骶前减压骶孔成形术治疗陈旧性骶骨骨折合并骶丛神经损伤的疗效分析

目的探讨经腹直肌外侧入路骶前骶孔扩大成形、骶丛神经减压治疗陈旧性骶骨骨折合并骶丛神经损伤的方法及疗效。方法回顾性分析2013年1月至2018年6月南方医科大学第三附属医院骨科收治的11例陈旧性骶骨骨折合并骶丛神经损伤患者资料。男8例,女3例;年龄17~54岁,平均38岁;骶骨骨折按Denis分型均为Ⅱ区;神经损伤按英国医学研究会(BMRC)标准分级:完全损伤2例,部分损伤9例;受伤至手术时间0.7~12.0个月,平均6个月。经腹直肌外侧入路显露腰骶干及S1神经孔周围结构,直视下行骶孔扩大成形、松解骨折块及骨痂压迫的S1神经根及腰骶干,不稳定骶骨骨折者同时行复位内固定治疗。通过评价骨折愈合、神经功能恢复(BMRC标准)等观察疗效。结果本组11例患者中有10例顺利完成手术,1例因术中探查发现骶骨骨折完全愈合且S1神经孔完全闭塞,无法完成骶孔成形术而终止手术。手术时间70~220 min,平均110 min;术中出血量450~2800 mL,平均1100 mL。术后复查X线片、CT示骶孔扩大成形明显,无手术并发症发生。所有患者术后随访12个月至4年,平均18个月。所有患者末次随访时根据BMRC标准评价神经功能恢复情况:完全恢复5例,部分恢复4例,未恢复1例。结论经腹直肌外侧入路能较好地显露腰骶干及S1神经孔周围结构,直视下骶孔扩大成形、松解骨折块及骨痂压迫的S1神经根及腰骶干,是治疗陈旧性骶骨骨折合并骶丛神经损伤的一种可行的方法。

Anterior expansion of sacral foramen and decompression of sacral plexus via lateral-rectus approach for sacral fractures complicated with sacral plexus injury

Objective To evaluate the anterior expansion of sacral foramen and decompression of sacral plexus via the lateral-rectus approach(LRA)in the surgical treatment of sacral fractures complicated with sacral plexus injury.Methods From January 2013 to June 2018,11 patients were treated at Department of Orthopaedics,The Third Hospital Affiliated to Southern Medical University for obsolete sacral fractures complicated with sacral plexus injury.They were 8 males and 3 females,aged from 17 to 54 years(average,38 years).According to the Denis classification,all the sacral fractures belonged to Denis ZoneⅡ.According to British Medical Research Council(BMRC)grading system,the nerve injury was complete damage in 2 cases and partial damage in 9.The mean time from injury to surgery was 6 months(range,from 0.7 to 12.0 months).After the sacroiliac joint was exposed via the LRA,the lumbosacral trunk was exposed and released between iliac vessels and the iliopsoas.Next,the S1 foramen was expanded and the S1 nerve root was released after separation of the median sacral artery and the internal iliac artery.Reduction and fixation of the sacroiliac joint was carried out for patients with unstable sacral fracture.X-ray and CT examinations of the pelvis were performed to evaluate fracture healing and neurological function recovery postoperatively.Results Of this cohort of 11 cases,operation succeeded in 10 but failed in one whose sacral fracture was found to have completely healed with the S1 foramina totally occluded.The surgical time averaged 110 min(range,from 70 to 220 min)and the blood loss 1,100 mL(range,from 450 to 2,800 mL).Postoperative X-ray and CT examinations showed that the sacral foramens were expanded significantly without any complications.The follow-up time averaged 18 months(range,from 12 months to 4 years).By the BMRC grading system at the last follow-up,the neural function was completely recovered in 5 cases,partially recovered in 4 cases and not recovered in one.Conclusion Significant anterior expansion of sacral foramen and decompression of sacral plexus via the LRA is a viable and effective alternative for treatment of sacral fractures complicated with sacral plexus injury.