胸腰椎骨折的微创手术策略

The strategy of minimally invasive surgery for thoracolumbar fractures

目的探讨不同类型胸腰椎骨折微创手术策略。方法回顾性分析1997年2月至2007年10月采用微创手术治疗的220例胸腰椎骨折患者。骨折按Gertzbein综合分型：A型185例，B型26例，C型9例；载荷分享评分4-9分。采用经皮椎弓根螺钉内固定术治疗123例，胸腔镜或头灯光源辅助的小切口胸腰椎前路手术治疗75例，后路小切口270°减压重建术治疗22例。采用Frankel分级评定术后神经功能恢复情况，通过术前、术后和随访时的X线及CT片比较伤椎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。结果220例患者均一期完成手术，189例患者获得随访，术前不完全性神经损伤患者术后神经功能均有不同程度恢复。经皮椎弓根螺钉内固定组、小切口胸腰椎前路手术组、后路小切口270°减压重建术组手术时间平均分别为75min、125min、215min，切口长度平均分别为2．3cm、5．6cm、5．8cm，术后Cobb角矫正平均为11°、18．6°、21．3°。仅小切口胸腰椎前路手术组有6例出现手术相关并发症，经治疗后症状消失。所有椎管占位病例术后CT显示椎管腔扩大，减压彻底。结论合理运用微创手术技术治疗胸腰椎骨折可以取得满意疗效，基于Gertzbein分型和载荷分享评分确立的各种微创手术适应证对指导临床具有重要意义。

Objective To explore the strategy of minimally invasive surgery for the different types of thoracolumbar fractures. Methods Retrospectively reviewing 220 cases of thoracolumbar fractures from February 1997 to October 2007. All patients, including 153 males and 67 females, with an average of 36.8 years old （range, 18-66 years）, underwent minimally invasive surgery. According to Gertzbein fracture classification, 185 cases belonged to type A, 26 to type B, 9 to type C. According to load-sharing score, 62 cases were of 4 scores, 48 of 5, 13 of 6, 21 of 7, 43 of 8 and 33 of 9. Of the 220 patients, 123 patients were treated with pereutaneous pedicle screws internal fixiation, 75 patients with anterior approach assisted by thoracoseope or headlight via a small incision, and 22 patients with 270° decompression and reconstruction via a posterior small incision. Preoperative and postoperative neurological status, the correction and loss of Cobb angle, the decompression scope of spinal canal, the location and union of bone graft were reviewed by X-ray and CT. Results All of 220 cases had successful surgery. One hundred and eight-nine cases were followed up. Neurological status improved in all of the 114 patients who had preoperative incomplete paraplegia. In the group of pereutaneons pedicle screws fixation, the average operative time was 75 min, the length of incision 2.3 em, and the correction of Cobb angle 11°, respectively. In the group of anterior approach, the average operative time was 125 min, the length of incision 5.6 cm , and the correction of Cobb angle 18.6°, respectively. Six cases of the anterior approach group had surgery-related complications. All the complications disappeared after treatment. In the group of 270° decompression and reconstruction surgery, the average operative time was 215 min, the length of incision 5.8 cm , the correction of Cobb angle 21.3°. It was shown that all the spinal canals were decompressed thoroughly by CT examination postoperatively. Conclusion It was necessary to appropriately select minimally invasive surgery on the basis of thoracolumbar fracture classification. The established minimally invasive surgery indications based on the theory of spinal three columns had great significance to guiding the treatment of thoraeolumbar fractures.