陈旧性DenisⅡ型骶骨骨折合并骶神经损伤的诊断与治疗

The diagnosis and surgical treatment of sacral fracture (Denis Ⅱ fracture) with sacral neurological damage

目的探讨陈旧性DenisⅡ型骶骨骨折合并骶神经损伤的诊断及手术方法.方法取60具骶骨干标本及26具完整骨盆标本,测量S1棘突与S1后孔间位置关系、骶前区血管、骶神经及梨状肌之间关系.对14例陈旧性DenisⅡ型骶骨骨折合并骶神经损伤患者,在常规骨盆X线片、CT、螺旋CT三维重建的同时,又采用显示骶神经全长的骶骨斜冠状位MR扫描,观察神经走向及毗邻关系.11例行自行设计的后路骶神经管扩大减压术,3例行非手术治疗.结果S1棘突位于S1后孔中上1/3者占90%.骶前区主要血管有骶外侧动静脉和骶外侧血管、骶正中血管及臀上血管进入骶前孔的分支.血管位于骶丛神经腹侧,骶外侧血管距离S1前孔大于10 mm,S2前孔大于5 mm.骶骨斜冠状位MR扫描可以显示骶神经全长及周围毗邻关系.骶神经损伤时,发现有神经根走行改变(13例),损伤处神经根周围脂肪消失(11例),神经根管狭窄(10例).14例均获得随访,随访时间6～12个月,平均7.1个月.术后改善情况:优9例,良1例,无变化1例.结论螺旋CT三维重建及骶骨斜冠状位MR扫描对于骶神经损伤的定位及定性诊断有重要价值.后路骶神经管扩大减压术是针对骶神经管、骶前孔处神经损伤的较理想手术方法.

Objective To explore the diagnosis and the surgical treament of scaral fracture (Denis II). Methods The blood vessels, sacral nerve of presacral region and piriformis,S1 spinous process and S1 posterior sacral foramina were observed and measured on 26 adult cadaveric specimens and 60 adult sacrals. From 1999 to 2003, 14 cases of the sacral fracture with sacral neurological damage were treated. All pa-tients accepted instrument examination including X-ray, CT, three-dimensional CT and oblique coronal MR of secrum. Posterior approach enlargement for sacral nerve canal-a new surgical procedure to Denis Ⅱ sacral fracture was used in 11 cases. No surgical treament in 3 cases. The BMRC score were used to evalu-ate the results. Results There was 90% of inferior borde of S 1 spinous process run parallel with middle of S 1 posterior foramina. The blood vessels of presacral region include lateral sacral artery, superior gluteal artery sacralis mediana artery and the anastomotic vessels between lateral sacral artery to superior gluteal artery, to sacralis mediana artery. Those vessels were located in ventral plexus never. The distance between major vessels stream to S 1 foramina >10 mm, to S 2 foramina >5 mm. Oblique coronal MR of secrum could show the full length of sacral never. There were some primiral espression of MR of sacral neurological dam-age -- the variation of sacral never canal, the fatty disappearance of peri-never, the route alteration of never. 14 patients were followed up from 6 to 12 months with an average of 7.1 months. According to the BMRC score system the excellent result was obtained in 9 cases, good in 1 case, no change in 1 case. Con-clusion Clinic history and neurological examination associated with X-ray, CT and MRI was the important of the diagnosis of sacral neurological damage, the new surgical approach may be a ideal approach to treat sacral neurological damage in the sacral nerve canal region.