胸腰段爆裂骨折椎管占位与早期神经损伤的关系

【摘要】 目的：探讨胸腰段爆裂骨折椎管内骨块占位程度与早期神经损伤的关系。方法：对2000年1月至2009年12月收治的115例胸腰段爆裂骨折急性期患者的CT扫描图像与神经损伤情况进行回顾性分析。无神经损伤组（Ａ组）43例,神经损伤组（Ｂ组）72例。对患者CT图像运用Image J图像分析软件进行测量,分别对伤椎及其相邻上下椎的椎管横径、矢状径和面积进行测量,计算相应的椎管占位率和矢状径与横径比值,将无神经损伤组与神经损伤组进行统计学分析。结果：伤椎的椎管矢状径、面积和矢状径/横径比值在T12节段A组分别     

Complication avoidance: thoracolumbar and lumbar burst fractures

Most thoracolumbar and lumbar burst fractures can be treated conservatively. Unstable fractures or fractures resulting in neurologic deficits usually require surgical treatment. Choosing an appropriate surgical approach requires a thorough understanding of the various techniques for decompression, fusion, and stabilization. Surgical options include an anterior approach, a posterior approach, or a combined anteroposterior approach. Each surgical option has unique advantages and disadvantages. Generally, the anterior approaches are best used at the thoracolumbar junction, posterior approaches are ideal for low lumbar injuries and lumbar injuries that result in complete spinal cord injuries,and anteroposterior surgeries typically are reserved for highly unstable fracture subluxations. Case illustrations show the various treatment options.     

Decision-making in burst fractures of the thoracolumbar and lumbar spine

The most common site of injury to the spine is the thoracolumbar junction which is the mechanical transition junction between the rigid thoracic and the more flexible lumbar spine. The lumbar spine is another site which is more prone to injury. Absence of stabilizing articulations with the ribs, lordotic posture and more sagitally oriented facet joints are the most obvious explanations. Burst fractures of the spine account for 14% of all spinal injuries. Though common, thoracolumbar and lumbar burst fractures present a number of important treatment challenges. There has been substantial controversy related to the indications for nonoperative or operative management of these fractures. Disagreement also exists regarding the choice of the surgical approach. A large number of thoracolumbar and lumbar fractures can be treated conservatively while some fractures require surgery. Selecting an appropriate surgical option requires an in-depth understanding of the different methods of decompression, stabilization and/or fusion. Anterior surgery has the advantage of the greatest degree of canal decompression and offers the benefit of limiting the number of motion segments fused. These advantages come at the added cost of increased time for the surgery and the related morbidity of the surgical approach. Posterior surgery enjoys the advantage of being more familiar to the operating surgeons and can be an effective approach. However, the limitations of this approach include inadequate decompression, recurrence of the deformity and implant failure. Though many of the principles are the same, the treatment of low lumbar burst fractures requires some additional consideration due to the difficulty of approaching this region anteriorly. Avoiding complications of these surgeries are another important aspect and can be achieved by following an algorithmic approach to patient assessment, proper radiological examination and precision in decision-making regarding management. A detailed understanding of the mechanism of injury and their unique biomechanical propensities following various forms of treatment can help the spinal surgeon manage such patients effectively and prevent devastating complications.     

胸腰椎爆裂骨折椎管内骨块占位与神经损伤

目的　观察胸腰椎爆裂骨折部位及椎管内骨块占位与神经损伤的关系。方法　对 14 1例包括胸椎 (T1 - T1 0 )、胸腰段 (T1 1 - L2 )及腰椎 (L3- L5)三个水平爆裂骨折 CT显示的椎管内骨块占位与神经功能关系进行了分析。结果　神经损伤组椎管内骨块占位程度明显高于无神经损伤组 (P <0 .0 5 ) ;在有神经损伤情况下椎管骨块占位严重程度依次为 :胸椎 <胸腰段 <腰椎 (P <0 .0 5 ) ;在 Frankel分类有功能障碍的四个神经功能级之间其椎管骨块占位程度无显著差异 (P>0 .0 5 )。结论　椎体爆裂骨折椎管内骨块占位压迫是神经损伤的重要危险因素 ;神经损伤的出现与骨折椎体节段和椎管内骨块占位程度联合相关 ;但神经损伤的严重程度与就诊时 CT表现的椎管内骨块占位程度具有不一致性     

Spinal canal remodelling after stabilization of thoracolumbar burst fractures

Summary Spinal canal areas were measured prospectively in 22 consecutive burst fractures of the thoracolumbar junction, preoperatively, within 1 week postoperatively and 1 year after operation. Preoperative canal encroachment averaged 38% (range 10%–70%) of the estimated original area. The 11 patients with neurological impairment had a significantly more severe initial canal encroachment (mean 48%) than those who were neurologically intact (mean 33%). Postoperatively, canal encroachment had decreased to a mean of 18% (range 0%–62%). Within 12 to 15 months postoperatively, canal encroachment was further reduced by resorption of bone fragments to a mean of 2%. The largest observed remaining encroachment was 29%. The amount of bone resorption correlated significantly with the persistent postoperative encroachment. A critical appraisal of the methods used to assess the pre-fracture canal area revealed that reconstructing the vertebral foramen of the fractured vertebra on CT scans substantially overrated the original area as compared with averaging the canal area of the two adjacent vertebrae.     

Remodeling of the spinal canal after thoracolumbar burst fractures

Thirty-one patients with thoracolumbar burst fractures, seven untreated, 16 treated nonoperatively, and eight treated operatively, were analyzed retrospectively and followed up for 3 to 7 years. The initial and final degrees of neurologic deficit and the stenotic ratio of the spinal canal were recorded. Stenotic ratio significantly decreased from the first examination (range, 12.3%-74.5%; average, 26.2%) to the final followup (range, 5.4%-46.5%; average, 19.2%), but there were no differences of the percentage of remodeling between patients who were untreated and those treated nonoperatively and operatively. The recovery rate was highly significantly related to the stenotic ratio at first examination. Nonoperative management may be considered for treatment of patients who are neurologically intact or only slightly impaired with thoracolumbar burst fractures.     

Anterior dural laceration caused by thoracolumbar and lumbar burst fractures

A retrospective review of the records of 60 patients with thoracolumbar and lumbar burst fractures was undertaken to document the incidence and evaluate the sequelae of dural injuries found during anterior procedures. In the entire series, six (10%) patients each had a preexisting vertically oriented dural tear. All patients with anterior dural lacerations were male and had associated neurologic deficits. In all six patients, preoperative computed tomography showed an asymmetrically retropulsed bone fragment. Dural tears were repaired primarily. A postoperative cerebrospinal fluid leak developed into the chest cavity of one patient, who was treated successfully with subarachnoid drainage. In patients with anterior dural laceration, primary repair is warranted and can be performed more easily after intraoperative correction of kyphosis. Subarachnoid drainage may be effective in cases of continued postoperative anterior cerebrospinal fluid leakage before repeated operation is considered.     

CT scan prediction of neurological deficit in thoracolumbar burst fractures.

In 139 patients with burst fractures of the thoracic, thoracolumbar or lumbar spine, the least sagittal diameter of the spinal canal at the level of injury was measured by computerised tomography. By multiple logistic regression we investigated the joint correlation of the level of the burst fracture and the percentage of spinal canal stenosis with the probability of an associated neurological deficit. There was a very significant correlation between neurological deficit and the percentage of spinal canal stenosis; the higher the level of injury the greater was the probability. The severity of neurological deficit could not be predicted.     

椎板开窗椎管减压治疗伴神经损伤胸腰椎爆裂骨折

目的探讨椎板开窗椎管减压治疗合并神经损伤胸腰椎爆裂骨折的手术效果。方法回顾性研究自2008-01—2013-06采用椎板开窗椎管减压、椎弓根钉内固定治疗的28例合并神经损伤的胸腰椎爆裂骨折。术后1周、12个月行X线片和CT检查,测量椎体前缘高度、椎管中矢径和椎管狭窄。末次随访时记录腰背痛VAS评分和神经功能Frankel分级恢复情况。结果 28例均获得平均20.1(18~36)个月随访。术后1周与术前比较,椎体前缘高度(t=27.040,P0.001)、椎管中矢径(t=22.620,P0.001)、椎管狭窄(t=20.470,P0.001)明显改善,差异有统计学意义(P0.05)。术后12个月与术后1周比较,椎体前缘高度少许丢失,差异有统计学意义(t=16.970,P0.001),但基本维持稳定;椎管中矢径(t=8.480,P0.001)、椎管狭窄(t=10.150,P0.001)进一步改善,差异有统计学意义(P0.05)。末次随访时,除2例完全性神经损伤外,不完全性神经损伤患者均有不同程度恢复,由术前分级(2.75±1.21)恢复至(0.86±1.30),差异有统计学意义(Z=-4.435,P0.001);腰背痛VAS评分为(2.25±0.17)分,较术前明显降低,差异有统计学意义(t=19.390,P0.001)。结论椎板开窗椎管减压、椎弓根钉内固定治疗合并神经损伤的胸腰椎爆裂骨折不仅保留了椎管结构和脊柱稳定性,而且可以使椎管得到有效减压。     

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.     

Nonsurgical treatment of three-column thoracolumbar junction burst fractures without neurologic deficit

STUDY DESIGN: Retrospective review of the outcome of neurologically intact patients with three column thoracolumbar junction burst fractures that were treated nonsurgically. OBJECTIVE: To further define the parameters for nonsurgical management of thoracolumbar junction burst fractures. SUMMARY OF BACKGROUND DATA: Many texts list involvement of the posterior column as an indication for surgery and state that casting or bracing is mandatory. This has not been the authors' experience. METHODS: Thirty-eight patients with nonpathologic, single-level burst fractures of T11, T12, L1, or L2, and with posterior element fractures were studied retrospectively. The selection criteria required that the patient be neurologically intact, that the pedicles and facet joints not be fractured or dislocated, and that the angle of kyphosis be less than 35 degrees. The extent of retropulsion, loss of vertebral height, and presence of lamina or process fractures were not criteria. No attempt was made to reduce the fracture. Patients were allowed immediate ambulation as tolerated. Jewett braces were used in nine patients, but no bracing was used in the remainder. RESULTS: There were 22 males, 16 females. Median age 37 years (range, 16-65). Fracture involved both endplates in 16 patients (12 crush-cleavage type), the superior end-plate in 21, and the inferior endplate in 1. The hospital stay was from 2 to 18 days (median, 8 days). Follow-up averaged 4.1 years (range, 2.1-6.3). All patients remained neurologically intact. Eight patients had no pain, 24 had minimal pain, 4 had moderate pain, and 2 had moderate to severe pain. Twenty-nine of 38 patients (76%) were able to work at the same level. The initial kyphosis angle averaged 20 degrees (range 10-35 degrees). At follow-up it averaged 24 degrees (range 12-38 degrees). The maximum increase was 6 degrees. Some degree of retropulsed fragment resorption was noted in 35 cases. Complications were limited to transient urinary retention. There were no thromboembolisms, decubitus ulcers, or pulmonary complications. CONCLUSION: Despite the use of less restrictive criteria, no brace, and early activity as tolerated, the results are similar to those obtained with more restrictive protocols. The presence of vertical lamina fracture, spinous process fracture, and transverse process fracture are not contra--indications. Activity restriction and bracing may be important for pain control but probably does not change the long-term result.     

直接或间接复位对无神经症状型胸腰椎爆裂性骨折椎管重塑的影响

目的探讨直接或间接复位对无神经症状型胸腰椎爆裂性骨折椎管重塑的影响。方法将52例无神经症状型胸腰椎爆裂性骨折患者按照手术方式不同分为直接复位组(n=26)和间接复位组(n=26)。比较两组患者椎体骨块占位率、椎体前缘高度降低百分比、Cobb角、椎管重塑矢状径的恢复比率及ODI评分。结果患者均获得随访,时间12~15个月。末次随访时,两组ODI评分均较术前明显降低(P<0.001),两组间比较差异无统计学意义(P>0.05);两组椎体骨块占位率、椎体前缘高度降低百分比及Cobb角均较术前明显改善(P<0.01),两组比较差异无统计学意义(P>0.05);椎管重塑矢状径的恢复比率间接复位组为15.7%±8.9%,直接复位组为11.8%±9.2%,两组间比较差异有统计学意义(P<0.01)。结论直接或间接复位治疗无神经症状型胸腰椎爆裂性骨折患者均可获得较好的临床疗效。间接复位手术操作步骤减少,创伤小,且后期椎管重塑较好,更具优势。     

后路选择性椎管减压在胸腰椎爆裂性骨折的应用

目的观察选择性椎管减压内固定对合并有神经损伤的胸腰椎爆裂骨折的治疗效果。方法经椎弓根钉钉棒系统内固定治疗胸腰椎爆裂骨折患者62例,对其中伴有脊髓神经损伤的49例从后路做选择性椎管减压。结果伤椎前、后缘高度分别从术前平均47．5％和76．2％恢复到正常的95．1％和98．5％,Cobbs角由术前23．34°恢复到术后的4．88°。CT示椎管截面积术前为45．2％,术后为88．7％。各项指标与术前比较差异有显著性（P〈0．01）,患者术后神经功能获得改善。结论后路选择性椎管减压技术对爆裂骨折的复位和椎管减压的作用是确切有效的。     

伴有椎管占位的单节段胸腰椎爆裂骨折手术策略

[目的]通过观察伴有不同程度椎管占位的单节段胸腰椎爆裂骨折患者采用三种手术方案的临床疗效,探讨此类骨折个体化治疗策略。[方法]对2016年4月～2018年1月伴有不同程度椎管占位的胸腰椎爆裂骨折42例患者进行回顾性分析,根据术前椎管占位程度分为三组,15例椎管占位30%者行后路伤椎单侧置钉短节段内固定术,14例占位30%～50%者行后路伤椎单侧置钉短节段内固定+经椎弓根打压植骨术,13例占位50%行后路伤椎者单侧置钉短节段内固定+经椎弓根打压植骨术+全椎板减压术。[结果]30%～50%组和50%组手术时间显著长于30%组(P0.05);50%组出血量显著高于30%组和30%～50%组(P0.05);三组间术口长度比较差异均无统计学意义(P0.05)。所有患者术后随访(14.46±2.25)个月。三组患者均随术后时间推移腰背痛VAS评分显著减少(P0.05),相同时间点三组间VAS评分差异无统计学意义(P0.05)。术后三组的伤椎前缘高度比、Cobb角及椎管占位率均较术前显著改善(P0.05);但三组间相应时间点上述影像测量指标的差异均无统计学意义(P0.05);三组随访期间无内固定松动、断裂等发生。[结论]伴有椎管占位的单节段胸腰椎爆裂骨折采用个体化手术方案可有效恢复并维持伤椎高度、Cobb角,解除椎管占位。     

Relationship between traumatic spinal canal stenosis and neurologic deficits in thoracolumbar burst fractures

Using CT scans of 112 consecutive patients with thoracolumbar burst fractures, we investigated the relationship between traumatic spinal canal stenosis and neurologic deficits. We calculated the stenotic ratios of the area occupied by the retropulsed bony fragments to the estimated area of the original spinal canal. We also examined the shape of the narrowed canal and the disruption of spinal elements. Burst fractures having the following ratios are at significant risk of neurologic involvement: at T11 to T12 with 35% more, at L1 with 45% or more, and at L2 and below with 55% or more.     

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.     

椎体后凸成形术治疗无神经症状的骨质疏松性胸腰段爆裂性骨折的疗效分析

[目的]探讨椎体后凸成形术治疗无神经症状的骨质疏松性胸腰段爆裂性骨折的可行性及其疗效。[方法]椎体后凸成形术试行治疗25例无神经症状的骨质疏松性胸腰段爆裂性骨折(Margel分型属A3型)。术中采用骨水泥分次灌注及C型臂X线机动态观察技术。术前、术后及术后12个月时采用疼痛视觉模拟评分(visual analogscore,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。并测量术前、术后及12个月时骨折椎体前缘高度、中部高度、Cobb角及椎管内骨块占位比例。[结果]术后患者症状迅速缓解,无神经损伤的并发症发生。4例患者少量骨水泥渗漏且无症状性并发症。患者VAS评分由术前8.2分降为术后2.8分(P0.05),术后12个月随访时维持在3.0分。ODI评分由术前的68.2%±6.6%改善为术后的35.3%±2.8%,术后12个月随访时仍能维持。椎体前缘高度从61.5%±13.9%纠正为术后的85.3%±10.6%(P0.05),中部高度由73.0%±19.3%纠正为83.3%±7.4%。Cobb角由术前的21.7°±7.8°改善为8.6°±6.6°。随访时椎体高度及Cobb角未见明显丢失。椎管内骨块占位率术前为20.1%±4.1%,而术后为17.8%±1.3%(P0.05)。[结论]椎体后凸成形术治疗无神经症状的骨质疏松性胸腰段爆裂性骨折是可行的,其疗效是满意的。骨水泥分次灌注及C型臂X线机动态观察技术可能有助于避免或减少骨水泥渗漏。     

改良后入路环椎管减压治疗胸腰椎爆裂骨折

目的探讨胸腰椎爆裂骨折的治疗方式.方法根据骨折类型不同,采用后入路不同方式的环椎管减压内固定术治疗胸腰椎爆裂骨折36例.结果36例平均随访26个月,术前后凸成角平均24°,术后平均10°;术前椎管狭窄率平均55%,术后平均10%.33例获得Frankel分级1～3级以上的改善.结论改良后入路环椎管减压内固定治疗胸腰椎爆裂骨折具有诸多优点,可做为治疗新鲜爆裂骨折的首选术式.