后路小切口270°减压重建术治疗严重胸腰椎三柱损伤

270° decompression and reconstruction via a posterior small incision for thoracolumbar fracture with severe three-column injury

目的:探讨后路小切口270°减压重建手术治疗严重胸腰椎三柱损伤的可行性及疗效。方法:2005年2月至2006年4月采用后正中切口、270°减压、椎体间植骨、伤椎上下椎体椎弓根螺钉内固定治疗严重胸腰椎三柱损伤患者共14例,男8例,女6例,年龄26～50岁。T123例,L17例,L23例,L31例。Denis分型:爆裂型8例,屈曲分离型4例,骨折脱位型2例;载荷分享评分为8～9分,平均8.6分。神经功能Frankel分级:A级4例,B级1例,C级5例,D级3例,E级1例。术后随访伤椎Cobb角的矫正和丢失情况,评估椎管减压范围、植骨块位置及愈合情况,评定术后神经功能恢复情况。结果:14例患者均顺利完成手术,手术切口长度4.8～7.5cm,平均5.6cm;手术时间2.8～5.2h,平均3.8h;1例术中出血达4700ml,其余病例出血量900～1800ml,平均1250ml。术中未出现其他手术相关并发症。术后14例患者X线检查显示后凸角矫正15°～28°,平均21.6°,CT显示椎管减压彻底,钛网植骨位置良好。随访1年以上12例,失访2例。3例FrankelA级患者神经功能无恢复;1例B级患者恢复至C级;5例C级患者中,4例恢复至E级,1例至D级;3例D级患者恢复正常。随访12例患者植骨界面均见骨性融合,未发生内固定器或植骨材料松脱、移位及断裂。结论:经后路小切口270°减压重建手术可以从单一入路同时完成椎管彻底减压、前中柱重建,恢复脊柱三柱稳定,临床疗效满意。

Objective：To evaluate feasibility and therapeutic effect of surgery of posterior 270° decompression and reconstruction for the treatment of tberacolumbar injury with severe three-column instability.Method：Between February 2005 and April 2006,14 patients with severe thoracolumbar three-column injuries underwent the surgery with 270° decompression,intervertebral bone graft and transpedicular screws internal fixation near the involved vertebra via a posterior midline small incision.There were 8 males and 6 females,aged from 26 to 50 years.According to Denis＇ classification：Bursting fracture was 8 cases,flex-distract was 4 cases,fracturedislocation was 2 cases.The involved levels were from T12 to L3.Four patients had neurologically complete paralysis,nine incomplete,one intact.Pre- and post-operative neurological status,the correction and loss of Cobbs angle,the decompression scope of spinal canal,the location and union of bone graft were reviewed.Result：All patients had the operation successfully.Operative time was between 2.8 hours and 5.2 hours（mean 3.8 hours）,blood loss was between 900ml and 1800ml（mean 1250ml） except one case of 4700ml,and the length of the surgical incision was between 4.8cm and 7.5cm （mean 5.6cm）.The follow-up time of 12 patients was from 12 to 21 months （mean 14.2 months ） .Two patients were lost in follow-up.Four patients with incomplete paralysis had improved 2 Frankel Grades,the other five had improved 1 Frankel Grades;three patients with complete paralysis had no improvement.The Cobbs angle of 14 patients was corrected 15°-28°（mean 21.6°）. The spinal canal was enlarged,and the spine curvature was recovered to normal.No iatrogenie neurological injury happened.All follow-up patients obtained bony fusion.No hardware failure was found.Conclusion：The author provides an alternative method for thoracolumbar injury with three-column instability and has proved thatsufficient decompression and rigid reconstruction can be obtained through posterior approach alone.The clinical therapeutic effect of this mothed is satisfactory.