胸腰椎爆裂骨折手术入路的选择

The choice and evaluation of anterior, posterior or combined surgery for thoracolumbar burst fractures

目的分析前路、后路和前后联合入路手术治疗胸腰椎爆裂骨折的疗效及适应证.方法回顾性分析1998年10月～2003年10月手术治疗的胸腰椎爆裂骨折89例,男76例,女13例;年龄17～51岁,平均36.8岁.骨折节段:T11 10例,T12 21例,L1 29例,L2 18例,L3 11例.骨折Magerl分型:A型68例,C型21例.采用后路手术41例,前路手术40例,前后联合入路8例.采用ASIA标准评定神经功能恢复情况,通过影像学检查比较伤椎和Cobb角的矫正及丢失,评估椎管减压范围、植骨块位置及愈合情况.结果78例随访6～48个月,平均12个月.术前不完全性神经损伤的65例患者神经功能恢复1级或1级以上.后路手术组出现椎弓根钉断裂2例,伤口深部感染1例;术后伤椎前缘高度和Cobb角平均矫正9.4 mm和14.8°,术后6个月分别丢失0.5 mm和7.5°.前路手术组因硬脊膜损伤未修补出现脑脊液漏2例,伤口深部感染2例;前后联合入路未发生并发症.前路和前后联合入路组术后脊柱序列和生理曲度基本恢复正常,椎管腔扩大,植骨块位于椎体前中部;随访时未见明显的矫正度丢失、假关节形成和内固定失败.结论胸腰椎爆裂骨折术式的选择取决于脊柱稳定性及神经损伤情况.具体应根据伤椎椎体压缩程度、椎管内骨性占位程度、是否伴有脊柱后柱结构不稳或骨折脱位来决定.

Objective To analyze the results and indications of anterior, posterior or combined surgery for thoracolumbar burst fractures. Methods A retrospective review of surgically managed thoracolumbar burst fractures from 1998 to 2003 was performed. There were 76 males and 13 females, and the age of the patients were from 17 to 51 years with an average of 36.8 years. The fractures were located at T11 in 10, T12 in 21, L1 in 29, L2 in 18 and L3 in 11. According to Magerl classification, type A fractures were 68, and type C were 21. Of the 89 patients, 41 received posterior surgeries, 40 anterior surgeries, and 8 combined anterior and posterior surgeries. Operative notes, preoperative and postoperative neurological status, radiographs, CT scans, and follow-up records were reviewed. Results All of the 89 cases had successful surgery. Seventy-eight patients were followed-up for 6 to 48 months (average 12 months). Neurological status improved at least 1 ASIA grade in all of the 65 patients who had preoperative incomplete paraplegia. In the posterior surgeries, pedicle screws broken in 2 cases, deep infection in 1 case which was cured after debridement. The correction of anterior vertebral body height and Cobb's angle averaged 9.4 mm and 14.8° postoperatively, and the correction loss averaged 0.5 mm and 7.5° respectively at 6 months after surgery. And the correction loss was most evident at the above disc spaces, then the below disc spaces. In the anterior surgeries, leakage of cerebrospinal fluid in 2 cases which cured with dressing change, the other cured after debridement, implant removal and posterior fixation. The spinal canal was enlarged, and the spine recovered normal curvature. No evident correction loss, pseudoarthrosis or implant failure was noted at follow-up. Conclusion The choice of anterior, posterior or combined surgery for thoracolumbar burst fractures depends on neurological status and column stability. The vertebral compression, canal encroachment, posterior column stability and concomitant displacement should be considered in the choice of appreciate surgical approach.