强直性脊柱炎脊柱骨折的临床特征及治疗策略

Clinical features and strategies for treatment of spinal fracture complicating ankylosing spondylitis

目的探讨强直性脊柱炎(AS)脊柱骨折的临床特征及治疗策略。方法15例 AS 脊柱骨折纳入本研究,其中男13例,女2例,年龄29～73岁(平均49.8岁),AS 病程10～45年(平均24.6年)。颈椎骨折6例,2例采用保守治疗;前路植骨融合内固定2例,后路内固定植骨融合1例,后路椎板切除减压、内固定植骨融合1例。胸腰椎骨折9例,7例伴胸腰椎后凸畸形,Cobb 角46～106°,平均为64°。胸腰椎骨折采用3种术式:(1)后路经椎弓根椎体截骨、内固定植骨融合3例;(2)前路病灶清除、内固定植骨融合2例;(3)前后路联合手术(一期后路经椎弓根椎体截骨/多节段 V 形截骨、内固定植骨融合,二期前路病灶清除植骨融合/内固定)4例。结果6例颈椎骨折,3例为经椎间隙的骨折,3例为邻近终板的椎体发生水平骨折。2例保守治疗的患者,均死于肺部感染。1例不全性瘫痪患者,采用后路椎板切除减压、内固定植骨融合术,末次随访时在步行器的帮助下能独立行走,4例采用前/后路内固定手术治疗的患者,末次随访时固定节段骨性融合。9例胸腰椎骨折,3例为邻近终板的椎体发生水平骨折;6例为经椎间隙骨折后假关节形成。7例胸腰椎后凸畸形术后Cobb 角22～42°(平均26°),平均纠正38°;末次随访 Cobb 角24～44°(平均28°),丢失2°,末次随访时 X 片均提示相邻椎体间已骨性融合。结论对于不稳定性 AS 颈椎骨折,保守治疗效果较差,应积极手术治疗,前/后路手术能有效重建稳定性及实现骨折愈合。对于无胸腰椎后凸畸形 AS 胸腰椎骨折/假关节,可采用前路病灶清除植骨融合内固定;AS 骨折/假关节伴胸腰椎后凸畸形,后路截骨纠正畸形的同时,可促进骨折/假关节的融合;若后路截骨术后椎间隙张开,导致显著的前柱缺损,须行补充性前路植骨融合,以支撑前柱、避免矫形失败。

Objective To explore the clinical features and strategies for treatment of spinal fracture complicating ankylosing spondylitis （AS）. Methods The clinical data of 15 patients with spinal fracture in AS, 13 males and2 females, aged 49.8 （10 -45）, with the average history of AS of 24.6 years, were studied. Fractures were found in the cervical spine in 6 patients and in the thoracolumbar spine in 9. Of the 6 cervical spine fracture patients, 2 were treated with conservative therapy, 2 underwent anterior internal fixation and fusion, 1 was stabilized with posterior fixation and fusion, and 1 underwent decompression, posterior fixation and fusion. Seven of the 9 thoracolumbar fracture patients developed thoracolumbar kyphosis with a mean Cobb angle of 64° （46 - 106°）. Three techniques were used in thoracolumbar fracture： posterior transpedicular vertebral osteotomy coupled with internal fixation and autogenous bone grafting was performed in 3 patients; anterior interbedy fusion and internal fixation was performed for 2 patients; and combined anterior and posterior surgery （using posterior osteotomy with instrumentation and autogenous bone grafting in stage 1, and anterior focal debridement and autogenous bone grafting in stage 2） was performed on 4 patients. Resets Of the patients with cervical fracture, three had the fracture lines through the disc spaces; the other 3 had their fracture lines through the vertebral bodies near the end plate. Both the two patients treated with conservative therapy died of severe pulmonary infection. One patient with incomplete neurological deficit undergoing posterior decompression and fixation could independently ambulate with the help of walking device at the final follow-up. Radiographic evidence of fusion was observed in the four patients with cervical fracture who underwent anterior or posterior fixation in the final follow-up. Of the patients with thoracolumbar fracture, three had the fracture lines through the vertebral bodies near the end plate; the other 6 patients had their fracture lines through the disc spaces with the formation of pesudoarthrosis. Postoperatively, the thoracolumbar kyphosis ranged 26° （22 -42°） and the correction of the kyphotic angle was 38°. In the latest follow-up, the range of thoracolumbar kyphosis was 28° （24 -44o） with 2° loss of correction. At the final follow-up, solid bony fusion had been achieved in all patients. Conclusion The cervical fracture in AS patient tends to be unstable, and conservative treatment cannot get better outcome. Prompt anterior or posterior stabilization can achieve reconstruction of spinal stability and fracture union. Thoracolumbar fracture patients without kyphosis deformity can be treated with anterior debridement and fusion with autogenous bone grafting. The transpedicular ostetomy technique can be used in patients with fracture or pseudoarthrosis with kyphotic deformity in AS, which can not only correct the kyphosis deformity, but also facilitate the union of fracture simultaneously. After posterior osteotomy, in order to prevent the intervertebral disc space anteriorly opening, which may result in deficiency of anterior column, anterior fusion with autogenous bone grafting is needed to strut anterior column and to prevent failure of correction.