改进的侧前方手术径路在胸腰椎爆裂性骨折中的应用

Clinical modification of the anterolateral approach for burst fractures of thoracolumbar spine

目的探讨改进的侧前方手术径路减压内固定治疗胸腰椎爆裂性骨折的疗效。方法2003年4月至2006年9月利用胸腰段的解剖关系，改进成“L”形肌间隙经椎间孔入路行骨折减压内固定治疗胸腰椎爆裂性骨折，临床应用16例（改进径路组），并将11例经传统胸腹膜外入路（传统径路组）作为对照组，比较两组在皮肤切口到完全显露椎体出血量、手术时间及总出血量、疗效等方面的差异，并观察术中、术后并发症情况。结果27例患者手术均获成功。所有患者获得6～26个月（平均13个月）随访。改进径路组从皮肤切口到完全显露椎体的出血量平均为（80．0±56．5）mL，总出血量平均为（450．0±273．1）mL，手术时间平均为（119．0±35．5）min；传统径路组从皮肤切口到完全显露椎体的出血量平均为（350．0±145．5）mL，总出血量平均为（900．1±421．3）mL，手术时间平均为（193．2±48．3）min，两组上述指标比较差异均有统计学意义（P〈0．05）。两组在Cobb角改善、伤椎前缘高度比值及神经功能恢复差异均无统计学意义（P〉0．05）。两组术中均无严重并发症发生，无截瘫加重、植骨块塌陷及高度丢失现象，无假关节形成和内固定失败。结论改进的“L”形肌间隙经椎间孔径路行胸腰椎爆裂性骨折侧前方减压入路简捷，出血少。既能充分减压，又能最大限度保持脊柱的稳定性，还可避免加重脊髓损伤、胸腹膜损伤等并发症。

Objective To discuss the modified anterolateral approach for the treatment of burst fractures of the thoracolumbar spine. Methods From April 2003 to September 2006, we treated 27 patients with burst fractures of the thoracolumbar spine. Sixteen of them were operated on through the ＂L＂ anterolateral approach modified out of the conventional thoraco-extraperitoneal approach using the space between the erector spine muscles and quadratus lumborum muscles according to the anatomic relation of the thoracolumbar spine. The other 11 cases were treated through the conventional approach. The average blood loss for vertebral exposure, operation time and the total operation blood loss, as well as intraoperative and postoperative complications were compared between the 2 approaches. Results All the 27 cases had successful surgery. There were significant differences between the 2 approaches （ P 〈 0. 05） in the average blood loss for vertebral exposure, the average operation time, and the average total operation blood loss. The were no significant differences between the 2 approaches （ P 〉 0. 05） in Cobb angle, height ratio of anterior borders of injured and normal vertebrae and neurological recovery. No serious complications were found in operation. After an average follow-up of 13 months, none of the patients had neurological deterioration, the spine recovered normal curvature and no implant failure happened. Conclusion The modified anterolateral approach for the treatment of thoracolumbar spine burst fractures have the advantages of less invasion, less blood loss, effective decompression and maintenance of the spinal stability, and fewer complications.