经后路椎体次全切除、钛网及椎弓根钉重建术治疗严重胸腰椎骨折

目的 探讨经后路椎体次全切除、钛网及椎弓根钉重建术治疗严重胸腰椎骨折的临床价值.方法 2006年1月至2007年8月,对36例严重胸腰椎骨折患者采用本术式治疗.按AO骨折分型,均为A3亚型;术前神经功能ASIA分级:A级8例,B级16例,C级8例,D级4例.手术采用后正中入路,显露伤椎及其上、下邻椎的椎板、关节突及椎弓根钉进钉点,在上、下邻椎内置入椎弓根钉,通过椎弓根内同定试行撑开复位或矫正脊柱序列,临时固定.切除伤椎椎板及相关的关节突间关节,切除一侧或双侧椎弓根内缘创建后外侧工作通道,然后通过后外侧工作通道用骨刀对伤椎进行适当的壳内次全切除,并将钛网置人伤椎椎体次全切除后的骨缺损区,透视满意后加压椎弓根钉使钛网牢固.通过比较术前、术后和随访时X线及CT片上Cobb角和骨块椎管占位比例来评价后凸畸形矫正情况、椎管减压程度及植骨融合情况.结果 术后随访12～24个月,平均18个月.所有患者在术后12个月时ASIA神经功能分级均有1级或1级以上的恢复.术后12个月时X线和CT片显示减压和复位效果满意.脊柱序列恢复正常,植骨融合率为97.3%.35例患者无继发性后凸畸形.1例患者出现钛网塌陷及后凸畸形.结论 经后路椎体次全切除、钛网及椎弓根钉重建术可结合前后路手术优势,一个切口一次完成减压、复位、固定、融合,重建三柱的稳定性;但尚须大宗病例的积累及长期随访验证.

Subtotal corpectomy with titanium mesh implantation and pedicle screw fixation by posterior approach for severe thoracic and lumbar fracture

Objective To analyze the results of subtotal corpectomy with titanium mesh implantation and pedicle screw fixation by posterior approach for severe thoracic and lumbar fracture.Methods From January 2006 to August 2007, 36 patients with severe thoracic and lumbar fracture were treated.According to AO classification, all patients were A3.According to ASIA, there were 8 cases for grade A, 16 cases for grade B, 8 cases for grade C, 4 cases for grade D.A posterior midline incision was taken for this surgery.The laminae of the injured vertebra and adjacent upper and lower vertebrae as well the facets and screw entry points were exposed.Then pedicle screws were put into the upper and lower vertebrae and a distraction reduction was tried to restore spinal alignment for temporary fixation.The lamina of the injured vertebra and relevant facet joints were resected.And also unilateral or bilateral medial part of pedicle was removed to build a posterolateral working pathway.Through this pathway a subtotal corpectomy was done and a titanium mesh with suitable size was implanted.The titanium mesh was fastened by compressing the pedicle screws after a satisfactory fluoroscopy.The efficacy of treatment was assessed by evaluation of the Cobb angle restoration and reduction of canal compromise.Results All these surgeries were performed successfully without any neurological deterioration.The 36 cases were followed up for 12 to 24 months (18 months on average).Neurological status of all patients improved at least 1 ASIA grade at 12 months postoperatively.35 patients obtained bony fusion.During follow-up, lumbar physical lordosis was reconstructed and no evident correction loss, fusion rate was 97.3%.One patient appeared titanium mesh sink and kyphosis recurrence.Conclusion One-stage combined anteroposterior surgery can be accomplished in a prone position.It was proved to be an effective treatment for severe thoracic and lumbar fracture.