例,跟骨骨折2例.新鲜骨折26例,陈旧骨折2例.均为单椎体爆裂骨折,T11 4例,T12 10例,L1 8例,L2 4例,L3 2例.均经后路行椎体次全切除椎管减压、椎体前中柱重建及植骨融合内固定术.采用ASIA分级进行神经功能评估.通过术前、术后即刻及末次随访时的X线及CT片比较伤椎前缘高度变化及椎管容积的变化评估骨折复位、减压及骨融合情况.结果:手术时间2～5h,平均3.8h;出血量650～2300ml,平均985ml.胸膜损伤1例,行胸腔闭式引流治愈,无血管、神经损伤和感染等并发症发生.随访5～25个月,平均14.5个月.脊髓功能除6例A级无恢复外均有不同程度的恢复.椎体前缘高度术前平均为正常椎体的45.45%.术后即刻为95.82%.末次随访时为94.43%,与术前比较明显改善(P<0.05);椎管容积(CT测量实际椎管容积占正常椎管容积的百分比)术前平均为44.19%,术后即刻为94.79%,末次随访时为96.21%,与术前比较明显改善(P<0.05).末次随访时植骨全部获得融合,无假关节形成.结论:后路椎体次全切除减压、前中柱重建治疗胸腰椎爆裂性骨折可有效恢复椎体高度及椎管容积,是安全有效的手术方式.     

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。     

中华长城系统治疗胸腰椎爆裂骨折

目的探讨中华长城椎弓根钉系统治疗胸腰椎爆裂骨折的优越性,并评价其临床效果。方法选择后正中入路椎管减压或单纯使用中华长城内固定系统治疗胸腰椎爆裂骨折40例。结果经3~18个月随访,椎体平均高度由术前的前34.5%和后74.5%恢复到术后的前95%和后98.5%,Cobb′s角由术前平均16.0°恢复为术后平均1.5°。对脊髓损伤的患者Frankel分级平均提高1.5级。未出现椎弓根钉松动和断裂。结论中华长城系统治疗胸腰椎爆裂骨折操作安全、固定确实、椎弓根大小设计合理,具有较明显的优越性,有待进一步临床应用观察。     

Low thoracic and lumbar burst fractures: radiographic and functional outcomes

Twenty patients with thoracolumbar burst fractures (type A3 in the classification of Magerl et al.) were studied prospectively for the evaluation of clinical, radiographic and functional results. The patients were submitted to surgical treatment by posterior arthrodesis, posterior fixation and autologous transpedicular graft. The patients were followed up for 2 years after surgery and assessed on the basis of clinical (pain, neurologic deficit, postoperative infection), radiographic (load sharing classification, Farcy s sagittal index of the fractured segment, relation between traumatic vertebral body height and the adjacent vertebrae (compression percentage), height of the intervertebral disk proximal and distal to the fractured vertebra, rupture or loosening of the implants) and functional (return to work, SF-36) criteria. Two patients presented a marked loss of correction and required the placement of an anterior support graft. Pain assessment revealed that eight patients (44%) had no pain; four (22%) had occasional pain, three (17%) moderate pain, and three (17%) severe pain. According to the classification of Frankel et al., 17 patients persisted as Frankel E and one patient presented improvement of one degree, becoming Frankel D. The mean value of Farcy s sagittal index of the injured vertebral segment was 20.67 degrees +/- 6.15 degrees (range 8 degrees -32 degrees ) during the preoperative period, 11.22 degrees +/- 8.09 degrees (range -5 degrees to 21 degrees ) during the immediate postoperative period, and 14.22 degrees +/- 7.37 degrees (range 3 degrees -25 degrees ) at late evaluation. There was a statistically significant difference between the immediate postoperative values and the preoperative and late postoperative values. The compression percentage of the fractured vertebral body ranged from 9.1 to 60 (mean 28.81 +/- 11.51) during the preoperative period, from 0 to 60 (mean: 15.59 +/- 14.49) during the immediate postoperative period, and from 8 to 60 (mean: 25.9 +/- 13.02) at late evaluation. There was a statistically significant difference between the preoperative and postoperative values and between the postoperative and late postoperative values. The height of the proximal intervertebral disk ranged from 6 to 14 mm (mean 8.44 +/- 2.66) during the preoperative period, from 6 to 15 mm (mean 10 +/- 2.30) during the immediate postoperative period, and from 0 to 11 mm (mean 7.22 +/- 2.55) during the late postoperative period. A significant difference was observed between the immediate postoperative values and the preoperative and late postoperative values. The height of the intervertebral disk distal to the fractured vertebra ranged from 7 to 16 mm (mean 9.94 +/- 2.64) during the preoperative period, from 5 to 18 mm (mean 11.61 +/- 3.29) during the immediate postoperative period, and from 2 to 14 mm (mean 9.72 +/- 3.17) during the late postoperative period. There was a significant difference between the immediate postoperative values and the preoperative and late postoperative values. Except for the height of the intervertebral disk proximal to the fractured vertebra, no correlation was detected between the clinical, functional and radiologic results. The results observed in the present study indicate that other, still incompletely defined parameters influence the functional result of thoracolumbar burst fractures.     

上腰椎爆裂型骨折外侧入路的手术方法

目的: 介绍上腰椎爆裂型骨折外侧入路的手术方法。方法: 沿骶棘肌外缘切口, 分离暴露L1、2、3横突, 切除横突、椎弓根、椎体后缘和突出的椎间盘, 减压硬膜管, 并同时作椎体间植骨骨水泥固定。结果: 50例患者均能达到脊髓前减压彻底和椎体间植骨融合稳定的目的。截瘫和下肢神经症状的恢复根据Frankel标准, 一般均能恢复 1~2个档次。结论: 上腰椎爆裂型骨折外侧入路的手术方法, 能达到脊髓前减压彻底和椎体间植骨融合稳定的目的。     

Application of transforaminal lumbar interbody fusion in old thoracolumbar fracture and dislocation

Background

The main indications for surgery for old thoracolumbar fractures are pain, progressive deformity, neurological damage, or increasing neurological deficit. These fractures have been one of the greatest therapeutic challenges in spinal surgery. Anterior, posterior, or combined anterior and posterior procedures have been successful to some extent. As far as we know, there is no report in the literature of transforaminal lumbar interbody fusion (TLIF) for old thoracolumbar fracture and dislocation.

Methods

Case report.

Results

A 26-year-old man with old fracture and dislocation of T12/L1 was treated with TLIF. At 12 months'' follow-up, multi-slice computed tomography (CT) scans showed that solid fusion had been achieved between T12 and L1. Back pain had resolved completely at 2-year follow-up.

Conclusions

We performed TLIF for in a man with old fracture and dislocation of T12/L1, with good clinical outcome. TLIF might be an option in the treatment of old thoracolumbar fracture.     

Application of transforaminal lumbar interbody fusion in old thoracolumbar fracture and dislocation

Abstract

Background

The main indications for surgery for old thoracolumbar fractures are pain, progressive deformity, neurological damage, or increasing neurological deficit. These fractures have been one of the greatest therapeutic challenges in spinal surgery. Anterior, posterior, or combined anterior and posterior procedures have been successful to some extent. As far as we know, there is no report in the literature of transforaminal lumbar interbody fusion (TLIF) for old thoracolumbar fracture and dislocation.

Methods

Case report.

Results

A 26-year-old man with old fracture and dislocation of T12/L1 was treated with TLIF. At 12 months' follow-up, multi-slice computed tomography (CT) scans showed that solid fusion had been achieved between T12 and L1. Back pain had resolved completely at 2-year follow-up.

Conclusions

We performed TLIF for in a man with old fracture and dislocation of T12/L1, with good clinical outcome. TLIF might be an option in the treatment of old thoracolumbar fracture.     

胸腰椎爆裂骨折的治疗和展望

胸腰椎爆裂骨折占胸腰椎骨折的50%以上,其经常导致神经损伤和脊柱后凸畸形,对于每一种类型的骨折其治疗方法各不相同,目前应用于临床的方法有保守疗法、前路手术、后路手术、前后路联合手术及微创手术,然而最佳的治疗方法仍然是不明确的,没有一种精确的分型来指导爆裂骨折的治疗及手术方式的选择。文章综述了胸腰椎爆裂骨折的治疗进展。有研究表明无神经损伤的稳定型爆裂骨折保守治疗和手术治疗并无明显差别。伴有神经损伤的不稳定型爆裂骨折早期手术减压和稳定是应当考虑的,有研究表明对于短节段固定联合各种不同方式的椎体成形术重建前柱可以明显减少内固定失败及远期脊柱后凸畸形的发生率而受到广大脊柱外科医生的推崇。按照生物力学原理及考虑到患者固定节段后相邻节段退变的发生,非融合技术已逐渐应用于临床,其远期疗效尚需进一步研究证实。     

The effect of surgery and remodelling on spinal canal measurements after thoracolumbar burst fractures

Bone fragments in the spinal canal after thoracolumbar spine injuries causing spinal canal narrowing is a frequent phenomenon. Efforts to remove such fragments are often considered. The purpose of the present study was to evaluate the effects of surgery on spinal canal dimensions, as well as the subsequent effect of natural remodelling, previously described by other authors. A base material of 157 patients operated consecutively for unstable thoracolumbar spine fractures at Sahlgrenska University Hospital in Gothenburg during the years 1980-1988 were evaluated, with a minimum of 5-years follow-up. Of these, 115 had suffered burst fractures. Usually the Harrington distraction rod system was employed. Patients underwent computed tomography (CT) preoperatively, postoperatively and at follow-up. From digitized CT scans, cross-sectional area (CSA) and mid-sagittal diameter (MSD) of the spinal canal at the level of injury were determined. The results showed that the preoperative CSA of the spinal canal was reduced to 1.4 cm2 or 49% of normal, after injury. Postoperatively it was widened to 2.0 cm2 or 72% of normal. At the time of follow-up, the CSA had improved further, to 2.6 cm2 or 87%. The extent of widening by surgery depended on the extent of initial narrowing, but not on fragment removal. Remodelling was dependent on the amount of bone left after surgery. The study shows that canal enlargement during surgery is caused by indirect effects when the spine is distracted and put into lordosis. Remodelling will occur if there is residual narrowing. Acute intervention into the spinal canal, as well as subsequent surgery because of residual bone, should be avoided.     

Wiltse椎旁入路治疗胸腰段压缩性骨折

目的探讨Wiltse椎旁入路治疗胸腰段压缩性骨折临床疗效。方法对59例胸腰段椎体压缩性骨折患者采用Wiltse椎旁入路固定治疗,记录术中出血量,对术前术后X线片进行测量。结果 59例均得到随访,时间1～18个月。按中医病症诊断疗效标准评价疗效:优38例,良16例,差5例,优良率为91.52%。术前椎体前缘高度14.38 mm±2.72 mm,Cobb角21.39°±2.64°;术后椎体前缘高度23.18 mm±2.96 mm,Cobb角16.27°±3.05°;差异均有统计学意义(P<0.01)。术中出血量130 ml±20 ml。VAS评分:术前为6.1分±1.3分,术后为0.5分±0.5分,差异有统计学意义(P<0.01)。结论 Wiltse椎旁入路应用于胸腰段压缩性骨折,创伤小、术后腰背疼痛轻。     

Nonoperatively treated burst fractures of the thoracic and lumbar spine in adults: a 23- to 41-year follow-up

BACKGROUND CONTEXT: Several studies report a favorable short-term outcome after nonoperatively treated two-column thoracic or lumbar burst fractures in patients without neurological deficits. Few reports have described the long-term clinical and radiological outcome after these fractures, and none have, to our knowledge, specifically evaluated the long-term outcome of the discs adjacent to the fractured vertebra, often damaged at injury and possibly at an increased risk of height reduction and degeneration with subsequent chronic back pain. PURPOSE: To evaluate the long-term clinical and radiological outcome after nonoperatively treated thoracic or lumbar burst fractures in adults, with special attention to posttraumatic radiological disc height reduction. STUDY DESIGN: Case series. PATIENT SAMPLE: Sixteen men with a mean age of 31 years (range, 19-44) and 11 women with a mean age of 40 years (range, 23-61) had sustained a thoracic or lumbar burst fracture during the years 1965 to 1973. Four had sustained a burst fracture Denis type A, 18 a Denis type B, 1 a Denis type C, and 4 a Denis type E. Seven of these patients had neurological deficits at injury, all retrospectively classified as Frankel D. OUTCOME MEASURES: The clinical outcome was evaluated subjectively with Oswestry score and questions regarding work capacity and objectively with the Frankel scale. The radiological outcome was evaluated with measurements of local kyphosis over the fractured segment, ratios of anterior and posterior vertebral body heights, adjacent disc heights, pedicle widths, sagittal width of the spinal canal, and lateral and anteroposterior displacement. METHODS: From the radiographical archives of an emergency hospital, all patients with a nonoperatively treated thoracic or lumbar burst fracture during the years 1965 to 1973 were registered. The fracture type, localization, primary treatment, and outcome were evaluated from the old radiographs, referrals, and reports. Twenty-seven individuals were clinically and radiologically evaluated a mean of 27 years (range, 23-41) after the injury. RESULTS: At follow-up, 21 former patients reported no or minimal back pain or disability (Oswestry Score mean 4; range, 0-16), whereas 6 former patients (of whom 3 were classified as Frankel D at baseline) reported moderate or severe disability (Oswestry Score mean 39; range, 26-54). Six former patients were classified as Frankel D, and the rest as Frankel E. Local kyphosis had increased by a mean of 3 degrees (p<.05), whereas the discs adjacent to the fractured vertebrae remained unchanged in height during the follow-up. CONCLUSIONS: Nonoperatively treated burst fractures of the thoracic or lumbar spine in adults with or without minor neurological deficits have a predominantly favorable long-term outcome, and there seems to be no increased risk for subsequent disc height reduction in the adjacent discs.     

The effects of pedicle screw adjustments on the anatomical reduction of thoracolumbar burst fractures

The short segmental pedicle screw device is widely used for the decompression of neural elements and reduction of normal anatomy. Many biomechanical studies concerning proper decompression are available. However, no study has determined the optimal device adjustment for reduction of the burst fracture to the normal anatomy. In this study, cadaveric thoracolumbar spine specimens (T11-L3) with L1 burst fractures were studied. A pedicle screw device was attached to the pedicles of the T12 and L2 vertebrae. Spinal postural changes were determined due to a set of eight clinically relevant adjustments of the device. The adjustments were combinations of axial translation (distraction/compression) and extension. The adjustments caused varying changes in spinal posture. The sequence of applying the translation and extension had no effect on the spinal posture changes. The adjustment combining 5 mm distraction with 6 degrees extension brought the burst fracture closest to the intact state, compared to all other adjustments. With this adjustment, on average the spine became 0.9 mm compressed and 2.0 degrees lordotic, compared to the intact. The results of the study show that the device adjustments of axial translation and sagittal angulation can be applied in any sequence, with the same results. The combination of 5 mm distraction with 6 degrees extension was the device adjustment that produced the closest anatomical reduction.     

Results of the AO spinal internal fixator in the surgical treatment of thoracolumbar burst fractures

Summary The potential for clinical instability following thoracolumbar fractures has evoked a progressive increase in interest in the surgical treatment of unstable thoracolumbar fractures. From September 1988 to October 1991, 44 thoracolumbar burst fractures were treated surgically by the AO Spinal Internal Fixator at the Orthopaedics and Traumatology Clinics of Ankara Social Security Hospital. Mean follow-up period was 28.8 (range 12–48) months. Fourteen (31.8%) of the patients were female, and 30 (68.2%) were male. Postoperatively, the mean anterior vertebral height loss and spinal canal compromise were corrected by 36.5% and 39.9%, respectively. Also, postoperatively 15.9° of improvement was obtained in the mean kyphosis angle. The mean compression angle, which was 19.5° preoperatively, was corrected by 12.3° and came to an average of 7.1° posteroperatively. In light of these data, it is suggested that the AO Spinal Internal Fixator effectively restores three-dimensional alignment of the spine and provides a rigid fixation.     

不同入路减压内固定治疗胸腰椎爆裂骨折

目的 探讨不同入路减压内固定治疗胸腰椎爆裂骨折的疗效.方法 将92例胸腰锥爆裂性骨折患者根据病情和患者知情同意分为两组：后路短节段椎弓根螺钉内固定融合术47例,前路减压钛网植骨内固定术45例.对两种治疗方式的疗效进行比较.结果 两组均获满1年随访.两组患者的神经功能均好转;两组患者治疗1年后较治疗前的椎体前缘高度、Cobb角均有明显改善（P〈0.05）;治疗后两组间椎体前缘高度、Cobb角比较差异无统计学意义（P〉0.05）;两组均无顽固性腰痛及内固定断裂等并发症发生.结论 后路短节段椎弓根螺钉内固定融合术和前路减压钛网植骨内固定术治疗胸腰椎爆裂骨折均可取得较好效果.     

AF钉间接减压复位治疗胸腰椎重度爆裂骨折

目的: 探讨AF钉间接减压治疗重度胸腰椎爆裂骨折的临床效果。方法: 50例胸腰椎爆裂骨折患者用间接减压复位内固定植骨术。结果: 随访6个月~9年, 平均3. 5年。伤椎高度由术前的40%恢复到术后的95%, 椎管狭窄指数术前平均2, 术后平均<1。术后除12例全瘫病例无神经功能恢复外, 不完全截瘫患者, 术后神经功能按Frankel分级, 均有Ⅰ级以上恢复。结论: AF钉系统具有操作简单、固定可靠, 能有效的间接减压, 并能很好的恢复脊柱的解剖序列, 是一种治疗重度胸腰椎爆裂骨折的首选方法。     

采用钛网融合器治疗胸腰段脊柱爆裂骨折

目的探讨钛网融合器治疗胸腰段爆裂骨折的手术方法、临床效果、生物力学特点及其适应证。方法采用前路减压、钛网和钛钢板重建脊柱稳定性治疗胸腰段脊柱爆裂骨折患者22例。骨折部位:T127例,L114例,L21例。按照Frankel分级:A级4例,B级6例,C级12例。20例有后凸畸形,后凸角平均为19.5°(12°～29°)。受伤至手术时间为4d～7个月。结果术后平均随访1.2(0.6～2.0)年,神经功能均恢复1级以上,15例患者术后能控制排尿。后凸角为3°～8°,平均5°。内固定物本身未引起并发症,疗效满意。结论治疗胸腰段脊柱爆裂骨折,应经前路减压、彻底去除对脊髓的致压物,钛网融合器加钛钢板可以重建脊柱的稳定性,符合脊柱生物力学,具有重要应用价值。     

Bone mineral density of the thoracolumbar spine in relation to burst fractures: a quantitative computed tomography study

The most common pattern among thoracolumbar burst fractures involves failure of the superior vertebra end-plate. There have been many biomechanical studies of thoracolumbar burst fractures, but the biomechanics related to the internal architecture of thoracolumbar vertebrae has been rarely documented. The objective of this study was to test the hypotheses that distribution of the bone mineral density (BMD) of the thoracolumbar spine is related to the stress concentration in this region and therefore, supports the pattern of burst fractures that occur most commonly. We measured spinal BMD of the first lumbar vertebra in 22 individuals using quantitative computed tomography (QCT) in three levels. At each level, the BMD for the trabecular compartment was determined from each of six sites and from one site within each pedicle. Thus the trabecular density was measured at a total of 20 sites for each person. The highest average QCT BMD was in the pedicle (sites 13 and 14), whereas the BMD was abruptly decreased at the posterior part of the vertebral body near the pedicles. The results of the study indicate that stress concentration of the spine related to the regional variation in vertebral bone density may be implicated in the biomechanical mechanism underlying thoracolumbar burst fractures. This finding may be correlated with the injury mechanism of thoracolumbar burst fractures and of clinical significance.     

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.