上胸椎椎弓根螺钉固定并发症的探讨

目的分析上胸椎椎弓根螺钉固定的并发症,总结其手术技巧和经验。方法回顾性分析2009年4月至2012年4月采用T1~4椎弓根螺钉技术治疗的各类上胸椎损伤68例(共384枚螺钉),上胸椎骨折/脱位45例,均行Ⅰ期后路切开复位内固定术;结核合并后凸畸形23例,均行前路病灶清除植骨融合内固定术+后路矫形术。所有患者结合术中胸椎椎弓根四壁探查、术后手术节段椎体X线片、CT扫描,观察螺钉在椎弓根内的位置、角度及与椎弓根壁的关系和距离。结果椎弓根壁损伤54枚(14.06%),其中外侧壁损伤39枚(10.16%),包括Ⅰ级损伤27枚(7.03%),Ⅱ级损伤12枚(3.12%);内侧壁损伤15枚,均为Ⅰ级损伤。无1枚螺钉损伤上下壁,无1枚螺钉同时损伤超过2个壁,无术中置钉失败,螺钉松动位移2枚,创伤患者Frankel分级无加重,非创伤患者脊髓功能JOA评分由术前的5.9分提高至术后的11.5分,未发现植骨不融合、假关节形成或节段不稳表现。结论上胸椎椎弓根螺钉固定的并发症发生率低,是相对安全的操作方法。术前详细分析影像学资料、熟悉局部解剖特点、掌握合理的置钉技术,可有效避免并发症的发生。

Investigation of the Complications Associated with Thoracic Pedicle Screws

Objective To analyze the complications of upper thoracic pedicle screw fixation in treatment of the upper thoracic spine disorders and the operative technique. Methods 68 cases with upper thoracic injury（384 screws in total）and 45 cases with upper thoracic fracture/ dislocation treated by using T1 ～4 pedicle screws from April 2009 to April 2012 were retrospectively analyzed and all above cases underwent Ⅰ stage posterior open reduction plus internal fixation;23 cases with tuberculosis and kyphosis underwent anterior debridement with autograft bone fusion plus internal fixation and posterior orthomorphia. Intraoperative probing and postoperative vertebral X-ray and CT scanning were taken to observe the location,angle of pedicle screw in thoracic spine,as well as its relation and distance with thoracic spine walls. Frankel grading and JOA scoring were determined for all patients pre and postoperatively. Results There were 54 pedicle screw（14. 06%）induced thoracic spinal wall injury. Of them,39 were lateral wall injuries（10. 16%）,including 27 grade Ⅰ injuries（7. 03%）and 12 grade Ⅱ injuries（ 3. 12%）;15 medial wall injuries and all of them were grade Ⅰ injuries. No pedicle screw involving upper and lower wall injuries was observed;no pedicle screw induced injuries involving more than two walls was observed. All pedicle screws were successfully placed;loosening and dislocation were observed in two pedicle screws. Frankel grading showed no worsening in traumatic patients and JOA score for spine marrow functioning increased from preoperative 5. 9 to postoperative 11. 5 in nontraumatic patients;failure of fusion of planted bones,formation of pseudoarticulation or signs of segmental instability were not observed. Conclusion Upper thoracic pedicle screw fixation has relatively low incidence of complications and is a safe operation. Complications can be minimized by sufficient preoperative image studies of the pedicles,familiar with the feature of structure and reasonable surgery technique.