椎旁肌间隙入路经伤椎强化内固定治疗老年胸腰椎骨折

目的:探讨椎旁肌间隙入路经伤椎强化内固定治疗老年胸腰椎骨折的安全性及临床疗效。方法:2007年8月至2010年8月,采用椎旁肌间隙入路经伤椎强化内固定治疗22例老年胸腰椎骨折患者,其中男14例,女8例;年龄60～71岁,平均64.6岁;受伤至手术时间1～4d,平均2.7d。均为单节段骨折,其中T112例,T125例,L111例,L24例。依据Denis骨折分型:压缩性骨折6例,爆裂性骨折16例。胸腰椎损伤分类及严重度评分系统评分(TLICS)4～9分,平均5.2分;Load-sharing评分为4～6分,平均5.4分。神经功能按ASIA分级:B级2例,C级3例,D级7例,E级10例。通过侧位X线片对手术前后的伤椎Cobb角、椎体前缘压缩百分比、椎体中央压缩百分比进行比较;通过视觉模拟评分(VAS)及ASIA标准对手术前后疼痛和脊髓神经功能进行评定。结果:手术时间50～95min,平均60.8min;术中出血量50～130ml,平均84ml;患者切口均Ⅰ期愈合。所有病例获得随访,时间12～48个月,平均21.6个月。伤椎Cobb角由术前的(19.5±9.5)°矫正至术后的(4.3±4.1)°,末次随访时的(6.2±4.7)°;椎体前缘压缩百分比由术前的(52.3±10.3)%恢复至术后的(6.1±4.2)%,末次随访时的(6.8±5.4)%;椎体中央压缩百分比由术前的(38.9±11.2)%恢复至术后的(8.3±4.7)%,末次随访时的(9.4±4.5)%。VAS评分由术前的(8.56±0.88)分恢复至术后的(3.48±0.91)分,末次随访时的(3.20±0.92)分。脊髓神经功能除10例E级无变化外,其余均有1～2级的恢复。所有病例未发现内固定失效及腰背部疼痛症状。结论:经椎旁肌间隙入路经伤椎强化内固定手术时间短、出血少,明显减低了手术创伤导致的椎旁肌的退变和术后腰背痛的发生率,可有效改善神经功能及维持矫正效果,大大降低内固定失效率。

Pedicle screw at the fracture level and vertebroplasty via paraspinal approach for the treatment of old thoracolumbar fractures

Objective:To investigate the feasibility and safety of the treatment for thoracolumbar fractures with pedicle screw at the fracture level and vertebroplasty via paraspinal approach. Methods:From August 2007 to August 2010,22 old patients with thoracolumbar fractures were treated with pedicle screw at the fracture level and vertebroplasty via paraspinal approach. There were 14 males and 8 females,ranging in age from 60 to 71 years (mean,64.6 years). The time from injury to surgery varied from l to 4 d(mean,2.7 d). All the patients suffered from single thoracolumbar fractures and located at T₁₁ in 2 cases,at T₁₂ in 5 cases,at L₁ in 11 cases and at L₂ in 4 cases. According to the Denis fracture classification,there were 6 compression fractures and 16 burst fractures. The mean preoperative load-sharing classification of spine fractures was 5.4 score. The mean preoperative thoracolumbar injury classification and scoring was 5.2. Based on the ASIA neurologic grading system,preoperative neurological function was grade B in 2 cases,grade C in 3 cases,grade D in 7 cases and grade E in 10 cases. The neurological function,vertebral central and anterior height,kyphotic angle of the vertebral fractures by radiographs and visual analog scale were calculated pre-operatively,post-operatively and at the last follow-up. Results:Median operating time was 60.8 min (ranged from 50 to 95 min) and median blood loss was 84 ml(ranged from 50 to 130 ml). The operative incisions were healed well. The duration of follow-up averaged 21.6 months(ranged from 12 to 48 months). The anterior vertebral body height was corrected from preoperative (52.3±10.3)% to postoperative (6.1±4.2)% and (6.8±5.4)% at the last follow-up. The central vertebral body height was corrected from preoperative (38.9±11.2)% to postoperative (8.3±4.7)% and (9.4±4.5)% at the last follow-up. The Cobbs angle of the injured vertebral segment was corrected from preoperative (19.5±9.5)° to postoperative (4.3±4.1)° and (6.2±4.7)° at the last follow-up. The VAS scores reduced from preoperative 8.56±0.88 to postoperative 3.48±0.91 and 3.20±0.92 at the last follow-up. The postoperative neurologic function of all 22 patients improved 1 to 2 degrees except 10 patients of grade E. There were no instances of instrumentation failure and no patient had persistent postoperative back pain. Conclusion:The pedicle screw at the fracture level and vertebroplasty via paraspinal approach has the advantages of less invasive and blood loss,and could prevent the development of kyphosis and offers improvement of the spinal cord function. Furthermore,it could decrease the risks of postoperative back pain and the failure of instrumentation.