胸腰椎骨折椎管狭窄与神经功能的关系

对106例连续性胸腰椎爆裂骨折进行回顾性研究,探讨椎管狭窄与神经功能的关系。按自行设计的改良Frankel法将神经功能分六级,将椎管分脊髓圆锥段和马尾神经段,用直线回归相关法分析椎管狭窄与神经损伤程度之间的关系,用等级相关法分析椎管狭窄与发生神经损伤可能性之间的关系。结果表明:无论在脊髓圆锥段或马尾神经段,椎管狭窄与神经损伤程度、损伤可能性之间均存在相关性(r或r_s=0.38～0.90,P<0.05),且脊髓圆锥段的相关程度较高;相同程度椎骨狭窄致神经危害性在脊髓圆锥段较大。发生神经损伤的最小椎管狭窄在脊髓圆锥段为38％,在马尾神经段为63％(?)认为胸腰椎骨折椎管狭窄是神经损伤的主要因素,X-CT扫描可较好地预测神经损伤程度和损伤可能性。     

胸腰椎爆裂骨折损伤部位和椎管内占位程度与神经损伤的关系

目的探讨胸腰椎爆裂骨折骨折部位及椎管内骨块占位程度与神经损伤的关系。方法对213例胸腰椎爆裂骨折根据骨折部位及CT测出的椎管内骨折骨块占位程度与神经损伤进行分析评定。结果神经损伤组椎管骨折骨块占位程度明显高于无神经损伤组;在有神经损伤情况下,骨折部位椎管内骨块占位程度腰段大于胸腰段;神经损伤程度与椎管内骨块占位程度无显著相关。结论胸腰椎爆裂骨折椎管内骨块占位压迫是神经损伤的重要因素;神经损伤与骨折部位和椎管内骨块占位程度联合相关。     

Does neurological recovery in thoracolumbar and lumbar burst fractures depend on the extent of canal compromise?

STUDY DESIGN: Prospective study. OBJECTIVES: Forty-five consecutive cases of thoracolumbar and lumbar burst fractures treated non-operatively were analyzed to correlate the extent of canal compromise at the time of injury with (i) the initial neurologic deficit and (ii) with the extent of neurological recovery at 1 year. The effect of spinal canal remodeling on neurological recovery was also analyzed. SETTING: University teaching hospital in south India. METHODS: The degree of spinal canal compromise and canal remodeling were assessed from computed tomography scans. The neurologic status was assessed by Frankel's grading. RESULTS: The mean canal compromise in patients with neurologic deficit was 46.2% while in patients with no neurological deficit it was 36.3%. The mean spinal canal compromise in patients with neurological recovery was 46.1% and 48.4% in those with no recovery. The amount of canal remodeling in patients who recovered was 51.7% and 46.1% in the patients who did not recover. None of these differences was statistically significant. CONCLUSION: This study shows that there is no correlation between the neurologic deficit and subsequent recovery with the extent of spinal canal compromise in thoracolumbar burst fractures.     

The efficiency of ultrasound guided spinal fracture reposition

Summary To calculate canal compromise and decrease of midsagittal diameter caused by retropulsion of fragments into the spinal canal we analyzed the pre- and postoperative computed tomographies of 32 patients with unstable thoracolumbar burst fractures treated by USS (universal spine system). Our intention was to examine the efficiency of ultrasound guided repositioning of the dispaced fragments which was performed in all 32 cases. We found a clear postoperative enlargement of canal area (ASP preoperatively 55 %, postop. 80 %) and midsagittal diameter (MSD preop. 58 %, postop. 78 %). 10 of 13 patients presented a postoperative improvement of neurological deficit, no neurological deterioration occured. Fractures with neurological deficit showed more canal compromise (52 %) and less midsagittal diameter (MSD compromise 51 %) than those without (40 % or 39 %). There was no correlation between the percentage of spinal canal stenosis and the severity of neurological deficit. Below L 1 the spinal canal is greater than between Th 11 and L 1, so a more important spinal stenosis is tolerated. In case of unstable burst fractures with neurological deficit the ultrasound guided spinal fracture reposition is an effective procedure concerning the necessary improvement of spinal stenosis: an additional ventral approach for the revision of the spinal canal is unneeded. In fractures without neurologic deficit the repositioning of the displaced fragments promises an avoidance of long-term damages such as myelopathia and claudicatio spinalis.      

Die Bedeutung des Wirbelkanaldurchmessers im thorakolumbalen und lumbalen Bereich nach Trauma

A relationship between traumatic spinal canal stenosis and the degree of neurological deficit is known for the cervical spine. However, this has not been proven for the thoracolumbar and lumbar spine. During a period of 4 years, from 1996 to 1999, 1168 patients with a spinal injury were treated at our department, 473 of these by operation. Thirty-five were examined in a separate group.They showed a single fracture of the thoracolumbar and lumbar spine with stenosis of the spinal canal. All fractures were single burst fractures after blunt trauma. All patients were conscious and fully oriented at the time of admission and a thorough neurological examination could be performed. The fractures were diagnosed by conventional X-ray in two views and computed tomography (CT). Using the transverse CT scans in horizontal view, the sagittal diameter was measured and the degree of stenosis calculated in percent at the level of the fracture and one below and above. The group included 25 male and 10 female patients, with a mean age of 38 years (range: 17-61 years). Of the 35 patients, 19 (54.3%) showed neurological deficits after spinal cord injury,and 16 (45.7%) were without any neurological complications at the time of first admission to the hospital. There was no correlation between the extent of spinal canal stenosis and the degree of the neurological deficit. One patient with stenosis of 20% suffered from neurological dysfunction, others with stenosis up to 80% were without spinal cord injury. The average stenosis of the spinal canal was 49.6% in cases with cord injury and 46.3% in patients without neurological dysfunction. No correlation and no predisposing anatomical structures could be found between stenosis and neurological deficit.     

Correlation of spinal canal post-traumatic encroachment and neurological deficit in burst fractures of the lower cervical spine (C3–7)

Summary Burst fractures of the lower cervical spine (C3–7) are often associated with severe neurological injury. During the last 5 years (1987–1992) we operated on 11 patients who had sustained burst fractures together with neurological deficit. The operations were performed through an anterior approach. The burst vertebra was excised, and the defect was filled with bone graft. Implants (plates and screws) were used in 10 cases. The preoperative examination was conducted by computed tomography and revealed that in 4 patients with complete tetraplegia (Frankel grade A) there was more than 50% spinal canal narrowing, whilst in the remaining 7 patients, with various levels of incomplete tetraplegia, there was less than 50% spinal canal narrowing, resulting in considerable improvement. The above results support the hypothesis that a correlation exists between the magnitude of the spinal canal encroachment, the initial neurological deficit and the final outcome.     

Neurological deficit and canal compromise in thoracolumbar and lumbar burst fractures

PURPOSE: To assess whether canal compromise determines neurological deficit in thoracolumbar and lumbar burst fractures. METHODS: 105 patients aged 17 to 60 (mean, 34) years who had burst fractures in the thoracolumbar (n=82) and lumbar (n=23) regions were included. Fractures were classified according to the Denis classification. The extent of spinal canal compromise was assessed by computed tomography, and the neurological status according to the modified Frankel grading for traumatic paraplegia. RESULTS: 19 (18%) of the patients had no neurological deficit. Of the remaining 86 (82%) with a deficit, 26 had complete paraplegia. The correlation between the type of the burst fracture and the severity of neurological deficit was not significant (Chi squared=10.57, p=0.835). The mean extent of spinal canal compromise in patients with deficits was 50%, whereas in patients with no deficit it was 36%. The difference between the extent of canal compromise and the severity of neurological deficit at the thoracolumbar and lumbar spine was not significant (p=0.08). Further subanalysis revealed a significant correlation at T11 and T12 (p=0.007) but not at the L1 (p=0.42) level. CONCLUSION: When studying neurological deficit, T11 and T12 injuries should be analysed separately from L1 injuries.     

胸腰段椎体爆裂骨折椎管容积和脊髓损伤的相关性研究

目的 测定胸腰段椎体爆裂骨折后椎管容积和脊髓损伤程度评分及脊髓损伤后遗症的关系.方法 前瞻性研究48例胸腰椎(T12-L2)爆裂性骨折的患者,15例有脊神经功能障碍,33例无脊神经功能障碍,用CT扫描来测量损伤水平及损伤水平上下节段椎管的矢径、横径和椎管的表面积,两组病人都用ISS评分作损伤程度评估.有脊髓损伤和无脊髓损伤者两组患者的测量数据用t检验作统计学分析.结果 在损伤平面其椎管横径的平均值,有脊神经功能障碍的患者明显大于无脊神经功能障碍者(P＜0.01).有脊神经功能障碍者其损伤平面以下的椎管表面积明显大于无脊神经功能障碍的患者(P＜0.05).有脊神经功能障碍者其椎管矢径与横径的比值明显小于无脊神经功能障碍患者(P＜0.01).结论 在胸腰段椎体爆裂性骨折后没有解剖学上的因素能预见神经的损伤.然而,损伤后椎管矢状径与横径的比值却能预测神经功能障碍的程度.     

The significance of thoracolumbar spinal canal size in spinal cord injury patients

STUDY DESIGN: A prospective, consecutive case series. OBJECTIVES: To determine the relation between spinal canal dimensions and Injury Severity Score and their association with neurologic sequelae after thoracolumbar junction burst fracture. SUMMARY OF BACKGROUND DATA: There is a relation in the cervical spine between spinal canal dimension and its association with neurologic sequelae after trauma. A similar relation at the thoracolumbar junction has not been conclusively established. METHODS: Forty-three patients with thoracolumbar junction burst fractures (T12-L2),13 with and 30 without neurologic deficit, were included. Computed tomographic scans were used to measure the sagittal and transverse diameters and the surface area of the spinal canal at the level of injury, as well as one level above and one level below the fracture level. Injury severity score was calculated for both groups. Statistical analysis comparing those with a neurologic deficit to those without was performed by Student's t test. RESULTS: The ratio of sagittal-to-transverse diameter at the level of injury was significantly smaller in patients with a neurologic deficit than in those without a neurologic deficit (P < 0.05). The mean transverse diameter at the level of injury was significantly larger in patients with neurologic deficit than in the neurologically intact patients (P < 0.05). The surface area of the canal at the level below the injury was significantly larger in the patients with a neurologic deficit than in those without a deficit (P < 0.05). Patients with a neurologic deficit had a statistically higher Injury Severity Score when admitted than those without a neurologic deficit (P < 0.0001), although the difference became insignificant after the neurologic component of the scoring system was eliminated. CONCLUSION: There are no anatomic factors at the thoracolumbar junction that predispose to neurologic injury after burst fracture. The shape of the canal after injury, however, as determined by the sagittal-to-transverse diameter ratio, was predictive of neurologic deficit.     

Clinical results of posterior stabilization without decompression for thoracolumbar burst fractures: is decompression necessary?

The purpose of this study is to investigate the clinical outcome of posterior stabilization without decompression for thoracolumbar burst fractures. Thirty-one consecutive cases of thoracolumbar fractures involving T11-L2 stabilized by a pedicle screw system were reviewed. Neither reduction of the height of a fractured body nor any decompression procedure was added during surgery. Twenty-two patients had incomplete paraplegia; one patient had complete paraplegia. Neurological recovery and remodeling of the spinal canal were evaluated. Neurological status was evaluated at the time of injury, just before and after surgery, and at final follow-up. The degree of spinal canal compromise was assessed using axial CT scan images. The duration of follow-up averaged 39.6?months. The mean spinal canal compromise at the time of injury was 41.6%, and no significant correlation was observed between the degree of canal compromise and the severity of the neurological deficit. Within 2-3?weeks, spinal canal remodeling had started in all patients whose spinal canal compromise was more than 30%, and canal compromise had decreased significantly 3-4?weeks after injury. Seventeen of 22 patients with incomplete paraplegia had already shown partial neurological recovery even before surgery. At the final follow-up, all patients with incomplete paraplegia had improved by at least one modified Frankel grade. This study suggests that the effect of decompressing thoracolumbar fractures with neurological deficits remains unclear and questions the need to operate simply to remove retropulsed bone fragments. Posterior stabilization without decompression should constitute appropriate surgical treatment for these fractures.     

Management of thoracolumbar fractures with accompanying neurological injury.

The optimal surgical approach for spinal canal reconstruction of thoracolumbar fractures is controversial, and the relationship between spinal canal reconstruction and neurological recovery remains unclear. To address these issues, 22 consecutive cases of thoracolumbar fracture with accompanying neurological deficit were reviewed. Neurological status was graded at the time of admission, postoperatively, and at a mean of 15 months postinjury. By using preoperative and postoperative radiographs and computed tomographic scans, the degree of spinal canal compromise was quantified in the sagittal, coronal, and axial planes. All fractures were stabilized by posterior instrumentation and fusion, and in 10 injuries, retropulsed vertebral body fragments were further reduced by posterolateral decompression. Spinal canal dimensions, neurological function, and operative approach were compared by using nonparametric statistical analysis. The greater the initial spinal canal compromise, the more severe the neurological deficit (P = 0.04). With injuries involving L1 and above, this relationship increased (P = 0.003). The extent of spinal canal reconstruction failed to correlate with neurological recovery. Compared with spinal instrumentation alone, transpedicular decompression showed no benefit in terms of postoperative canal dimensions or neurological outcome. On the basis of this experience, transpedicular decompression offers no advantage over spinal instrumentation alone. The relationship between initial spinal canal encroachment and neurological deficit demonstrates that the degrees of bony and neurological injury directly reflect the kinetic energy transferred at the time of impact. The lack of correlation between the extent of spinal canal reconstruction and neurological recovery suggests that ongoing neural compression/distortion contributes little to the overall neurological injury.     

Neurological deficit in injuries of the thoracic and lumbar spine

Summary Seventy consecutive patients with injuries of the thoracic and lumbar spine accompanied by neurological deficit were prospectively studied and followed-up.In 40 of these patients with a burst fracture, the degree of involvement of the cross-sectional area of the spinal canal, as revealed on first CT after admission, was not correlated with the type and degree of initial neurological deficit.In patients with injuries of the lumbar spine, neurological deficit may be mild, although the sagittal diameter of the spinal canal may be reduced by as much as 90%.We cannot establish a difference in neurological recovery between those cases who were managed conservatively and those in whom a surgical decompression and stabilization procedure was performed.Surgical stabilizing procedures, however, result in immediate stabilization of the spine, they diminish pain, facilitate nursing care and allow more rapid mobilization and earlier active rehabilitation.If major extraspinal injuries form a relative contra-indication to surgical decompression of the cord and stabilization of the spine injury, the patient can quite well be treated conservatively without endangering neurological recovery.     

72例胸腰段爆裂性骨折患者神经功能缺失与伤后椎管狭窄相关性的研究

目的：研究胸腰段爆裂性骨折患者脊髓损伤程度与相应椎管狭窄两者间的相关性。方法：对1998年6月～2004年3月间收治的72例胸腰段爆裂骨折患者进行回顾性分析,脊髓功能按照Frankel分级进行评定,使用透明毫米尺对患者CT片椎管正中矢状径进行测量以此代表椎管面积,分别计算T11、T12、L1、L2四个节段两者的相关系数并进行直线相关分析。结果：T1、T12、L1、L2节段两者问相关系数分别为：O．3348、0．8457、0．6691、0．3336。提示T12水平两者具有较高的相关性,而在L1、L2节段两者的相关性较低。对相关系数进行显著性检验,结果显示在T12、L1椎管狭窄和脊髓功能损伤之间具有直线相关关系（P〈O．001）,而在T11、L2两个节段不能认为椎管狭窄和脊髓功能损伤间具有直线相关关系（P〉0．5,0．10〈P〈0．20）。结论：脊髓的损伤程度与椎管狭窄程度具有相关性。测量患者胸腰段爆裂骨折CT扫描图像中椎管占位面积的大小可以作为神经损伤程度的一个预测因素。     

胸腰椎爆裂性骨折后椎管重建—兼论非手术治疗的意义

目的 证实胸腰椎爆裂性骨折后的椎管重建现象,并探讨非手术治疗的意义。方法 回顾性分析３１例胸腰椎爆裂性骨折,其中未治疗７例,非手术治疗１６例,手术治疗８例,随访时间３～７年。记录初次诊治入院时和随访时脊髓损伤程度。以及出院和随访时椎管狭窄率。结果 ３１例患者的椎管狭窄率由初次诊治出院时的１２．３％～７４．５％（平均２６．２％）降至随访时的５．４％～４６．５％（平均１９．２％）,差异具有极显著性意义     

椎体后凸成形术治疗骨质疏松性椎体爆裂骨折

骨质疏松性椎体爆裂骨折被认为是经皮椎体成形术及椎体后凸成形术的相对禁忌证。无神经症状的骨质疏松性椎体爆裂骨折在临床上较常见,其治疗方法有待探讨。目的：探讨椎体后凸成形术治疗骨质疏松性椎体爆裂骨折的可行性、疗效及椎管重建情况。方法：回顾性分析2008年1月至2009年1月采用椎体后凸成形术治疗的无神经症状的骨质疏松性椎体爆裂骨折患者18例。术前、术后及末次随访时采用疼痛视觉模拟评分（visual analog score,VAS）评估疼痛程度;Oswsetry功能障碍指数（Oswsetry disability index,ODI）评估患者日常生活功能;测量术前、术后及末次随访时骨折椎体椎管内骨块占位率,骨折椎体前缘、中缘的高度,Cobb角。结果：18例全部获得随访,随访时间为12—33个月,平均20．4个月。术后无感染、肺栓塞等并发症,仅1例患者出现椎间盘少量骨水泥渗漏但无症状。患者术后疼痛迅速缓解,VAS评分术前8．2±1．3分,术后2．8±0．8分（P〈0．05）,末次随访时维持在3．04-0．8分。ODI评分术前为67．4％±7．7％,术后降至37．8％±3．1％（P〈0．05）,末次随访时为38．9％4-2．6％。椎管内骨块占位率术前与术后无统计学差异（P〉0．05）,术前与末次随访比较有统计学差异（P〈0．05）,椎体前、中缘和Cobb角的术前与术后、术前与末次随访比较有统计学差异（P〈0．05）。结论：椎体后凸成形术治疗骨质疏松性椎体爆裂骨折安全、有效;椎体后凸成形术治疗骨质疏松性椎体爆裂骨折亦存在椎管重建现象。     

The effect of posterior instrumentation of the spine on canal dimensions and neurological recovery in thoracolumbar and lumbar burst fractures

A prospective study was designed to determine whether posterior instrumentation of the spine in thoracolumbar and lumbar burst fractures produces indirect decompression of the spinal canal leading to better remodeling and neurological recovery. The study was conducted in Kasturba Medical College Manipal, India. Sixty-eight consecutive cases of thoracolumbar and lumbar burst fractures were treated by posterior instrumentation, and approval from the hospital ethical committee was obtained. The degree of initial spinal canal compromise, indirect decompression, and remodeling were assessed from the computed tomography scans. The neurological status at the time of presentation and at final follow-up was assessed by the American Spinal Injury Association’s modified Frankel’s grading. The median canal compromise in patients with and without neurological deficit was 47.32 and 39.33%, respectively. The overall mean canal compromise at the time of admission, post-operative, and final follow-up were 47.37, 26.58 and 14.85%, respectively (P = <0.001). The median canal compromise in patients who recovered was 44.5% and in those with no neurological recovery was 55.85%. The median percentage of canal decompression achieved in patients who recovered was 22.15%, whereas it was 22% in those who did not recover. The median remodeling in recovered and non-recovered groups was 64.50 and 80%, respectively. None of these differences was statistically significant. This study shows that posterior instrumentation of the spine produces significant indirect decompression of the spinal canal and better remodeling. However, these factors may not improve the neurological recovery.     

The neurological outcome following surgery for spinal fractures

Sixty consecutive patients with spinal injuries and encroachment upon the spinal canal of greater than 20% were assessed for neurological outcome. The patients were divided into two groups, those undergoing posterior surgery alone, and those undergoing anterior surgery for formal decompression with or without anterior or posterior instrumentation. In those patients undergoing posterior surgery, an improvement rate in the neurological function of 83% was noted in patients with incomplete lesions, whereas an 88% improvement rate was found in those undergoing the anterior procedure. There was no statistical difference in outcome between these two groups. Positive correlations were found between the level of injury and Frankel grades. The cord lesions tended to demonstrate more severe neurological deficit, whereas the cauda equina lesions were associated with a lesser severity of neurologic deficit. A component of dislocation to the injury also resulted in a more severe neurological deficit. There was no apparent difference between the degree of bony encroachment of the spinal canal and the initial Frankel grade, nor was there a clear difference between those patients undergoing anterior versus posterior surgery.     

经皮椎体成形术治疗不伴神经症状的骨质疏松性椎体爆裂骨折简

目的探讨经皮椎体成形术（percutaneousvertebroplasty,PVP）治疗不伴神经症状的骨质疏松性椎体爆裂骨折的临床效果。方法回顾性分析2006年9月至2012年6月间我院治疗的25例不伴神经症状的骨质疏松性椎体爆裂骨折患者的临床资料,男9例,女16例;年龄65～82岁,平均73．5岁。损伤节段在T10-L3之间,共36个节段。所有患者均伴有5％～20％的椎管占位。分别于术前和术后1周、1、6、12个月,采用视觉模拟疼痛评分（visualaria—loguescores,VAS）和Oswestq功能障碍指数（oswestrydisabilityindex,ODI）评估患者的临床效果;通过侧位x线片测量患者椎体中线高度和矢状位Cobb角;通过轴位CT测量椎管占位程度,对患者的骨水泥渗漏、感染等并发症情况进行记录。结果9例（25％）椎体发生骨水泥渗漏,但均未出现相关临床症状。无感染、神经损伤、肺栓塞等病例出现。在VAS评分、ODI评分以及椎体中线高度、矢状位Cobb角、椎管占位程度测量评估方面,患者术前与术后各个时间点比较,术后评估结果显著优于术前,差异均有统计学意义（P〈0．05）。结论对于椎管占位5％一20％的无神经功能损害的骨质疏松性椎体爆裂骨折患者而言,PVP技术是一种安全、有效的治疗方法,且不增加病椎椎管占位程度加重的风险。     

The natural history of burst fractures at the thoracolumbar junction

Conservative management of 54 patients with thoracolumbar (T12 and/or L1) burst fractures was investigated. The fractures were subdivided according to the Denis classification and a modification was suggested. Most type A and B fractures showed good results regarding reduction and neurological improvement. However, severe type B (with anterior column compression and spinal canal narrowing exceeding 50%), D, and E fractures were to a large extent complicated by intractable low back pain, neurological involvement, and signs of instability. This study suggests predictors for complications in patients with burst fractures in the thoracolumbar junction. These are (a) compression rate of the anterior column exceeding 50%, (b) narrowing of the spinal canal exceeding 50%, (c) signs of rotational malalignment in fracture level, and (d) level of the injury (L1 fractures).     

Anterolateral decompression for neural involvement in thoracolumbar fractures. A review of 78 cases

Of a total of 905 patients with fracture or fracture-dislocation of the thoracolumbar spine admitted from 1969 to 1982, a neurological deficit was present in 334 (37%). All unstable injuries were initially treated by reduction and posterior fusion. In 79 of these patients, an anterolateral decompression was undertaken later because of persistent neurological deficit and radiographic demonstration of encroachment on the spinal canal. One patient died of pulmonary embolism; 78 were reviewed after a mean period of four years. Of these 78 patients 18 made a complete neurological recovery while 53 appeared to have benefited from the procedure; 25 remained unchanged. The best results were obtained in burst fractures at thoracolumbar and lumbar levels when a solitary detached fragment of a vertebral body had been displaced into the spinal canal. These results indicate that anterolateral decompression of the spinal canal should be considered, after careful evaluation, for certain injuries of the spine in which there is severe neural involvement.