前路减压＋后路硬膜内松解治疗陈旧性胸腰段骨折伴不全瘫

Treatment of old thoracolumbar fractures combined with paraparesis through anterior decompres- sion plus posterior intradural release

目的探讨前路减压加后路硬膜内松解治疗陈旧性胸腰段骨折伴不全瘫的效果。方法对2004年1月-2008年1月收入我院的22例陈旧性胸腰段骨折伴不全瘫患者采用前路减压加后路硬膜内松解术，该22例患者均已在外院行后路减压椎弓根系统内固定术，术后神经功能较术前恢复不明显，且CT证实椎管内仍有骨性压迫，MRI显示脊髓连续性仍存在。除2例患者改为前路减压Z—plate固定外，其余20例均保留原椎弓根系统，仅植入自体髂骨。术后3～6个月Ⅱ期行后路硬膜内显微松解术。结果19例获随访，随访时间17～49个月（平均28个月）。减压术后22例中20例有不同程度的神经功能改善，ASIA运动评分由术前的平均59．4分提高到术后的平均71．3分。Ⅱ期后路硬膜内松解后，获随访的19例患者均有不同程度的改善，ASIA评分最后提高到平均80．6分。结论对于陈旧性胸腰段骨折伴不全瘫患者，除了前路骨性压迫的减压外，硬膜内瘢痕及纤维束带压迫的松解也是非常重要的。

Objective To explore the effect of anterior decompression plus posterior intradural release in treatment of old thoracolumbar fractures with paraparesis. Methods A total of 22 patients with old thoracolumbar fractures with paraparesis were admitted to our hospital since January 2004 to January 2008. Before admission, all patients were treated with decompression and internal fixation with posterior pedicle system, with bony compression to the spinal cord found through CT scanning and intact spinal cord found by MRI but without obvious neurofunction recovery. Of all, 20 patients were kept with the original posterior fixation except for two patients that were fixed with Z-plate after removal of posterior hardware. Autologous bone grafts from iliac were utilized in all patients. Intradural release was done 3-6 months after anterior decompression. Results Of all, 19 patients were followed up for 17-49 months （average 28 months）. Twenty patients obtained varied recovery of neurofunction after anterior decompression, with ASIA motor scores increasing from average 59.4 points before decompression to 71.3 after decompression. The followed-up patients won further recovery after secondary posterior intradural release, with ASIA motor scores further increasing to average 80.6 points. Conclusion For patients with old thoracolumbar fractures combined with paraparesis, the release of intradural scar and fibrocompression is also important besides anterior decompression.