胸腔镜辅助小切口前路减压内固定治疗胸腰段爆裂骨折

Thoracoscopy-assisted mini-open anterior decompression and fixation for the surgical treatment of thoracolumbar spine burst fractures

目的:探讨胸腔镜辅助下小切口前路减压内固定治疗胸腰段爆裂性骨折的适应证和疗效。方法:2000年6月～2006年6月应用胸腔镜辅助前路小切口行伤椎切除、椎管减压、植骨重建及内固定治疗胸腰段爆裂骨折患者42例,男28例,女14例,平均年龄34.7岁。均为单一椎体骨折,骨折部位:T118例,T1216例,L118例,平均后凸角23.8°,均伴不完全性瘫痪。均采用前路钉板或钉棒系统固定,其中经胸腔膈肌上入路28例,胸腹联合经膈肌入路14例。随访观察治疗效果。结果:1例因术中大出血转为开放手术;余41例顺利完成手术,自体髂骨植骨31例,钛网植骨10例。手术时间120～250min,平均165min;出血量460～2900ml,平均750ml;胸腔引流时间3～5d,平均3.3d。术后3例伤口表浅感染,1例发生乳糜漏,2例合并肺部感染,对症治疗后均愈合。融合节段平均后凸角4.9°,矫正率80%。术后平均随访20.2个月,无内固定失败,矫正度无明显丢失,均获得良好植骨融合;末次随访时神经功能均获1级以上改善。结论:胸腔镜辅助小切口技术为前路手术治疗单节段胸腰段爆裂骨折提供了安全、有效的微创方法。

Objective：To discuss the efficacy and indication of thoracoscopy-assisted mini-open surgery in the management of thoracolumbar spine burst fractures.Method：Between June 2000 and June 2006,42 patients with fractures of the thoracolumbar spine were treated with a thoracoscopically assisted mini-open procedure.There were 28 males and 14 females and the age of the patients were from 16 to 52 years with an average of 34.7 years.The fractures located at T11 in 8 cases,T12 in 16 cases,L1 in 18 cases.The average kyphotic angle was 23.8°.All cases occurred incomplete paraplegia.Transthoracic transdiaphragmatic approach had 28 patients and transdiaphragmatic combined with retropleural and retroperitoneal approach had 14 patients.Surgery strategy：according to the location of fracture,anterior vertebra resection,decompression,bone graft reconstruction and internal fixation were performed by thoracoscopy-assisted and mini-open surgery via trans-diaphragmatic thoracic approach and retropleural-retroperitoneal trans-diaphragrnatic approach.Result：One case was required operative conversion from thoracoscopic to an open surgery due to obvious blood loss.41 cases were successfully completed,autograft with iliac bone in 31 cases,titanium mesh cage in 10 cases.The operative time was from 120 to 250min with an average of 165min,the blood loss was from 460 to 2900ml with a mean of 750ml,the thoracic cavity drainage time was from 3 to 5d with 3.3d in average.The postoperative complications including 3 with superficial incision infection,1 with chylous leakage,and 2 with pulmonary infection,all above complications were cured by symptomatic treatment.The average postoperation kyphotic angle in fusion segments was 4.9°.During an average 20.2 months follow-up period,internal fixations failure,the loss of corrective kyphotic angle were not observed and all patients had successful fusion.Postoperation neurological improvements were above 1 grade observed in the last follow-up.Conclusion：Thoracoscopy-assisted mini-open anterior decompression and fixation provides safe and effective technology for the surgical treatment of singlesegment burst fractures in the thoracolumbar spine.