胸腰椎骨折分类研究进展

胸腰椎骨折分类与临床治疗密不可分,以往经典的胸腰椎骨折分类系统存在诸多不足。胸腰椎损伤严重度评分系统（TuSS）和胸腰椎损伤分类及严重度评分系统（TLKs）将骨折与神经功能状态相结合,对胸腰椎骨折进行综合评价,具有全面性及较高的可信度和可重复性,是目前最为可靠的分类评分系统。     

胸腰椎骨折分类研究进展

胸腰椎骨折分类与临床治疗密不可分,以往经典的胸腰椎骨折分类系统存在诸多不足。胸腰椎损伤严重度评分系统(TLISS)和胸腰椎损伤分类及严重度评分系统(TLICS)将骨折与神经功能状态相结合,对胸腰椎骨折进行综合评价,具有全面性及较高的可信度和可重复性,是目前最为可靠的分类评分系统。     

胸腰椎骨折分类的若干问题

一、胸腰椎骨折分类的历史和现状Ｎｉｃｏｌｌ[1] 在 1949年将胸腰椎骨折分为 4型 :前方楔形骨折 ;侧方楔形骨折 ;骨折脱位 ;椎弓骨折。然后根据棘间韧带是否完整及骨折的位置判断其稳定性。其中稳定性骨折分为前方楔形骨折、侧方楔形骨折和腰 4以上的椎板骨折 ;不稳定性骨折分为复合棘间韧带损伤的所有半脱位的骨折、骨折脱位、椎弓骨折和腰 4(Ｌ4 )、腰 5 (Ｌ5)的椎板骨折。196 3年 ,Ｈｏｌｄｓｗｏｒｔｈ[2 ] 提出双柱概念 ,即 :前纵韧带、椎体及其椎间盘和后纵韧带为前柱 ,椎后复合结构为后柱。并根据后柱受损与否将胸腰椎骨折分为两大…     

胸腰椎骨折分类及治疗研究新进展

随着现代工业、交通运输业的蓬勃发展,意外事故发生率随之上升,各种创伤性疾病明显增多,特别是脊柱骨折及脊髓损伤。脊柱脊髓损伤后果严重,且其损伤机制复杂,这就给诊断和治疗带来了很大的挑战。一直以来,国内外学者试图搞清其损伤机制,制定出合理的损伤分型及治疗方案。自从Bohler首次提出脊柱损伤分型概念以来,对脊柱损伤分类及治疗相关研究已取得了很大的进步,然而目前仍无一种被广泛接受而又非常实用的方法。本文综合国内外相关文献,对胸腰椎骨折的分类及治疗进展作一综述。     

AF系统治疗胸腰椎骨折的临床观察

AF系统为具有多重矫正力的内固定系统，同时具备AO与RF两系统的优点。我科自1999年2月～2000年12月应用AF系统治疗胸腰椎骨折24例，取得一定疗效，报告如下。     

两种微创椎弓根螺钉系统治疗胸腰椎骨折的临床疗效比较研究

目的通过对120例患者行两种不同微创椎弓根螺钉系统治疗胸腰椎骨折的临床疗效进行比较,评价其价值。方法选取2012年1月至2013年12月本院收治的无神经损伤症状的胸腰椎骨折患者120例,随机分为观察组（Can-Help）和对照组（Sextant）。其中观察组60例,男性31例,女性29例。对照组60例,男性28例,女性32例。分别行不同微创椎弓根螺钉系统手术治疗,术后随访观察两组患者临床结果及影像学数据。结果对所有病例行8~20个月随访,平均15.39±1.87个月。术后2周及末次随访测量Cobb角,观察组分别为（2.96°±1.68°）、（4.28°±2.91°）,对照组分别为（5.07°±4.46°）、（6.56°±1.58°）。术前、术后2周及末次随访时VAS评分,观察组分别为（2.41±0.54）、（1.03±0.68）,对照组分别为（2.53±0.84）、（1.67±1.16）。术后2周和末次随访ODI评分,观察组分别为（41.97±2.74）、（17.69±4.31）,对照组分别为（40.45±1.58）、（19.37±5.36）。比较发现,观察组末次随访VAS评分较低,ODI评分结果改善更加明显。结论 Can-Help系统治疗无神经损伤的胸腰椎骨折较Sextant系统能更有效缩短术中X线暴露及手术时间,具有更好矫正后凸畸形及防止矫正丢失能力,对于治疗胸腰椎骨折更加有有效。     

AF系统治疗胸腰椎骨折

目的总结AF系统治疗胸腰椎骨折的经验。方法使用AF系统内固定加植骨治疗胸腰椎骨折54例。结果术后12～24个月随访，脊柱生理弯曲，椎体前缘高度恢复理想，未见脊柱失稳，21例有Frankel分级一级以上的改善。结论AF系统结构简单，操作方便，固定坚固，重建了脊柱的生理弯曲，椎体高度，后路植骨可有效保持后柱稳定，为脊髓神经功能恢复和日后护理创造条件。     

胸腰椎骨折的分类系统及手术治疗研究进展

<正>随着生活节奏的加快、交通运输方式的多样化,脊柱骨折的发生率也越来越高,在全身骨折中脊柱骨折占5%~6%[1,2],而脊柱骨折中又以胸腰椎骨折最常见,约占40%[3],并呈逐年递增趋势。胸腰椎是指T10~L2脊椎,此处系两个生理弧度交界处,应力较集中,活动度较大区域,因此胸腰椎骨折最为常见。胸腰椎骨折不仅可以造成脊柱序列稳定性破坏,而且可以压迫脊髓,造成脊髓神经损伤,目前在诊疗过程中对于判断胸腰椎骨折的类型、手术适应证以及     

后路钉棒内固定治疗胸腰椎骨折的临床疗效分析

目的 探讨应用后路钉棒内固定系统治疗胸腰椎骨折的临床效果。方法 自2009年1月至2010年12月,我科采用后路钉棒内固定系统联合或不联合椎管减压植骨融合治疗胸腰椎骨折33例,其中,男21例,女12例,年龄21～57岁,平均37.5岁。根据术前脊髓神经损伤Frankel评定分级：A级1例,B级2例,C级2例,D级10例,E级18例,术前Cobb角为23.40±1.64°,椎体平均高度前缘32.02±2.99% 和后缘78.27±1.65%。结果 本组平均手术时间为3.9h（3～5h）,平均出血量为495mL（200～800mL）,术后发生未伤口感染、血肿或其他严重并发症。经术后X线照片检查,未发现内固定材料断裂、松动以及胸腰椎骨折、移位。随访6～24个月,术后Cobb角为3.15±1.64°,椎体平均高度恢复到术后的前缘（90.15±1.72）%和后缘（98.09±1.14）%。神经功能恢复：A级1例,B级0例,C级1例,D级2例,E级29例。结论 后路钉棒系统手术相对简单、操作方便、固定可靠,是胸腰椎骨折的一种有效治疗方法。     

AF系统治疗胸腰椎骨折合并截瘫临床疗效

目的 评价AF系统治疗胸腰椎骨折合并截瘫的临床效果。方法 分析43例应用后路Luque、Dick、AF内固定治疗胸腰椎骨折合并截瘫患者术前、术后及随访时椎体前缘高度变化、Cobb‘角的纠正程度及截瘫指数恢复程度相比较。结果 AF系统在改善椎体前缘高度、Cobb‘角的纠正程度及神经功能恢复方面均优于Luque、Dick。结论 AF系统是治疗胸腰椎爆裂骨折合并截瘫和减少并发症的有效方法。     

胸腰段结核的手术治疗

目的：探讨胸腰段结核的手术治疗,以提高胸腰段结核的手术治愈率。方法：１９９１年１月至１９９９年１月,我院共实施胸腰段结核手术３４例,其中前路病灶清除兼椎间植骨融合术３２例,后路病灶清除并横突间植骨融合术２例。结果：术后对所有病人进行了０．５￣６．５年,平均３．５年的随访,手术优良率为９４．１％。结论：多数胸腰段结核适合于前路病灶清除术Ⅰ期椎间植骨融合术,部分可以选用后路病灶清除并Ⅰ期横突间植骨融合     

以棘突定位胸腰椎经椎弓根内固定的应用解剖学研究及意义

目的 研究胸腰椎棘突与椎弓根的解剖关系,提供相关数据为椎弓根穿钉确定一种新的解剖定位点。方法 测量30具正常成人尸体的干燥胸腰椎标本,80个正常成人胸腰椎X线片及60人胸腰椎CT片(T_(10)～L_5节段)之棘突上缘根部至椎弓根上缘、下缘及中轴线的距离。用5具新鲜尸体做实验室手术模拟。结果 获得了相关解剖学数据,据所得数据设计螺钉入点。实验室80个螺钉全部穿钉成功,并成功临床应用6例。结论 该研究揭示了棘突与椎弓根的解剖关系,为经椎弓根手术提供了一种新的解剖学定位方法。     

USS通用脊柱系统在胸腰椎骨折治疗中的应用

目的　介绍和总结USS通用脊柱固定系统在胸腰椎骨折中的应用经验。方法　应用SYNTHES产品USS通用脊柱系统治疗胸腰椎骨折 2 1例。其T10 2例 ,T112例 ,T12 5例 ,L14例 ,L2 3例 ,L3 3例 ,L42例。分别行后路减压 ,伤椎上下各 2个椎体共四组椎弓根螺钉复位内固定 ,小关节突及横突间植骨融合。结果　 2 1例均获随访 ,时间 6～ 18个月 ,骨折均愈合 ,18例椎体高度完全恢复。 3例残留 10 %～ 2 5 %的压缩未能恢复。 2 0例植骨融合良好。无内固定松动现象。结论　USS系统操作简便 ,固定可靠 ,骨折复位和胸腰椎正常弧度可以分步骤一次完成。重建的脊柱稳定性好 ,可早期下床活动     

Treatment of Patients with Unstable Fractures of the Thoracic and Lumbar Spine: A Follow-up Study of Surgical and Conservative Treatment

A follow-up study was made to compare the effect of surgical reduction and stabilization of unstable vertebral fractures with the results of conservative treatment. Twenty patients treated by conservative methods and 18 patients subjected to surgical stabilization were analyzed with respect to period of immobilization, healing time, degree of residual deformity, neurological restitution and incidence of complications. The wide variety of initial impairment did not permit any definite conclusions with regard to neurological restitution. In all other respects, however, surgical stabilization produced better results as reflected by shorter periods of immobilization, hospitalization and rehabilitation, less residual deformity, and a lower incidence of complications. It may be concluded therefore that surgical treatment of unstable vertebral fractures may be of benefit to both patients and society.     

原发性胸腰椎肿瘤的CT诊断和治疗

本文报告了９例原发性胸腰椎肿瘤，术前均经ＣＴ检查，并经病理证实，采取侧前方手术切除肿瘤２例，后路减压、肿瘤部分切除４例，单纯化疗２例，手术结合放疗４例。通过３月～３．５年的随访，作者认为ＣＴ对其诊断和治疗选择有着极重要的作用，手术的选择应依肿瘤侵犯的程度、范围及脊椎的部位而采用前和／或后路手术切除肿瘤、固定术，为提高术后疗效，必要时应辅以化疗或放疗。     

Pedicle Morphology of Lower Thoracic and Lumbar Spine in Ankylosing Spondylitis Patients with Thoracolumbar Kyphosis: A Comparison with Fracture Patients

ObjectiveThe pedicle morphology of ankylosing spondylitis (AS)‐related thoracolumbar kyphosis patients may be different from that of individuals with normal spine due to the ectopic ossification and kyphotic deformity. However, there was no literature analyzing the pedicle morphology of AS patients with thoracolumbar kyphosis. Therefore, the present study aimed to investigate the pedicle morphology of lower thoracic and lumbar spine (T9‐L5) in ankylosing spondylitis (AS)‐related thoracolumbar kyphosis patients.MethodsA retrospective review of AS patients with thoracolumbar kyphosis (AS group) and the patients with spinal or rib fracture (fracture group) who underwent CT scans of the lower thoracic and lumbar spine between February 2017 and September 2018 was performed. Patients with spinal tumor, spinal tuberculosis, severe degenerative spinal diseases including degenerative scoliosis, degenerative spondylolisthesis, degenerative spinal stenosis or history of previous spine surgery, or AS patients with pseudarthrosis which influenced the measurement of pedicle parameters were excluded. The measured parameters on CT images included transverse pedicle angle (TPA), transverse pedicle width (TPW), chord length (CL), pedicle length (PL), and sagittal pedicle angle (SPA). The intraclass correlation coefficient (ICC) was used to evaluate the agreement of radiographic parameters between observers. The independent sample t test was applied for the comparison of pedicle parameters between the two groups. The gender distribution between the two groups were compared using the Fisher''s exact test.ResultsA total of 1444 pedicles of 53 AS‐related thoracolumbar kyphosis patients and 30 patients with fracture were analyzed. TPA was significantly smaller in AS group (p < 0.05). Significantly larger TPW was found in AS group in the lumbar spine (p < 0.05). TPW ≥ 7.5 mm was observed in 95.3%–98.1% of the pedicles at the levels of L3‐L5 in AS group. The CL and PL were significantly larger in AS group at the levels of T9‐L5 (p < 0.05). The CL ≥ 50 mm was found in 84.0%–96.2% of the pedicles in mid‐to‐lower lumbar spine in AS group. Significantly smaller SPA was found in AS group at the levels from L3 to L5 (p < 0.05).ConclusionsPedicle screws with relatively large diameter of 7.5 mm and length of 50 mm could be used in mid‐to‐lower lumbar spine in the majority of AS‐related thoracolumbar kyphosis patients. Also, the insertion angle of pedicle screws in both the transverse and sagittal plane should be appropriately reduced in these patients. This study may help surgeons select the pedicle screws of appropriate size in AS patients.     

椎旁肌间隙入路内固定治疗胸腰段椎体骨折

目的探讨经多裂肌及最长肌肌间隙入路（以下简称肌间隙入路）和传统后正中入路钉棒系统内固定治疗胸腰段椎体骨折临床疗效比较。方法回顾2006年8月至2010年3月经后路钉棒系统撑开复位内固定治疗56例无神经症状胸腰段椎体骨折患者,其中采用肌间隙入路30例,男17例,女13例,年龄30～60岁,平均40．7岁;传统椎旁肌剥离人路26例,男19例,女7例,年龄24～54岁,平均3Q．2岁。记录两组患者手术时间和出血量,测定两组患者术前术后胸腰段后凸畸形Cobb角,对相关临床数据进行统计学分析。结果所有患者均获得随访,术后随访时间18～24个月,平均19个月,肌间隙入路手术时间短,出血少,两组患者术前术后Cobb角差异有统计学意义,临床疗效相同。结论肌间隙入路钉棒系统内固定治疗无神经症状的胸腰段椎体骨折具有置钉方便、手术时间短,创伤小、出血少、并发症少、恢复快等优点,临床疗效满意。     

椎弓根系统内固定同期前路植骨治疗胸腰椎结核

目的　探讨应用椎弓根系统内固定同期前路植骨融合术治疗胸腰椎结核的临床效果。方法　 1998年 2月至2 0 0 3年 2月采用后路椎弓根系统内固定同期前路植骨融合的胸腰椎结核患者 36例 ,包括植骨融合率 ,截瘫恢复情况和后凸畸形矫正情况。随访时间 1～ 4 a,平均 2 .6 a。结果　所有患者均显示骨性融合 ,融合时间平均 7.9个月 ;2 4例合并截瘫患者中 ,症状改善 2 2例 ,改善率 91.7% ;术后后凸畸形平均矫正 2 9.4°,1～ 4 a后随访 ,后凸角度平均丢失 2 .1°。结论　后路椎弓根系统内固定同期前路植骨融合能加强脊柱的稳定性 ,促进骨融合和截瘫恢复 ,矫正后凸畸形。     

Choice of Lumbar Spine Bone Density Reference Database for Fracture Prediction in Men and Women: A Population-Based Analysis

The diagnosis of osteoporosis in men is controversial, although most studies demonstrate similar fracture rates for men and women with the same level of hip bone mineral density (BMD). Whether this applies to the lumbar spine is currently uncertain and has important implications with respect to choice of reference population for T-score calculation and osteoporosis diagnosis. This question was specifically addressed in the population-based Canadian Multicentre Osteoporosis Study cohort of 4745 women and 1887 men ages 50+ yr at the time of baseline lumbar spine dual energy x-ray absorptiometry. In up to 10 yr of observation, incident clinical major osteoporotic fractures occurred in 110 men (5.8%) vs 543 women (11.4%) (p < 0.001). Mean lumbar spine BMD in men was greater than in women, both among those with and those without incident major osteoporotic fracture (p < 0.001). Men were at slightly lower risk for incident major osteoporotic fracture than women for an equivalent lumbar spine BMD (age- and BMD-adjusted rate ratio 0.75, 95% confidence interval 0.60–0.93, p = 0.008) with similar findings after adjustment for the World Health Organization fracture risk assessment clinical risk factors or competing mortality. No significant sex difference in the BMD relationship was seen for vertebral fractures (clinical or radiographic) or for all fractures. In summary, this large population-based longitudinal cohort study found similar or lower fracture risk for men vs women after adjustment for absolute lumbar spine BMD and additional covariates. The least complicated model for describing fracture risk is therefore to use the same reference lumbar spine data for generating T-scores in men and women.     

单侧经椎间孔腰椎间融合术在退变性腰椎疾病中的应用

目的探讨单侧经椎间孔腰椎间融合术(TLIF)在退变性腰椎疾病的应用。方法采用TLIF治疗退变性腰椎疾病89例。结果术后随访6～24个月,平均15个月,骨融合率为100%。疗效评定按日本骨科学会(JOA)下腰痛评分15分法评定,术前平均3.6分,术后平均13.8分,随访结果采用改善率表示,术后平均改善率89.47%。优级改善率75%～100%共71例(79.78%),良级改善率50%～74%(11例),可级改善率25%～49%(7例)。本组优良率92.13%。结论TLIF治疗退变性腰椎疾病,融合率高,可早期康复。