经骨折椎椎弓根直接复位固定治疗胸腰椎爆裂性骨折

Treatment of thoracolumbar burst fractures with direct reduction and fixation through the pedicle of fractured vertebra

目的探讨胸腰椎爆裂性骨折经骨折椎椎弓根直接复位固定的可行性及原理。方法2001年6月～2005年11月手术治疗胸腰椎单节段爆裂性骨折患者24例,男16例,女8例；平均年龄32．5岁。骨折部位：T_(11) 2例,T_(12) 9例,L_1 11例,L_2 2例。按ASIA脊髓神经功能障碍分级标准：A级1例,B级2例,C级5例,D级3例,E级13例。按椎管阻塞面积分为4度：Ⅰ度3例,Ⅱ度9例,Ⅲ度10例,Ⅳ度2例。手术方法：骨折椎及相邻的上、下椎体经椎弓根置入螺钉后,按固定区的正常矢状面形态将棒预弯；旋转预弯棒,利用中间螺钉作为支点,将骨折椎向前推顶,纠正伤椎后突畸形及水平移位；上、下椎弓根钉撑开,行后外侧植骨。结果所有患者获得3～34个月(平均21个月)随访,伤椎高度恢复至正常的93．6%,水平移位恢复至正常的0．6%,矢状面Cobb角由术前26．5°恢复至术后的3．1°。椎管面积由术前的44．6%增加至术后的92．1%。骨折椎体愈合满意,不完全神经损伤手术后脊髓神经功能有1～2级的恢复。无神经损伤及加重等并发症。结论经骨折椎椎弓根螺钉固定是安全可靠的方法；对骨折直接复位和固定可提高复位质量,改善固定强度及应力分布。

Objective To evaluate the feasibility and principle of direct reduction and fixation through the pedicle of fractured vertebra in treatment of thoracolumbar burst fractures. Methods Between June 2001 and November 2005, 24 cases of one level thoracolumbar burst fracture, 16 males and eight females, were treated in our department. Their average age was 32. 5 years old. The fractured vertebrae were as follows： T11 in two cases, T12 in nine cases, L1 in 11 cases and L2 in two cases. According to the ASIA （American Spinal Injury Association） neurological function grading system, there were one grade A, two grade B, five grade C, three grade D and 13 grade E. The vertebral canal area blocked was rated as grade Ⅰ（ 〈 1/4） in three cases, grade Ⅱ （1/4 - 1/2） in nine cases, grade Ⅲ （1/2 -3/4） in 10 cases and grade Ⅳ （〉 3/4） in two cases. The pedicle-screws were implanted into the pedicles of the fractured vertebra and its adjacent ones. The connective rod was pre-bent according to the normal sagittal curvature of the fixation segment. After necessary decompression of the vertebral canal, the pedicle-screws stabilized the rod which was rotated to prop open upper and lower pedicle screws and push the burst vertebra so that the kyphosis and lateral dislocation were corrected. The graft bone was implanted between the transverse processes, Results On average, the height of fractured vertebra was restored from 48, 3% of the normal value before operation to 93, 6% after operation, the lateral dislocation from 17. 1% to 0. 6%, the Cobb＇s angle on the sagittal plane from 26. 5° to 3. 1°, and the Cobb＇s angle on the frontal plane from 9. 5° to 0°, The area of vertebral canal was enlarged from 44, 6% of the normal value to 92. 1%. There were no complications, For incomplete neurological injuries, improvement of one to two grades was made in neurological functions, Conclusion Direct reduction and fixation through p edicles of fractured vertebrae is a safe and effective therapeutic option to treat the thoracolumbar burst fracture, for it can improve the stabilization and stress distribution.