一期同体位前后联合入路手术治疗严重胸腰椎骨折脱位

Lateral position one-stage combined anteroposterior surgery for serious thoracolumbar fracture dislocation

目的探讨一期同体位前后联合入路手术治疗严重胸腰椎骨折脱位的治疗效果。方法1998年10月至2005年9月手术治疗胸腰椎骨折脱位192例,对其中34例严重胸腰椎骨折脱位者采用一期同体位前后联合入路。男25例,女9例;年龄18￣56岁,平均34.2岁。损伤节段:T112例,T125例,L111例,L28例,L35例,L42例,L4,51例。Magerl分型:A3型12例,B1型2例,B2型2例,C1型12例,C2型4例,C3型2例;ASIA分级:A级7例,B级10例,C级8例,D级6例,E级3例。有神经根损伤症状3例。患者取侧卧位,先行后路椎板减压,椎弓根钉系统临时固定。同体位下再行损伤节段的前路减压支撑植骨,对于骨折脱位者前后协同复位。复位满意及减压彻底后,后路椎弓根钉系统适度加压抱紧前侧支撑植骨,一次完成减压、复位与固定,重建三柱稳定性。结果手术时间180～320min,平均230min。出血量900～2400ml,平均1200ml。术前不完全性神经损伤的24例患者术后神经功能均恢复1级或1级以上。6例出现肋间神经损伤症状,保守治疗后好转。32例随访6￣60个月,平均13个月。X线和CT片显示减压和复位效果满意,与术后比较伤椎高度无明显丢失,内固定未见断裂及松动。结论一期同体位前后联合入路可充分发挥前路与后路手术各自的优势,一次完成减压、复位与固定,为严重胸腰椎骨折脱位提供了一种有效的治疗方法。但手术技术要求较高,应严格掌握手术适应证。

Objective To analyze the results of one-stage combined anteroposterior surgery in lateral position for serious thoracolumbar fracture dislocation. Methods A retrospective review was performed for surgically treated thoracolumbar fractures from October 1998 to September 2005. Of all the 192 patients, the 34 serious cases were treated with one-stage combined anteroposterior surgery. There were 25 males and 9 females, 34.2 years old on the average （ranging from 18 to 56 years）. Segments involved： T11 in 2 cases, T12 in 5 cases, L1 in 11 cases, L2 in 8 cases, L3 in 5 cases, L4 in 2 cases and L4.5 in 1 case. According to the Classification of Magerl, there were 12 cases of type A3, 2 cases of B1, 2 cases of B2, 12 cases of C1, 4 cases of C2 and 2 cases of C3. During the operation the patients were in lateral position. Laminectomy and pedical screw insertion were performed posteriorly first; anterior corpectomy, reduction and strut graft were accomplished through an additional anterior approach. The final fixation was finished by clapping the strut graft with pedical screw system. Operative notes, preoperative and postoperative neurological status, ASIA scales, radiographs, CT scans, and follow-up records were reviewed. Results All these surgeries were performed successfully without any neurological deterioration. 32 of 34 patients were followed-up for 6 to 60 months （13 months on average）. Neurological status improved at least 1 ASIA grade in 24 patients with preoperative incomplete paraplegia. 6 patients complained intercostals nerve injury symptom which alleviated with conservative treatment. During follow-up, lumbar physical lordosis was reconstructed and no evident correction loss, pseudoarthrosis or implant failure was noted. Conclusion One-stage combined anteroposterior surgery can be accomplished in a lateral position. It was proved to be an effective treatment for serious thoracolumbar fracture dislocation.