保留伤椎前路减压治疗腰椎爆裂骨折的临床早期研究

PRELIMINARY CLINICAL STUDY OF TREATING LUMBAR BURST FRACTURE WITH RESERVATION OF INJURED VERTEBRAL BODY AND ANTERIOR DECOMPRESSION

目的研究对不适合单节段固定融合手术的腰椎爆裂骨折采用保留伤椎前路减压治疗的手术方法及早期效果。方法2007年9月-2008年12月收治11例该类爆裂骨折患者,采用伤椎后上角切除、伤椎下位椎间盘切除、植骨融合内固定治疗。其中男8例,女3例;年龄21～48岁,平均29.4岁。均为高处坠落致伤。经影像学检查确诊为爆裂骨折DenisB型。骨折平面位于L1和L2各4例,L32例,L41例。术前神经功能评价采用Frankel分级,B级4例,C级3例,D级4例;视觉模拟疼痛评分(visual analogue scale,VAS)为(7.30±0.98)分。侧位X线片测量患者后凸畸形Cobb角为(24.94±12.21)°;邻近融合节段上、下椎间盘高度分别为(12.78±1.52)mm和(11.68±1.04)mm;CT扫描测量椎管矢状径为(9.56±2.27)mm。CT三维重建显示,伤椎下份骨质完整性高度低于50%,骨折线通过椎弓根下份。受伤至手术时间3～11d,平均4.8d。术后即刻及术后3个月对患者进行神经功能和影像学评价,并与术前进行比较。结果11例顺利完成手术,伤口均Ⅰ期愈合。患者均获随访,随访时间6～18个月,平均14个月。所有患者均有一定程度的神经功能恢复,Frankel分级在术后即刻和术后3个月均有1～2级的恢复。VAS评分术后即刻(2.80±1.49)分,术后3个月(1.54±0.48)分,术前、术后即刻与术后3个月3个时间点间比较差异均有统计学意义(P<0.05)。术后即刻椎管矢状径扩大至(18.98±4.82)mm,术后3个月为(19.07±4.37)mm;术后即刻Cobb角为(7.78±4.52)°,术后3个月为(8.23±3.57)°;与术前比较差异均有统计学意义(P<0.05)。术后即刻和3个月时邻近融合节段上、下椎间盘高度与术前比较差异无统计学意义(P>0.05)。术后3个月X线片及CT扫描示内固定位置良好,未见内固定物松动移位。结论保留伤椎前路减压治疗腰椎爆裂骨折能够达到减压目的,缩短了脊柱融合时间。

Objective To investigate the surgical method and preliminary clinical result of managing the patient with lumbar burst fracture but not suitable for single-level fixation and fusion surgery with the reservation of the fractured vertebral body and the anterior decompression. Methods From September 2007 to December 2008,11 patients with lumbar burst fracture underwent the removal of the posterior superior corner of the injured vertebral body,the removal of the inferior intervertebral disc adjacent to the injured vertebral body,bone graft fusion,and internal fixation. There were 8 males and 3 females aged 21-48 years old （average 29.4 years old）. All the fractures caused by falling from high places. Imaging exams confi rmed all the fractures were Denis type B burst fracture. The fracture level was at the L1 in 4 cases,the L2 in 4 cases,the L3 in 2 cases,and the L4 in 1 case. Before operation,the nerve function was graded as grade B in 4 cases,grade C in 3 cases,and grade D in 4 cases according to Frankel scales; the visual analogue scale （VAS） was （7.30 ± 0.98） points; lateral X-ray fi lms displayed the kyphosis Cobb angel was （24.94 ± 12.21）°; the adjacent superior and inferior intervertebral disc height was （12.78 ± 1.52） mm and （11.68 ± 1.04） mm,respectively; CT scan showed the vertebral canal sagittal diameter was （9.56 ± 2.27） mm; CT three-dimensional reconstruction revealed that the intact part of the injured vertebra was less than 50% vertebra body height and the fracture line crossed the pedicle. The time from injury to operation was 3-11 days （average 4.8 days）. The neurological and radiological evaluations were carried out immediately and 3 months after operation,respectively,and compared with the condition before operation. Results All the patients successfully underwent the surgery. The wound all healed by first intention. All the patients were followed up for 6-18 months （average 14 months）. All the patients had a certaindegree of nerve function recovery. The Frankel scales in all the patients were increased by 1-2 grade immediately and 3 months after operation. The VAS score was （2.80 ± 1.49） points immediately after operation and （1.54 ± 0.48） points 3 months after operation,suggesting there were signifi cant differences among three time points （P 〈 0.05）. The vertebral canal sagittal diameter was significantly enlarged to （18.98 ± 4.82） mm immediately after operation and was （19.07 ± 4.37） mm 3 months after operation. The Cobb angle was （7.78 ± 4.52）° immediately after operation and （8.23 ± 3.57）° 3 months after operation. There were significant differences between before and after operation （P 〈 0.05）. For the adjacent superior and inferior intervertebral disc height,there was no signifi cant difference when the value immediately or 3 months after operation was compared with that of before operation （P 〉 0.05）. X-ray films and CT scan 3 months after operation showed good internal fixation without the occurrence of loosing and displacement. Conclusion For the treatment of lumbar burst fracture,the method of reserving the injured vertebral body and anterior decompression can decompress the vertebral canal and shorten the duration for bony fusion.