植入椎弓根螺钉内固定胸腰椎骨折患者术后的矫正度丢失:植入体特征与临床技术的关系

Loss of correction in patients with thoracolumbar fracture after transpedicular screw fixation:Relationship between implant feature and clinical skills

目的:分析植入椎弓根螺钉内固定胸腰椎骨折患者术后矫正度丢失的原因及预防措施,指导临床实践。资料来源:应用计算机检索Medline1997-01/2005-07相关文章,检索词“thoracolumbar;pedicle screw;complication”,并限定文章语言种类为English。同时检索万方数据库1994-01/2006-07文献,检索词“胸腰椎;椎弓根螺钉;并发症”,限定文章语言种类为中文,。资料选择:文献纳入标准:①随机对照研究。②前后对照研究。③个案报道。排除标准:重复研究和综述类文献。资料提炼:共收集36篇文献,通过查找全文,重点引用文献30篇,排除6篇为重复研究和综述文献。30篇文献分别对胸腰椎骨折经椎弓根螺钉内固定后矫正度的丢失的原因和预防方法进行了分析。资料综合:预防术后矫正度丢失的措施:①增加椎弓根固定系统的稳定性,可通过增加螺钉的把持力和降低螺钉的应力负荷实现;重建前、中柱的骨缺损,通过经椎弓根椎体内植骨和经椎弓根椎体内注入骨水泥来实现。②正确的术后康复。避免术后过早负重,术后坚持佩戴支具,避免过早取除内固定;伴骨质疏松症者术前术后可采用药物、运动等疗法以改善骨密度。③认识导致术后矫正度丢失的原因。椎体骨缺损未及时修复;相邻间隙的椎间盘退变;内固定存在缺陷;严重椎体骨折;其他如术后过早去除内固定,术后过早负重或未佩带支具,严重骨质疏松。结论:植入椎弓根螺钉内固定后胸腰椎骨折患者矫正度的丢失主要包含伤椎的骨塌陷和相邻间隙的继发性狭窄两个方面。其原因可能是单一因素所致,但多数是多因素所致,预防术后矫正度丢失的主要措施是增加内固定的稳定性和重建伤椎前、中柱的骨缺损以及介入正确的术后康复。

OBJECTIVE： To analyze the reason and countermeasure of loss of correction in patients with thoracolumbar fracture after transpedicular screw fixation, and then instruct the clinical practice. DATA SOURCES： The relevant articles published between January 1997 and July 2005 were searched for by using computer with the key words ＂thoracolumbar, pedicle screw, complication＂ in Medline in English. Meanwhile, such articles published between January 1994 and July 2006 were also searched for in Wanfang database with the key words of ＂thoracolumbar, pedicle screw, complication＂ in Chinese. STUDY SELECTION： Inclusive articles were those about （1）rendomized controlled experimental studied, （2）before-after controlled clinical studies, （3）case reports. Exclusive articles were repeated studies and reviews. DATA EXTRACTION： Full texts of the 36 collected articles were searched for, among which 30 were quoted. The rest 6 articles were excluded due to their receptivity and review. The 30 articles analyzed the reason and countermeasure of loss of correction in patients with thoracolumbar fracture after transpedicular screw fixation. DATA SYNTHESIS： Countermeasure of loss of correction after prevention： （1）The stability of transpedicular screw fixation was strengthened by strengthening control of screw and decreasing the stress loading of screw. Before remodeling, stelar bone defect was established by bone and bone cement transplantation in pedicle of vertebral arch. （2） Correct postoperative rehabilitation： To avoid postoperative early loading, wearing orthosis, to avoid remove the fixation early. Patients with osteoporosis could take drug and do exercises after operation so as to improve bone mineral density. （3）Reason of loss of correction after operation： Bone defect of vertebral body did not repair promptly; the cataplasia of intervertebral disk of interproximal clearance; the shortcoming of internal fixation; severe vertebral fraction; removal of internal fixation, loading early, or did not wear orthosis after operation, severe osteoporosis. CONCLUSION： The loss of correction in patients with thoracolumbar fracture after transpedicular screw fixation is compnsed of two aspects, bone collapse of the fracture vertebra and secondary retrogression of adjacent disc. The loss of correction may cause by one single factor, but in many cases, it may be caused by multiplicate factors. To prevent the loss of correction after prevention mainly depends on such measures： enhancing the stability of fixation, remodeling the anterior and central cylinder structure of the fracture vertebra, choosing a suitable postoperative rehabilitation treatment.