改良椎体成形术联合椎管成形加内固定治疗胸腰椎骨折

Treatment of thoracolumbar fractures with spinal cord injury through modified kyphoplasty and laminoplasty:a clinical study

[目的]探讨脊柱后路改良式椎体成形术和保留后部结构的椎管扩大成形术、短节段椎弓根钉内固定,提高脊柱后部结构的稳定性,减少术后矫正度丢失的可行性。[方法] 70例胸腰椎骨折患者,病人随机分为2组:A组(n=20)采用改良式椎体和椎管成形术:颗粒骨经椎弓根椎体内植骨椎体成形、短节段椎弓根钉内固定;B组(n=50)采用单纯短节段椎弓根钉内固定。对后突畸形角度及矫形角度、椎体前缘高度以及椎管矢状径进行测量,采用Frankel功能分级和Denis疼痛分级方法进行神经功能改变的评价。[结果]后突畸形术后矫形度数较术前两组均很明显(A组:6.4°;B组:5.7°)。随访中,A组矫形度数的丢失(0.30°±1.41°)明显小于B组矫形度数的丢失(6.20°±6.70°),(P=0.0001)。术后伤椎前缘高度百分比增加值A组为(+12.9%),B组为(+2.30%),两组比较有显著差异(P<0.001)。术后随访中,A组伤椎椎体前缘高度无丢失(P<0.001),A组伤椎椎体前缘高度无明显变化(0.13%±4.06%),B组伤椎椎体前缘高度有丢失(-6.17%±1.21%;P<0.05)。采用Denis疼痛分级,两组术后均有很好的改善(P1或P2),但B组中10%的患者有严重和持续性疼痛(Grade P4和P5)(P<0.001)。采用Frankel功能分级,术后神经功能变化,A组患者平均提高优于B组。A组中未出现内固定失败患者,未出现明显的临床并发症,如颗粒骨块进入椎管、神经功能缺失等。B组中(n=50),6例患者(12%)出现内固定失败,其中2例为椎弓根钉拔出,2例为椎弓根钉断裂,2例为椎弓根钉松动移位。[结论]改良式椎体成形术,结合内固定治疗胸腰椎骨折植骨融合率高,能有效恢复椎体高度和防止术后矫正度丢失,值得在基层医院推广。

[Objective] To evaluate the efficacy of reinforcing short-segment pedicle screw fixation with posterior morselized bone grafting in vertebrae for spinal fusion in patients with thoracolumbar vertebrae fractures.[Method]Seventy patients with thoracolumbar vertebrae fractures were treated with short-segment pedicle screw fixation.Fractures in Group A（n =20） were reinforced with posterior morselized bone grafting in vertebrae for spinal fusion.Group B patients（n =50） were not treated with morselized bone grafting.Kyphotic deformity,anterior vertebral height,instrument failure rates,and neurological function outcomes were compared between the two groups.[Result]Kyphosis correction was achieved in Group A（morselized bone grafting） and Group B（Group A,6.4 degrees,Group B,5.4 degrees）.At the end of the follow-up period,kyphosis correction was maintained in Group A but lost in Group B（Group A,0.33-degree loss,Group B,6.20-degree loss）（P=0.0001）.After surgery,greater anterior vertebral height was achieved in Group A than in Group B（Group A,12.9%,Group B,2.3%）（P〈0.001）.During follow-up,anterior vertebral height was maintained only in Group A（Group A,0.13±4.06%,Group B,-6.17± 1.21%）（P〈0.001）.Patients in both Groups A and B demonstrated good postoperative Denis Pain Scale grades（P1 and P2）,but Group A had better results than Group B in terms of the control of severe and constant pain（P4 and P5） （P〈0.001）.The Frankel Performance Scale scores increased by nearly 1 in both Groups A and B.Group B consisted of patients who experienced instrument failure,including screw pullout,breakage,disconnection,and dislodgement（n =6）.There were no instrument failures in Group A.[Conclusion]1.Reinforcement of short-segment pedicle fixation with morselized bone grafting for the treatment of patients with thoracolumbar vertebrae fracture may achieve and maintain kyphosis correction,and it may also increase and maintain anterior vertebral height.Morselized bone grafting in vertebrae offers immediate spinal stability in patients with thoracolumbar vertebrae fractures,decreases the instrument failure rate,and provides better postoperative pain control than without morselized bone grafting.